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Through the looking glass
  1. G Bolton1
  1. 1Medicine and the Arts, King’s College London University, Department of English, Strand, London, WC2R 2LS, UK;

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    “Stories do social and political work. A story is never just a story—it is a statement of belief, of morality, it speaks about value.”1

    “Knowledge is limited. Imagination encircles the world.”2

    Life is perspectival. Looking in through a window at one’s life in order to reflect on it from outside is impossible. Medical and health care clinicians, however open about themselves and their practice, can only perceive and understand from their own viewpoint. With the best, most empathic, will in the world no practitioner can understand a patient or colleague’s point of view. As Anais Nin says: “We don’t see things as they are, we see them as we are.”3

    A fully objective account is not possible from anyone about any situation. To be objective is to be “not influenced by personal feelings or opinions in considering or representing facts; impartial, detached” according to the Oxford English Dictionary. Every attempt is made in certain situations—for example, to be uninfluenced by personal feelings etc, but it is not possible to be totally detached or impartial. Even a video recording of a situation must be partial: for instance the stance of the camera must be considered, and the fact that only sight and sound are recorded. Letters, emails, or other writings accurately record communications, because they are the communication. Even then, however, they only record each individual’s precise written words, not what the writer or recipient felt or thought at the time, or any other circumstance.

    Impartiality and detachment are conspicuously impossible within medicine and health care, as they are essentially interpretive activities,4 full of inherent paradox and ambiguity, and therefore there is an inevitable lack of transparency.

    Individual clinicians’ perspectives and values can, however, be widened and deepened, in order to develop their practice as effectively as possible. I remember George Herbert’s hymn from school chapel: “A man that looks on glass, /on it may stay his eye; /or, if he pleaseth, through it pass, /and then the heav’n espy”. Lewis Carroll’s Alice does even better: she crawls right through the looking glass, leaving her stuffy Victorian rule bound world, entering a world in which everything “was as different as possible”, things are “all alive”, where dynamic connections are made between divergent elements.5

    A creative leap is required to support widening and deepening of perspective, and the ability to mix tacit knowledge with evidence based or explicit knowledge effectively.6 The clinical arena can be opened up to artistic scrutiny; practitioners can observe and reflect upon life and practice through the lens of artistic processes. We are still anchored to our own perspective, but these perspectives will be artistically and critically enhanced. We cannot pass through the mirror’s silvering, and can inevitably reflect only upon ourselves, our own thoughts and experiences. Artistic processes can, however, enable a harnessing of—for example, material such as memories which we do not know we remember, and greater access into the possible thoughts and experiences of others.

    The artistic method I have used, and which has fostered many Wordhoard accounts, is writing.6 Wordhoard featured writers usually write about their own professional or personal experience. The perspectival nature of these writings is acknowledged—that is, they do not purport to be objective or even necessarily true accounts, and many of the writing skills used are those of literature.

    Clinician/writers are being heard clearly, both students in reflective writing courses,7,8 and practitioners, (see Annals of Internal Medicine: Physician/Writers’ Reflection series.9) “By rendering whole that which they observe and undergo, doctor/writers can reveal transcendent truths, exposed in the course of illness, about ordinary life.”10 Samuel Shem says fiction writing has been an essential way for him of humanising medicine.9

    Writers acutely observe small details and subtle nuances of behaviour and situations. A clinician/writer observes details missed by a good observant clinician.11 Try it. Observe a patient walking into your consulting room, clinic or ward. Capture on paper: how they hold themselves, breathe, move their limbs, their characteristic gestures and sayings. What do they remind you of—a cat, a big soft armchair, a locked filing cabinet?

    A writer has the unparalleled privilege also of entering into the life of another. That this person is a character on a page does not make it any less of a privilege. Deep understandings can be gained by entering (virtually) another’s feeling, thinking, perception, and memories. This is a process of writing beyond what you know: if you know where writing is going to take you, start at that known point, and write on from there into the unknown. Try it. Take the patient you have just described. Write the conversation they might have had on returning home from their consultation or interaction with you, or in the pub that night.

    Remember this is an artistic exercise: do not think about it, let your hand do the writing, free of the policeman of your mind. If you add in something about how they got home, where they live or drink, you really are allowing your imagination to take you through the glass. You are tapping into your understanding of this patient which is latent in your mind, but has possibly not been so fully exercised before.

    This is fiction; the writing has been invented imaginatively. That process of imagination, however, draws upon deep experience and memory of human interaction. It matters not a jot that your patient had a totally different response to their consultation with you from the story you have depicted. What does matter is that you have brought what you understand and think about this person into the forefront of your mind.

    Sharing this writing with a colleague can offer effective reflection upon understandings. Rewrite with the fresh insight gained. And perhaps a colleague, also present at the encounter with the patient, might write an account. Reading each other’s will offer the different perspectives from which you unwittingly work.

    This method of reflection does not jeopardise clinical accuracy of perception.12 Neither does it impose distorted interpretations about patients because its purpose is to explore and express what is already there in clinicians’ understanding and perception.13 It brings this to the fore to be reflected upon critically and effectively. It also brings to the forefront of attention the perspectival nature of our perception. No one can know what really happened in any situation. Perhaps this writing work might make it clear that the doctor had a totally different understanding of the patient from the nurse, or that the doctor might think and write one thing today, reflect upon that writing (perhaps with a peer or group of peers), and write something different tomorrow; their perception enhanced by the writing and discussions. Such a collection of stories can build up a composite picture of a situation, and what was thought and felt—getting as close as possible to what really happened.

    This is the kind of work I facilitate in the reflective writing programmes I run.6 The first three stories below were written for such groups by medical practitioners. All these stories are part of the flux and flow of our understanding about life. Being written, and even being published, does not ossify them. They indicate where the understanding of the writer rested at the moment of writing. Retaining this reflexive fluidity in these writing explorations is vital.



    • This was said to Sylvester Viereck by Albert Einstein in an interview in Berlin in 1929.

    • Opening the word hoard is edited by Gillie Bolton. Items should be sent to her at the address at the end of her editorial.