Introduction: waxing lyrical

In researching teamwork in the operating theatre, one of us (AB) observed intestinal surgery of a male patient suffering from Crohn's disease, carried out by a senior, male surgeon who would not mind being described as ‘old school’.

Crohn's disease, otherwise known as inflammatory bowel disorder, offers a puzzle to scientific medicine. Its exact causes are unknown and there is no cure at present. The symptoms can be debilitating—mild to severe inflammation and thickening of the intestinal tract (anywhere from mouth to anus, although usually the large or small intestine) leading to general fatigue, abdominal cramps, diarrhoea and weight loss. Crohn's disease appears to be a product of an overactive immune response, an autoimmune disorder. Where lifestyle, diet and drug therapies fail, surgery offers a final option. A portion of the inflamed intestine is removed in a bowel resection, giving relief but not cure.

The surgeon in question was carrying out this operation and talking his assistant through the anatomy, when he suddenly stopped in midstream and asked the whole team to gather around the patient on his side of the table. The fact that the invitation was so cordial took some of the team by surprise, as they dutifully moved closer. The surgeon had gently lifted a portion of the intestine to reveal some fascia (connective tissue). A combination of the reflective surface from the liquidity of the tissue illuminated by surgical lights was producing an extraordinary local rainbow effect. The gut fascia was shimmering. The surgeon wanted to share with the team this moment of wonder, the revelation, or perhaps the conjuring, of this interior rainbow. He seemed to be talking to the temporary phenomenon itself, in a moment of touching gratitude and celebration. More so, this was a revelation for the team members. The scrub nurse said afterwards that she had never heard this particular surgeon ‘wax so lyrical’, and that this moment really touched the team as a whole, who felt drawn together as a unit to experience this delicate and temporary wonder. The operation, it should be noted, was deemed a success.

A man who had a similar operation for Crohn's disease has uploaded a You Tube video2 of a portion of the procedure, giving the following explanatory commentary:Taken in about 1995, I gave my surgeon my video camera and somehow convinced him to video tape (sic) my operation. The operation was to remove several diseased sections of colon/small bowel effected (sic) by my Crohn's Disease. This was actually the 2nd time my surgeon had opened me up like this and pulled a whole bunch of pieces out. I got to hold almost the entire length of my large intestines in my hands (after the surgery was complete of course). I guess I'm a tinkerer to the end, even when it concerns my own body mechanics.

What is striking about this commentary is its embodied lyricism. The man continues in the same vein: ‘I love to know how stuff works. There's one shot I particularly like where you can hear the heart monitor beeping and you can see the intestines giggle subtlety (sic) with each beep.’ More, he then notes how the surgeon engages lyrically with the patient. In talking his assistant through technique, the surgeon addresses his teaching not to his assistant, but directly to the patient himself, as if he was awake, so that the patient says: ‘And I absolutely adore how they are explaining each step to ME (sic) in the first-person as the video proceeds while I'm laying there dead (ish) on the table.’

In literature, the lyrical poem is characteristically autobiographical and expresses feelings, drawing out elements of beauty and form. At its best, such literature offers close observation of sensible events rather than abstractions. In these surgical cases, the lyrical is both embodied (the beauty of the patient's gut), and embedded—in immediate, lived tragedy (the gut is diseased).

Ironically, Crohn's disease signifies the opposite to the fine discrimination advertised by the lyrical genre. It seems as if the body has lost its ability to discriminate. Where the immune system normally fights off foreign invaders, in Crohn's disease there is a loss of discrimination between the normal, healthy life forms in the gut and foreign bodies. The body then attacks itself. This can be thought of as a form of auto-anaesthesis—the opposite of a discriminatory sensibility or the ability to choose between what is and what is not of value. An anaesthetic dulls, where the aesthetic event acutely raises awareness, or attunes the senses. Crohn's disease then acts as a metaphor for what opposes the lyrical—thickening, irritability and an inability to discriminate what is of value resulting in unintended self harm, rather than autobiographical finesse. It is a burden for its sufferers, and a blessing to see that in both of these surgical examples lyricism, in a sense, was part of the intervention to relieve suffering.

In the case of the first surgeon, who drew attention to the chance appearance of the rainbow in the gut fascia, what impulse grabbed this normally taciturn man to announce such an embodiment of beauty and radiance in a frankly uncharacteristic moment of tenderness and lyricism? Such tender-minded behaviour is normally denied, or openly mocked, in the tough-minded climate of the operating theatre. Indeed, to whom was this surgeon speaking? Not, as it seems on first appearance, to the gathered audience of the surgical team and attendants, but rather to the self-display of the intestine itself, as an embodiment of lyricism. This moment could be read as a recognition and celebration of the lyrical as the Cinderella partner to the more commonly noted epic, tragic and comic events by which medicine and surgery are more easily recognised.

Medical genres

The lyrical is usually overshadowed, or indeed squeezed out, by the dominance of the epic, tragic and comic genres in medicine. That medicine is concerned with the epic is self-evident—the cycle of life from prebirths to comas and deaths; whole population epidemics; slow-burning viral disorders; large scale pharmaceutical interventions from birth control to antidepressants; the new plagues linked to conspicuous consumption, where populations inflict diseases—such as type 2 diabetes—upon themselves through lifestyle, unable or unwilling to make changes; avoidable medical error as a major source of injury and death; and so forth.

Tragedy is everyday in medicine—‘acute’, ‘emergency’ and ‘intensive’ care; sudden and serious illness; genetic disorders; chronic conditions that wear down the body and spirit; spirited people who suffer from terminal illness yet live life to the full; patients in a coma with loved ones talking to them in blind hope; the desperation of those who wish to end their lives in dignity but are legally blocked from doing so; and so forth.

The widespread use of the comic genre as a mode of initiation or socialisation and identity construction has been the medical profession's long-standing secret and a source of interest and critique particularly for sociologists and psychoanalysts, but is now publicly advertised as a common theme for medical television soap operas. The comedy is dark—‘black’, or ‘gallows’, humour. The French surrealist André Breton first coined the term humour noir to describe gallows humour, where the topic is usually illness, suffering and death, often aimed at a specific victim.1

Breton credits Jonathan Swift as the primary source for modern black humour, whose stock-in-trade includes taboo subjects usually associated with bodily functions.1 This connection with the suffering body makes it easy to see why black humour should be adopted in medicine, yet the motive is rarely to poke fun at the victim but rather to use such humour as a defence against carrying the full emotional impact of daily exposure to suffering, and to initiate clinicians into expert use of this ego defence. Sigmund Freud3 famously defined all humour as an emotional anaesthetic, deflecting and absorbing the full impact of affect that would otherwise be too much to bear, where the ego ‘insists that it cannot be affected by the traumas of the external world.’ Black humour affords the biggest sponge, soaking up the emotional excess that would otherwise swamp us in times of trial.

Patients would be horrified to hear the banter—often at their expense—in the tearooms of intensive care teams or the changing rooms of surgical teams. In places close to death, such as intensive care units, accident and emergency departments, and surgical theatres, black or macabre humour is carefully hidden from patients' families and friends, as a ‘backstage’ performance. In the public realm, sick jokes about tragedies generally backfire. The danger of accepting that we can laugh at the tragedy of others, or institutionalise this in public comedy, is that we become desensitised to the very thing we are trying to protect ourselves from through comedy.

Lyricism, however, serves a different function. The lyrical impulse draws our attention to delicacy, tenderness and the joyous (jouissance), and to verve, desire, eroticism, the fecund, abundance and generation. Synonyms for ‘lyrical’ include musical analogies such as choral, dulcet, harmonious, chiming, lilting, songlike, tuneful and rhythmic; others concern the tasteful, such as poetic, pleasing and rhapsodic. Such delicate flowers are hard to sustain in the face of the tragic, epic and dark comedic currents prevailing in medicine. Indeed, the rare beauty of the lyrical and poetic is more likely to be overshadowed by the sublime,4 where the epic comes to absorb lyricism.

The sublime is the bigger and darker force in aesthetics—the awe and wonder felt in the presence of a thunderstorm. Traditionally associated with the ‘divine’, the sublime appeals to the faux divinity characteristically attributed to the headline-grabbing heroic acts of big surgical or medical intervention. While the sublime is a headline grabber, most medicine takes place beyond or behind the front page. In this apparently mundane medicine, we may find that ‘small is beautiful’ offering an everyday radiance of care—again, the tender and delicate, the sudden revelation of the embodied lyrical with which we opened this article. In what sense do we celebrate, or even encourage such lyricism in medicine?

We believe that we need to maintain the profile of lyrical work as a gesture of resistance against the dominance of the epic, tragic and dark comedic in medicine. There is a pragmatic reason for this. At the heart of good medical practice is an acute sensibility expressed through diagnostic acumen. This is the ability to take a good history, including a physical examination, and to subsequently make good clinical judgements. Fifteen per cent of avoidable medical errors are due to misdiagnoses,5 where diagnostic acumen is a combination of a keen narrative sensibility (hearing patients' stories)6 and heightened use of the other senses such as sight7 and smell. As Abraham Verghese8 notes:Smells registered in a primitive part of the brain, the ancient limbic system. I liked to think that from there they echoed and led me to think ‘typhoid’ or ‘rheumatic fever’ without ever being able to explain why. I taught students to avoid the ‘blink-of-an-eye’ diagnosis, the snap judgement. But secretly, I trusted my primitive brain, trusted the animal snout.

Repression of the lyrical equates to dulling or anaesthetising of the aesthetic possibilities of medical practice—a more acute and generous sensibility whose practical outcome is closer noticing for better diagnoses and overall humane care. Conversely, emphasis upon the lyrical may turn medicine from a tough-minded to a tender-minded practice in a tough-minded world, again challenging the classic emphasis of medicine on ‘cure’ rather than ‘care’.

The erosion of care

Improvement in doctors' ability to communicate well with patients and with colleagues is of pressing concern in medical education. This relates particularly to the continuing phenomenon of ‘communication hypocompetence’.9 Where technical competence is generally good in graduates from medical schools, the non-technical areas of communication and teamwork present an ongoing concern, despite over 30 years' worth of attention to formally teaching communication in undergraduate curricula. The symptoms of our inability to produce doctors who can communicate effectively with patients and colleagues has produced an iatrogenic epidemic of epic proportions—that of unintended medical error.10

Medical error is a major source of injury and death. In 2000, an estimated 225 000 people died as a result of medical error in the USA.11 Indeed, in 2004 medical error was recorded as the third major cause of death after cancer and heart disease in the USA.12 A similar iatrogenic epidemic can be noted in the UK, where estimates for deaths caused from medical error vary between 11 000 per annum to 72 000 per annum.13 Vincent14 puts the figure at 40 000. While this is more than 10 times the number of fatalities from road traffic accidents, we should not forget that there are 400 million successful patient episodes each year in the UK National Health Service. Clearly, however, we have to address this iatrogenic epidemic grounded in communication hypocompetence.

Medical students are usually keen to gain meaningful contact with patients, but even before graduating, they show signs of empathy decline.15 16 The evidence base suggests that doctors as a whole are fairly poor at communicating with patients,17 but communicating with colleagues in, and across, team settings (supposedly coordinating practice around patient care pathways) is particularly bad, where ‘70%–80% of healthcare errors are caused by human factors associated with poor team communication and understanding.’18 This can be addressed by ‘improving communication and teamwork skills’.19

Current forms of education into effective communication within structures of professionalism, now often learnt in simulated settings, appear to be failing. Thus, ‘Medical mistakes still occur at an alarming rate’20 and improvement is ‘slow and sporadic’.21 We seem to forget that what Owen Barfield22 called ‘poetic diction’—the ability to turn a phrase beautifully according to context—is a health intervention in its own right as ‘good communication’.17 We then call for medicine to explicitly inhabit the lyrical genre, where grace, elegance, sensibility, sensitivity and so forth, are seen as essential capabilities for the humane practitioner. Without the lyrical, medicine is impoverished, or instrumental.

We suggest that repression of the lyrical in medical education, for whatever reasons, may be the cause of the well-documented phenomenon of empathy decline in medical students and junior doctors. ‘Empathy decline’ is a technical term that dissimulates its complexities—the excessive dulling of sensibility, as overcompensation for potential emotional overload, in the face of the epic and tragic. Such dulling of sensibility may lead to erosion of care.

Our suggestion goes further—the erosion of care is not confined to a containment of emotional response, rather it includes the blunting of the senses, compromising perceptual acuity necessary for expert physical examination and diagnosis. We are not the first to notice such perceptual erosion—Abraham Verghese23 has campaigned for many years to maintain quality of hands-on doctoring in an era of increasing reliance upon remote imaging and tests for diagnostic purposes. For Verghese, hands-on bedside technique is also a lyrical medicine, one of intent to care and engage. Verghese is both a respected physician and an accomplished writer, for whom the territories of lyrical composition and sense-based medicine are clearly complementary.

Our plea is then for an aesthetic medicine informed by the lyrical. By ‘aesthetic’ medicine we do not mean ‘surgical enhancement’. Freud's dictum that the repressed returns in a distorted form can be applied to medical practice and medical education, where repressed aesthetic (beauty) returns as its opposite form—anaesthetic, dulling, brutality and the ugly. This runs throughout patient services—numbing schedules, top heavy clinics, impossible targets, heavy handed or cumbersome management, bad food, poor design in hospitals such as lack of natural light, uncared for buildings—to unfeeling face-to-face care.

Shall we then learn our lyricism from physician-authors such as Verghese? Certainly, this provides a meaningful touchstone for medical students because such writers draw on their experiences of the ethical and sensible practice of medicine to illustrate their lyrical themes. But all lyrical writers ultimately owe a debt to Homer, for it is in Homer and the Homeric imagination that we find the uber-examples of the lyrical sensibility. Importantly, in Homer, the lyrical is embedded in the epic, tragic and comic—as is the practice of medicine—and is embodied, or illustrated in relation to the physical stresses and strains of the human body.

The lyrical body in Homer

In previous articles24–26 we have argued that a return to Homer provides a rich context for better understanding of communication in medicine. For example, study of Homer can help us to clarify precisely what we mean by ‘empathy’.25 We have also argued that formal presentation of the medical case history follows a Homeric oral-formulaic tradition.26 In this article, we extend our interest in ‘thinking with Homer’ against habitual communication practices, and for new formulations with an emphasis upon reclaiming the lyrical ground of medicine.

To illustrate this, where in previous articles we have returned to Homer as a primary source, with one of us (RM) often translating from the Greek to better our understanding of the Homeric imagination, in this article, we purposefully draw on a secondary source. This is a contemporary lyrical rereading of Homer's Iliad as an atmospheric war memorial by the poet Alice Oswald.27 We transpose Oswald's poetic technique onto medical culture, to ask unsettling questions—in particular about the strained relationship between communication and medical error.

In her collection Memorial, the poet Alice Oswald offers a radical reworking of Homer's Iliad. She takes the primary action of Homer's epic—the quarrel between Agamemnon and Achilles and its consequences (dictated by the whims and favours of the gods)—and places this in the background, indeed, out of sight. This rhetorical move effectively erases the epic's narrative structure to reveal its lyrical pockets of action. Through this erasure, she reveals and foregrounds a set of ‘atmospheres’, the poem's enargeia—a ‘bright and unbearable reality’. This is a term used by the ancient Greeks to describe the autobiographical appearance of the gods rather than appearances in disguise, and is then a term describing epiphanies. A lyrical account is of course in its own right an epiphany—a realisation of the extraordinary in the ordinary.

Oswald's technique is to foreground, from the brief slice of the Trojan War described in the Iliad, the listed dead soldiers and their means of dying, as if creating a war memorial. These short descriptions offer highly compact biographies and intensely direct ways of knowing, leading us straight to the heart of the individual. Naming, or ‘personifying’,28 is compounded through similes, so that a death in battle is, in Oswald's reading of Homer, ‘Like a wind murmur’ or ‘Like the war cries of cranes going south escaping the rain.’ Such radiant similes, suggests Oswald,27 derive from pastoral lyric, ‘because their metre is sometimes compressed as if it originally formed part of a lyric poem.’

Collectively, the descriptions of how these soldiers die that Homer offers add up to an atmosphere or climate that we can equate with medicine as well as war, with patients replacing soldiers. Medicine of course characteristically draws on militaristic metaphors such as the ‘war on disease’ and ‘fighting infections’. Paradoxically, medicine's Achilles' heel is its historical legacy of working within militaristic hierarchies and command chains, which frustrate the collaborative and democratic communication exchanges needed for effective teamwork around patients, and supportive communication with patients in consultations. Just as war has its casualties, some caused by ‘friendly fire’, and many of which are civilian (‘collateral damage’), so medicine has its casualties—natural and unnatural deaths, including that spectre of the iatrogenic epidemic grounded in communication hypocompetence that we have described above, and can be thought of as medicine's own unfortunate friendly fire.

Oswald's poetic strategy also foregrounds Homer's lyrical charge, a lyricism often overshadowed in the Iliad by its sweeping epic and tragic concerns (while the Odyssey more obviously has lyrical concerns, as well as its epic and tragic themes, and its comic incidents). We suggest that this same poetic strategy can be applied to medicine and medical education. Students and junior doctors learn a good deal about the foreground of the epic, tragic and dark comic. However, what is missed is the overall atmosphere or climate that is constituted by the deeply lyrical content of the passage of people's lives through the clinic, the hospital and the operating theatre. Let us take an illustrative example, transposing Oswald's poetic device on to medicine.

First, we must ask: where is the medical memorial, the tally of the dead and the equivalent to the war memorial? Of course, millions pass through healthcare systems every day, mostly without deeper consequences. But what, for example, of the thousands killed unnecessarily each year through medical error—where is the memorial and the accompanying epic songs that may account for this tragedy? Will a shift to a more lyrical medicine gradually erode such a tragedy, restoring empathy to young medical students and doctors in a recovery of humane care?

Oswald's poetic technique develops empathy (or rather the deeper and more universal sense of ‘pity’, as we argue in a previous article)25 in the reader for the ‘unknown’ fallen soldier, elsewhere a mortality statistic, through an autobiographical moment using lyrical form. Thus:‘Another man springing into his chariotFelt a blow on his shoulder and droppedLike a leaf from a topmost twigHis name was IPHINOUS.’

We come to know Iphinous, albeit briefly, through the lyrical association with a gently falling leaf, and in this brief elegy, gravity, honour and dignity are suddenly restored to the soldier. Another soldier is hit by an arrow:‘And now the arrow flies through GORGYTHIONSomebody's darling son.As if it was JuneA poppy being hammered by the rainSinks its head downIt's exactly like thatWhen a man's neck gives inAnd the bronze calyx of his helmetSinks his head down.’

These pithy descriptions are also, in medical terms, ‘cases’—their ‘causes of death’ now described poetically and sensibly, rather than technically and in dull prose. A further example evokes the feeling of a very ill patient in the intensive care unit—one minute there, the next, gone:‘Poor ARCHEPTOLEMOSSomeone was thereAnd the next moment no oneLike fire with its loose hair flying rushes through a cityThe look of unmasked light shocks everything to rubbleAnd flames howl through the gaps.’

To add insult to injury for family members, where tragic medical errors are made, apologies are sometimes not forthcoming, or communication with family members fails to fully disclose the error for fear of malpractice claims being filed:29‘POLYDORUS is dead who loved runningNow somebody has to tell his fatherThat exhausted man leaning on the wallLooking for his favourite sonLike a lion leading his cubs through a woodWalks into a line of huntsmenAnd stares himself strongerClenching his whole face fistlikeAround the stones of his eyes.’

The tradition of ‘lament poetry’, which Oswald reveals as the atmospheric caul hooding Homer's otherwise muscular epic, could readily be adopted as a core ‘competency’ in learning communication ‘skills’ in medical education (we use these contemporary instrumental words with a health warning, where they devalue the complexity of doctors communicating with patients and colleagues). Rather than reinforcing the tradition of poor, even disgraceful, dealing with disclosure ‘when things go wrong’ in medical care, perhaps we can learn from lament poetry about lyrical communication—in other words, the so-called ‘breaking bad news’ that is sensitive, sensible and deeply felt. This would constitute a medical language that speaks directly to the person concerned—the anaesthetised patient as if she were fully aware; the relatives of the dead in honest but caring and supportive terms; the everyday patient as person and equal; and the colleague as a collaborator.

Finding a place for the lyrical

Part of the vitality of The Iliad and The Odyssey rests in their retelling. Audiences expected the bards to stay true to the oral tales first written down by ‘Homer’ or many ‘Homers’, but also craved the individual touches of bards who improvised around familiar themes producing lyrical effects. As Christian Meier30 notes, by around 600 BC in ancient Greece, festivals were being held that featured competitions between singers. Such competitions ‘clearly stimulated efforts to retell old myths in ever new, better, and more beautiful forms.’ Lyricism was added to the epic cycles, tragedy and comedy.

It would be unfair to say that the lyrical has been abandoned, or driven out of medicine altogether, through the dominance of other genres. While the Greek idea of the Symposium (literally a ‘drinking party’) is usually associated with philosophical and political debate, special symposia included poetry contests as platforms for development of lyrical forms of expression that celebrated unique personhood and moral virtue. In medicine, the Grand Round can be seen as a version of the poetry symposium, encouraging eloquent and pithy ‘case’ presentations. Here, as in the ancient Greek festivals, the epic song cycles with their familiar tropes, such as aphorisms (wisdom condensed into sayings),31 as medical lore are re-storied for contemporary times through lyrical inventions. The old myths concerning symptom—grounded in tragedy and epic forms—are embroidered or carefully compacted in lyrical forms as they are personalised for this particular patient at this particular bedside. They are mannered performances, where the practical and critical forms of evidence-based medicine are given lyrical form as idiosyncratic, narrative-based patient histories.