Medicine and Metaphor

Poetry as Prescriptive: The interdisciplinary study of medicine, psychology, literature, and history is a burgeoning area in medical education. Physicians and literary scholars alike are finding that the intersection of medicine and the humanities enriches both disciplines.

A pulmonary intensive care unit might be the last place you would expect to find poetry. But it is here, every day.

"This is a place where 25 percent of patients die. Most are strangers to us when they arrive. Most suffer greatly," says physician Peter Kussin. "Medical students here see the whole range of human suffering. They immerse themselves in the details of patient care to ward off thoughts about the misery around them. When the suffering does become apparent, they are frequently overwhelmed. The poems help."

X-ray of human body

A pulmonary intensive care unit might be the last place you would expect to find poetry. But it is here, every day.

"This is a place where 25 percent of patients die. Most are strangers to us when they arrive. Most suffer greatly," says physician Peter Kussin. "Medical students here see the whole range of human suffering. They immerse themselves in the details of patient care to ward off thoughts about the misery around them. When the suffering does become apparent, they are frequently overwhelmed. The poems help."

Kussin, who is an associate clinical professor of pulmonary medicine at Duke Medical Center, uses daily doses of poetry as part of students' training during their rotation in the ICU. "It's remedial poetry for doctors," he says. Despite their lack of formal instruction in literature, he adds, medical students and nurses are able to use poetry to explore their often-suppressed feelings of grief, sadness, and even guilt about the patients they serve.

Ninety-nine percent of doctors were science majors, Kussin says. "Physicians live in a world of PDAs, pagers, and cell phones. Along with that comes a risk of the loss of a part of the human machinery. I can't turn off my pager. But there is a way out--and it all begins with William Carlos Williams."

Kussin sees the noted physician-poet, who often scribbled lines of poetry on prescription pads as he made his rounds, as the exemplar of the way in which poetry can encourage empathy, bringing a sick patient's individuality and feelings vividly to life. Williams showed that "poetry can counter the pull of professional gravity and help create more soulful physicians," says Kussin. "Why do I read poetry with my students? Because when you get to the core, it's the deepest part of what we do."

Williams himself saw his two arts as inseparable. "As a writer, I have never felt that medicine interfered with me, but rather that it was my very food and drink, the very thing that made it possible for me to write. Was I not interested in man? There the thing was right in front of me. I could touch it, smell it. It was myself naked, just as it was, without a lie telling itself to me in its own terms."

Physicians and literary scholars alike are finding that the intersection of medicine and the humanities enriches both disciplines. The field of medical humanities--the interdisciplinary study of medicine, psychology, literature, and history--is a burgeoning area in medical education around the country. Johns Hopkins University publishes the scholarly journal Literature and Medicine. Columbia University College of Physicians and Surgeons publishes Reflexions, a journal of writing by medical students. And physicians' and medical students' poems and stories are making their way into anthologies, chapbooks, e-zines, small literary magazines, and even venerable journals such as The Lancet, the Journal of the American Medical Association, and Annals of Internal Medicine.

Duke has been linking poetry and medicine for decades. The Health Arts Network began offering poetry workshops for Duke patients and their families as part of a pilot project in 1986. Today, volunteers read poetry to patients, patients keep journals, and hospital employees, medical students, and others gather in the medical library for literary discussions twice a month. On display on the walls of the medical center are fifty poems by poets, classic and contemporary. Among them is one of Kussin's favorites, Langston Hughes' "Mother to Son," with its lines:

Life for me ain't been no crystal stair. / 
It's had tacks in it, / 
And splinters, / 
And boards torn up, / 
And places with no carpet on the floor-- / 
Bare. / 
But all the time / 
I'se been a-climbin' on....


 Pope: "We turn to poetry to repair some damage". Photo: Les Todd


"Poetry," says Kussin, "is the word transformed at the edge of experience. It speaks to working at the borders of experience, which is where a lot of medical practice happens. Poetry works best with physicians when it can be harnessed to help them cope with their own misery in dealing with the suffering they see, or help patients deal with it, or just to understand more about what the patient is experiencing. Nothing is as important as understanding suffering. Nothing."

A scientist as well as a poetry lover, Kussin recently wrote a grant proposal to fund a randomized, controlled study of medical residents who will either study poetry or some other intervention. "We want to find out if the poetry improves their ability to communicate with patients in the intensive care unit," he says.

But Kussin is already convinced that it does. "I tell the interns, 'Here's the poem we're going to read on rounds today.' It may be Lucile Clifton. It may be William Carlos Williams. It may be Shakespeare or Robert Frost or something brand new. Whatever the poem, it's poetry to heal the healer."

Poetry can heal the patient, too, as novelist, poet, and professor Reynolds Price '55 discovered when he was diagnosed with a spinal tumor in 1984. Recalling his days in the hospital after a surgery to remove the tumor, Price says that he often silently quoted long excerpts of verse to himself as he lay in his hospital bed.

Price was the keynote speaker at "Vital Lines, Vital Signs," a poetry and medicine conference convened by Duke's Center for the Study of Medical Ethics and Humanities. "How did these poems help me?" Price said to the audience. "What do words do to us? What do the sounds of words do to our brains that then happens to our bodies? I do not know. But one of the great blessings to me was to recite hours of good and bad and mediocre poems that I had read."

As he moved through the diagnosis and treatment of his cancer, Price suspended work on his novel, Kate Vaiden, and instead wrote poetry in his daybook. He recited to the audience the first poem he wrote shortly after his return home from his first surgery. The words reconnected him with the past, and with the pleasures of his life:

Perfect pears no bigger than hen eggs / 
Gold, spotted brown, one mouthful even / 
For me as a boy. My father's brought them / 
Home from a trip; and I devour / 
Them in one long evening, then sleep / 
Black dreamless night till he shakes me--Sunday, / 
His day. / 
Forty-six years pass. Home / 
From surgery (tumor still in me), I wake / 
At dawn and taste that cool flesh; / 
Hear his waking voice.

"That poem recorded something that was quite critical to my recovery," he said.

Price added that his prognosis had been dire, but "I am still here, fat and sassy, as we say in Eastern North Carolina. I think the poems had a lot to do with it."

Deborah Pope, a professor of English at Duke, also believes in the healing power of poetry. The author of several critical studies, as well as three books of poetry from Louisiana State University Press, Pope last year offered for the first time an undergraduate course, "Poetry and the Healing Arts," which ranged from literary analysis and research to discussion of the role of poetry in psychotherapy, readings in medical journals, a lecture on neuroscience, and a visit to a brain-imaging lab.

"Literature is being called upon to guide and instruct medical personnel on matters from ethics, to diagnostics, to teaching empathy, to creativity itself as a coping, mediating instrument," Pope wrote in her description of English 170. "We will explore questions such as, What can poetry tell us about the body? What is poetry's place in trauma? What can poets learn from doctors? What can doctors learn from poets?"

On a mild, sunny afternoon not long before the end of the 2004 spring semester, members of the class present the topics they had chosen for their final projects. One student, Christine Mullis, chose to write about poetry and diabetes. (She had just been diagnosed with the disease.)

"It's a constant balancing act that infiltrates all aspects of your life," she tells the class, explaining that she wants to look at the emotional aspects of diabetes and how reading poetry might facilitate management of the disease and its attendant depression and loss of control. She reads aloud the long poem "Diabetes" by James Dickey to her classmates. It begins:


One night I thirsted like a prince / 
Then like a king / 
Then like an empire like a world / 
on fire.

Healing the healers: Kussin, second from  left, reading poetry with medical residents before rounds

Healing the healers: Kussin, second from left, reading poetry with medical residents before rounds Photo: Les Todd.


"Knowing that something you've experienced is important enough to be in a poem helps somehow," Mullis says.

Another student's research topic involves analyzing how "autopathography"--autobiography seen through the lens of illness such as Audre Lorde's Cancer Journals--can improve how medical professionals treat issues of sexuality in breast-cancer patients. "We are looking at literature as a strategy or a tool," Deborah Pope interjects. "I love this experiment. It's an ongoing diagnostic."

The class goes on to discuss the use of metaphor to describe cancer, the efficacy of poetry in therapy, and a report on the debate about the use of poetry in medical education through arts and humanities programs, including how such programs might measure success. It also looks at the poetry as documentation of disease in Muriel Rukeyser's Book of the Dead, a poem sequence that tells the story of the lung disease silicosis, compared with a Labor Department description of the disease.

"My students did some original work," says Pope. "They were in on the beginning of something, doing the kind of synthesizing work that is galvanizing this field. Duke, with its liberal-arts college set on the border of a cutting-edge medical center, is uniquely poised to do this work. We're at the launching point of an interdisciplinary conversation, and these students were doing that talking."

[caption]Price: Writing poetry was part of his curePrice: Writing poetry was part of his cure. Photo: Les Todd

The conversation was continued and broadened at the "Vital Lines, Vital Signs" conference convened in April, just a week after the semester ended. It was the first-ever national conference on poetry and medicine, drawing some 200 participants from thirty-two states, Canada, England, and Australia. Health-care professionals, poets, and scholars came together to investigate the connections among illness, health, suffering, recovery, and the writing and reading of poetry. The idea, says Kussin, who with Pope and others was an organizer of the conference, was to find "new ways of talking to each other."

To do that, the conference offered presentations focusing on the clinical (curricular applications of poetry to medical education); the testimonial (writing and the healing process from the point of view of patients and physicians); and the theoretical (formal literary explorations of the language and poetic constructs of pain, healing, and recovery). Nationally acclaimed poets, including Lucile Clifton, Mark Doty, Rafael Campo, and Li-Young Lee, gave readings. And late each evening, dozens of conference participants--physicians, nurses, psychologists, professors of English, patients undergoing treatment, medical students putting their hand to verse for the first time--gathered to share their own poems.

"The conference didn't have the answers," says Pope. "But you can always ask a better question. A question we asked in my class was, What is it about condensed language and structure that comes forward in times of trauma? Maybe by reading a poem, a doctor can understand. Maybe by writing a poem, a patient can gain some control."

At Columbia University Medical Center, physician Bertie Bregman, who spoke at the Duke conference, has instituted the reading and writing of poetry into the routine of the interns and residents he supervises during their internal-medicine rotation. This approach not only allows them to write about clinical experiences that have no official place in the medical record, but also to analyze medicine as a narrative art.

Bregman's approach is part of a new trend in medical education known as "narrative medicine"--listening to and then writing down patients' stories, as opposed to jotting a shorthand list of their symptoms. Medical students read literary texts and then write about themselves or their patients in their own words. This encourages the students to see patients as people, not "the gall bladder in Room 31," and can tease out nuances of symptoms, habits, and feelings that can help doctors determine appropriate treatment.

Bregman says that he finds that writing poetry, with its compression and speed and intensity, is an especially useful exercise for interns. "We work with very sick patients," he says. "The students see intense family and patient interactions. They are stuffed with impressions that they don't have a place to express. Reading and writing poetry can create that place. We teach them to pay attention to the way the poem looks on the page, to be aware of rhyme and line endings. I want the poems to make us slow down and listen."

At Duke, a student in Pope's class, Benjamin Morris '04, also cites poetry's power to make us pay attention. He says, "Poetry and medicine in their highest forms really teach the practice of how to be a better listener and how to see to 'the heart of the matter,' to quote Graham Greene." He adds, "A truly fine poet and a truly fine physician knows when to be silent and when to receive rather than to give, to find that moment of stillness, if you can just make it out."

For the course, Morris wrote about the mythological origins of the caduceus, which expressed Apollo's duality as god of both poetry and medicine, in his research paper for Pope's class. His project explored images of the caduceus in medical bookplates found in the Duke Medical Library History of Medicine Collection. (An exhibit, "The Art of the Serpent in Medical Bookplates," based on Morris' research is on display in the Center for the Study of Medical Ethics and Humanities through mid-December.)

In her class, humanities students were outnumbered, Pope says. "A third were English majors, a third psychology, a third pre-med. Medical humanities creates a whole new way of using the love of literature. As an English teacher, I wanted to demonstrate that many of the properties that doctors and patients went to poetry for could be accomplished without a sacrifice of quality. I wanted to look at the many richnesses of poetry. We turn to poetry to repair some damage."

Morris, who took the class last spring and is now pursuing a master's in creative writing, says, "There was an atmosphere of enthusiasm and camaraderie and excitement in the class. We had pre-poets and pre-physicians haggling over the same question. We were poets learning to think like doctors, and doctors learning to think like poets."

Pope says she began to think about poetry as a healing art in the aftermath of the terrorist attacks on September 11, 2001. "I look to the eruption of poetry after 9/11. It was everywhere. I had never experienced poetry that way--as a means of exchange. People did not have the discursive language to talk about what had happened, so they would exchange poems."

Pope agrees with Peter Kussin that poetry can illuminate the subjective experience of patients, allowing doctors to glimpse the humanity behind the illness. This theme was repeated again and again at the "Vital Lines, Vital Signs" conference. "Poetry is a window on the thoughts and feelings of medical students because it is so different from standard forms of medical communication, has a capacity to incorporate the language of emotion, and addresses questions of meaning and values," Joanna Shapiro, director of the Program in Medical Humanities at the University of California-Irvine, reported at the conference.

Shapiro has analyzed 181 medical poems written by first-, second-, and third-year medical students, teasing out major themes that emerged in their work. Medical students, she says, view medical education as engulfing and all consuming. They worry about the effect of med school on who they are. They worry about losing their compassion, as this poem by a third-year student expressed:

And I do not flinch ... / 
And I do not flinch ... / 
And I silently weep / 
For the tears that do not come.

Says Deborah Pope, "The energies and synergies and undertakings that resulted in our pioneering conference have continued to spark additional ventures, which was one of our original goals--not to just be a 'one and done' conference, but a base for ongoing interaction between the medical and humanities areas of the university." Several initiatives have been sparked by the conference already, she reports--among them, the formation of a yearlong humanities and medicine roundtable on suffering and a program to bring together third-year medical students and advanced humanities graduate students to explore cross-disciplinary issues and collaborate on projects and research.

Connections were made during the conference, too, as when poet Sharon Olds shared the stage with poet-physician John Stone, professor emeritus of cardiology at Emory University and a co-editor of On Doctoring: Stories, Poems, and Essays. (Since 1990, the Robert Wood Johnson foundation has distributed this book free to every first-year medical student in the U.S.)

Before she began reading, Olds turned to Stone and said, "I am honored to share the podium with a fellow maker."

"Maybe we're kin," the cardiologist replied.

"We are," the poet said.


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