Reflecting on the humanities, related to experiences of illness, with a creative exploration of metaphoric spaces

Tags: narrative medicine, literature, CREATIVE EXPLORATION, Charles Dickens, Psychiatria Danubina, Qatar University of Calgary, patient relationship, Rudyard Kipling, body language, listening skills, Calgary, London, Hausheer R. Farrar, Shakespeare W., New York, Shimmering Light, El Ingenioso Hidalgo Don Quixote de la Mancha, Conference paper, S557 Mohamud A. Verjee, Nasir-i Khusraw, Mohamud A. Verjee Weill Cornell Medicine, Affluent Society, Isaiah Berlin, Nico Tinbergen, Walt Whitman, Somerset Maugham, quantum electrodynamics, John Kenneth Galbraith, Richard Feynman, Columbia University, Sir MacFarlane Burnet, Nobel Prize for Physics, Physiology and Medicine, Ibn Sina, Cornell University, absolute knowledge, Nobel Prize, Konrad Lorenz, Dr. Martin Luther King Jr, medical school
Content: Psychiatria Danubina, 2017; Vol. 29, Suppl. 3, pp 556-558 © Medicinska naklada - Zagreb, Croatia
Conference paper
SUMMARY Every patient has a story to tell, and every experienced physician has a bank of stories to recall. A patient's visit is not chance but a search for a cure, amelioration of state, advice, guidance, a prescription, or for seeking reassurance, comfort, and in some circumstances, permission to "be well". From the simplest tale to the most complex, narratives abound. Sometimes, the most intimate information shared with the physician confidante, go dark and deep, with a yearning to "tell all" after a period of suppression. Successful communication and rapport also depends on the carer's response, the degree of concentration, listening skills, body language, eye contact engagement, the patient relationship and empathy. How do we as physicians cope with emotion on both sides when it comes to listening to a narrated story, keeping matters in perspective, recognizing the effects of depression, grieving, anger, forgiveness, or the strength of the patient to be able to face their demons when cowardly acts of abuse have been committed. The professionalism of doctors should always be at the highest level, but individuals vary in their responses. A price may be paid with arising stress, unsolved patient problems, an increase in new ones, and the general challenge of coping. Time may not be the only enemy with modern day medical practice. Does narrative medicine have a place in reducing this dissonance, and will learning to share stories, as well as being a good listener, limit adverse outcomes? Key words: narrative medicine - professionalism - doctors - communication - rapport - carer's response - concentration - listening skills - body language - eye contact engagement - the patient relationship - empathy
Literature and Medicine ­A narrative reflection At the age of seven, I read Charles Dickens (18121870) (Johnson 2000, Dickens 1870). Not pretending to understand the whole context of his books, I found his classical style of writing enthralling. Vivid with the criminal Magwitch scaring the central character Pip in a graveyard, it was not perhaps the best Dickens novel to read first, but probably one of the best known. The book is a lesson in human nature involving abuse, fear, prolonged grief, honour, generosity, reward, heartbreak, death and eventually a happy ending. Reading generated a plethora of ideas. Subsequent finds were books on Greeks and Romans revealing ancient history read for the first time - thrilling. Rudyard Kipling's books (1865-1936) followed with "Kim" in the "Just So" (Kipling 1902) stories, capturing children's attention with imaginative tales exploring the "myths of creation" based on human eccentricities. Had I known better about psychiatry, I might have had greater insight into both Dickens and Kipling but I read for joy and not for medicine, the seeds of a medical career sown at an early age. Being born in Brighton, Sussex, not far from Rottingdean where Kipling lived, I recall a memorable visit to his home, now a museum. The ambiance where he wrote was palpable. His accolade as a Nobel Prize winner set my imagination alight.
Suffering from asthma as a child, my general practitioner, Dr. Blair Griffiths, in Hove, Sussex, was my first doctor. With his care, my health improved and I outgrew my problem. He became my perfect role model. His approach further stimulated thoughts of the pursuit of medicine in the future; schoolboy dreams no doubt. Dr. Griffiths died aged 94 in 1997, long after I qualified in 1978. I read his obituary in 1998 in the British Medical Journal (BMJ 1998), with pangs of regret wishing I could have seen him once more to say "Thank you." If only he knew how much he had inspired me. An elementary school in the 1960's assigned books to study during summer vacations. I completed four full written reviews: My Family and Other Animals by Gerald Durrell (Durrell 1956), Ring of Bright Water by Gavin Maxwell (1960), A Man for All Seasons by Robert Bolt, (Bolt 1960), and Typhoon by Joseph Conrad (Conrad 1902). I loved them all, each with distinctly different styles. Durrell wrote hilariously on the fortunes and misfortunes of his widowed mother and his dysfunctional family on holiday in Corfu, with his irascible brother Lawrence being dismissive of everyone. Maxwell's book developed the theme of a man devoted to living with otters and the deep grief that followed after an ignorant and untruthful truck driver needlessly killed his first pet otter. He valued animal communication almost more than human interactions,
developing attachments of a unique kind. It was the first book that reduced me to tears, feeling the concept of human emotion and love caring for creatures. I still have the original hardback book from 1960 safely on my bookshelf. Bolt's story needs no summary, with Sir Thomas More sticking unflinchingly to his principles, suffering the accusation of high treason for his beliefs and being beheaded by a potentate king. "I do none harm, I say none harm, I think none harm. And if this not enough to keep a man alive in good faith, I long not to live." From the Bible (Deuteronomy), I invoke the sharp phrase "Vengeance is mine to avenge. I shall repay." Both Cromwell and Cranmer in the tale suffered similar fates in real life, the former beheaded and the latter burned at the stake. Conrad's "Typhoon" is a seafaring tale which recounts the dogged obstinacy of the character Captain McWhirr with his emotional detachment of crew and family, to avoid skirting the storm and heading straight into the maelstrom. Collectively, these four works combined the spirits of humour, hope, sensitivity, love, caring, kindness, honesty, loyalty, dedication, tenderness, discovery, as well as principles, misery, desolation, futility, treachery, and death. Reading for pleasure revealed more about human nature than could be imagined, with the Hippocratic Oath's Primum non nocere coming to the fore. Books and plays at school followed with intent: Shakespeare's Macbeth, (Shakespeare W. 1603) Twelfth Night, (Shakespeare W. 1602) and Henry V (Shakespeare W. 1599) being notable. I read words that drew me closer to my career: Lady Macbeth, (Shakespeare W. 1603) "Yet do I fear thy nature. It is too full o' the milk of human kindness, to catch the nearest way" signifying compassion and benevolence. Malvolio, (Shakespeare W. 1602) "Be not afraid of greatness: some are born great, some achieve greatness, and some have greatness thrust upon them," with his profound misinterpretation. Henry V's part (Shakespeare W. 1599) in Act II, Scene V, "In peace, there's nothing so becomes a man as modest stillness and humility," expressing character formation, resolving to win with a purpose. George Orwell's Animal Farm, (Orwell 1945) Aldous Huxley's Brave New World, (Huxley1932) Grahame Greene's Brighton Rock, (Greene 2004) Miguel de Cervantes 'Don Quixote, (Cervantes 1615) gave rise to new concepts. In the lattermost, phrases such as "Tilting at Windmills," arose and chivalry became unique as "Quixotic." The two-part novel moves readers to emotion, with both tragedy and comedy used effectively. The preamble of reading I found, was essential for learning about science and medicine. Narrative medicine is about stories. Authors hatch plots, based on experience and imagination. Engaging stories are not forgotten quickly. Discoveries are irreversible. Sir Peter Medawar mastered immunology and discovered a means of re-joining severed nerve ends. He went on to receive the Nobel Prize in Medicine and
Physiology in 1960 with his close colleague Sir MacFarlane Burnet. Dr Richard Feynman from Cornell University (1918-1988) won a Nobel Prize for Physics in 1965 jointly for work directed towards quantum electrodynamics (QED). Like Einstein, he did not utter a single word until three years old. Konrad Lorenz's studies of imprinting with geese became a translation of human behaviour. He attended Columbia University, New York, home of the Pulitzer Prize for literature. Later, he met Nico Tinbergen with whom he later shared the Nobel Prize in Physiology and Medicine in 1973. I started my medical career that same year after five years of unsuccessful attempts to gain entrance to a Medical School. Thirty-nine years have now passed since graduation. I still feel the excitement of medicine, daily, with aspring of step and the urge to learn more. Reading continued to be a journey of discovery, with Somerset Maugham's Of Human Bondage, (Somerset Maugham 1993) Walt Whitman's Leaves of Grass, (Whitman 2019) and Ibn Sina, better known in the West as Avicenna, for medicine. Add Al-Farabi for philosophy and discussion of the Arabic word "aql" for intellect or reason, and John Kenneth Galbraith's Economist (Galbraith 1970) and The Affluent Society, (Galbraith 1958) the man who coined the phrase "conventional wisdom." My appetite for reading became insatiable. In Isaiah Berlin's essays, A Proper Study of Mankind, (Berlin 2000) he wrote a famous sentence: "Reality is knowable, and that knowledge and only knowledge liberates, and that absolute knowledge liberates absolutely." The Civil Rights activist Dr. Martin Luther King Jr (1929-1968) said, "If you truly believe in all you aspire and attempt to do, you will come through." Viewing his iconic "I have a dream" speech, his fervour and passionate expressions are irrefutable, and honored to this day (King 1963). As a physician, all knowledge gaps need to be recognized and then narrowed or closed whenever possible. Life simulates dynamic ebbs and flows, continuously adapting to every action and reaction. Whatever profession one may pursue, intellectual stimulation with literary sustenance is life changing. Understanding art, music, science, law, medicine, and philosophy needs intellect. In medicine, everything counts. The only limitation is self-imposition, and then one may never be able to reveal one's true capacity and ability. Learning narrative medicine from the literature may provide seasoned answers to many of today's concerns. History does not lie as a rule, although its interpretation may depend on who interprets and records events. Life is punctuated with reading. One cannot tell how much literature has enriched life, a medical career, raised one's sense of inquiry, provided guidance on ethics, fed ambition, seeded imagination, and urged disciplined ­ the effect has simulated a propelling force.
Ponder on the translation of a poem by the Persian poet Nasir-i Khusraw called Time and Destiny from a book called Shimmering Light (Khusraw 1997) an anthology of poetry. O you who have been sleeping at night, if you have been rested, do not think that time too has been resting. Consider that your personality is always on the move ­ do not think it eats or sleeps even for a moment! The momentum of time and the turning sphere, draws all animals by night and day, to ceaseless motion. Acknowledgements: None. Conflict of interest: None to declare. References 1. Berlin I. A Proper Study of Mankind. 2000, Ed. Hardy H, Hausheer R. Farrar, Straus & Giroux. ISBN: 9780374527174. BMJ 1998; 316:1172 2. Bolt R. A Man for all Seasons, 1960. Heinemann. ISBN 10-0394703219 3. Cervantes M de. 2004 (1615), Don Quixote - El Ingenioso Hidalgo Don Quixote de la Mancha. Penguin Classics. ISBN-13:978-0142437230 4. Conrad J. 1902, Typhoon. Pall Mall Magazine serialization. G P Putnam. New York & London 5. Dickens C. Great Expectations literature/g/great-expectations/about-great-expectations Accessed January 29, 2017
6. Durrell G. My Family and other Animals: 1st Trilogy in
Corfu (1956) ISBN 0755111974
7. Greene G. 2004, Brighton Rock. Penguin Classics. ISBN-
8. Galbraith JK. 1970, Economics as a System of Belief.
American Economic Review. 60(2):469-78.
9. Galbraith JK, 1958. The Affluent Society. Houghton
Mifflin, New York.
10. Huxley A. 1932, Brave New World. Published David
Rehak. ISBN: 9780060850524
11. Johnson EDH. Charles Dickens: An Introduction to His
Novels, 2000.
dickens/edh/chronology.html Accessed January 28, 2017
12. Khusraw N. 1997, Shimmering Light, Ed. Kassam K. IIS,
London. I B Taurus Publishers, London and New York.
13. King ML. 1963, "I have a dream" speech. Accessed 22
14. Kipling R. Just So Stories (1902) How the Leopard got his
Accessed January 28, 2017
15. Maugham S. 1993, Of Human Bondage. Random House
Publishing Group. ISBN-13 9780679600763
16. Maxwell G. Ring of Bright Water, 1960. Longmans. ISBN
17. Orwell G. 1945, Animal Farm, a Fairy Story. Secker and
Warburg, London, England.
18. The Bible, Deuteronomy 32.35
19. Shakespeare W. 1603, Macbeth.
20. Shakespeare W. 1602, Twelfth Night (or What you Will).
21. Shakespeare W. 1599, Henry V, Act 2, Scene 5.
22. Whitman W. 2019, Leaves of Grass: The Original 1855
Edition. American Renaissance Books.
Correspondence: Mohamud A. Verjee, BSc(Hons), MBChB, MBA, DRCOG, CCFP, FCFP Clinical Medicine (Weill Cornell Medicine-Qatar) Qatar E-mail: [email protected] S558

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