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Alexander and his Doctor, about 1648-9, Eustache Le Sueur

According to classical anecdote, Alexander the Great suffered from mysterious maladies and from his own mystique. No one dared to treat him for fear that a bad outcome would doom the would-be healer to certain persecution by Alexander’s wildly solicitous minions. Finally, Phillip, Alexander’s physician, frustrated by the young king’s decline, offered care in the form of a salubrious potion. But a general had already impugned Philip in a letter to Alexander, which claimed Philip to be acting seditiously on behalf of Alexander’s Persian enemies, and not to be trusted. Despite this warning, Alexander boldly drank the medicine, as he did so, handing the letter to Philip to read.

In the painting, Philip stands above a recumbent Alexander, as the doctor-patient relationship would demand. But Alexander’s broad chest and raised eyes reveal his power, while Philip’s stooped posture and frown expose the frailty of his position. The painting reveals, perhaps unwittingly, the vital duality of the relationship, each risking himself, proffering his full commitment to the other. Here the physician assumes the role of servant rather than patriarch, though his experience and wisdom are evident.

The intern who cared for Vincent van Gogh after he severed his ear. The painting was a tributary gift. While Dr. Rey was quite fond of Van Gogh, who mentioned the physician favorably and intimately in his letters, Rey did not appreciate the painting, at least not at first. His parents used it to cover a hole in a chicken coop. Nevertheless, Dr. Rey clearly appreciated the essential role art played in his patient’s life, and recommended Van Gogh continue to pursue it. At this time, of course, Van Gogh’s painting was for the most part unknown and/or dismissed.

Haus LebensWert is a philanthropically developed and supported facility in Cologne, Germany where patients may receive oncology services free of charge.  An integral part of Haus LebensWert’s vision and mission is to vigorously help cancer patients cope with life both during treatment and afterwards.  Another key component is the use of alternative and complimentary therapies.  These therapies are made available to patients in addition to traditional measures as part of a seamless whole.   Examples include psycho-oncology, art & music therapy, gymnastics and other exercise, voice instruction, Feldenkrais training, Nordic walking, dance therapy, massage and aroma massage, Tai-Qi, Qi-gong and acupuncture.   The Haus LebensWert, which complements a more traditional hospice, has been well received by both patients and practitioners, including those who refer their patients from outside (Hematology Am Soc Hematol Educ Program. 2009:320-5).

Critics of “complimentary and alternative medicine” (CAM) frequently complain of a double standard, and a lack of rigor in its evaluation.  Some feel this looseness encourages bloat and charlatanism, and risks distracting patients and practitioners from the path to “good outcome.”

“Academic medicine integrates three of the most honorable human activities: treating the ill, teaching, and research. The quality that all three share is persistent quest for truth. However, there is reluctance of academic medicine today to openly defend scientific truth by challenging the arguments and the very existence of “complementary and alternative medicine” (CAM). There is no sound proof of CAM effectiveness, no hypotheses on the mechanisms of their action, nor scientific reports testing them. The fact that patients are charged for these “healing” activities makes CAM a plain fraud. With these facts in mind, the name “complementary and alternative medicine” is undeserved and misleading. CAM advocates maintain that CAM should be recognized precisely because it is widely practiced and very promising, that it has a special holistic/human approach, and works at least as a placebo in situations where medicine can do nothing more. As it seems that the public interest in paramedicine will only grow stronger before it grows weaker, scientists must raise their voice and question the truthfulness of CAM more openly.”
Croat Med J. 2004 Dec;45(6):684-8.

While a truth-centered paradigm is difficult to dispute, there is more than scientific truth at stake in the quest for human understanding.  There is also existential truth.  While physician-scientists optimize therapeutic regimens by evaluating their effects on controlled trial populations, each individual patient attempts to grapple with his or her radically changed reality both in terms of life, and death.  Quantity—be it months of survival, tumor size, or fraction cured—can be measured with increasing accuracy and predictive value.  Quality can’t be so easily parameterized.  Moreover, even attempts made to evaluate “quality of life” tend to fall short because experience transcends subjective criteria when they are too rigidly circumscribed.  Patients exist within the larger communities of other patients, clinicians, family, and the omnibus of culture.  If society views the sick as mechanisms in need of repair, and devalues anything regarded as “touchy feely,” then those in charge will cut the funds that allow physicians to spend time talking with patients or considering the larger life outside the body, while adding to the already glutted ranks of surgi-centers and MRI scanners.  Certainly the possible advantages of reinvigorating the art of medicine, or even expanding it to include real art, such as expressive writing, or speaking, as therapy,will be viewed as unworthy of “serious” exploration.  This is what has happened so far.  The impersonal and alienating experience of illness is nearly a truism, at least in the U.S.

Hospitals, especially large referral centers, can be daunting and soulless places.  As we move necessarily towards more “cost-effective” healthcare it will be important not to lose sight of the fact that quality and quantity exist to a large degree as orthogonal axes.  Designing healthcare to have a more empirical and inclusive approach to alternative healing strategies assures a better chance at quality of life, and should be encouraged as long as these don’t induce patients to forego proven treatment.   A life of fear and despair may be nearly as much a lost life as for the patient who dies of his or her disease.

Haus LebensWert, by the way, means House for a Life Worth Living.

Understanding how a patient makes sense of chronic or disabling illness can be critical to the effective treatment of that illness.  Repairing the body doesn’t necessarily repair the life. Patients must confront changes to their bodies and in how they live their lives, psychological dimensions of disease physicians and allied practitioners have appropriately tried to address more vigorously.  But human beings, perhaps uniquely, not only live in the here and now but also in a larger narrative of their existence that includes their past and also projects a future.  Our identity and self-esteem are not only tied up in what we see in the mirror, but in what others see, and in who we see ourselves becoming: our plans and expectations for ourselves in the context of a long and healthy life.  All of this helps us tell the story of who we are. The term “biographical disruption” has been applied to the pernicious ability of disease to damage this narrative.   To fully treat disease one must also treat the damaged story.  There is evidence that poetry can be part of such treatment, allowing patients to creatively frame and perhaps modify their story through dialogue with themselves and with others.

Below is a poem written by a young woman afflicted with severe arthritis, reprinted from Cases Journal (Cases J. 2008; 1: 153).

Where have I gone?

Where’s the woman who weighed less than 9 stone?

Who wore a dress size 12 and didn’t need to wear shapeless clothes or jogging suits?

Who had shaped and tidy eyebrows that would complement her latest hair colour and style?

Whose painted nails, with manicured hands and feet, were perfect for holidays in the sun?

Where’s the woman who had a vocation not just a job, but who exists on benefits, a step away from poverty?

Where’s the woman who owned her own home that gave her safety and privacy, it was her pride and joy?”

Where’s the woman whose hobbies include travel, gardening, decorating, furniture restoring, sewing, reading and studying at home?

Here I am and life before my impairment has gone, the only thing I can do is hold a pen with a special grip and writing is agony.

Where has she gone?

Where has she gone?

WHERE HAVE I GONE?

Do you see me?

How can you ever know me, when all you see is my chair?

My limitations are all you see and you say they complicate your life.

Will you ever see the deep pools of love in my eyes for you?

When you half close yours with pity and turn away from me.

The beating of my heart in expectation of your closeness isquickly cooled by your fleeting hug or, worse, patting my shoulder.

I wait in anticipation remembering the taste and softness of
your kiss, you offer me a warm ‘peck’ on the cheek.

I smell your aftershave … you say I smell clean!

I remember running my fingers through your hair,

Ripping buttons off your shirt but that’s difficult when you
stand behind me pushing my chair, we can’t even hold hands anymore.

The power of my emotions makes me feel strong,

Then I catch that pitying look in your eye,

They die in my heart.

I do not speak, my smile fills my face but you will never know …

You’ll never see the real woman who is me

Who sits and is seen by the world framed by a wheelchair

Cut off emotionally just because I cannot stand or walk.

Thank you

Thank you to those who take the time to listen to difficult and unclear speech, for you help us to know that if we persevere we can be understood

Thank you to those who walk with us in public places, ignoring stares and whispers from strangers, for in your friendship we find enjoyment, laughter and happiness

Thank you for never asking us to ‘hurry up’, but even more special is you don’t snatch our tasks from us or offer ‘Care’ in such a way as to make us feel that we are still children, with no control and respect

Thank you for standing beside us when we enter new experiences and try new adventures
Though our success may be outweighed by our failure, the experience will stay with us forever and there will be many occasions when we surprise ourselves and maybe even you!

Thank you for asking for our help and expertise,
As self-confidence and awareness come from being needed by you and others

Thank you for giving us respect

You acknowledge our value as experts in our fields and that we require to live with equality in society

We shouldn’t have to ask or have laws to enforce it or remind you

Thank you for assuring us that the things that make us individuals are not our medical impairments, as everyone has those and they don’t define ONE’S SELF, it’s people’s attitudes that create barriers that exclude us from you.

Treat us as we treat you.

It is now a common practice for first year medical students to take part in a ceremony honoring the donors of cadavers used in dissection for the teaching of anatomy. The manner of the students’ participation is up to them; the reading of poetry, including original poems is not uncommon.

Here is such a poem by Fiona Horgan, reprinted from Yale Journal of Biology and Medicine.

                                                                 

Lab 16

Today’s session begins just as those gone by.
As my labmates begin to unfurl the gauze and commence our exploring,
instinctively, but unbeknownst to the others,
I am quick to assume my self-appointed duty of rewrapping,
carefully ensuring that her hands are not exposed.
Is this naïve, knowing that today would come
and I would have to spend my entire afternoon focused on them?
And why, after so many hours with her,
so many delicate procedures,
does looking at her hands still stir unparalleled emotion in me?
“Trace the radial artery . . .”
I only see hands that still possess the pallor of life,
nails bearing the remnants of rose-colored polish.
Did a loved one tenderly paint them?
And did they hold her hands as she faded from this life?
I search for her pulse.
“Divide the transverse carpal ligament . . .”
Isee my grandmother’s hands.
Hands that expertly smoothed wrinkled sheets.
Hands that pressed coins to buy sweets into her grandchildren’s eager palms.
Hands that wore a symbol of my grandparents’ love for 56 years.
I trace the fine lines on her palms.
“Examine the thenar muscles . . .”
I see my mother’s hands.
Hands that nurture children when they are sick.
Hands that dance along piano keys.
Hands that feed and clothe the homeless.
I smooth her wrinkled skin.
“Identify the tendons of the superficial and deep digital flexors . . .”
I look at my hands alongside hers.
They are the tool with which I will first touch my future patients.
Each time I lay my hands on those I hope to heal,
I will remember hers.
I reach out and fully grasp her hands.

                                                                  –Fiona Horgan

(From: The 2008 Anatomy Ceremony: Voices, Letter, Poems
Yale J Biol Med. 2009 March; 82(1): 41–46)

Poet Valeria Tsygankova gave this review of Primitive Mood in the literature and arts magazine Philadelphia Stories:

“In his newest book, Primitive Mood, David Moolten picks at humanity’s darkest tendencies and deepest capacities for suffering. Like a patchwork quilt of the twentieth century, the poems in this volume handle violence and loss, questioning and disillusionment, determination and resilience. In quiet, authoritative and incantatory language, Moolten probes the fabric of culture in the West – from the Brothers Grimm to Arshile Gorky – for material that bears his project witness. What emerges is a densely woven and engaging collection of poems, delivered with rhythmic diction, and sometimes reminiscent of spoken word poetry in its rolling momentum and charged endings. With all of the darkness of war, genocide and internment that Moolten lays bare in this volume, there is also a light that enters through the “aperture” of his writing to illuminate the everyday people silhouetted against the dark backdrop of history, reworking their own suffering into beautiful stories. It is this creative power of narrative that stands against the destruction evident in human history in Primitive Mood, and which is also present in Moolten’s powerful and intelligent writing. Moolten’s language is crisp and evocative, and lends itself well to his project of storytelling and remembering.”

Philadelphia Stories, Fiction, Art, Poetry of the Delaware Valley, Winter 2009/2010

I think part of the problem with modern “criticism” is that much of it isn’t really criticism, not in the traditional sense. There are few critics today like T.S. Eliot (not going back too far), who wrote about poetry from the standpoint of a core philosophy he had engineered. I don’t particularly care for Eliot or his unpleasantly biased point of view. But he did have intellectual rigor when it came to criticism. We do have a few individuals, all parochial in the end of course, like Eliot, and academic, like Eliot–these are the drawbacks of such criticism. Helen Vendler comes to mind for one.

Unfortunately, even here one finds a kind of “kingmaker” apparatus, where the critic anoints those poets deemed worthy of “serious” consideration in our time. Less attention is paid to poetry in general, and the qualities that make it poetry, or (less often) great poetry.

Most of what passes for critique,however, is the “book report” capsule review one finds in literary journals and newspapers. Here, I fear, it is difficult to disentangle true criticism from the commercial process. Newspapers and magazines as published instruments have a natural incentive to favor books they can praise since these are books people might buy. Poetry is desperately undervalued in our culture and it’s the poets who are desperate. Desperate to be heard and desperate to be read. The poetry world is very small, insular and incestuous. Most of those who read verse also write it. Is it a great surprise that few are willing to be fully candid in their reviews? It’s far more expedient to be circumspect and political. It’s also easier, since the evaluative criteria are of course subjective, and few critics write from a core philosophy they can articulate, never mind defend. Knowing who your friends are becomes the one constant. Worse, those who resist this tendency often write with such scathing arrogance that their example hardly begs others to write negative reviews and join them on the “dark side.”

Clearly there is bad poetry being written. Every book contains some, or nearly every book. Some books, even by good poets, are nearly all bad. We all know about the complacency that afflicts the “major” poet in mid to late career, and the Emperor’s New Clothes effect, with regard to his/her work. The same applies to the latest fad offering from the latest “iconoclastic” hotshot. Unfortunately we have become so accustomed to our little world of vanity and desperation that we can’t tolerate the truth, only occasional ad hominem rants. Here’s to more integrity, intelligence, and rigor in criticism, but I’m not holding my breath.

(In response to Travis Nichols, The Poetry Foundation, Should Poetry Critics Go Negative?)

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