“Of Course It’s Real Blood,” Damienne Merlina, Los Angeles, California
Art captures a multitude of meanings and guides us to see the world in different ways, as it offers visual expression to help medical students better understand those with illness.
The family of a patient being treated for a stroke at Ronald Reagan UCLA Medical Center this past year wrote a note to the hospital, thanking the team of doctors and nurses for providing outstanding care to their convalescing father. Such notes are not uncommon, and this one, like many, praised the standard battery of tropes — kindness, compassion, attentiveness — that contributed to a speedy recovery and eventual discharge. One line, however, stood out. The family recalled, “One of you even asked, ‘What was he like before the stroke?’” Embedded in this simple question is a crucial and historically overlooked attribute in the practice of medicine: clinical empathy.
At first blush, empathy seems to arise innately in some people and not in others, like musical ability or aptitude for foreign languages. But speaking French and playing the violin don’t simply happen without cultivation and practice. Empathy, too, can be learned and taught, irrespective of natural predisposition. And yet, empathy does not conform to scales or grammatical rules — its mechanics and expression are hard to pin down. How, then, does one go about teaching it? Flush with talk of humanistic and patient-centered care, medical schools across the country are seeking ways to fold instruction on clinical empathy into the curriculum. At the David Geffen School of Medicine at UCLA, the faculty and administration have engaged an unlikely ally: art.
The Learning Resource Center, or LRC, is a hub for medical students who come there to study and attend classes at least three times a week. It sits nestled like a concrete bunker behind a row of pine trees on the UCLA campus, at the intersection of Westwood Plaza and Charles E. Young Drive South. For the past five years, the LRC also has housed an art gallery, sponsored by the medical school’s Center for Educational Development and Research. On a recent visit, a series of large portraits lined the walls of the foyer — bright, colorful, messy mixed-media collages depicting a nude female form missing her right arm from the elbow down. The artist, Damienne Merlina, who lost her arm in an accident 11 years ago, funneled into her art practice the shock of suddenly possessing a radically altered body. One piece replaces her skin with a layer of bricks. On another, hateful insults are scribbled atop her flesh.
New work goes up in the LRC four times a year, coordinated thematically with the medical school’s curriculum. Each show aims to expose students to artwork that has been used as an emotional outlet for patients with conditions that range from cancer to multiple sclerosis to a debilitating phobia of germs. “We’re trying to get medical students to look at their patients and say, ‘This person needs a new heart valve, and maybe that’s the source of her poetry or her painting,’” says Ted Meyer, the LRC’s artist-in-residence and creator of the gallery program. “It’s about seeing the patient as more than an illness.”
Not only do students pass by the artworks on their way to and from class, but each artist also gives a talk about the realities of living with illness and using art as a tool to convey that experience. “We had one artist with cystic fibrosis who came in with his oxygen tank and talked about what it’s like to be waiting for new lungs,” Meyer says. “You could have heard a pin drop.”
For medical students, direct, unhurried interaction with patients is hard to come bfy so early in their training. Neveen El-Farra, MD (RES ’05), interim associate dean for curricular affairs in the David Geffen School of Medicine at UCLA, sees this type of exposure as crucial to shaping truly humanistic physicians. “Students come in and are very fixated on their studies and exams,” Dr. El-Farra says. “Those are important, but one thing we’re working on is an early authentic clinical experience that our students have with patients to better develop a sense of connection and understanding.”
Until clinical rotations begin in the third year, patients often remain an abstraction, a hypothetical battleground of symptoms and interventions scrutinized in the classroom and lab. Third-year medical student Eric Ottey appreciates how the gallery focuses on aspects of the patient experience that easily slip out of the academic conversation. “It’s very different from what we get just being in the science books all the time,” Ottey says. “We are given opportunities to practice our humanity in the first two years — there’s a separate curriculum created to practice that— but art provides a good opportunity to see and think about it in a different way.” In a sense, the gallery deepens and complements these parts of the curriculum, in which students discuss cases as mock practitioners, by giving those stories a real, human face. “We spend a lot of time talking about patient-centered care,” says Margaret Stuber, MD (RES ’82, FEL ’84), assistant dean of student affairs for well-being and career advising. “But having artwork that dramatically illustrates the fear, anxiety, number of pills involved, distortions of the skeleton — it hits them in a different, more emotional way.”
Ted Meyer (top) has curated the Gallery at the LRC. “
IN AN ESSAY ENTITLED “THE EMPATHY EXAMS”, the writer Leslie Jamison reflects on her stint as a medical actor performing illnesses for medical students. She observes: “Empathy isn’t just listening; it’s asking the questions whose answers need to be listened to. … It suggests you enter another person’s pain as you’d enter another country, through immigration and customs, border crossing by way of query.”
Empathy comes from the Greek empatheia — the joining of em (into) and pathos (feeling) — the richer, more penetrating sibling of sumpatheia, sympathy, whose prefix derives from sun (with). The latter implies commiseration — I’m with you — but not necessarily understanding — I’m putting myself into your shoes. It’s a subtle but important distinction. An empathetic doctor understands, for example, that she’s not simply treating a kidney with a disease, but a person with a diseased kidney, a person whose life began long before checking into the hospital and will (ideally) continue long after checking out of the hospital.
Until the latter quarter of the 20th century, this sensitivity to the patient experience was called “good bedside manner.” It rarely was more than a garnish atop the meaty entrée of technical expertise. If a doctor had it, great, but it wasn’t something to be fussed over. That changed in the late 1970s, when Arthur Kleinman, MD, a prominent psychiatrist at Harvard University, proposed his “explanatory model,” a series of eight questions designed for healthcare providers to better understand their patients’ lived experience of illness. At the time, against a backdrop of rapid economic inflation and unexpectedly high Medicare expenditures, the United States was going through a healthcare crisis. Many Americans felt the cost of care was rising and the quality was worsening, even though advances in medical technology should have meant the opposite. Dr. Kleinman’s model aimed to bridge the gap between the medical establishment and its patients, bringing the conversation back to a concrete, mutual understanding of what got people sick, how it made them feel and what they could do to fix it.
LuAnn Wilkerson, EdD, senior associate dean for medical education, sees the current emphasis on humanistic and patient-centered care as a natural extension of Dr. Kleinman’s work. “There’s always been a tension in medicine between technical expertise and your capacity to treat the whole person,” she says. “We had probably tipped the balance.”
In a healthcare environment increasingly enhanced by technological interfaces, from the implementation of electronic medical-record keeping throughout UCLA Health to the fleet of Tug robots that deliver drugs, linens and meals to patients in the UC San Francisco Medical Center at Mission Bay, patients and doctors alike reap the benefit of better, more efficient health outcomes, with one big side effect: They may directly interact much less with each other.
Since the 1980s, studies consistently have measured diminishing face time between doctors and patients, recently finding the average encounter to last a mere seven-to-eight minutes. Technology has, of course, enabled this reduction; perpetual tickertape of electronic data unspools from patients’ bedside monitors across closely watched tablets and screens in nearby nursing stations. Automated alerts raise red flags and remind caregivers when to feed and medicate.
Dr. El-Farra recently attended a presentation given by Abraham Verghese, MD, of Stanford University, in which he quipped that the patient has become the iPatient. “He had this image, from probably the 19th century, of a woman sprawled out on a couch and doctors kneeling by her, doctors looking at her, everyone surrounding her,” Dr. El-Farra recalls. “And then he flips to modern times and shows a picture of five residents all surrounding a computer, and the patient is on the other side of the room!”
To be clear, neither Dr. El-Farra nor Dr. Verghese is a Luddite railing against modern innovation. The evolution of technology in medicine has transformed impossible into routine. The challenge now for healthcare providers is to harness this technological power without sacrificing the opportunity for empathetic connection. The art program at UCLA fortifies its students for the challenge, long before they are beset by the exhausting and time-consuming demands of real-world medical practice.
“Art teaches us how to see the world from another perspective,” Dr. Wilkerson says. “We can wait for that to happen on its own, or we can build in opportunities that will help students understand how it feels to be trapped with an illness.”
THOUGH THERE APPEARS TO BE A CONSENSUS that art should play a role in the medical-school experience, there’s little empirical research on the topic. That might explain why Meyer had such a difficult time pitching his idea for UCLA to host a regular exhibition of patient art. It took about six months of repeated calls to the school before Meyer was able to connect with Dr. Wilkerson. She was not immediately receptive. “My initial thought was, ‘Oh, I’m way too busy,’” she says. “It was actually my assistant’s insight as an artist that made me realize this was an idea worth pursuing — a kind of ‘aha’ moment.”
Meyer’s own experience makes him especially suited to develop such a program; he has been creating art about illness for almost his entire life. As a child, he was diagnosed with Gaucher’s disease, an enzyme deficiency that leads to deterioration of the joints and organs, which had him boomeranging in and out of hospitals, on crutches and in constant pain. Then, in his late 30s, after several successful surgeries and the advent of improved treatments, he felt relatively healthy for the first time. “I started doing work about other people’s illnesses, because I still felt like I had a narrative to tell about illness but nothing left to say about my own,” he says.
His Scarred for Life project documents the experiences of people who have been marked by illness or accident. Meyer applies paint directly to the skin of his subjects — a woman with a scar down the length of her spine, the result of multiple surgeries following a fall from a tree; a man whose stomach is marked where a shunt drained water from his brain as an infant; breast-cancer survivors with mastectomies — and makes a print of the scarred area, to which further details are added in collaboration with the model. “They tend to find me when they’re ready,” Meyer says. “I’m like the Studs Terkel of scarred people. I feel a real responsibility to tell these stories and be very respectful of them.”
For more than 15 years, Ted Meyer has been creating a graphic depiction of people’s suddenly altered bodies and the resulting scars in an ever-enlarging collection of artworks entitled Scarred for Life.
The Scarred for Life project has been exhibited nationally. It works on two levels. For the scarred person, it provides an opportunity to bring a part of his or her body out of hiding, to proudly flout the rule that scars are embarrassing or shameful or best left unmentioned. At the same time, the viewer sees that art can emerge from unlikely places and that a person’s relationship to trauma is more complicated than it often seems. The art program at the LRC draws its water from the same well. Not only does it aim to increase the medical students’ understanding of what it’s like to be a patient, but it also provides a platform for patients to share their experience with the students. Until they find the right doctor, or the right treatment, many people living with chronic illness feel like a hot potato lobbed between specialists and clinics. Meyer’s program allows them to share the frustrations and realities of that journey, which is cathartic on an individual level, while simultaneously sensitizing a new batch of future doctors to the value of slowing things down and really listening to the people they are treating.
OTHER UNIVERSITIES DO INTEGRATE HUMANITIES AND ART into their medical-school programming, though few use it like UCLA to enhance the patient-doctor connection specifically. In most other cases, elective classes in art aim to enrich observational skills, which are commonly thought to be declining as more diagnostic work is taken over by machines. A growing number of institutions — including Yale, Harvard and Weill Cornell — take groups of students on trips to museums to hone their aptitude in pattern recognition, description and looking closely, all crucial tools in the exam room. But, as Dr. Wilkerson points out, this approach could “totally miss the message about feeling.”
The closest analogue to the gallery at UCLA’s LRC is Columbia University’s Program in Narrative Medicine, in which seminars and workshops sift through a broad range of artistic practices — from literature and philosophy to film and dance — to develop the cognitive tools related to understanding, processing and absorbing stories of illness. Though the program at Columbia shares with UCLA the common goal of helping doctors find a way into the patient experience, it widens its lens far beyond the visual arts and offers a diverse roster of open lectures and classes, in addition to a full MS degree in narrative medicine.
The Los Angeles Times wrote about Judi Kaufman and her struggle with brain cancer in January 2015.
Why They Gave
In a January 2015 Los Angeles Times article, philanthropist and author Judi Kaufman talked about what having brain cancer meant in her life. Surprisingly, it was not all bad. “I lost all my inhibitions as a result of the cancer,” she said. Kaufman began to write poetry again, and she believed that her disease had given her a purpose. She and her husband Roy established Art of the Brain to encourage other patients to explore their creativity, to raise money for brain-cancer research and to support the work of Timothy Cloughesy, MD (RES ’91, FEL ’92), in the UCLA Neuro- Oncology Program. Since its inception, Art of the Brain has raised more than $7 million. Judi Kaufman died in September 2015.
With increases in funding and support, the gallery at the LRC could pursue similar growth. “The gallery offers us a perspective into medicine that the medical curriculum cannot — a vision into the minds of the people we will one day serve,” says Aaron Reyes, a first-year medical student. “I would hope the artists’ talks could merge with the medical school’s lectures to emphasize the equal importance of disease process and patient experience.” Meyer, too, is eager to expand. “I always want to be able to do more with it,” he says.
IN 2013, THE ARTIST SUSAN TRACHMAN EXHIBITED at the LRC work that dealt with her multiple sclerosis. She collects and arranges empty bottles of medication and saline solution, creating intricately patterned, highly ordered collages that emerge from her inability to create order and balance, often physically, in life. After giving her talk, she recalls a student approaching her: “She said, ‘I could spend hours and hours studying, but I would never get this kind of an education from a textbook.’”
Ottey echoed this sentiment. “It’s so different from the everyday education we get,” he says. “It’s done sort of as an extra thing now, but if there were more artists, and it was given more of a space, that would be even better.”
Beginning in 2015, the Medical College Admission Test for the first time included questions from the social sciences and humanities, a barometer of the increasing importance placed discipline-wide on holistic capabilities. “People are starting to realize that we can’t extinguish the humanities side of our students,” Dr. Stuber says. “We’re trying to tap into a different part of the way that you think.”
It’s a classic win-win: Medical students get to explore dormant interests apart from their vocational training, and these interests in turn push them to be better doctors. “If I’m going to have a chat with you about the experience of a below-the-knee amputation, it could be technically oriented, or I could bring in a piece of art from a patient to think about how this person will have to change his daily habits,” Dr. Wilkerson says. “You could talk about how it was a successful amputation, how there was no infection, and other technical measures, but the art might be the cause to discuss how we can help the patient move back into life.”
And that, after all, is what the best doctors do.
Micah Hauser writes about art and culture. His articles have been published in the Los Angeles Review of Books, The Bluegrass Situation and The Huffington Post.