Literature and Medicine: Contributions to Clinical Practice

Sick persons rely on their physicians for skilled diagnosis, effective therapy, and human recognition of their suffering. Although medicine has made dazzling progress in achieving the first two of these goals, its capacity to fulfill the third goal seems to have diminished [1, 2]. Medicine has incorporated the knowledge and methods of scientific disciplines such as molecular biology, human genetics, and bioengineering to achieve progress in diagnosis and therapy. Physicians are now beginning to turn to the humanities, to disciplines such as literary studies, to achieve equally essential progress in comprehending their patients' suffering so that they can accompany patients through illnesses with empathy, respect, and effective care [3-5]. Until the initiation of progressive educational reforms in the 1960s, medical schools expected their students to become empathic and attentive clinicians by watching skilled physicians at work. Students were supposed to absorb the human competencies of doctoringwhat many call the art of medicineduring training [6, 7]. But just as physicians can no longer learn the scientific bases of practice in apprenticeship programs, they can no longer learn the human bases of practice without explicit and ongoing training. Such training is not meant to recapture some long-lost proficiency in compassionate doctoring from generations ago but to extend the accomplishments of the past using knowledge that was unavailable to physicians in former times. Along with other disciplines in the humanities and along with the social and behavioral sciences, literature and literary studies contribute to this educational effort. The relation between literature and science has fueled impassioned debate since the Victorian era. Matthew Arnold defended literaturehe called it criticism of lifewhen Thomas Huxley proposed to replace humane letters with natural sciences in general education [8]. C.P. Snow's 1959 suggestion that the scientific and the literary cultures were irreparably estranged and that the future belonged to the scientists elicited profound disagreement from scientists and literary scholars alike [9-11]. This historical conversation continues today in U.S. medical schools, in many of which, since 1972, literature has joined science in the curriculum. Using literary methods and texts, literary scholars have been teaching medical students and physicians how to listen more fully to patients' narratives of illness and how to better comprehend illness and treatment from patients' points of view [12-14]. These skills help physicians to interview patients, to establish therapeutic alliances with patients and their families, to arrive at accurate diagnoses, and to choose and work toward appropriate clinical goals. The most quickly growing area of the medical humanities, the field of literature and medicine is a recognized subdiscipline of literary studies that has its own scholarly journals, professional societies, graduate school programs, federally funded training programs, and research agendas [15-17]. In 1994, approximately one third of U.S. medical schools taught literature to their students, according to our informal surveys of members of the Society for Health and Human Values, and the number is growing quickly. Medical students in the preclinical and clinical years, house officers, and practicing physicians participate in literature courses and writing workshops. Usually co-taught by literary scholars and physicians, such courses can be either required or elective elements of the curriculum. Physicians have joined literary scholars in writing about the connections between literature and medicine and the benefits that literature provides to the physician; this confirms the clinical relevance of such teaching and scholarship [18-20]. The study of literature contributes in several ways to achievement in the human dimensions of medicine: 1) Literary accounts of illness can teach physicians concrete and powerful lessons about the lives of sick people; 2) great works of fiction about medicine enable physicians to recognize the power and the implications of what they do; 3) through narrative knowledge, the physician can better understand patients' stories of sickness, thereby strengthening diagnostic accuracy and therapeutic effectiveness while deepening an understanding of his or her own personal stake in medical practice; 4) literary study contributes to physicians' expertise in narrative ethics and helps physicians to perform longitudinal acts of ethical discernment; and 5) literary theory offers new perspectives on the work and the genres of medicine. Although our discussion of literature's contributions to medicine focuses on works of fiction, genres such as poetry, drama, and film are equally valuable to the physician and the medical educator. The Patient's Life What do sick people worry about? How do they live their lives around their diseases? What sense can they make of the random events of illness? How can their physicians help them to find meaning in their experiences of illness and thereby facilitate participation in treatment or acceptance of the inevitability of death? The asking and answering of such questions should permeate all aspects of diagnosis and treatment, yet medical training does not generally confer on physicians the skills that make this possible. One rich source of knowledge about the human experience of illness is literature. Illuminating patients' experiences in the full, rich, nuanced particularity seldom if ever available elsewhere, literary accounts of illness widen physician-readers' knowledge of the concrete realities of being sick and enable these readers to appreciate their own patients' stories of sickness. By mobilizing the imagination, literary works engage the reader more fully than do clinical, sociologic, or historical descriptions, even when the same experiences are portrayed [21]. Although physicians witness countless actual people wrestling with illness, few can articulate, as could William Shakespeare or John Donne or Henry James, the universal and complex human sequelae of disease. By reading narratives of illness written by gifted writers, physicians can more precisely fathom the fears and losses of patients with serious illnesses, identifying in fictional characters and then in their own patients the inevitable conflicts and uncertainties that sickness brings. Narrative accounts of patients' experiences of illness are regularly considered in medical school courses and in professional reflections on the patientphysician relationship, aging, death and dying, disability, and women's health [22-26]. Examples of such writings vary in period and in genre. Dante's epic journey in The Inferno parallels the journey of illness; Virgil, his guide, stands for the patient's physician [27]. Leo Tolstoy's The Death of Ivan Ilych brings the reader to the bedside of a middle-aged bureaucrat who is dying of cancer and who articulates, without flinching, the regrets of a selfish life and the fears of a lonely death [28-32]. Tillie Olsen's Tell Me a Riddle represents the living and dying of EvaRussian-Jewish immigrant, revolutionary, mother, grandmother, and patient with cancer whose diagnosis is withheld from heramid the deceptive gambits and the caring acts of her family [29, 30, 33]. Henry James's aging protagonist Dencombe in The Middle Years reviews his waning life, seeking from his physician the chance for another go but receiving instead a deep and healing confirmation of his worth [34, 35]. Franz Kafka's Gregor Samsa awakens as an insect in The Metamorphosis; this is an allegory of the many-leveled transformations of illness for patients and their families and clinicians [36, 37]. In his madness, the protagonist of King Lear finds the clarity of vision and value that many dying persons and their families crave [38, 39]. Besides works of fiction and imagination, pathographiesthe narratives that patients write about their illnessesoffer case histories of illness and treatment from the patients' points of view [2, 40, 41]. Both biographical and fictional writings by members of particular cultural or ethnic groups help physicians by situating illness within specific cultural and spiritual understandings of the body [42, 43]. Reading these and other accounts of illness and death deepens the physician-reader's grasp of human need. In a time when physicians and patients are often strangers from different religious traditions and cultural backgrounds, physicians cannot rely on what they know of illness from their personal lives. Literature can supply full-bodied and profound accounts of illness and death in all places and among all peoples. Great works of literature may be unsurpassed in their ability to teach about suffering, death, and the human condition. The Physician's Work Literary representations of the physician's work, written by nonphysicians as well as physicians, clarify the many roles and expectations of medicine and thereby help readers to understand not only the responsibilities of physicians and the position of medicine within a culture but also the social crises to which physicians must respond. Such novels as Middlemarch by George Eliot, The Magic Mountain by Thomas Mann, and The Plague by Albert Camus delve into the personal, professional, and political worlds of physicians and explicitly acknowledge the nonclinical implications of the physician's work [44-46]. Because the creative writer is often at the forefront of a culture's awareness, literature often heralds the understanding of new crises in medicine such as the acquired immunodeficiency syndrome or the threat of nuclear war [47, 48]. Physician-writers such as Anton Chekhov, William Carlos Williams, Walker Percy, Richard Selzer, and Oliver Sacks write with great insight about medicine. Chekhov's Ward Number Six describes the inner conflicts of Dr. Ragin, simultaneously the paralyzed idealist a