Kumagai, Arno K. MD; Wear, Delese PhD
Why art? In light of the increasingly popular use of stories, film, drama, and art in the education of doctors, the rationale for these offerings has been called into question. The goals of activities in these areas have been explored from a variety of theoretical perspectives,1–7 and an important role has been proposed for humanities-related disciplines to enhance empathy, perspective-taking, and openness to different viewpoints, and to prompt reflection on self, others, and the world.2,4 This article investigates another crucial function of the arts in this context: the use of art to “make strange”—that is, to trouble one’s assumptions, perspectives, and ways of being in order to view anew the self, others, and the world. This technique may serve a critical educational function in the development of reflective, humanistic clinicians.
Enstrangement: An Introduction
Although this type of approach has been present in art for centuries (think: Aristophanes’s “Frogs,” Hieronymus Bosch’s Garden of Earthly Delights, Tolstoy’s Kholstomer, or Dalí’s Persistence of Memory), the theoretical concept of defamiliarization in literature was first articulated in the 1920s by the Russian formalist critic Viktor Shklovsky,8 who described its use in the structure of narrative. According to Shklovsky, all human perception involves an inevitable habituation to familiar objects, people, and places. Gradually, that which is familiar “fades away” and becomes inaccessible to consciousness. Perception becomes automatic:
If we examine the general laws of perception, we see that as it becomes habitual it also becomes automatic. So eventually, all of our skills and experiences function unconsciously—automatically.… And so, held accountable for nothing, life fades into nothingness. Automatization eats away at things, at clothes, at furniture, at our wives and at our fear of war.8(p5)
Thus, according to Shklovsky, a major function of literature—and of art in general—is to force us to look at the familiar with new eyes through a process that he calls “enstrangement” (ostranenie):
In order to return sensation to our limbs, in order to make us feel objects, to make a stone feel stony, man has been given the tool of art. The purpose of art, then, is to lead us to a knowledge of a thing through the organ of sight instead of through recognition. By “enstranging” objects and complicating form, the device of art makes perception long and “laborious.”8(p6)
Through this disruption of automatic recognition, art forces its viewers to look on the familiar in new ways—ways from which new ways of seeing, thinking, and being arise.
Influenced by Shklovsky, the German playwright Bertolt Brecht9 further elaborated the notion of enstrangement in his theories of epic theater and gave it a decidedly sociopolitical turn. According to Brecht, it is not perception per se that dulls our ability to see the world as it is. Instead, it is the societal superstructures and disparities in power—all rooted in a specific social order and stage in history—that make injustices and inequalities appear to be part of the natural state of affairs. According to Brecht, modern theater is a theater of philosophy, of contemporary ideas: Its themes are not eternal but are rooted in history and societal contexts, and theater is meant to question and challenge existing power relationships.10,11 Following closely in the footsteps of Shklovsky, Brecht maintains that a critical function of the modern theater and art in general is to distance the spectator from the actors and drama, a phenomenon that Brecht calls “alienation” or the “A-effect”:
The artist’s object is to appear strange and even surprising to the audience. He achieves this by looking strangely at himself and his work. As a result everything put forward by him has a touch of the amazing. Everyday things are thereby raised above the level of the obvious and automatic.12(p91)
In an explicit challenge to the Aristotelian concept of dramatic theater, Brecht maintains that the aim of modern theater is not to stimulate identification and empathy between the audience and characters, nor to aid in the cathartic release of the audience’s emotions through this connection. Instead, the audience should be astonished at the circumstances under which the characters develop and the story occurs.13 This attitude, according to Brecht, leads to the adoption of a critical gaze and questioning of all that is considered “natural.”
And yet there is already an attempt here to interfere with the course of nature; the capacity to do so leads to questioning; and the future explorer, with his anxiety to make nature’s course intelligible, controllable and down-to-earth, will always start by adopting a standpoint from which it seems mysterious, incomprehensible and beyond control. He will take up the attitude of someone wondering, will apply the A-effect.12(p96)
The point in all of this artistic effort, according to Brecht, isn’t a disinterested dissection of societal structures, but is a stimulus towards action for social change. In a spin on early Marx,14 Brecht proposes,
The theatre became an affair of philosophers, but only for such philosophers as wished not just to explain the world but also to change it.15
Uses of Enstrangement: Applications in Medical Education
We and others have argued that medical education in areas of social and societal relevance, such as medical ethics, professionalism, the doctor–patient relationship, diversity, global health, and social justice, should not be reduced to static, overly simplified competencies but should aspire to fostering a critical consciousness, an orientation toward a critically reflective understanding of oneself, others, and the world, as well as a commitment to identify and address issues of inequity and injustice in health care.16–22
An integral part of this orientation is the critical questioning of taken-for-granted assumptions, unconscious biases, and unquestioned attitudes that may distort and dehumanize relationships and interactions in medical care. To stimulate this type of critical questioning, we have used literature, movies,23 art,5 and interactive theater24 to engage students and faculty in reflective exploration and discussions and have made use of a key pedagogical tool, that of provoking a state of cognitive disequilibrium—that is, the sense of discomfort one may feel when encountering a person, an experience, or a perspective which is unfamiliar.17,24,25 Through this state of disquiet and discomfort, one is prompted to reflect on personal values, beliefs, perspectives, and life experiences in an attempt to incorporate this new entity into one’s understanding, and in doing so, reflection broadens and enriches one’s worldview. It is a concept that finds resonance in Dewey’s principle of the “forked road,”26 in Schön’s “reflection-in-action,”27 in Habermas’s “hypothesizing attitude,”28 in Freire’s “reading the world,”29 or in Mezirow’s “disorienting dilemmas.”30 All have in common a state of discomfort in which confrontation with the unknown prompts reflection and action. This state may be achieved through the posing of provocative questions, paradoxes, contrasts, and contradictions17; and through dialogue, one may arrive at new ways of seeing and understanding. This goal of critical reflection may also be achieved through the use of literature and art to “make strange”—that is, to trouble one’s vision and assumptions by making “natural” relationships appear unusual or even bizarre and by forcing one to look on them anew.
So, how does one “make strange” in ways that foster critical consciousness in physicians-in-training? Some examples.
Enstrangement in Literature and Criticism
Dagoberto Gilb’s31 short story “please, thank you” is an internal monologue by a middle-aged Mexican American man who is recovering from a stroke. Through an unpunctuated, stream-of-consciousness narrative, he describes the ward where he is hospitalized and the staff who interact with him in ways that bring out differences in race, class, and power and critique the order of things. At one point, he struggles to understand why the staff keep asking him the same questions over and over, which appears to be done as part of a mental status exam:
if i tried to say something, they started asking the same questions. what is your name? what is the date? Where were you born? like that. or sometimes, como te llamas? que es la fecha de hoy? like im from mexico and just crossed, not american like them. im from here! ill bet my familys been here longer than yours! i was semper fi, cabron, and then i was an ironworker for ten years, were you? always, always has made me so mad, even if i dont say it out loud to these people here.31
The character’s observations and insights are disjointed and fragmented and drift in and out of the main narrative as they would drift in and out of consciousness. By disturbing the narrative in this way, Gilb allows a glimpse into the disrupted perception of someone in the poststroke period. He takes something like a mental status exam and turns it on its head in order to comment on issues of race, class, and privilege in the context of health care.
In “Think about pink,” the essayist Peggy Orenstein32 offers a view of the industry surrounding the “pink movement” of breast cancer awareness, one that presses readers to examine ubiquitous tropes that turn serious discussion and social activism into the language of “ta-ta’s” and “boobies.” She is startling in her critique; she takes on what most would view as compassionate public health activism promoting awareness on all fronts for the young and old, for both men and women, for “survivors” and supporters, for big donors and buyers of bracelets and T-shirts. Her language is strong and disturbing. She problematizes why anyone would support some of the retail campaigns that claim to support the “cause”:
There is Save the Ta-Ta’s (a line that includes T-shirts and a liquid soap called Boob Lube), Save Second Base, Project Boobies (the slogan on its T-shirts promoting self-exam reads, “I grab a feel so cancer can’t steal”…). And there is “I ♡ Boobies” itself, manufactured by an organization called Keep a Breast.…32
Her essay is sarcastic (“I hate to be a buzz kill”), ironic (“Hot breast cancer. Saucy breast cancer. Titillating breast cancer!”), and accusatory (“Going pink made [corporations] a lot of green”). She disrupts the taken-for-granted and alienates the effort to find lessons in suffering; she asks readers to look where they previously had not for motives and assumptions underlying the various campaign narratives:
A funny thing happened on the way to destigmatization. The experience of actual women with cancer … —women like me—got lost. Rather than truly breaking silences, acceptable narratives of coping emerged, each tied up with a pretty pink bow. There were the pink teddy bears that, as Barbara Ehrenreich observed, infantilized patients in a reassuringly feminine fashion. “Men diagnosed with prostate cancer do not receive gifts of Matchbox cars,” she wrote in her book Bright Sided.32
The idea of an “acceptable” breast cancer narrative cannot be examined without recognition of one of the most critically acclaimed breast cancer narratives, Audre Lorde’s33 Cancer Journals. Her critical read of prosthesis and reconstructive surgery turns a taken-for-granted “fix” on its head by arguing that the “emphasis upon the cosmetic after surgery reinforces this society’s stereotype of women, that we are only what we look or appear, so this is the only aspect of our existence we need to address.”33(p58) Literary scholar and queer theorist Eve Sedgwick34(p69) similarly wrote about sitting angrily through a breast cancer support group and being told that “with proper toning exercise, makeup, wigs, and a well-fitting prosthesis, we could feel just as feminine as we ever had and no one (i.e., no man) need ever know that anything had happened.” Thus, “save the ta-ta’s” continues the same line of unexamined thinking a decade later, resulting in what Judith Segal35 calls a “cultural production of ignorance” of breast cancer narratives that depart from the marketed heroic—and, above all, triumphant—battles against cancer. It is precisely this type of thinking that may be “made strange” and called into question through engagement with these texts.
In one of the most brilliant literary examples of “making strange,” Franz Kafka’s36 Metamorphosis begins with the protagonist Gregor Samsa’s realization upon waking that he had been turned into a gigantic cockroach. Written in 1912, the novella is often interpreted as Kafka’s portrayal of his alienation as a German-speaker in Czech-speaking Prague and as a Jew living during a period of profound anti-Semitism. Yet the story may be read and discussed as an extraordinary illumination of an individual’s feelings of isolation and alienation in illness, and the dehumanizing practices he routinely experiences because of his helplessness. All vestiges of a “normal life”—getting in and out of bed, going to work, interacting with family, eating—are now viewed through the eyes of a cockroach unable to do any of these, watching those he loves watch him with disgust. His sickroom/bedroom—now home to a bug—becomes cave-like when his family pulls out most of his furniture, letting him forget his past “when he had still been human.” Their disgust is profound, and he knows it, covering himself with a sheet so his caretaker sister will not be forced to look at him. Read as an allegory of humanness lost in a helpless or ill body, the story reminds us of “the illusive truth of illness.”37
Enstrangement in Video and Film
From the sheer weirdness of Wiene’s Cabinet of Dr. Caligari (1920) or works by Jean-Luc Godard, film has been used to effectively “warp” perspective and challenge conventions. Akira Kurosawa’s masterpiece Rashomon (1950), which uses the retelling of a murder mystery from multiple views to explore the unstable, mutable nature of perception, can be used to explore the “slipperiness” of testimony—either during a criminal proceeding or medical interview. Another example of this alienating technique is In My Language, a short film created by Amanda Baggs,38 a woman with severe autism. The first half shows Baggs engaged in repetitive movements—humming, rocking, scraping, clinking—without narration. The movements and actions—rubbing her face with a magazine, rapping on a door handle, playing with a slinky—are unintelligible and bizarre and appear to reinforce a common impression of the closed-off, impenetrable world of autism. In the second half of the film, however, similar, seemingly disjointed acts are accompanied by Baggs’s own commentary, which she achieves through a computer program’s voice synthesizer. Although also somewhat alien, Baggs’s disembodied voice connects the series of seemingly random motions into a more intelligible whole and emphasizes her main point: that contrary to common belief, individuals with autism are not locked within the confines of the self but interact with the world around them in a complete and holistic manner, using all of their senses and the movement of their bodies through space to communicate in their own language.
One of us (A.K.K.) has used the Amanda Baggs video in small-group discussions on disabilities. Small-group instructors are asked to show the first half of the video and then facilitate a discussion about the students’ emotional reactions to Baggs’s seemingly random behaviors. The second half of the video is shown, and the students are asked to reflect on and discuss questions, such as “What surprises you about Amanda Baggs and her ability to communicate?” “Baggs refers to her narration as a ‘translation.’ What is meant by that?” “In this sense, whose ability to comprehend is ‘impaired’?” and “What does Baggs mean to ‘say’ about privilege, disability, and language?”
In My Language may be seen as a counterexample (seemingly chaotic, nonsensical behaviors are “familiarized” through a demonstration of their underlying meaning); however, the video is also and significantly meant to disturb commonplace assumptions (and biases) regarding autism and to force reflection and reconsideration. Like Dagoberto Gilb’s short story, estrangement here serves the function of breaking apart conventional views about individuals with disabilities, such as autism, and allows a glimpse at alternate ways of seeing and being in the world.
Enstrangement in the Visual Arts
Painting and sculpture may also serve to trouble one’s vision and understanding of the world. Modern art is particularly noteworthy in this regard, and in fact, one might argue that the whole of modern (and especially postmodern) aesthetics is designed to disrupt and subvert assumptions about art, human beings, nature, and life. For example, Francis Bacon’s Study After Velásquez’s Portrait of Pope Innocent X (a.k.a., “the Screaming Pope”), Egon Schiele’s distorted, haunted nudes, the manic celestial swirls in Vincent Van Gogh’s Starry Night, or Giorgio de Chirico’s desolate architectural landscapes embody this type of enstrangement. They leave the viewer with a pronounced sense of discomfort about things—a famous painting, a naked body, a quiet evening, or a city street—that may otherwise be swallowed up in the habituating perceptions of “everydayness.”
Two particular examples may apply directly to illness and doctoring. Francis Bacon’s Figure With Meat (1954) shows the blurred portrait of a man (taken from his Study After Velásquez) sitting dwarfed between two raw, bloody, hanging sides of beef. The meat is eerily anatomical and calls to mind the stringy tendons and oozing muscle—the depersonalized “meat”—of the gross anatomy lab or the operating table; the man in the portrait is skeletal and screaming and radiates dementia and loss of control. Frida Kahlo’s Broken Column (1944) is a searing self-depiction of the artist’s struggles with chronic disability and pain after serious injury in a bus accident at age 18. It shows Kahlo’s torso flayed open to reveal a cracked and crumbling marble column on which her head is precariously perched; her open chest in turn is barely held together by constrictive bands. In a modern version of St. Sebastian’s martyrdom, Kahlo’s body is pierced by dozens of nails in a bristling sign of vulnerability and agony. Although the latter clearly elicits perspective-taking, it does not evoke empathy; instead, one has a sense of shock, even revulsion. Both works call into question assumptions about human bodies that are placed under the invasive hands of healers and of the nature of lifelong, unending suffering and pain. Comfort is disrupted, and a troubling awareness is achieved. Used in an educational context and prompted by provocative questions (e.g., “Why does this painting make you feel so uncomfortable?” “What does Kahlo mean by her flayed-open chest?”), these works may be used to spark reflection, dialogue, and exploration of identity, suffering, objectification, and power in the context of health and illness.
One of us (D.W.) has used modern paintings, and in particular, the Impressionist works of Claude Monet, the cubist paintings of Marcel Duchamp, Georges Braque, and Pablo Picasso, and the abstract expressionist, “all over compositions” of Jackson Pollock to introduce enstrangement to students’ perceptions. Through study of these artworks, learners may explore themes of shifting, multiple perspectives; differing views of reality; concepts of flux and change in characteristics and identities; and seemingly chaotic combinations of fragments of identity to form a life with illness.6
In the practice of medicine, one often falls into patterns of thinking and acting—practices of gathering data, performing diagnostic reasoning, creating and implementing treatment plans and approaches to teaching—patterns that may increase one’s efficiency and effectiveness as a clinician and educator. However, in areas of social relevance in medicine—for instance, interactions between doctors and patients, issues of professionalism and ethics, diversity, disparities, and social justice—the automaticity of these very patterns of thinking and acting may undermine one’s ability to provide truly patient-centered, humanistic clinical care. One assumes things and quickly draws conclusions; in the view of Shklovsky,8(p6) instead of one’s knowledge being guided by sight, it is given by recognition. Whether this habituation is due to the inevitable march of perception towards automaticity (Shklovsky8) or to the overwhelming power of social forces in creating stigma, prejudice, and oppression (Brecht15), this type of automatic perceiving and thinking threatens to reduce patients to things: the 42-year-old obese diabetic, the noncompliant 48-year-old female with invasive breast cancer, the 27-year-old African American woman with sickle cell disease. Although efficient, this practice of putting individuals into demographic categories or “risk profiles” threatens to deprive them of all individuality and the capacity for uniqueness and change.
Enstrangement fights against this trend. By making perception “laborious,”8 it disrupts automaticity and hinders cognitive leaps to preconceived conclusions. It forces us back to our original impressions and renews our critical gaze and sense of inquiry. It frees us from, in Heidegger’s39(p30) words, “the preconceptions [that] shackle reflection.” It prompts us to ask “why,” not only about another individual’s motivations but also about our own assumptions. It provokes us to ask in whose interest it is to call a patient “noncompliant” or “difficult.” In all, this disruption causes a momentary pause between thought and action—a pause that is an essential component of mindful, reflective practice.27,40 The type of questioning that results is one of critical inquiry—what Freire refers to as “reading the world”29—in which one questions the notion of inequity or injustice as “the state of things as they are” and initiates a search for solutions, for action.
Broadening the scope of this inquiry, one can also argue that the application of enstrangement in medical education can reach beyond socially relevant aspects of medicine and into the heart of clinical practice itself. Although physicians often rely on evidence-driven protocols and heuristic reasoning, an essential part of expertise when confronting a dilemma is to shift from more “automatic thinking” to a critical questioning of approaches, evidence, and interpretations27—that is, to “make strange” one’s usual assumptions in practice. In clinical teaching and practice, this may be accomplished in much the same manner as the classical Socratic method of questioning the supposedly obvious. On rounds or in conferences, one may question terms like “noncompliant” or “difficult patient,” or phrases such as “nothing more can be done,” thereby leading to new insights and answers.
And yet, the ability of the arts to “make strange” does something else in addition to prompting critical inquiry and action. By forcing us to reconsider familiar ideas, situations, and relationships in new and different ways, this process of alienation and enstrangement frees thought and reflection to pursue entirely new avenues of questioning and discovery. It stimulates us to fully appreciate the wonder and mystery that lie at the core of human interactions during times of struggle. In the presence of birth and death, tragedy and loss, suffering and resilience, one may glimpse at what makes us fully human. Heidegger39(p70) claims that the nature of art is the revealing of truth (aletheia), which he defines as the “unconcealedness of Being,” that is, an “open place” in which we see things for what they really are:
The nature of art, on which both the artwork and the artist depend, is the setting-itself-into-work of truth. It is due to art’s poetic nature that, in the midst of what is, art breaks open an open place, in whose openness everything is other than usual.
Enstrangement through art allows the medical student or physician to reexamine relationships in health care as interactions between individuals qua human beings—in all their individuality, fallibility, and strength.41 This ability of art to provide health care professionals an “open space” to explore, bear witness, and engage with other individuals who are in the midst of becoming is perhaps art’s greatest gift of all.
Acknowledgments: The authors would like to acknowledge Drs. Rebecca Garden, Joseph Zarconi, Eric P. Skye, and Preeti Malani for many enlightening discussions. Dr. Kumagai would also like to acknowledge the volunteers, students, staff, and faculty of the Family Centered Experience Program for their commitment to teaching and learning.
1. Wear D. The Medical Humanities at the Northeastern Ohio Universities College of Medicine: Historical, theoretical, and curricular perspectives. Acad Med. 2003;78:997–1000
2. Kumagai AK. A conceptual framework for the use of illness narratives in medical education. Acad Med. 2008;83:653–658
3. Kohn M. Performing medicine: The role of theatre in medical education. Med Humanit. 2011;37:3–4
4. Charon R. Reading, writing, and doctoring: Literature and medicine. Am J Med Sci. 2000;319:285–291
5. Kumagai AK. Perspective: Acts of interpretation: A philosophical approach to using creative arts in medical education. Acad Med. 2012;87:1138–1144
6. Wear D. Painters and patients: How art informs medicine. Fam Med. 1991;23:531–533
7. Garden R. Telling stories about illness and disability: The limits and lessons of narrative. Perspect Biol Med. 2010;53:121–135
8. Shklovsky VSher B. Theory of Prose. 1991 Elmwood Park, Ill Dalkey Archive Press
9. Brecht BWillett J. Brecht on Theatre: The Development of an Aesthetic. 1964 New York, NY Hill and Wang Methuen
10. Brecht BWillett J. The modern theatre is the epic theatre. Brecht on Theatre: The Development of an Aesthetic. 1964 New York, NY Hill and Wang Methuen:33–42
11. Jameson F Brecht and Method. 1998 London, UK Verso
12. Brecht BWillett J. Alienation effects in Chinese acting. Brecht on Theatre: The Development of an Aesthetic. 1964 New York, NY Hill and Wang Methuen:91–99
13. Benjamin WArendt H, Zohn H. What is epic theater? Illuminations. 1969 New York, NY Schocken Books:147–154
14. Marx KTucker RC. Thesis on Feuerbach XI. The Marx–Engels Reader. 1972 New York, NY Norton:145
15. Brecht BWillett J. Theatre for pleasure or theatre for instruction. Brecht on Theatre: The Development of an Aesthetic. 1964 New York, NY Hill and Wang Methuen:69–77
16. Wear D. Insurgent multiculturalism: Rethinking how and why we teach culture in medical education. Acad Med. 2003;78:549–554
17. Kumagai AK, Lypson ML. Beyond cultural competence: Critical consciousness, social justice, and multicultural education. Acad Med. 2009;84:782–787
18. Bleakley A, Brice J, Bligh J. Thinking the post-colonial in medical education. Med Educ. 2008;42:266–270
19. Wear D, Kumagai AK, Varley J, Zarconi J. Cultural competency 2.0: Exploring the concept of “difference” in engagement with the other. Acad Med. 2012;87:752–758
20. Wear D, Zarconi J. The treachery of images: How René Magritte informs medical education. J Gen Intern Med. 2011;26:437–439
21. Dogra N, Giordano J, France N. Cultural diversity teaching and issues of uncertainty: The findings of a qualitative study. BMC Med Educ. 2007;7:8
22. Wear D, Zarconi J, Dhillon N. Teaching fearlessness: A manifesto. Educ Health (Abingdon). 2011;24:668
23. Ross PT, Kumagai AK, Joiner TA, Lypson ML. Using film in multicultural and social justice faculty development: Scenes from Crash. J Contin Educ Health Prof. 2011;31:188–195
24. Kumagai AK, White CB, Ross PT, Purkiss JA, O’Neal CM, Steiger JA. Use of interactive theater for faculty development in multicultural medical education. Med Teach. 2007;29:335–340
25. Piaget JBrown T, Thampy KJ The Equilibration of Cognitive Structures: The Central Problem of Intellectual Development. 1985 Chicago, Ill University of Chicago Press
26. Dewey J How We Think. 2005 New York, NY Barnes & Noble
27. Schön DA The Reflective Practitioner: How Professionals Think in Action. 1983 New York, NY Basic Books
28. Habermas JCronin C Moral Consciousness and Communicative Action. 1990 Cambridge, Mass MIT Press
29. Freire PRamos MB Pedagogy of the Oppressed. 199320th anniv ed New York, NY Continuum
30. Mezirow J Transformative Dimensions of Adult Learning. 1991 San Francisco, Calif Jossey-Bass
31. Gilb D. please, thank you. Harpers. 2010:65–70
33. Lorde A The Cancer Journals. 1980 San Francisco, Calif Spinsters
34. Sedgwick EKRaz H. White glasses. Living on the Margins: Women Writers on Breast Cancer. 1999 New York, NY Persea Books:57–75
35. Segal JZ. Breast cancer narratives as public rhetoric: Genre itself and the maintenance of ignorance. Linguist Hum Sci. 2007;3:3
36. Kafka F The Metamorphosis. 1972 New York, NY Bantam Books
37. Morris DB Illness and Culture in the Postmodern Age. 1998 Berkeley, Calif University of California Press
39. Heidegger MHofstader A. The origins of the work of art. Poetry, Language, Thought. 1971 New York, NY Harper & Row:17–86
40. Epstein RM. Mindful practice. JAMA. 1999;282:833–839
41. Kumagai AK. On the way to reflection: A conversation on a country path. Perspect Biol Med. 2013;56:362–370