On Christmas morning 1877, Sir Luke Fildes's eldest son, Philip, died. The child was attended by Dr. Murray, who directed all his skill and attention toward the patient. The devotion of the doctor impressed Fildes, and when Fildes was commissioned 10 years later by Sir Henry Tate for a painting of the artist's choice, he decided to paint a family physician holding a vigil by the bed of a seriously ill child.
The resulting painting, The Doctor, depicts a family doctor during a home visit in 19th-century England. The doctor, the focus of the painting, concentrates his full attention on the child. The doctor seems to be focusing the light coming from the top left-hand corner (perhaps indicating the presence of God) onto the sick child. The parents in the rear of the painting are in shadow, and the father places a comforting hand on his wife's shoulder. The mother seems to be crying or perhaps praying.
In Nepal there has been rapid progress in the field of medical education, and in the last 15 years many new medical schools have opened there, especially in the private sector. Most doctors are concentrated in urban areas or emigrate, and there is a shortage of medical personnel in rural areas. The role of the doctor has lost respect under these circumstances, and there have even been reports of violence toward and manhandling of doctors. In response to the declining reputation of physicians, KIST Medical College uses a medical humanities module to engender humanistic values and behaviors in each entering class of 100 medical students. The module, titled Sparshanam (touch in Sanskrit), uses case scenarios, role-plays, paintings, and activities to explore the humanities.
We have used the painting The Doctor in the medical humanities module to explore the decreasing status of the doctor in modern society. The 20th century was one of great technological advances in medicine. Diagnostic and treatment modalities improved. In contrast, the 19th-century doctor had very little to offer to cure various diseases. He could often offer only support and a shoulder to lean on. The good family physician was considered a member of the family, coming to know the family intimately through good times and bad. He was accessible day and night and was totally devoted to the care of his patients. In contrast, the 20th and the 21st centuries have been an era of specialization and depersonalized medicine. It is now far less common for doctors to have a close relationship with patients. The daily pressures of practice may mean that doctors are not able to devote sufficient time to their patients, and patients may become dissatisfied and confused. Doctors are often sued in developed nations and are the victims of violence in developing ones. This painting brings to light the changing nature of the doctor–patient relationship and allows us to reflect on what may have gone wrong.
From a modern perspective, we notice that there is very little technology in the painting. The doctor sits leaning toward the patient, giving him his full attention. This underscores the fact that the science of medicine and technology has dominated medical thought recently. In fact, medical humanities emerged in the West to offer the contrasting perspective of the arts and the humanities and the importance of communication and the doctor–patient relationship. In our humanities module we focus on areas like empathy, what it means to be sick in Nepal, the role of the doctor, the experience of the patient, and the doctor–patient relationship. We use artwork to encourage reflection on these topics, instructing students to “discuss what you see and what you feel and create a story of 100 words about the painting.”
This painting shows the doctor in a positive light as an ally in the fight against disease and suffering. The Doctor can serve as a positive role model for medical students and as a beacon of light in our troubled times. Our students have stated that the painting makes them proud to be doctors. In Nepal there is an increasing trend toward specialization and superspecialization. Medical care is becoming sophisticated, expensive, and unaffordable. In a stark dichotomy that is becoming more common worldwide, the urban elite and rich rural families have access to the best modern medicine has to offer, while the urban poor and rural majority are excluded from modern medicine. In many areas in South Asia, the family doctor is becoming sidelined as people go directly to specialists for medical care, even though specialist care is more expensive and may not be needed in many cases. Sir Luke Fildes's painting can serve to introduce students to the evolution and changes in the doctor–patient relationship, the role of technology in medicine, specialization in medicine, and increasing cost of medical care. It also can be used to explore emotions and feelings about these changes.
P. Ravi Shankar, MD, and Huw Morgan, MB, ChB
Dr. Shankar is professor, Department of Medical Education, and MBBS phase I program coordinator, KIST Medical College, Kathmandu, Nepal; e-mail: [email protected]
Dr. Morgan is director, Postgraduate Training Programme for General Practice, Bristol, United Kingdom.