In lived experience we grasp the self, neither in the form of its full course nor in the depths of what it encompasses, for the scope of conscious life rises like a small island from inaccessible depths. But an expression can tap these very depths. It is creative. Thus, in understanding, life itself can become accessible through the re-creation of creation.
—Wilhelm Dilthey, 19101(p241)
The fact that through a work of art a truth is experienced that we cannot attain in any other way constitutes the philosophical importance of art, which asserts itself against all attempts to rationalize it away.
—Hans-Georg Gadamer, 19752(pxxi)
The use of the arts has become increasingly popular in medical education. In a 2002 survey conducted by Rodenhauser and coworkers3 of U.S. medical schools, over half of the respondents reported using the arts—including the visual arts (painting, sculpture), film, literature, theater, music, and dance—in some type of learning activity. The objectives for including art have varied greatly, and activities have involved both the viewing and the creation of art by students as well as faculty. Medical educators have used paintings by recognized artists to help medical students sharpen their skills in observation and description4–7 and to foster their critical thinking and communication skills.8 The visual arts have also been a means for students both to explore the human dimensions of illness, suffering, and death9,10 and to delve into what being a physician means.9,11,12 Students have learned body painting to better understand spatial relationships in human anatomy13; housestaff have created artwork as a means of providing self-care as they cope with grieving14 and as a stimulus for reflecting on the experience of illness.9,15,16
In this article, I will extend and reformulate earlier discussions on the use of narrative17–21 and the use of art in medical education15 to explore how the creation of art by medical students may elucidate the acts of interpretation that occur in human relationships—including those between doctors and patients—and how the creative arts may embody the types of tacit learning and understanding that students gain through human interactions in medicine.
The Family Centered Experience
The major educational context for the use of the creative arts at the University of Michigan Medical School has been the Family Centered Experience (FCE),18,19 a required course in which first- and second-year medical students are matched with volunteers in the community who have one or more serious or chronic illnesses. Over the course of two years, pairs of students visit the homes of patient–volunteers (or simply “volunteers”) for a series of conversations about their experiences with illness and health care. Throughout this time, students also meet in small groups for discussions and activities aimed at exploring the perceptions, understandings, and insights that arise from these conversations. The overall aim of the FCE is to use the power of stories—and of storytelling itself—to foster a patient-centered, reflective orientation to medicine in students and, ultimately, to “rehumanize” relationships in medical care: that is, to revitalize the physician–patient relationship and emphasize the personal and humanistic aspects of medicine.17–20
Midway through their first year, the students carry out a task. Working in groups of two or three (each representing a different volunteer and his or her story), the students consider common experiences, themes, emotions, or perspectives and express their understanding through the creation of an interpretative project. The course encourages the students to choose any medium for their work. At times, faculty instructors have assigned students to work in specific subgroups; however, more frequently in recent years, students with disparate but related interests (e.g., poetry and musical performance; songwriting and the visual arts; photography and sculpture) have teamed up to create pieces whose strength and depth arise from a truly collaborative interplay of perspective, experience, and expertise. Over the nine years since the University of Michigan Medical School has offered the FCE, this assignment has resulted in a tremendous variety of original paintings, sculptures, musical pieces, poems, songs, dances, films, dramatizations, and multimedia presentations that have explored such themes as the impact of illness on identity and family, isolation and loss, stigma, courage and triumph in illness, relationships between doctors and patients, faith and spirituality, and systems of support.15 Each year, the students present their projects to the other members of their small groups, and a number of selected projects are subsequently showcased at an evening presentation for students, volunteers, medical school faculty, and staff. Several interpretive projects have been published in this journal22–26 or featured at national and international meetings.27–29
For many students, the interpretive projects have served as an explicit way of giving back to their FCE volunteers and of acknowledging, through a creative process, the effects that the families’ stories have had on themselves and their views of medicine. The creation of these projects—as well as their presentations and viewings, and the discussions that follow—nurture and reinforce humanistic concerns and attitudes in developing physicians.
Stories, Ways of Knowing, and the Fostering of Empathy
To understand the impact of the creative arts in the FCE—and to encourage their use elsewhere—I would like to explore learning processes and interactions that may enhance empathy and lead to both the act of creative interpretation and the consequences of that interpretation.
Stories enhance empathy by recapitulating core processes in its development.19 This enhancement occurs through the fostering of an affective identification with the Other, through perspective-taking and self-reflection, and through encouraging the development of a more expansive worldview through exposure to new ideas, identities, and experiences.17,19,21 Furthermore, the physical presence of the narrator (in this case, a volunteer) telling the story of his or her life confers on the story a sense of power and intimacy, which in turn is strengthened over time by the rapport that develops between the storyteller and the listener (here, a student). The student thus learns of the volunteer’s illness experience through cognitive, affective, and experiential means, which turns the act of listening to the volunteer’s story into an interaction, a relationship, a lived memory.
My colleagues and I have suggested that there is a type of knowing gained through these stories that differs from knowing acquired through the more traditional activities of medical education—through attending lectures and reading textbooks. The kind of knowing that emanates from hearing others’ stories is a context-specific, individual knowledge about illness that is expressed in the everyday, truly human language of discomfort, pain, fears, and loss.17,30 The educational result of perspective-taking, self-reflection, and exposure to other identities, experiences, and ideas, contributes, I believe, to each student’s tacit or implicit knowledge about people, illness, and doctoring.
Some of the qualitative studies conducted on FCE have demonstrated this not-always-conscious understanding.17,18,20 When investigators ask students what impact their relationship with the volunteers has had on their perspectives, students often initially deny any clear effect; however, explorations (e.g., through interviews, discussions, writing) of the students’ thoughts, feelings, and impressions uncover clear evidence that their conversations with families have had a profound influence on their understanding of their roles as physicians.17,18 Polanyi’s31 description of tacit knowledge—knowledge which lies beyond conscious awareness—finds resonance in these observations; Polanyi posits that “we know more than we can tell.”31(p4) In contrast to explicit knowledge, tacit knowledge is deeply rooted in memory and in the unconscious, and it involves processes that cannot be easily explained. Tacit knowledge is gained through lived experiences, including exchanges with others.31 In the same way, the relationships that students develop with the volunteers have the potential to create moments of significance for the students. Students’ memories of these interactions will enter their consciousness in much the same way that a significant experience does—lying perhaps largely under the surface but accessible through moments of what colleagues and I have previously termed “empathic memory.”17(p323)
The Functions of Creative Art
Art can play a role in this fostering of empathy, in the interactions between storyteller and listener, memory and knowing. Despite the great variety of materials, media, and themes appearing in the students’ interpretive projects over the years, art has continually served certain educational functions: as an expression of identity, as a critique of the status quo, and, ultimately, as a means of interpretation that supersedes reflection and feeling and aspires toward the formation of a community of understanding and shared values.
Art as identity
The student–artists have used their projects to form a bridge of identity between themselves and their volunteers. The works themselves become tangible, physical expressions of their attempts to take the perspective of the Other. Art that serves as an expression of identity centers on the impact of the illness on a person’s sense of self, on her relationships with others, on his life and environment. It portrays the burdens and challenges of living with chronic illness as well as the effects of stigmatization and isolation.
For example, in Reflections (Figure 1), Zhao, Weiser, and Wilson have studied the duality of living with a chronic illness that is not visibly apparent. Within the confines of one’s private life, one’s private Self, the illness is always present, as represented by the bottles of pills; however, a person with such an invisible disease may try to project normalcy to the world outside the window, that is, the world outside the Self. The mirror reveals such an individual, but the individual’s identity is obscured—the full Self is not shown—because of fears of stigmatization. Echoing this theme, the painting is infused with a soft, melancholy light and a lingering sense of isolation and loss.
In The Face of Illness (Figure 2, published as cover art in Academic Medicine, June 2011), Li, Carulli, and Nayak-Young24 have used pieces of a photographic portrait mounted on a board to explore the fragmentation of identity that often comes with visible disability or chronic illness. From a variety of different angles, the fragments appear strange—even grotesque—however, when viewed en face, a clear portrait emerges of a whole, albeit altered, Self. The art work demonstrates the shattering of identity that often comes with a devastating diagnosis; the reductionist vision that some physicians and others have, which transforms an individual into a list of diagnoses and symptoms; the physical stigmata that others see; and the courage to “remake” the Self in illness.
The sculpture in Dehudy and Strangas’ Enough Time (Figure 3) takes the form of a clock and represents the constant time pressures in the lives of families that face chronic illness. Responsibilities, appointments, and necessities are mingled with the activities of family life, attempts to stay healthy, fears of hereditary consequences, and, ultimately, thoughts of one’s own mortality.
Akira Kurosawa’s movie To Live inspired Nguyen’s28 quiet, profound scrolling line poem of the same name. The poem centers around a woman and her partner, Sarah, who learn to live together with breast cancer. In a call–response manner, the poem builds gradually—filling in the tiny details of a life lived, of a blossoming relationship—to the diagnosis and its aftermath. The poem’s crescendo is the affirmation of love, courage, and dignity—and of life itself:
This poem and the visual art mentioned are evocative. They all create a sense of identity between the art work’s subject and the audience: Mediated by the work, the audience sees the world through the patient’s eyes. The ties between the student artists and volunteers, between the audience and the interpretive work, are resonant with shared emotions and humanity.
Art as critique
Many of the FCE students’ works critically reflect on the status quo (e.g., the extant power structures in health care and society; traditional physician–patient relationships and power dynamics; reductionist ways of seeing people with chronic illness as collections of diagnoses rather than as individuals). When artists express a critique of medicine, they are taking the perspective of another, specifically that of the patient. They look with a critical gaze at how an individual patient or his or her condition is treated by health care professionals, by strangers, and by society.
Qian, Chapman, and Chapman created “The Face Behind the Illness” (Figure 4), a shadow sculpture. The artifacts of a life with illness form a sphere that appears to be a haphazard collection of debris; however, when illuminated from a certain perspective, it casts a shadow in the distinct profile of a man. The work critiques the predominant biomedical view of patients and their illnesses, a view that leaves their patients’ specific stories, their individual personhood, and their lives “in the shadows.”
“Lullaby,” by Kaplan-Singer, Collins, and Yang,27 is a spoken word poem accompanied by music in which the story of a young girl with disabling migraines is first introduced in the dry, detached language of a case presentation:
Patient is a cheerful and smiling 11 year-old female in 6th grade presenting with chronic head and neck pain (comma), but is currently asymptomatic (period).
The story continues years later:
Patient is a depressed 15 year-old female presenting in obvious physical distress with extreme pain and nausea (period). Patient admitted dozens of times for CT scans and MRIs; spinal taps, morphine drips, and oceans of other potions, procedure, procedure, procedure, please proceed her to Outpatient (period). Repeat steps, over and over again.
Into this litany of signs and symptoms, tests and treatment, a second voice—that of the young girl—weaves and repeats a haunting lullaby, which the girl uses to ease her suffering and help her sleep:
Lullaby, let me fly tonight,
somewhere out there, I could hide.
Shake me, wake me, take me from this nightmare,
through the darkness, to the morning light.
While the lullaby is still sung softly in the background, the piece ends with one of the girl’s journal entries:
During sleepless, sheep-less nights, I lull my cries goodbye with lullabies. I have been in and out of hospitals for more than 8 years, and yet, often the best medicine is a silly little song. For those few melodic moments, I fly away to a deserted island and watch the waves explode as the wet sand runs between my toes and drags my lows away. During those fleeting notes I float to a place of peace where I can almost escape enough to forget my struggle, where I can almost make myself believe, that tomorrow, somehow, it will all be better (period … question mark).
This work is an eloquent critique of the failure of medicine both to understand the personal dimensions of human suffering and to lessen the toll this suffering takes on a young person. The poem expresses abandonment but also outrage at the system; it is, in its essence, an attempt to seek peace through a very human, comforting activity, the singing of a lullaby.
These and similar works express a critical consciousness regarding the practice of medicine—a moral awareness of injustice and unfairness, an alliance with those whose voice is often silenced, and a commitment to act to serve justice, especially in the role of physician.21 Such works often, though implicitly, call the audience members to examine their own views, values, and assumptions and to see illness and patient care from new perspectives.
Art as interpretation
In the interactions that the students have with their volunteers, and in the creation and presentation of the interpretative projects, a number of conversations occur: between the volunteers and the students; among the students in their small groups; between, as Schön32(p151) would say, the artists and their materials; between the artwork and the audience; and among the audience members. In effect, these conversations are acts of interpretation in which individuals seek to extract meaning and significance from their interactions with the artwork and one another. In this sense, each of these conversations does not represent a mere repetition of what has been said but, instead, is a re-creation of meaning or, as Dilthey1(p241) wrote, the “re-creation of creation”—mediated by each individual’s own perspective and life experiences. Importantly, because works of art often signify and express more than even the artist intends,1(p235) it is through these different conversations (e.g., among artists, audience members, and art) that multiple and unique meanings emerge.
To clarify how meaning-making on multiple levels occurs and how the creation and experience of art opens new dimensions of learning, we can benefit from looking at this process through a hermeneutic lens. Hermeneutics may be broadly defined as the study of interpretation and understanding. Hermeneutic approaches have existed from antiquity and originally centered on the interpretation of ancient texts or Biblical exegesis; however, since the early 19th century—chiefly through the works of Friedrich Schleiermacher, Wilhelm Dilthey, Martin Heidegger, and Hans-Georg Gadamer—the hermeneutic tradition has extended to explorations of the meaning of art, music, and, most fundamentally, the processes of understanding and the very nature of being itself.33
Although major differences exist among the modern philosophers of hermeneutics, they share a common belief that the human sciences—that is, those fields that study humans as social, expressive, historical beings (e.g., sociology, history, anthropology, art history, and literature)—involve modes of experience, understanding, and knowledge that exist outside of the realm of the natural sciences. According to these theorists, truth arising in the human sciences cannot be validated by the methodological approaches of the natural sciences but must be realized through a different type of understanding that is central to lived experience and to the nature of being. In this context, hermeneutical understanding is not a cognitive operation—a mere method—but, rather, it is ultimately a dialectical interplay among individuals, tradition, history, and the world.33 Dilthey1(p233) writes,
The mystery of the person lures us for its own sake into ever new and deeper attempts at understanding. In such understanding the realm of individuals, encompassing human beings and their creations, opens up.
According to Dilthey,1(p236) each individual’s life course becomes increasingly narrow and determined in its possibilities. Understanding, in contrast, opens up a wide realm of possibilities that are not normally available to the individual within the limitations of his or her ordinary life.
Gadamer’s2(p302) concept of “horizon” is important here. Gadamer defined horizon as a way of seeing the world, including beliefs, values, and prejudices, in the context of the history and traditions to which one belongs. Interactions between an individual and a text (be it visual or not), and between an individual and another person, involve what Gadamer2(p304) refers to as a “fusion of horizons”—the merging of different ways of looking at history and at the world—that leads to a more inclusive knowledge of people as beings-in-the-world. According to Gadamer, this type of interpretive interaction and this fusion occur in all human relationships, including collaborative interactions between patients and physicians.
The conversations that occur between the volunteers and students offer the students a glimpse at the meanings that the volunteers have constructed from their experiences with illness; that is, the students receive access to the volunteers’ own interpretive horizons. This access may challenge the students’ worldviews with new, and at times disturbing, ideas, identities, and feelings.34,35 Hearing of the volunteers’ experiences forces the students to broaden their own horizons to take in the new perspective.34 The interpretive projects that the students create as a result of this new view are the concrete expression of the “fusion of horizons” that occurs when the volunteers’ stories are understood through the students’ own life experiences. The work may consequently reflect or recreate the discomfort that the student–artists may feel in their attempts to understand the patient’s perspective. A similar process then occurs for the audience members who view or experience the projects: They interpret the art through the lens of their own lived experiences and horizons—and they, too, may be challenged by new and unique ways of seeing and understanding. In this regard, the paradoxical nature of art and of this type of narrative education19 share common ground. Whereas both art and stories may appeal to universally held emotions, they also have the ability to disrupt the viewers’ habitual ways of seeing things: By “making strange” taken-for-granted opinions, assumptions, attitudes, and identities, both art and stories force one to step back in self-reflection and to look at oneself, others, and the world anew.
From Reflection Towards Transformation
In this article, I propose that using the creative arts in medical education may “open up” learners’ horizons by encouraging them to seek an understanding of the perspectives, feelings, and experiences of patients and families. In this sense, the interpretive project serves as a concrete expression of students’ understanding of a patient’s perspective, a tangible expression of the depths of their knowing. Students communicate their knowledge and understanding not through behaviorist notions of “demonstrating competence” but, rather, through a visual or auditory expression of the affective, experiential, cognitive, and existential lessons they have learned through stories. Furthermore, because art has the capacity to express more than the artist has consciously intended, students’ projects also allow access to the tacit knowledge that they have gained from their interactions with the volunteers.
There is currently an emphasis on reflection in education and clinical practice36–38; however, without a social component—that is, a change in the interactions of Self with Other—reflection runs the risk of being limited to feeling instead of acting. Through a call for interpretation, art and the conversations associated with its creation have the potential to move reflection beyond the Self. Through the “fusion of horizons” that occurs between individuals and a work of art and between individuals and others, art broadens the horizon of each. Taking up Dilthey’s1(p227) concept of transposition—the attempt to see the lived experience of another “from the inside”—Gadamer2(p304) makes the intriguing proposal that this fusion of horizons is neither the mere empathic identification with another individual nor the subordination of another’s perspective to one’s own worldview but is, in fact, the superseding of individual relationships to a more universal understanding of human beings and their experiences. To extend this characterization, one can see how this fusion of horizons may help to change the extant culture and nurture a community of understanding—an understanding that validates and values individual humans, the human dimensions of illness and suffering, and the spectrum of expressions of humanistic care.
Widespread implementation of this approach—asking students to create art in an effort to promote patient-centered, humanistic care—faces several challenges. The interpretive projects, as well as other approaches to fostering patient-centered care, are often initially met with resistance by students and faculty who may see them as distractions in a learning environment in which the biomedical sciences predominate. What is essential in such a context is ongoing faculty development that helps to create and nurture an educational milieu which values thoughtful reflection, creativity, critical awareness, and humanistic values in medicine.19,39 Also crucial is the allocation of curricular time for the thought, discussions, and effort needed to create art. Finally, institutional commitment—beyond mere words—to the importance of humanistic values and patient-centered care is critical. Colleagues and I have previously documented the impact of the narrative-based FCE approach on the attitudes and perspectives of medical students and faculty.17,18,20 Nonetheless, evidence of the long-term effectiveness of the creative arts to teach patient-centered care awaits future study. I believe, however, that these future investigations should be qualitative; in-depth, narrative- or interview-based studies are better for accurately tapping into and elucidating the tacit meanings that students and physicians construct from their experiences with art, doctoring, and medicine.
The volunteers’ stories that the students explore in the FCE become a part of each student’s understanding of illness, and they build a foundation for a humanistic approach to medical care. The interactions and conversations the students have with their volunteers have the capacity to instill profound lessons—and tacit knowledge—about medicine that, in turn, have the potential to fundamentally shape students’ professional and personal worldviews. The creative arts have a role in this process. The creation of art and the interpretive processes that underlie the “re-creation of creation” allow students to explore the affective, experiential, and existential aspects of the patient’s perspective and provide tangible evidence of their reflective, often transformative, vision.
Acknowledgments: The author would like to acknowledge each of the artists who have generously permitted the presentation of their work: J. Zhao, N. Weiner, and S. Wilson; L. Li, A. Carulli, and S. Nayak-Young; A. Dehudy and Y. Strangas; Dr. J. Nguyen; and B. Kaplan-Singer, C. Collins, and H. Yang. The author would also like to thank H.A. Kumagai, H. Wagenschutz, and Dr. Eric P. Skye, Dr. Evangelia Dimaraki, Dr. E.A. Kinsella, and Dr. Rachel L. Perlman for many important discussions. The author is grateful to J. Westfall, and A. Yao for critical assistance in preparation of the Family Centered Experience Web site.
Other disclosures: None.
Ethical approval: Not applicable
Previous presentations: An abstract containing parts of this discussion was presented at the International Conference for Communications in Healthcare meeting, Chicago, Illinois, October 2011. “Family Centered Experience Interpretive Project: To Live” by J. Nguyen was presented at the First International Conference on Engaging Reflection, London, Ontario, Canada, May 2009. “Family Centered Experience Interpretive Project: Lullaby” by B. Kaplan-Singer, C. Collins, and H Yang was presented at the International Conference for Communications in Healthcare meeting, Miami, Florida, October 2009. “Family Centered Experience Interpretive Project: I feel like I’m more” by B.A.P. Tran was presented at the International Conference for Communications in Healthcare meeting, Chicago, Illinois, October 2011.