Worcester Medicine - Summer 2023

Your skills are in demand at many health systems. But only Reliant Medical Group offers you the right care culture in which to flourish. To collaborate and share your expertise. To give patients the attention they deserve. To leverage the latest treatment advances, information technologies and analytics to push the boundaries of medicine. Join us and there’s only one thing to do — your life’s best work. SM

Reliant is a proud member of the Optum family of businesses. www.practiceatreliant.org

Humanities in Medicine

Summer 2023

Humanities in Medicine

Perspective 4

David Hatem, MD

President’s Message, Featuring Berlin Writing Award Essay: “Don’t Shoot the Messenger” by Sarah Danforth 6

Giles Whalen, MD

The Humanities as a Tool 6

Kayla Thomas, MS, RN

Embracing the Good, the Bad, and the Weird 8

Megan Hansen, MD

Writing: An Outlet and a Vessel 9

Rebecca Kowaloff, DO

Channeling Creativity: Medical Humanities in Medical School and Residency at UMass Chan 11

Anindita Deb, MD and Hugh Silk, MD, MPH

For Parkinson’s Disease, Strike Up the Band 14

Joel Popkin, MD, MACP

published by Worcester District Medical Society

321 Main Street, Worcester, MA 01608

wdms.org | mwright@wdms.org | 508-753-1579

wdms officers

President Giles Whalen, MD

Vice President Alwyn Rapose, MD

Secretary Michelle Hadley, DO

Treasurer B. Dale Magee, MD

wdms administration

Martha Wright, MBA, Executive Director

Melissa Boucher, Administrative Assistant

Looking and Listening with Learners: Art Museums in Medical Education 16

Sara G. Shields, MD, MS, FAAFP

Illness on Canvas: Diseases Depicted in Renaissance Art 18

Parul Sarwal, MD

The Healing Power of Stories 19

Wendy Arena, MS, RN

The Intersection of Art, Architecture, Biology, and Medicine: A Convergence of Disciplines Shaping Our World 20

Akil A. Sherif, MD

GHHS Writing Contest: Ice, a Warm Cup of Tea, and a Night in the ED 22

Golda Grinberg, MS4

In Memoriam

James L. Erwin, MD 10

wdms editorial board

Lisa Beittel, MBA

Sonia Chimenti, MD

Anthony L. Esposito, MD

Larry Garber, MD

Rebecca Kowaloff, DO

Susan Krantz, MD

Julianne Lauring, MD

Anna Morin, PharmD

Nancy Morris, PhD, NP

Thoru Pederson, PhD

Joel Popkin, MD

Alwyn Rapose, MD

Parul Sarwal, MD

Akil Sherif, MD, SVH, Cardiology Fellow

Robert Sorrenti, MD

Martha Wright, MBA

Peter Zacharia, MD

Alex Newbury, MD, UMass, Radiology Resident

Arunava Saha, MD, SVH, Medicine Resident

Olivia Buckle, Student Representative

produced by

Hana Lasell

advertising

Inquiries to Martha Wright mwright@wdms.org

508-753-1579

thank you to

The Reliant Medical Group, UMass Memorial Health

Music Worcester

Physicians Insurance AdCare Hospital of Worcester

Worcester Medicine does not hold itself responsible for statements made by any contributor. Statements or opinions expressed in Worcester Medicine reflect the views of the author(s) and not the official policy of the Worcester District Medical Society unless so stated. Although all advertising material is expected to conform to ethical standards, acceptance does not imply endorsement by Worcester Medicine unless stated. Material printed in Worcester Medicine is covered by copyright. No copyright is claimed to any work of the U.S. government. No part of this publication may be reproduced or transmitted in any form without written permission. For information on subscriptions, permissions, reprints and other services contact the Worcester District Medical Society.

What are the Humanities Doing in Healthcare Education?

David Hatem, MD

We are forever envisioning and re-envisioning healthcare education. Each time we do this, there seems to be a new emphasis. The original Flexner Report emphasized standards for medical school, the scientific basis of medicine, and the evolving body of knowledge in medicine (1). More recently, healthcare education has sought to integrate foundational and applied science, reinforcing that there is a scientific underpinning to this endeavor, and that clinical care is ultimately the end goal, even from the most dedicated and focused research.

Recent additions to the healthcare education mandate include an emphasis on health systems science(2), a foundational framework for the study and understanding of how care is delivered, how health professionals work together to deliver that care, and how health systems can improve patient care and healthcare delivery. A second recent emphasis is professional identity formation—the process by which our education takes developing humans and layers onto their existing identity new knowledge, skills, and values that help them “think, act, and feel like healthcare workers.” (3)

These overarching concepts reinforce that healthcare work has scientific underpinnings, but it is also delivered by people to people in a specific context. While the scientific foundation is crucial and a source of impressive advancement, the need to apply our knowledge each day when caring for patients entails significant uncertainty. This is exactly where the healthcare humanities can integrate with evidence-informed care to help us to personalize our approach while developing as caregivers.

“i sing of arms and a man” —-virgil, the aeneid

The Aeneid is not only a story about war, it is a story about a man and his unique experience with hardship and trauma. In healthcare, at the juncture of science and care for people, is a place for stories about those people, with distinct hopes and specific disappointments in their role as parents and children. Healthcare humanities can expand and add depth to the personal. In The Death of Ivan Ilych, Ivan grapples with his impending death, evaluates the worth of his life, and ultimately reconciles with his family while he is dismissed by physicians who remain above the fray and of little help. Only Ivan’s servant, who stays with and comforts him, is truly moved at the end and at a loss for his passing. It is he who knows the man (4). Kayla Thomas, RN reminds of this in “Humanities as a Tool» on page 6, where she invites us to elicit our patients’ perspectives, and step into their experiences to understand them.

“ we read many books, because we cannot know enough people” – t.s. eliot

Eliot encourages our reading about people as much as about medicine. Medicine provides countless stories about illness that personalize this, with particularity, and uniqueness. The novel, The Curious Incident of the Dog in the Night Time by Mark Haddon, in which a boy with autism investigates the murder of his neighbor’s dog, provides great insight into the character’s way of experiencing the world. Entering into the world of another requires embracing uncertainty and engaging openly with others. In her article, “Embracing the Good, the Bad, and the Weird» on page 8, medical student Megan Hansen encourages us to embrace patient stories and create the possibility that these stories will embrace and change us. On page 19, Wendy Arena writes about eliciting stories from our patients, helping them make meaning of their experience, and helping medical professionals make meaning of our work. She also reminds us of the power of listening-- allowing our patients to be heard, and to be seen.

As we broadly consider health, medicine is asking us to engage our imagination and embrace social science research that suggests that factors beyond the personal inform health outcomes. These social determinants of health include economic stability, educational access and quality, healthcare access and quality, neighborhood and built environment, and social and community context (5). Conversations about these topics bridge healthcare humanities, medical ethics, history, and public health in works like The Immortal Life of Henrietta Lacks by Rebecca Skloot (unconsented medical research), Bad Blood by James H. Jones (observational syphilis study despite developed treatment), and Life on the Line by Emma

“

Our task as clinicians is to remain curious — inquiring about the next detail and coaxing the story out.

Goldberg (COVID-19), to name a few. Community factors and what is truly going on in our patient’s lives sometimes require us to re-story what we are told, like in Roddy Doyle’s The Woman Who Walked into Doors, where stories of personal injury beyond what the history suggests are envisioned for what they are: acts of intimate partner violence. These accounts encourage us to enter into our patient stories, into their communities, and into their lives.

Our task as clinicians is to remain curious -inquiring about the next detail and coaxing the story out. I recall seeing a patient whose lung disease rendered him short of breath, most easily measured by how winded he was when he walked his dog around the local golf course. After several years, I recall him telling me that he was no longer having trouble keeping up with his dog. I was ready to conclude that his lungs were getting better until the next question occurred to me, “so how old is the dog?” What followed was the story of an aging dog increasingly hobbled by arthritis, cutting across the golf course instead of walking around it, shortening the walk, and slowing its owner. In this case, curiosity allowed me to personalize the story and seek another way to measure his day-to-day lung function. Rebecca Kowaloff’s article on page 9 provides context about curiosity in patient care as she talks about the skills and the function of narrative medicine.

Sometimes physicians write stories. While practice is full of engaging stories, healthcare is also delivered by people, who happen to be healthcare workers. In this issue, we see Gold Humanism Honor Society’s award winner Golda Grinberg’s piece about the challenge of her busy life as a healthcare worker when it is interrupted by the illness of her child as an example of balancing life and learning as a medical student with life and learning as a mother. Telling these stories can enhance self-awareness, lead to personal growth and development, promote personal reflection, and build an integrated personal and professional identity (6, 7). This process of growth and identity formation continues, as does the story (8, 9).

Healthcare is delivered by people, to people in a specific context. Currently, that context is changing. We are coming to appreciate the health system as a player, sometimes welcoming, sometimes a barrier to the delivery of caring. On page 11, Hugh Silk and Anindita Deb consider how to integrate the health humanities into the medical curriculum, and call for true integration, bringing literature or works of art related to the healthcare topic being discussed

so that the scientific and the humanities perspective on disease is discussed together.

While much of this issue is focused on reading and writing, art, music, and history are also part of the health humanities. In a provocative piece on page 14, Joel Popkin explores music as therapy, cleverly demonstrating how thinking about music engages the mind, while listening to music engages the heart. This issue also includes pieces by Parul Sarwal and Sara Shields that consider incorporating works of art into healthcare education to reinforce the powers of observation, dealing with ambiguity, and the need for skillful interpretation.

As you read this issue, I hope that it activates not only your cerebral cortex, but that it activates emotional engagement. Healthcare that includes humanities aims for whole people taking care of whole people in a humanistic context. I hope you read, listen, then engage your whole selves in the practice of health care. It is likely to be moving. +

David Hatem MD, Professor of Medicine at UMass Chan Medical School, teaches reflective writing to medical students to help them learn from their experiences.

References

1. Ludmerer KM. Abraham Flexner and medical education. Perspect Biol Med. 2011 Winter;54(1):8-16. doi: 10.1353/ pbm.2011.0009. PMID: 21399378.

2. Gonzalo, Jed D. MD, MSc; Ogrinc, Greg MD, MS. Health Systems Science: The “Broccoli” of Undergraduate Medical Education. Academic Medicine 94(10):p 1425-1432, October 2019. | DOI: 10.1097/ACM.0000000000002815

3. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med. 2015. 90:718-25. doi: 10.1097/ ACM.0000000000000700. PMID: 25785682.

4. Tolstoy, Leo. The Death of Ivan Ilych. Translated by Ian Deiblatt, Melville House, 2009.

5. https://health.gov/healthypeople/priority-areas/socialdeterminants-health, accessed 3/31/23

6. Binyamin G. Growing from dilemmas: developing a professional identity through collaborativereflections on relational dilemmas. Adv Health Sci Educ Theory Pract. 2018 Mar;23(1):43–60. https://doi.org/10.1007/s10459-017-9773-2.

7. Levine RB, Kern DE, Wright SM. The impact of prompted narrative writing during internship on reflective practice: a qualitative study. Adv Health Sci Educ Theory Pract. 2008;13(5):723–33. https://doi.org/10.1007/s10459-007-9079-x.

8. Grinberg GR. When Practice Questions Become Real Life. JAMA 2022;328(8):711. doi:10.1001/jama.2022.13837.

9. Grinberg GR. Staying Home. JAMA. 2023;329(8):633–634. doi:10.1001/jama.2023.0040

President’s Message

In this edition of Worcester Medicine, Dr. David Hatem has beautifully curated and edited a paean to Humanities in Medicine. It reminds us that while there has been an explosion in our understanding of the molecular, biochemical, and epidemiological basis of disease and how our bodies work mechanically along with computer aided ability to analyze almost incomprehensible amounts of data, all physicians remain part of a human experience –shared not only with each other and our patients, but also with everyone who has spent time on our planet. We are fortunate that even ancient experience is accessible to us through art, music, and literature. It can sustain and nurture the nobler aspect of being a person and a doctor, and certainly can help teach us important things about the practice of medicine – which is in the end one of the most privileged of human endeavors.

Enjoy how the articles in this edition show practical ways to incorporate the humanities into medicine and medical education and how these new voices can contribute to both our medical and human story. I’d also like to bring your attention to this year’s Berlin Writing Award The Gerald F. Berlin Creative Writing Award at the University of Massachusetts Chan Medical School honors the poetry, fiction and essays of medical students, physicians, in training (interns, residents and fellows), graduate students and nursing students from the medical school. The award was established to encourage creative writing by health professionals-in-training and to honor the father of Richard M. Berlin, MD, who sponsors the award. Congratulations to Sarah Danforth, the 19th annual Berlin Writing Award winner. Go to https:// tinyurl.com/BerlinAward to read it.

We recently held our Annual Business Meeting (https:// tinyurl.com/summersocietysnippets), are currently developing our 2023-2024 Calendar of Events and very much look forward to resuming all of our programs, in person. And finally, we are in the process of updating our 20232024 Committee Roster (https://tinyurl.com/20222023Roster), so please consider volunteering or nominating a colleague. This appeal now includes suggestions for our annual Cottle Lecture (October) and Oration (February).

As our membership continues to grow, we welcome suggestions from all and look forward to seeing you all at next year’s events.

Have a healthy, safe and fun-filled summer! +

Giles Whalen, MD, President

The Humanities as a Tool

Kayla Thomas, MS, RN

Iam prepping a patient for surgery, and they have been waiting longer than they expected. They begin to pull off their leads and head toward the exit, but my colleague reminds them that they have an IV still in place and that they must return so we may remove it. They sit down and the colleague and I begin to investigate the root of the pending elopement. They are nervous about the procedure, and they have had ample time to run through all possible poor endings; a moment of reassurance and understanding from the people caring for them was what they needed to await the surgery. It would be easy to explain the behavior as rash if not for the moment of understanding that existed among the three of us; stepping into their experience allowed us to see what they experienced instead of as another patient with imprudent behavior.

The nursing profession provides us with tangible skills and tools that afford us the opportunity to sit with someone in their darkest moments and allows us to see a person at their most vulnerable. Our current education and practices help us to see the patients we encounter as individuals to help, to provide care for, to give of ourselves to, and even to “other.” We may sit bedside, offer our hand of comfort, provide for the patient’s practical desires, and leave our work feeling satisfied. But how do these patients, these human beings, feel at the end of their encounters with us? Perhaps they feel that their needs were met, that we anticipated their basic requirements, and that we gave them the best of care we could with the busy schedules we are required to keep. But do they feel seen and genuinely cared for? In most settings, there may be great benefit in seeing our shared experiences from their perspective.

Historically, there has always been more to nursing; always been a human connection aspect to this career we have chosen. Slowly the coasts of our care and humanity have been ebbed away by the tides of patient overload. The answer to this predicament we are in may just lie in the humanities. Humanities includes the study of the arts, culture, language, and societies; in other words, the things that truly make up each unique human, and humankind. Our very human experiences, when expanded past our box of medicine and patient care can nurture our overworked spirits and bring joy back into our careers.

Recognizing that the humanities may be a tool in understanding an individual’s perspective and experience, how do we cultivate introspection and cultural exposure in a career that demands so much of someone to begin with? How do we ask for more generosity of self from nurses, when we are faced with career lethargy and heavy work tasks?

Immersing students in the literature and focused discussions, Moyle and colleagues (1) noted their worldviews opened, and they

featuring berlin writing award essay: “don’t shoot the messenger” by sarah danforth

Humanities in Medicine

were able to conjure more empathy for others and enlarge their appreciation for what it means to experience hurt and disease. Another strategy is contemplating the arts. While standing in front of a piece of art, we can try and understand the artist who painted it, we listen to a song and endeavor to feel what the artist went through to conjure up the lyrics, we read a new book and attempt to understand the character’s decisions, or we take an instant to understand why a patient may be nervous going into a procedure. This may be the first chisel in the walls we have built in our minds. Perhaps we may even go further to take up a new hobby, and as we catalyze the new experiences, we connect deeper to those whose own humanities encouraged us to develop ourselves further. Practicing these experiences, and wrestling with our ideas around them, may quite possibly be the practice that Moyle and colleagues found to be so helpful. My challenge to those perusing this commentary is to pull our minds out of the medical and patient care

Embracing the Good, the Bad, and the Weird

Megan Hansen, MD

boxes we have constructed for ourselves. We may have the knowledge, we may know the differential diagnoses, and we undeniably know how to tangibly care for patients; however, to sit and soak up what we may learn from our patients, to absorb the beauty of a piece of art from the artist’s perspective, or to sit ourselves on the exam table and try to feel what it is a patient feels when they receive a terminal diagnosis – this is to live. This is to be human, to experience the humanities around us and expand our worlds a little more. Not just for the patients we encounter, but for ourselves, our families, and our short existence on this rotating orb. +

Kayla Thomas, MS, RN is a Psychiatric Mental Health Nurse Practitioner DNP Student at the Tan Chingfen Graduate School of Nursing, UMass Chan Medical School.

References

1. Moyle, W., Barnard, A., & Turner, C. (1995). The humanities and nursing: Using popular literature as a means of understanding human experience. Journal of Advanced Nursing, 21(5), 960–964. https://doi.org/10.1046/j.1365-2648.1995.21050960.x

Idecided to become a doctor to tell stories. When I tell people this, they are understandably confused. Writers tell stories. Editors adjust them. Even lawyers know how to spin a tale. What, they ask me, is the connection between practicing medicine and storytelling?

I tell these people any number of things. I tell them that the first thing we learn in Patient History Taking 101 is to prompt a patient with, “Tell me your story,” and that there is immense power in showing a patient that they are in the driver’s seat. I tell them that, in How to be a Third Year Medical Student 101, we learn how to craft a narrative to present patients to our attendings, and that the words have profound impacts on patient care. I even tell them that, in How to Fight Burnout 101, we learn about the importance of writing as both a creative outlet and a mode of advocacy. What I do not tell them, what I have just begun to understand, however, is the way patients’ stories have shaped my own.

It’s strange, this career we have chosen. We are with patients for some of the best and some of the worst and some of the weirdest days of their lives, and we often have no choice but to absorb all of the good and the bad and the weird. Before I started medical school, I thought that I had a relatively strong sense of self—or at least, as strong a sense of self as a 22-year-old fresh-out-of-college, faints-at-the-sight-of-blood,

newly-minted medical student can have. As I reflect on my years here, however, I am struck by how much I have been molded by the patients who have come into my life. They have changed my story.

I was with a 22-year-old patient when he found out he had CNS lymphoma, a complication of uncontrolled HIV. I sat with him while the doctors explained his chemotherapy options, keeping a hand on his shoulder while they broke the news that he would likely have less than a year to live. Just an hour before, we had been swapping Netflix recommendations and looking at pictures of his (adorable) one-year-old son. I absorbed the news with him that he would, in all likelihood, not live long enough to see his son’s second birthday. He passed away three months later, and I had a front row seat to his loved ones’ profound grief. These moments changed my story.

I was part of a clinic visit for a 42-year-old woman who had tried for years to get pregnant. She and her husband had gone through several rounds of in-vitro fertilization with two miscarriages but no successful births. They had resigned themselves to the fact that they would never have a child and had tried to make their lives as rich as possible—they adopted a mutt, went on long vacations, and took up gardening. The patient came in for an OB/Gyn office visit because she had missed a period. Assuming she was starting

menopause, she wanted to check in and talk about controlling symptoms. Instead, her urine pregnancy test was positive. I sat with her as she sobbed uncontrollably, unable to contain her joy. I was by her side while she video called her husband, who cried even harder. We laughed together and danced around the room for far longer than the 15-minute appointment allowed. These moments changed my story.

I was called to consult on a patient whose mental status overnight had changed; he had reportedly been unresponsive to sternal rub. He had since perked up, but the primary team wanted neurology to evaluate whether he had had a stroke or seizure. I entered the room and asked the patient whether he remembered people trying to wake him up overnight. “Yes,” he told me, rolling his eyes. He went on to share that he found it “very annoying” that people are always “poking and prodding” in the hospital and that his care team “talked too darn much,” so he had decided to “play dead to punish them.” Just a month prior, I had lost my grandfather, a less dramatic but similarly no-nonsense Kansas farmer; this patient reminded me so much of him that I laughed until I cried. I ended up sitting with him for an additional 30 minutes as we swapped stories about our loved ones. These moments changed my story.

Pre-rounds, rounds, orders, consults, afternoon rounds, around and around. It is easy to get lost in the tasks and the routine and forget to pause for the moments of humanity. As I look ahead to my next steps, I am most looking forward to countless more moments that will change my story. The patients who will make me cry or smile or laugh until my belly hurts. The attendings who will remember a patient’s birthday and go out of their way to celebrate it and the nurses who remember family members’ names and the peers who will make me feel like I am not alone. This job is good and it’s bad and it’s weird, and my only hope is that we allow ourselves to be flexible, to be unsure of what sort of doctor we want to be and to instead allow the strange, wonderful humanity that is the medical field to shape us and never let it stop shaping us. +

Megan Hansen, MD is a graduate of UMass Chan Medical School. She will be pursuing Internal Medicine residency at Duke University.

Writing: An Outlet and a Vessel

Rebecca Kowaloff, DO

In healthcare we are witnesses to and protagonists in the key elements of drama. Every day we face sorrow, pain, elation, love, anger, and suffering, through and with our patients. Stories unfold with unexpected twists and the constant character in all of it is the sometimes-fickle human physiology. Often, we are the visionaries, fairly certain we know the story, and we must bear the burden of an exclusive knowledge which feels like foresight, unable to author a different ending. We carry the unbelievably precious weight of human lives and wellbeing in our hands, and though we have specialized knowledge and honed skills, we are, after all, only fellow human beings tasked with a superhuman mission. How do we bear this burden, when so many of those with whom we are closest do not understand, and when medicine demands perfection and precision and worships the deity of cure? For some, an outlet lies in narrating these dramas, and in examining our role as a participant in them and our feelings tied to them.

There is a growing wealth of literature on teaching narrative medicine skills and its benefits for healthcare professionals. Writing helps many in healthcare process the daily tragedies and our self-doubts in the face of such an awesome responsibility and allows us to acknowledge our emotional investment and “to midwife the life scrutiny that inevitably accompanies illness” (1). Writing about patient encounters provides an opportunity to sit with an experience, to examine it with a metaphysical lens, and to reflect on the “transcendent truths, exposed in the course of illness, about ordinary human life” (2). I have found that as I have written more about patient encounters, I have begun to notice more of the concrete personal aspects of the experiences, such as items of clothing and mentions of hobbies or careers, that suggest more about the person and inform their experience of illness. This has helped ground me in the moment, reminding me to capture its entirety, surely making me a more attentive and thoughtful doctor. Writing can be both an off-ramp for sadness and feelings of powerlessness, and an on-ramp to a level of emotional engagement with our work that is not encouraged in our training or by the structure of modern healthcare delivery.

Combating burnout is a popular topic in post-pandemic healthcare discussions. Writing and engagement with the arts as a way to comprehend our work and rediscover our purpose can serve as a powerful tool in this mission. The act of switching from left brain to right brain thinking in and of itself can help sustain us through the stresses of a medical career, giving us a break from focusing on minute changes in lab values and piecing symptoms into diagnoses, to appreciating human physiology and the privilege of being entrusted with another’s health and sometimes their deepest fears and secrets. As physician-writer Anton Chekhov wrote about his two “mistresses,” medicine and literature: “when I get tired of one, I spend the night with the other … neither

Humanities in Medicine

Writing:

An Outlet and a Vessel Continued

of them loses anything from my infidelity” (3). Storytelling can be a way to acknowledge doubts about our abilities or shame over our mistakes that we couldn’t directly acknowledge to our colleagues or patients. Characters in literature are complete people, rather than the collection of diagnoses or snippets of history they can become in our notes and offices, and writing about our patients is a way to connect back to why so many of us went into a healthcare profession: to help people.

Many medical journals are recognizing the necessary role of the humanities in the practice of medicine and are adding sections for readers’ poetry and prose. I look forward to these pieces as windows into other types of illness and patients that I do not regularly treat, but also as mirrors to my own experience and feelings of wonder, gratitude, frustration, and inadequacy as a physician. Medical schools – as they increasingly envision and put into practice curricula that move beyond Abraham Flexner’s science-centered, four-year course – are more actively recruiting pre-medical students who majored outside of the basic sciences and are building narrative medicine experiences into their coursework. These tools are good training for honing observation and listening skills and help students view patients as whole people from the beginning of their training. Narrative medicine training also helps build the types of clinicians who “can stay with the emotional and personal complexities of illness without retreating into silent detachment or worse, simply avoiding the human aspects of healthcare altogether” (4). Additionally, time spent focusing on the humanities can also be a break from the rigors of medical education and give students skills they can turn to later in their career to process the physician experience.

You may not consider yourself “a writer,” but I encourage you to try to reflect on your practice or to write about something wholly outside of it to explore what it may do for your mental health, your enjoyment

In Memoriam

of your work, and perhaps for how you show up for your patients. Writers always say, “write what you know,” and as physician-writer Abraham Verghese writes, “illness is a story” (3). +

Rebecca Kowaloff, DO is board certified in palliative medicine and is a member of the inpatient Palliative Team at UMass Memorial Medical Center. She loves to educate lay people and medical providers in palliative care.

References

1. Charon, R. (2006). Narrative medicine: Honoring the stories of illness. Oxford University Press.

2. Charon R, Narrative and Medicine, N Engl J Med 2004; 350:862-864.

3. Beck D (2016, June 1). Cover Story: The Physician-Writer: Good Doctors are Good storytellers; some make it a second career. American College of Cardiology. https://www.acc.org/latest-in-cardiology/ articles/2016/06/10/11/12/cover-story

4. Lewis B. Narrative Medicine and Contemplative Care at the End of Life. J Relig Health. 2016 Feb;55(1):309-324.

James L. Erwin, MD, 91, of Shrewsbury, passed away on Friday, February 17, 2023. He was predeceased by his first wife Elizabeth in 1968 and his second wife Dorothy in 1998.

Jim was born on December 24, 1931 in Baltimore, Maryland to Dr. John J. and Margaret (O’Connor) Erwin. He grew up in Baltimore and graduated from Johns Hopkins University for his undergraduate studies and Medical School.

He served as a captain in the U.S. Air Force at the Selfridge Air Force Base in Michigan. Jim was a distinguished member of the medical community of Worcester, practicing as an obstetrician and gynecologist for over 40 years. He was in private practice in Worcester for many years prior to joining the Fallon Clinic where he worked for 19 years. He was a proud member of the Worcester District Medical Society (he joined in 1966), Massachusetts Medical Society, New England Obstetrical and Gynecological Society, and Worcester Economics Club.

Jim is survived by his eight children and 16 grandchildren, and many nieces and nephews.

I first met Jim shortly after starting my practice in Worcester. He was a most helpful and practical colleague, making sure that I got all of the details of joining the hospital staff (where to park, where to get keys, etc.) that others wouldn’t think to offer and I wouldn’t think to ask. Good natured, highly intelligent and quiet but always helpful, he made our medical community a better place. +

B. Dale Magee, MD

Channeling Creativity: Medical Humanities in Medical School and Residency at UMass Chan

Anindita Deb, MD Hugh Silk, MD, MPH

wherever the art of medicine is loved, there is also a love of humanity. — hippocrates

Medical humanities are a powerful yet subtle tool for teaching many important aspects of medicine. The Association of American Medical Colleges (AAMC) reports that medical humanities foster teamwork, collaboration, personal insight, flexibility, understanding of other cultures, social advocacy, and support learner wellness and resilience (1). In addition, trainees and physicians can learn to be better observers and interpreters, deal with ambiguity, and build empathy and communication skills. Medicine is ultimately about people – caring for them, interacting with them, finding cre-

Humanities in Medicine

ative ways to motivate them, and understanding what they are enduring. Furthermore, healthcare is about caring for ourselves and other colleagues. We are humans dealing with humanity every day.

Eighty percent of medical schools in the United States have at least one offering in the medical humanities not including ethics. The top-ranked schools in the country offer multiple (2). There are various types of media being used, including art observation, creating art, music making and listening, writing prose and poetry, close reading of essays and other writings, history, photography, theater, use of podcasts and TED Talks, and many more.

At UMass Chan Medical School there have been significant efforts made to increase medical humanities offerings throughout undergraduate and graduate medical education programs. In the Family Medicine Residency, prior initiatives have included a medical humanities session during intern orientation, a bi-annual humanities retreat, and sessions offered at the Worcester Art Museum to learn to use art to improve teamwork, deal with uncertainty, and understand wellness.

Humanities in Medicine

Channeling Creativity: Medical Humanities in Medical School and Residency at UMass Chan Continued

Here we describe two recent initiatives. Hugh Silk, MD, MPH has worked with Shannon West (UMass Chan Medical School ’23) and Sara Shields, MD to infuse medical humanities into standard Tuesday afternoon residency core teaching sessions. This latest initiative acknowledges that medical humanities is not a novelty; but rather medical humanities have real value. To that end, the goal is to use medical humanities to deepen the learning of mandatory teaching topics such as hypertension management, domestic violence screening, and procedures like skin surgery. Faculty are offered “pairings” to go along with the topic of the session. For example, they may use a poem to understand family dynamics when caring for someone with congestive heart failure; a local blog entry to humanize and address cultural elements in a session on nephrolithiasis; or an art series portraying historical depictions of gout and other rheumatological disease (3,4,5). These pairings humanize the lesson of the day. It is one thing to learn the pathophysiology of the disease, it is yet another lesson to learn how the patient adjusts to the illness through suffering, coping, and enduring.

Faculty are offered the poem or art piece to use as they see fit. This student-led capstone project has developed into a broader initiative to create faculty development for these pairings and start an online database. Hugh Silk has teamed up with Philip Day, MD and Maine artist Augusta Sparks Farnum thanks to a grant from the Society of Teachers in Family Medicine to create this web-based repository. As a result, family medicine residencies around the country will be able to access this repository to enrich their teaching with media that offers different perspectives on core family medicine residency teaching topics.

In the undergraduate medical school curriculum at UMass Chan Medical School, medical humanities have been offered through various methods. There have been several student-led electives on music, art, and writing. Many courses require reflective writing and there has been a “meet the author” series. The new Vista curriculum for the Class of 2026 offers more opportunity for utilizing medical humanities. The Pathways program is a new addition as part of this curriculum and offers students seven different pathways to choose from, including but not limited to Entrepreneurship and Biomedical Innovation; Population; Community and Global Health; Structural

Inequity; Advocacy and Justice; and Clinical, Translational and Community Research. Anindita Deb, MD, in her role as the Pathways Director, has encouraged Pathways leaders to infuse medical humanities into pre-reading for sessions and within lectures. Additionally, a dedicated core session for the entire class will focus on medical humanities and include art, writing, and other modalities which will be discussed in the context of their specific pathways. Students are also encouraged to incorporate medical humanities into a four-year Pathways Longitudinal Project. Building on previous capstone projects, students may choose to use photography to document injustice in Worcester or create a podcast to memorialize the voices of people living in another country and the health issues they face.

Modern learners want to be challenged and engaged. Gone are the days of boring lectures. Students and residents learn better when a film or video is utilized to share the voice of a patient, or a painting is presented to guide the learners to solve together the story within. UMass Chan is finding ways to tap into the creativity of their faculty and students and take medical education to the next level with the use of medical humanities. +

Anindita Deb, MD is Associate Professor of Neurology, Co-Chief of Movement Disorders Division and Director of the UMass Chan Pathways Program.

Hugh Silk, MD, MPH is Professor and Vice Chair of Community Health in the Department of Family Medicine and Community Health and co-leader of the UMass Chan Medical Humanities Lab.

References

1. Howley L, Gaufberg E, King B. The Fundamental Role of the Arts and Humanities in Medical Education. Washington, DC: AAMC; 2020.

2. Howick, J, Zhao, L, McKaig, B, et al. Do medical schools teach medical humanities? Review of curricula in the United States, Canada and the United Kingdom. J Eval Clin Pract. 2022;28:86– 92.

3. Lee L. The sound of rain outlives us. Viewed on March 8, 2023 at: https://nataliejabbar.wordpress.com/tag/li-young-lee/

4. Xie A. As long as we communicate. The Interstitium. Sept 2019. Viewed on March 8 2023 at: https://theinterstitium. home.blog/2019/09/30/as-long-as-we-communicate/

5. Chatzidionysiou K. Rheumatic disease and artistic creativity. Mediterr J Rheumatol. 2019 Jun 29;30(2):103-109. doi: 10.31138/mjr.30.2.103.

For Parkinson’s Disease, Strike Up the Band

Joel Popkin, MD, MACP

Parkinson’s Disease (PD) is a truly multisystem disorder, involving to a varying degree the central and autonomic nervous systems, the immune system, and gastrointestinal tract. In addition, a number of serious non-motor symptoms are often present, including dementia, psychosis, depression, anxiety, and sleep disturbances, among others. A complex multidisciplinary approach is often required (1).

Exercise is a protective factor for PD (1), and intensification of exercise is an integral part of music therapy (MT) – the topic of this article –although music therapy covers a lot more territory than simply exercise. Music therapy has been defined “as the use of sounds and music within an evolving patient-therapist relationship to support and develop physical, mental, and social spiritual well-being.” (2)

In light of the multifaceted nature of PD, MT programs vary considerably in design and purpose, with emphasis on diverse approaches such as listening, rhythm, rhythmic auditory stimulation (RAS), singing, and other interventions. Importantly, MT plays a powerful and well-documented non-pharmaceutical role in the management of PD. (2)

Exercise therapy alone has been increasingly applied in PD rehabilitation, and it is reported to significantly improve non-motor symptoms such as anxiety, fatigue, and depression, as well as quality of life. Since external cues during exercise further improve gait and motor function in PD, (3) you know where I’m going with this: Music perfectly fulfills the role for external cueing. Its effects are related to timing of auditory stimuli and an activation of pleasure induced by activation of the limbic system and consequent dopamine release (4). This may in part be due to remodeling of fronto-centroparietal/temporal connectivity, which could counter the loss of automatic and rhythmic movements in PD. Cueing that is specifically tailored to individual patients further amplifies the therapy (3).

Because well-designed MT has generally positive effects on the emotion and reward systems, therapy is almost universally enjoyed by the patient. It therefore encourages patients to actively take part in their treatment of PD. Improved balance and mobility are documented for at least the first and second years of music-cued dance training, pointing to long-term beneficial effects (4). Therapy that is so acceptable is particularly important for long-term compliance, since the effects are not maintained if therapy ends, and losses in cognition and muscle strength occur as well (5).

But it is only recently that we have had robust meta-analytic data to confirm the actual effect of MT on a patient’s motor function, balance, gait, mental health, and quality of life. The story is positive for walking velocity, improvement of freezing, and improved mental health, leading to an overall improvement of quality of life (4).

Voice development with a group singing program – another significant part of MT – has led to improvements in memory, language, speech

processing, voice, and respiratory muscle strength in the elderly community, and this has also been the case with PD (2). Group singing has been especially beneficial for offsetting the onerous social isolation and poor morale that so often accompanies PD.

This has not been lost in my own community of Shrewsbury, Massachusetts, where The Choral Singing Program for Parkinson’s, directed by David Russell, meets weekly to offer a therapeutic singing program. The commentary from participants is inspiring. (6)

If music therapy, which broadly incorporates listening and processing of music, seems so effective, what about “mental music?” Can simply thinking about music or humming tunes produce similar effects?

A study by Harrison (7) shows that different tempos of internal cueing by singing aloud or thinking about tunes can improve gait and improve motor performance for elderly adults as well as those with PD. Walking trials with internal and external cueing were conducted at 90%, 100%, and 110% of their preferred cadence. High cadence rates seem advantageous, but optimal cueing needs to be determined individually. Participants modified their cadence and stride length and reduced gait variability. But gait variability, a risk factor for falls, was reduced only with internal clueing (7), and traditional external cueing may actually increase variability (8). In a more practical sense regarding internal cueing, when walking down the street, mental singing may be less attention-grabbing than singing out loud. (8)

The anatomical model of what is happening with mental music hasn’t been entirely elucidated, but I have some ideas. About six or seven years ago I stopped by the functional MRI research lab at UMass Chan Medical School and asked if they would consider doing an fMRI music study on me. They kindly set up the three tests I requested:

1. The control – listening to the bylaws of our hospital, read by my wife in the most boring monotone she could muster. The plan was for this to be the fMRI equivalent of being brain dead.

2. Listening to a sonata that I know very well –the Rachmaninoff Cello Sonata – with which for years I struggled mightily with on the piano to accompany my son.

3. Silence – only thinking about playing the Rachmaninoff.

To make any sense of the following fMRIs, we need to recall that the areas of uptake in red and yellow are in comparison to another parameter

Humanities in Medicine

For Parkinson’s Disease, Strike Up the Band Continued

which is subtracted from the scan. So, if activity is equally increased in both of those parameters, we will see gray – which could seem to indicate that nothing is going on, but that’s therefore not necessarily the case. (Don’t fret over this.)

Using a few representative slices of brain, what follows is an “executive summary” of multiple MRI images taken for the three parts of the study.

In Fig 1a, listening to the bylaws and subtracting listening to music, somewhat surprising is my auditory cortex lighting up with the bylaws reading (red outline), but no emoting, as opposed to Fig 1b, in music listening fMRI where we see much emotional activity (yellow outline), but no activity in the auditory cortex. (I was obviously intensely engaged by my wife’s rendition of the bylaws.)

In listening to the bylaws and subtracting thinking about music (Fig 2a), the music is silent, so this time we expect (and see) substantial uptake in the auditory cortex (outlined in red) and an absence of emoting. In Fig 2b mental music produces no auditory uptake, but leads to striking emoting (outlined in yellow) and brain stem activity (outlined in green). The brain stem (most prominent uptake of which is in the pons) includes pathways exiting the brain to activate motor activities in the body.

Fig 2

Fig. 2a. Listening to Bylaws > Thinking Music

Fig. 2a. Thinking Music > Listening to Bylaws

Fig. 1a. Listening to Bylaws > Listening to Music

Fig. 1b. Listening to Music > Listening to Bylaws

Fig. 1

It seems that no matter what the parameter, the pons lights up with mental music. Is my brain directing my fingers to start working, and am I “visualizing” the keyboard and/or the score? This (finally) gets to my question about mental music impacting so dramatically on gait – probably more than external cueing, which in its own right is so impressive. Is this because of activation of the brainstem (corticospinal tract), and would this be an area worth further study?

The medical literature most often leaves the human side of interventions to our imagination, since the hard objectivity of p values is unlikely to activate our brains’ emotional centers. About six years ago I diagnosed my brother-in-law, Gary, with PD. In the last year or so he has struggled. I was unable to find a music therapist in his home country of the Philippines, but my niece found a dance instructor whose enthusiasm and skills are infectious, and he put together a wonderful program on the fly.

So, allow me to introduce you – with their permission – to Gary, music/dance therapist Jaypee, and home aide Glenda. By spending eight minutes watching this video, I think you will experience a valuable human side to this story.

In conclusion, MT improves mobility, balance, voice, speech processing, anxiety, fatigue, depression, socialization, and more. Unfortunately, impressive functional gains are not maintained if therapy is discontinued. The hope for our PD patients is that our medical colleagues will more actively write prescriptions for music therapy, importantly coordinated by a skilled music therapist.

Luana Katlen da Silva et al. (5) astutely recommends this take-home message for our patients: “Never stop the music.” I think we should certainly consider this advice. +

Humanities in Medicine

Fig 3

In Fig 3a, listening to music, as expected, lights up the auditory cortex (outlined in red), but in Fig 3b with thinking, we see executive decisions flying (outlined in blue), as well as much emoting activity outlined in red. This activity took place in the right basal ganglia, the parietooccipital regions, the cerebellum, and all sorts of non-specific areas, including the visual cortex. The brainstem outlined in green is prominent.

References

1. Costa, H.N., Esteves, A.R., Empadinhas, N., et al. Parkinson›s Disease: A Multisystem Disorder. Neurosci. Bull. 39, (2023) 113–124

2. Sotomayor, Manuel Joaquín Machado, ArufeGiráldez, Víctor, et al. Music Therapy and Parkinson’s Disease: A Systematic Review from 2015–2020. Int. J. Environ. Res. Public Health 2021, 18, pp. 01-16.

3. Calabrò, Rocco Salvatore et al. Walking to your right music: a randomized controlled trial on the novel use of treadmill plus music in Parkinson’s disease. Journal of NeuroEngineering and Rehabilitation (2019) 16:68.

4. Zhou, Zonglei, Zhou, Ruzhen et al. Effects of music-based movement therapy on motor function, balance, gait, mental health, and quality of life for patients with Parkinson’s disease: A systematic review and metaanalysis. Clinical Rehabilitation (2021). Vol. 35(7) 937–951.

Fig. 3a. Listening to Music > Thinking Music

Fig. 3b. Thinking Music > Listening to Music

Joel Popkin, MD, MACP is a Professor of Medicine at UMass Chan Medical School and a Program Director Emeritus at St. Vincent Hospital.

Humanities in Medicine

For Parkinson’s Disease, Strike Up the Band Continued

5. Da Silva, Luana Katlen, et al. Music-based physical therapy in Parkinson’s disease: An approach based on international Classification of Functioning, Disability and Health. Journal of Bodywork and Movement Therapies. (2021) Vol 26, pp. 524-529.

6. https://www. apdaparkinson.org/ community/massachusetts/ resources-support-ma/ arts-movement-classes/artmusic/ (Accessed March 28, 2023)

7. Harrison, EC, Horin, AP, Earhart, GM. Mental singing reduces gait variability more than listening to music for healthy older adults and people with Parkinson’s disease. J. Neurol. Phys. Ther. 2019, 43, 204–211.

8. Harrison, EC, Earhart, GM. The effect of auditory cues on gait variability in people with Parkinson’s disease and older adults: a systematic review. Neurodegenerative Disease Management. 2023 Jan 25. (Ahead of Print.)

Looking and Listening with Learners: Art Museums in Medical Education

Sara G. Shields, MD, MS, FAAFP

An art museum may not seem like a setting for medical education, but many medical training programs are starting to incorporate art observation into their curriculums. The UMass Family Medicine (FM) Residency has partnered with the Worcester Art Museum (WAM) since 2013 to train its residents in the art of observation, communication, and teamwork, and UMass medical students have long been visiting WAM as part of electives in the humanities or professionalism and lifelong learning.

The goal in bringing medical learners to a museum is not to make them into art historians, but to teach important skills for physicians to gain, outside the usual hospital or clinic setting. Being in an art museum allows students and residents to practice close observation, thoughtful communication, non-judgmental listening, and critical thinking skills, while encouraging them to develop a tolerance for ambiguity. The quiet, light, and space at WAM – in contrast to the noise and hubbub of hospital or medical office settings – offer an environment in which these skills can flourish, making it a unique learning space.

When Hugh Silk, MD, MHA and I were first developing the UMass FM humanities curriculum, we presented our work at a family medicine conference and were partnered with a residency program from New Jersey that was focusing on art as a topic in medical humanities. This program took residents on a yearly trip to the Metropolitan Museum of Art in New York City and used a specific teaching method called visual thinking strategies (VTS) to guide residents through looking at art together. The VTS format – with facilitators guiding a group through three standard questions about an artwork – is a natural fit for adult learning in reinforcing curiosity, deeper observation, and close listening to others’ observations, all of which match goals for medical learners. Dr. Silk and I immediately realized both the value of this approach in medical teaching and the natural fit with our amazing local museum, so we started talking with WAM about incorporating visual art observation into our humanities program. We met with the now-retired WAM director Jim Welu, who had been teaching art observation with medical students intermittently for years and shared some of his favorite methods with us as we started our program.

As is true for our entire FM residency curriculum, we have invited and responded to resident feedback about our approaches, with the curriculum thus evolving over the years. With the guidance of our then-associate residency director and medical humanities expert Sherrilyn Sethi, we moved from somewhat unplanned visits once a year to a more deliberate wellness-inspired curriculum, with specific artworks used to guide the WAM docents (some of whom are retired physicians themselves) in planning tours. We began incorporating more free time for the residents to explore the museum’s galleries themselves and then share what they found with their colleagues. We were also able to use WAM’s studios for residents to be creative with watercolor, clay modeling, and pastels. In recent years, as curricular time has shifted, we come once a year to WAM with our incoming interns and use the site to introduce our full humanities curriculum with writing exercises as well as gallery observation time using the VTS framework.

One of my favorite moments with residents over the years in the museum involved a group of second-year residents from the Family Health Center of Worcester,

where I have been on the faculty since 1995. While looking together at Winslow Homer’s The Gale, this group (which included some who themselves were mothers of young children) began discussing how this painting might remind them of different mothers they have seen in their practice and how society defines and judges “good” mothering. With another group, we had a similarly profound discussion of the multiple emotions of pregnancy while observing Otto Dix’s The Pregnant Woman, a painting showing a nude pregnant person in the late stage of pregnancy with their face hidden, challenging observers with its frank and depersonalized depiction.

My own role at WAM has also evolved as part of this teaching. In 2018, the timing was right for me to take the nine-month docent training course that WAM was offering, allowing me to dig deeper and learn from both the museum curators and my fellow docents (some of whom are amazing art historians) in ways that could enrich my own teaching. While the clinical demands of the pandemic prevented me from participating fully in docent work, I now focus on bringing medical groups and participating as much as I can.

UMass students also continue to visit WAM as part of different curricular options. Students taking an optional enrichment elective called Art for the Physician have come for tours each of the last two fall semesters. I teach annually in Dr. Frank Domino’s Leadership and Professionalism elective for fourth-year medical students and other groups at the medical school have organized tours during student wellness electives throughout the school year. In Dr. Domino’s course, we have done both virtual and in-person art observation sessions. I especially appreciate taking students in these sessions to the Renaissance Courtyard at WAM, where we start by simply enjoying the space and light and then move to looking at the powerful large wall mural, These Days of Maiuma. Its complexity of images and objects begs close observation and inspires ongoing speculation about its meaning. Every time I take a group to see this work, I enjoy observing the moment when they recognize how it is related to the permanent mosaic collection, and I relish in learning every time someone knows about art that I have

Otto Dix, The Pregnant Woman, 1931. Courtesy Worcester Art Museum not previously noted or known. As is often true in medical education, the teacher learns from the learners in the art museum as well! +

Sara G. Shields, MD, MS, FAAFP Professor of Family Medicine and Community Health Director of Inpatient Perinatal Services for FMCH UMass Chan Medical School Family Health Center of Worcester

Worcester Art Museum. Courtesy Kenneth C. Zirkle, Wikimedia Commons

Humanities in Medicine

Illness on Canvas: Diseases Depicted in Renaissance Art

Parul Sarwal, MD

It was 2014. I was on a pediatric nephrology rotation at Mass General as a visiting medical student. One day, while making my way to the noon conference, I came across a poster that instantly caught my attention. “What is Italian Renaissance art doing in a pediatric unit?” I thought, somewhat distracted by another pressing question: whether there would be lunch at the conference. Following my subsequent hour-long struggle with renal tubular acidosis, I stayed back to check out the poster on Ellison 17. Titled Pediatric Disease in Artwork, it was authored by one of the residents, Dr. Thomas Heyne. After the first couple of paintings and reading about the physical signs they depicted, I was quite pleased with myself for having “diagnosed” most of the other pictures. After all, spot diagnosis is every medical student’s leisurely pursuit in any given setting. This incident spurred a nascent interest I had long harbored. I spent that evening looking up paintings related to nephrology. I stumbled upon the manuscript, Michelangelo: Art, Anatomy, and the Kidney (1) by Dr. Garabed Eknoyan, a nephrologist at Baylor. He writes about Michelangelo’s interest in anatomy which the latter refined by performing dissections on cadavers. This interest later translated into textbook illustrations by the artist in his collaboration with the Italian anatomist and surgeon Realdo Colombo. Michelangelo, who was known to have recurrent nephrolithiasis, was treated by Colombo for his stones. I personally find some irony in knowing that the sculptor’s medium was also his malady. Dr. Eknoyan postulates that the Renaissance man’s tryst with obstructive nephropathy may have inspired his panel showing God separating the Earth from the Waters on the ceiling of the Sistine Chapel (figure 1). The nephrologist interprets the shape of the painting resembling a bisected right kidney in the panel and thus Michelangelo’s allusion to the concept of filtration of gravel (or stones) from fluids.

I eventually wrote to Dr. Heyne to thank him for the inspiration and shared the above paper. Fast-forward two years—I had now moved to Boston for my research fellowship. It was HubWeek 2016. One of the events was Michelangelo to Van Gogh, organized by the Arts and Humanities Initiative (AHI) at Harvard Medical School (HMS). The audience was called on to participate in a collective visual thinking exercise to diagnose disease in the works of famous artists. I was quite pleased to see Michelangelo and the kidney feature in this symposium. In addition to Dr. Heyne, the panelists included Dr. Joel Katz, Vice Chair for Education at Brigham & Women’s Hospital, who has spearheaded the use of visual arts in clinical training. He is the co-director of the HMS course Training the Eye: Improving the Art of Physical Diagnosis at the Museum of Fine Arts (MFA) in Boston. Having participated in the AHI during my two years in Boston, I had the chance to attend one of his sessions at the MFA and observe an adaptation of this program myself.

For over a decade now, Worcester has had an analogous curriculum locally, led by Drs. Hugh Silk and Sara Shields at the UMass Family Medicine Residency. This multifaceted program (2) includes an introduction to the concepts of humanities in medicine and narrative writing at the beginning of residency. Every year, the residents are taken on a guided tour of the Worcester Art Museum to examine the art, utilizing it as a tool to hone the skills of observation, team building, and communication. So, what comes of exploring disease depicted in art? It is an exercise in observation, which is the essence of diagnostic medicine. This lends itself to the art of interpretation with limited information or clinical context at one’s disposal. Looking for disease in paintings cultivates an appreciation of the physical exam, a fading skill in today’s defensive and imaging-focused clinical culture. It creates the opportunity to become comfortable with ambiguity, with detecting patterns, and with presenting differential diagnoses. Finally, it nurtures a meditative inner dialogue, while simultaneously encouraging communal conversation on the deviations from a healthy form.

An interesting sample is hidden in plain sight in Raphael’s Sistine Madonna (figure 2). Upon closer inspection, you would notice that Pope Sixtus is illustrated to have six fingers on his right hand. Whether this was simply wordplay on Raphael’s part, or subtle

Figure 1: Separation of the Earth from the Waters, Michelangelo, 1511, and a schematic1 to draw a comparison to the kidney with the renal pelvis (inset); Figure 2: The Sistine Madonna, Raphael, 1513-14.; Figure 3: St. Luke healing the Dropsical Child, Giovanni Lanfranco, 1625.

Illness on Canvas Continued

symbolism of the Pope’s fabled sixth sense, continues to be debated (3). Either way, it is an interesting depiction of a case of hexadactyly in a painting.

Another example – and one of the paintings Dr. Heyne has referenced in his works (4) – is Giovanni Lanfranco’s St. Luke Healing the Dropsical Child

(figure 3) It shows Luke the Evangelist palpating the radial pulse of a toddler with a distended abdomen. This is speculated to be one of the earliest portrayals of congenital heart disease, specifically a ventricular septal defect. The cyanotic appearance of the child displaces liver or kidney dysfunction on the differential. So, the next time you look at a certain Italian noblewoman in one of da Vinci’s iconic masterpieces, you will not miss the golden glimmer of her xanthelasma. +

Dr. Sarwal is an internal medicine hospitalist at Saint Vincent Hospital. After graduating from Kasturba Medical College in India in 2015, she completed a research fellowship at Mass General Hospital before moving to Worcester for residency. Taken by the industrial charm of the city, she decided to stay on. In her free time, she enjoys birding and is an ardent member of Mass Audubon.

References:

1. Eknoyan, G. “Michelangelo: Art, Anatomy, and the Kidney.” Kidney International, vol. 57, no. 3, Mar. 2000, pp. 1190–201. PubMed, https://doi. org/10.1046/j.1523-1755.2000.00947.x.

2. Silk, Hugh, and Sara Shields. “Teaching Humanities in Medicine: The University of Massachusetts Family Medicine Residency Program Experience.” Journal for Learning through the Arts, vol. 8, no. 1, 2012. escholarship.org, https://doi.org/10.21977/ D9812657.

3. Beccia, Carlyn. “Can You Spot the Medical Conditions in These Famous Paintings?”

The Grim Historian, 9 Sept. 2022, https:// medium.com/grimhistorian/can-you-spot-themedical-conditions-in-these-famous-paintingsa2a0d3c35776. Accessed 29 Mar. 2023.

4. Heyne TF. Lanfranco’s Dropsical Child: The First Depiction of Congenital Heart Disease? Pediatrics, vol 138, no. 2, Aug. 2016;138(2):e20154594. https://doi. org/10.1542/peds.2015-4594

The Healing Power of Stories

Wendy Arena, MS, RN

Precision is something we tend to equate with numbers rather than words. However, precision isn’t limited to the domain of quantifiable data. Precision of language is equally meaningful. This is just one of the reasons why we need the humanities in health care. The Oxford Dictionary defines humanities as “the subjects of study that are about the way people think and behave, for example literature, language, history and philosophy.” The humanities help us to understand and communicate with the people with whom we work and for whom we care.

I’ve discovered that many of us who gravitate to the helping and healing professions often have personal reasons for wanting to make the world a better place. In some cases, it was because the environments we lived in as children were not safe or nurturing. This was my situation, and I’ve talked to many nurses and nursing students who have shared similar stories. Fortunately, I learned to read before I began school. Literature became my window into other worlds and ways of life. Through stories I learned about other people, places, and times. I learned about the natural world and our connection to its inhabitants. It was through the humanities that I learned that life was full of possibilities.

As alluded to above, the humanities seek to explain how people think and behave. In many cases, this is through the use of stories. To tell a story is to create meaning from circumstances that may otherwise seem senseless. We communicate through stories. They provide a foundation for our culture and our personal and collective histories. Stories are how we create our truth. It isn’t just the creation of the story that has such power, but also the sharing. Stories are how we connect and relate to one another. Humans are the only species (of which we are aware) that has evolved to the level of being able to read, write, and speak. These are powerful tools when wielded skillfully and intentionally.

Creating the emotional space and trust required for a person to share their story is a fundamental, but often underutilized, skill. Allowing a person the time and space to tell their story has become a luxury in our time-pressured modern health system. It requires being fully present and listening to what is said as well as what is not said. Our patients are telling us stories all the time if we are willing to listen with our full attention.

I work in and teach mental health nursing, which is focused more on forming relationships with patients and less on performing tasks. The main focus of mental health nursing for undergraduate students is building therapeutic communication skills. Interviewing a patient is basically eliciting a person’s story in their own words. The most important communication skill is also the most challenging: listening.

Many nursing students dread their mental health rotation. There is still a stigma when it comes to mental health. In addi-

Humanities in Medicine

The Healing Power of Stories Continued

tion, many student nurses are accustomed to “doing for” rather than “being with” our patients. Students inevitably ask what they will be doing while they are on the mental health unit. Patients don’t usually look ill, after all. The majority of people are up and walking around. Most of them don’t even appear mentally ill. Not to the untrained eye, anyway. On the inpatient mental health unit, people are admitted in crisis. Many are suicidal. Many have substance use disorders. Some are homeless. Students tend to panic the first few days as they struggle to interact, terrified of saying the “wrong thing.”

Initially, students watch me interview patients. They comment on how open people are in talking about their struggles. We talk about the sense of relief and validation that comes with feeling seen and heard; with having one’s humanity validated rather than judged. Eventually, students do the interviews under my supervision. I can see the transformation taking place as I read their reflection journals over the weeks that they are with me. They use words like “fascinating,” “eye-opening,” and “misconception.” My exams can’t capture this change in attitude, but their writing clearly does.

As nurses, we are trusted with the most intimate details of people’s lives. We witness individuals and families at their most vulnerable. Within the sorrow, fear, and suffering, however, there are also glimpses of profound joy. Being a nurse means carrying around the stories of the people whose lives we’ve been priv-

ileged to touch over the years. Some of the stories are heartbreaking. Without attending to our emotions, the heart eventually reaches a point where it can no longer break into smaller pieces. It either calcifies into an impenetrable fortress or it liquefies into a pool of pure emotion. Neither is conducive to proficient nursing care.

Between these extremes is the balance where tenderness and compassion can be found. While some might say that being tender-hearted is a liability, I would argue that it gives us the capacity for empathy. It is through this tenderness that we can access the humanity that inspires stories, poetry, and art.

Despite all of the advances in science and technology, there are limits to what can be explained empirically. Despite our best attempts, we always reach the edge of certainty and truth. The humanities fill in the gaps that empiricism cannot. The humanities allow us to navigate uncertainty with a sense of grace and creativity. They add color to an otherwise black-andwhite world.

Most of the students I teach will not go into mental health nursing, but I remind them that if they are caring for humans then they will be using the skills they have learned in my course. Humanities, like mental health, is a field of study that helps us to understand how people think and behave. Through learning and understanding human behavior, we acquire the ability to relate to and communicate with one another. This is fundamental to every aspect of health care. +

The Intersection of Art, Architecture, Biology, and Medicine: A Convergence of Disciplines Shaping Our World

Akil A. Sherif, MD

Throughout history, art has had a profound impact on various disciplines, including the field of medicine. The dynamic interplay between art and medicine has been a catalyst for the evolution of these fields, consistently driving progress forward. Art has long been revered as an expressive and communicative medium, but it has also played a critical role in how we perceive and comprehend the complexities of the human body and illness. Trailblazing artists have contributed greatly to the depiction, documentation, and innovation of our knowledge of the human anatomy and its intricate workings, inspiring significant advancements and breakthroughs.

During the Renaissance, a significant shift occurred in medical illustration and anatomical comprehension. Art and science intersected as innovative artists and anatomists such as Leonardo da Vinci and Andreas Vesalius embarked on meticulous studies of human anatomy, resulting in exceptional anatomical illustrations. Da Vinci’s in-depth drawings of the heart and circulatory system, for example, established the basis for cardiology studies. Similarly, Vesalius’ publication, De Humani Corporis Fabrica (On the Fabric of the Human Body), revolutionized the field of anatomy and presented an exhaustive visual guide to the cardiovascular system. These illustrations helped advance the evolution of modern cardiovascular medicine through the provision of significant insight into the heart’s configuration and function. In the 17th century, English physician William Harvey followed in the footsteps of his predecessors, including Vesalius and da

Wendy Arena, MS, RN; Nursing Instructor at Fitchburg State University and PhD Nursing student at Tan Chingfen Graduate School of Nursing, UMass Chan Medical School.

Intersection of Art, Architecture, Biology, and Medicine

Vinci, to unravel and outline the circulatory system’s purpose. His publication, “De Motu Cordis” (1628), revealed the heart’s capacity as a pump that distributes blood throughout the body. The striking illustrations created by artists of the time were instrumental in supporting Harvey’s work and helped communicate his discoveries to the medical community and the general public. This groundbreaking study established the basis for contemporary cardiology while illustrating a pivotal and inextricable correlation between art and medicine. Today, medical illustrators continue to play an important role in medicine, crafting elaborate visuals for use in textbooks, scientific journals, and materials designed to educate patients. Despite the changes in the tools and techniques employed by healthcare professionals due to technological advancements, the significance of visual representation in medical communication continues to be of utmost importance.

Art and artists have continued to play a crucial role in medicine despite the evolution of modern times. Although certain traditional aspects of this relationship may have waned, new opportunities for collaboration and influence have emerged. With the advent of simulation and virtual reality (VR) technology, medical students and professionals can now gain hands-on experience of surgeries and treatments before performing them in real life. Furthermore, VR can be used to create calming virtual environments that can help ease patient anxiety and reduce the need for sedatives and painkillers, resulting in vastly improved patient experiences. The convergence of art, biology, and technology has led to the development of stunning visualizations of complicated medical information, which play a significant role in improving communication between medical professionals, researchers, and patients. The collaborative efforts of medical illustrators, bio-artists, and data visualization experts with healthcare experts have resulted in the creation of accessible, informative, and visually compelling data that can help educate patients and support informed healthcare decisions.

Art has also played an important role in highlighting important public health issues, with artists creating captivating works that touch upon health-related themes and stir up dialogues on various matters. Keith Haring, recognized for his vibrant and unique style, was an influential figure and social activist during the 1980s. In the midst of the unprecedented AIDS epidemic, Haring crafted numerous pieces that tackled the crisis, generating awareness about AIDS, and calling for enhanced

funding for research, prevention, and treatment. One of his most iconic images, Silence=Death, became the emblem for the AIDS activism movement. Similarly, Vik Muniz, a Brazilian artist renowned for his innovative use of non-traditional materials in his photography, created stunning portraits using discarded waste along with waste pickers at the world’s largest landfill in Rio de Janeiro, Brazil, in his Wasteland collection. The project was captured in the Academy Award-nominated film “Wasteland” (2010), highlighting the significance of waste management, sanitation, and the daily lives of waste pickers who make valuable contributions to environmental sustainability. These types of examples spotlight the extensive interdisciplinary nature of art, with artists utilizing their craft to offer perspectives that redefine cultural norms.

Notably, Frida Kahlo, an acclaimed Mexican painter, known for her intensely introspective and evocative self-portraits, sensitized the world to the experiences of people like herself battling a life of chronic pain and disabilities. These examples demonstrate the power of art to address critical public health issues and raise awareness, often transcending cultural and geographic boundaries to engage audiences worldwide.

Although it may seem that the intersection of art and science is slowly fading away in its traditional sense, both art and humanities as a field of study have continued to evolve as much as science and technology. In fact, both fields have become increasingly intertwined over time, with each influencing the other in a more profound way. An interesting example to highlight this is the contemporary evolution of mobile phone technology which saw a significant metamorphosis with the genesis of the iPhone. The iPhone was born out of a formidable creative design philosophy that forced technology to adapt and fostered a new era of technological innovation that would conform to the demands of this new design philosophy, eventually leading to the advent of many of the popular devices we use today. Creative visions and philosophies akin to this have always been the catalyst in the history of technological advances.

In the same vein, the unique blend of ideas arising from the fields of art, architecture, and biology has given rise to a transformative and innovative approach to design named “material ecology.” The movement combines nature’s principles and processes to create adaptable and eco-friendly structures. Dr. Neri Oxman, an inventor, architect, and designer, is a pioneering figure driving this interdisciplinary approach. Her work, which spans various fields such as 3D printing, architecture, and science, blurs traditional design boundaries, and her input has been critical in redefining how we see design. Her approach, which unites diverse fields, has led to numerous innovative creations that defy the traditional limits of art, architecture, and biology. For instance, the Silk Pavilion – an architectural wonder built by 6,500 silkworms – utilized cutting-edge digital fabrication and biological processes to produce a one-of-a-kind cocoon-like structure. This showcased the unparalleled promise of combining biology and technology in design.

Seeking to revolutionize material production and disposal, the Aguahoja project displays an array of colossal, 3D-printed installations crafted from water-based biopolymers. By demonstrating the potential to incorporate biodegradable elements in design, the Aguahoja initiative underscores how these structures can be entirely composted and returned to their original environment. These initiatives have sparked crucial

Humanities in Medicine

The Intersection of Art, Architecture, Biology, and Medicine Continued

conversations surrounding the role of technology and biology in tackling environmental concerns, and the future of design in a resource-limited world.

Another example of interdisciplinary convergence is seen in the emergence of biomimicry – the practice of utilizing nature’s principles and processes to create eco-friendly solutions. Cutting-edge medical designs, prosthetic devices, and surgical tools are being created using this approach, resulting in more efficient and sustainable outcomes. Moreover, biomimicry has inspired biophilic architecture, a design strategy that incorporates natural elements into buildings to boost human wellness. According to studies, biophilic design in healthcare settings reduces anxiety, promotes quick recovery, and improves patient outcomes. Furthermore, advancements in digital fabrication techniques, particularly 3D printing, have changed the medical world in many ways. Such technology allows for the creation of customized medical devices, implants, and pros-

thetics that cater to patients’ particular requirements while providing them with unique solutions. Moreover, 3D printing shows great promise in the field of tissue engineering and regenerative medicine, which could play a crucial role in the future of human organ transplantation. Looking back, despite all the challenges we are facing and those that lay ahead, now is the most exciting time in human history. And our vision of tomorrow is built upon the work of giants across generations, across disciplines, whose lives and work continue to influence ours today. Science, technology and medicine today are closely intertwined and are recognized as such. However, the influence of the humanities in these fields is frequently forgotten. Paraphrasing Fareed Zakaria, the sciences are the how, and the humanities are the why - why are we here, why do we believe in the things we believe in, why do we respond the way we do, why do we have the emotions that we have. It is therefore paramount for us as good stewards to encourage, support, foster and empower our peers across disciplines to enable these confluences that will enable us to build a better tomorrow. +

Akil A. Sherif, MD is a second year fellow and chief fellow elect at the St. Vincent Hospital Cardiology fellowship program.

Ice, a Warm Cup of Tea, and a Night in the ED

Golda Grinberg, MS4

The Gold Humanism Honor Society (GHHS) is a community of medical students, physicians, and other leaders who have been selected by their peers for their compassionate care. GHHS reinforces and supports the importance of the human connection in healthcare, which is essential for the health of patients and clinicians. Founded in 2002, through the generous support of Robert Wood Johnson Foundation, The Berrie Foundation, and an anonymous donor, GHHS now has more than 180 chapters in medical schools and residency programs and more than 45,000 members. GHHS hosts many initiatives and events that are open to all, including Solidarity Week for Compassionate Care, Thank a Resident Day, the Gold Connection podcast, and Golden Glimmers (https://www.gold-foundation.org/programs/ghhs).

On behalf of the GHHS, in honor of the annual transition of Solidarity Week, we held a creative writing contest, eliciting creative or non-fiction responses to the following prompt: What makes someone humanistic or what is an example of humanism you have observed in others? Congratulations to our winner, Golda (Goldie) Grinberg, MS4, UMass Chan Medicine School.

Ihad just finished a surgical knot tying workshop and rejoiced in finally settling into the groove of my OBGYN clerkship. I felt a buzz and looked down to see a text from my husband, who was supposed to be taking our baby to multiple outpatient appointments that morning: He had a few apneic seizures this morning. Going to the ED just to be safe. Can you come? I started to mentally rearrange my schedule and calculated against the extra 90 minutes of driving to stop at home and get my breast pump. I had planned to use the one in the lactation room at my current location but figured I had enough time

to find one in the ED where I was headed. On the drive over, I relaxed to Disney music as I prepared for the marathon ahead. As a parent of a medically complex child, this wasn’t my first rodeo. I knew that stress wouldn’t be productive in the moment.

I walked into the room and surveyed the scene. Thankfully, our son was asleep, taking up a small fraction of the stretcher with his G-tube hanging on the railing. Without pausing for too long to relish the opportunity to catch up with my husband over lunch, I found his nurse and repeated my well scripted line: “Can I please have a pump, two 8oz bottles, a washing bin, two bags of ice, and dish soap, so I can pump soon?” In truth, I still had an hour until my next session, but experience had taught me that it’s best to ask as soon as possible because of the flurry of activity

Ice, a Warm Cup of Tea, and a Nigh in the ED

in the ED. A few hours later, just I was starting to painfully engorge, the nurse finally walked in with a pump and bottles. She couldn’t find the rest. With a sigh I assembled the apparatus and stuck the flanges on. The milk can stay a room temperature for four hours, and since our son had been stable thus far, maybe we could make it home by then.

Just as I started a let-down of milk, he went stiff and pale. Before the pulse oximeter registered his apnea, I slammed the red “Staff Assist” button. I hunched over the stretcher railing as I snaked the oxygen tubing near his nose, trying to not lean too far and spill my precious collection. Thankfully the last few months of exclusive pumping had provided adequate maneuvering practice. The room suddenly filled with people who stabilized him in a few minutes. The team then introduced themselves as the oncoming providers and shared the new plan of admission for neurologic monitoring. The last to file out was the attending physician. She glanced down at my chest, which was double its normal girth due to the flanges and bottles bulging under an oversized shirt that I had draped over to preserve some modesty. Without skipping a beat, she asked with confidence, “What can I get you?”

I answered with my previous request of supplies, and miraculously, three minutes later, she walked in with a bin, dish soap, and plenty of ice to keep the milk cool. I knew something like this didn’t randomly happen. I joked, “I’m guessing you’ve pumped before?” She affirmed with a smile and said that’s where she was about to go.

The admission orders included plenty of blood work, which typically required the specialized IV team equipped with ultrasound guidance to find a viable vein in our son. The ED team gladly acquiesced but warned that the IV team would likely only be able to come in the middle of the night. Sure enough, we were starting to feel the adrenaline crash when the IV team finally arrived. We recognized the nurse from a previously successful attempt and felt comfortable slumping into nearby chairs for a reprieve. I turned to my husband to discuss logistics for the rest of the night. We had learned that at least one of us should sleep in a nearby hospitality house to recharge physically and mentally in order to effectively communicate and advocate for our son. I offered, “You can sleep there tonight, but if

you can find anywhere open, some tea would be great.” We keep kosher, so the available food options were slim. He packed up and left. Thirty minutes later, I concluded he hadn’t found an open shop. I tried to energize through the fact that they had successfully drawn labs. Just then, the nurse walked in, holding a cup of steaming tea. He had overheard our conversation, and I guess I looked desperate enough for a caffeine boost. That tea powered me until we finally were admitted hours later.

I often meditate on the sensation of feeling seen by the attending and nurse. Those positive emotions fill me up and override the more numerous, less than ideal ED memories. What is it about those experiences that tug on my heart strings? My best guess is that they are a reminder that providers are human, too. Their assessment of a situation can run deeper than knowing which order sets are necessary to narrow the differential. The attending drew on her own experience as mother and realized the timeliness of obtaining pump supplies. The nurse recognized that the wellbeing of parents also impacts a patient’s care and that their stamina needs to extend beyond a single shift. Now, when I meet a family for the first time when they arrive on the floor, I try to remember that they usually haven’t slept for a night or two. I try to find out if there’s a small service that I can provide to show that we care about them, too. +

In loving memory of our son, Seffi Grinberg.

Golda Grinberg, MS4 is a fourth-year medical student at UMass Chan Medical School going into pediatrics. She started writing as a way of reframing precious experiences as a mother of a medically complex child into a narrative that helps physicians deepen their understanding of the patient and family perspective.