By Ranit Mishori
Special to The Washington Post
Tuesday, January 27, 2004; Page HE01

There's a poem about breasts that Caroline Wellbery thinks every physician should read:

They were born when I was thirteen

They rose up half out of my chest

Now they are forty, wise, generous

I am inside them, in a way, under them

Or I carry them

I was alive so long without them

I can't say I envy them,

though their feelings are almost my feelings

As with someone one deeply loves . . . .

They were a gift to me

And then they were ours

Like little nurslings of excitement and plenty

I remember my surprise when Wellbery introduced this work, "Poem for the Breasts," by Sharon Olds, into a lecture on "common breast problems" she delivered at a Washington clinic where I was a medical intern. This was not the way medical students are traditionally taught to think about what most of their teachers would call . . . mammary glands. But Wellbery, a physician and a teacher, had a purpose.

"It gives you insight about the fact that breasts aren't just there," Wellbery said when I spoke with her recently. It's a reminder, she says, that for female patients, "there's a lot of emotional investment in them."

Obvious? Not necessarily to doctors for whom breasts are among many, many "body parts" they've been trained to understand by tissue type or by place in a biological system.

Wellbery hopes that when doctors counsel a woman with breast cancer, the poem will come back to them and give them pause. She wants them "to remember and understand, 'Wow, breasts can really mean something to a woman,' and that offering a mastectomy, for example, may be very noxious to the person or to the breast."

In a course Wellbery leads for medical students and faculty at Georgetown University School of Medicine and in similar programs that have recently begun to proliferate around the country, here is some of what is on the curriculum:

• Hayden Carruth's "Notes on Emphysema," which tells of the writer's daily struggles trying to breathe.

• Raymond Carver's "What the Doctor Said," which details an encounter with his doctor during which Carver, who wrote short stories and poems, learns the bad news about his lung cancer.

• "The Promise" by Veneta Masson, a nurse and a poet, about fighting obesity.

• Mary Swander's essay "The Fifth Chair." A poet and novelist who was injured in a car accident, Swander describes what it is like living with debilitating back pain and how she came to terms with it.

• "The Elephant Man," the movie in which Joseph Merrick, a man with a disfiguring disease, bellows at his doctor: "I am not an animal! I am a human being! I am a man!"

• "Diabetes," a poem by James Dickey, best known for the novel (and its Oscar-winning film adaptation) "Deliverance." In "Diabetes," Dickey writes about how difficult he finds it simply to follow doctor's orders.

There is much more Wellbery considers important: paintings, essays and more poems -- all works produced by artists and patients and doctors who never mention sodium levels, oxygen saturation, acid-base balance or pharmacokinetics.

Wellbery and others are trying to introduce the humanities into medical education, and the medical field is taking these efforts seriously.

Last year, the American Association of Medical Colleges (AAMC) sponsored an international conference titled "The Healing Continuum: Medical Humanities and the Good Doctor."

The journal Academic Medicine dedicated its October issue to the topic, detailing "medical humanities" programs around the world. Forty-one programs were highlighted, but there are dozens more.

As Lisa Dittrich, one of the journal's editors, puts it: "Advances in medicine make the study of the humanities even more relevant and necessary. The study of the humanities can illuminate human interactions and concerns in a way the genome map or nano-medicine cannot."

Further, she contends that studying medicine through the arts "can also be humbling -- something physicians and researchers, particularly in the United States, badly need."

The reality is that most medical students are so burdened with science courses that they never have time for art and literature. Now, across the United States and Canada, nearly every medical school is offering a course or two to remedy that. There are also programs for doctors in practice.

One program -- it started six years ago in Maine and has now been copied in seven other states -- operates like a book club and involves not only practicing physicians but also nursing staff and health administrators. Assigned readings include "The Plague" by Albert Camus, ""Regeneration" by Pat Barker and "Lying Awake" by Mark Salzman.

Rita Charon, an internist who runs a medical humanities program at Columbia University's College of Physicians and Surgeons, says such discussions fill a need in the medical profession: "We don't know how to talk about pain and suffering and bad luck and these random, unfair things that happen to people." Novels and plays, she says, give doctors a language to speak, so that "we might be in a position to start these conversations."

While most medical humanities courses and seminars revolve around the written word, there are some notable exceptions. A New York medical school has organized trips to the Metropolitan Museum of Art, as part of a course on end-of-life issues. Students spend time among the Egyptian mummies on display there, studying and reflecting on ancient rituals of death and dying.

Other schools put more emphasis on film, music or photography. The Healer's Voice, a Web site run by the American Medical Student Association, features paintings, drawings and photography by and for medical students.

Clearly, many in the medical profession think there's something to this "humanities thing." While there is not hard evidence that seeing the right plays generally improves a doctor's performance, some studies suggest there are measurable increases in empathy; others show that training in the fine arts can enhance visual diagnostic skills.

Deborah Kirklin, director of the Centre for Medical Humanities at the Royal Free and University College Medical School in London, and her colleagues are trying to provide evidence that when doctors and nurses, with help from an artist, are trained to "observe objects and colors in detail, describe the objects and draw them," they show improvement in clinically relevant observational skills such as being able to identify skin lesions.

Irwin Braverman of Yale University School of Medicine has enlisted the help of the Yale Center for British Art to give first-year medical students a fine arts class. In a 2001 article in the Journal of the American Medical Association, he describes a study that involved three groups of students. One group received the usual clinical tutorial session; a second heard a lecture on anatomy; a third attended a course in which the participants were asked to study a painting for 10 minutes before describing it in detail.

When students from all three groups were shown photographs of people with medical disorders and asked to describe in detail what they saw, those who had been assigned to the art group achieved the highest scores.

Similar programs are springing up in various medical schools: Cornell, Brown, Duke, Stanford and the University of Texas in Galveston.

But not everyone is enthusiastic, starting with many medical students themselves. Dittrich says that some students required to take these courses do so "sometimes kicking and screaming."

Schools' resistance to incorporating humanities into the curriculum involves a lot of things: lack of time in an already jam-packed curriculum, lack of money, lack of resources.

Most important, there's the plain fact that many doctors would rather spend time reading the latest issue of the Annals of Internal Medicine than poetry. A lot of people in the medical field are, to put it simply, "science guys" and gals. That's one reason they were drawn to the field in the first place.

Wellbery, who teaches the poem about breasts, has conducted focus groups of medical students. She found that while many are interested in the humanities -- and believe there is more to life than the pure assimilation of knowledge -- many, perhaps most, are keener on the specifics of graspable information.

She recalls one student who reported that, after a lecture on palliative care, he complained: "After two hours worth of notes, there was only five minutes of information."

That attitude troubles Wellbery. "The idea that death and dying is boiled down to a few rudimentary facts that you can be tested on is tragic," she says. "It ignores so much of what life is. And medicine is per se the intersection between the personal and scientific spheres."

Some medical schools try to offer humanities incentives beyond giving academic credit, grants and salaried positions to faculty. The University of California, Irvine, plans to introduce a "Graduation with Distinction" designation for students who take on extra work in the humanities. A New York University School of Medicine program offers literary publishing opportunities for its students and residents. The University of Rochester School of Medicine and Dentistry is planning to mention students who complete a humanities program in their graduation proceedings.

"People want to be rewarded for what they do," Wellbery offers. "They want to see how it leads to this goal or that goal. And with arts and humanities it is very hard to see. It is much easier to do with dry information." But, the paradox is, as Wellbery points out, that beyond "measurable outcomes," the process is what's important. In the end, "it's about the journey."

Charon thinks doctors need to stretch themselves, not just by studying the arts, but by practicing them as well. She assigns her third-year medical students at Columbia to write stories about the people they treat, as she herself has been doing since the 1980s.

It began as an experiment, after she took a writing seminar. It changed forever the way the way she saw herself as a doctor.

"I couldn't stop writing about patients," she recalls, "and realized that as I wrote about them, even if I didn't know something about them, like what the patient did before she came into my office, I'd just make it up."

So yes, this was "creative writing." But still, Charon says, it wasn't exactly fiction, either.

"I realized I wasn't making it up completely from scratch. There were things I knew about this patient, but wasn't really conscious of knowing. It was that knowledge that somehow nourished my clinical imagination, which I have grown to very much treasure."

She found herself creating a portrait, an impression, built from small details, things she picked up that weren't strictly . . . "medical."

"It's how a patient sits in a chair. It's the particular tone of voice in which a patient explains why she left her medicines at home. It's the fact that the 48-year-old guy starts to weep when I ask him to tell me everything about his situation that he thinks we should know."

But what skills applicable to medicine does such an exercise teach?

"It is that set of skills that enables any human being to hear or read a story and understand what it means, to be engaged in the story, and to see it from the point of view of different characters," Charon says. "The more we look at it, the more we see that it is that equipment that's often missing in the doctor interaction."

The real payoff, she says, comes when she shares what's written with the patients themselves. "Did I get it right?" she asks them, and the question itself leads to a deeper relationship.

"Patients see that, if nothing else, you're trying [to understand them], and they're often rather impressed to see that their internist thought about them last night, at least enough to write something down. It is usually rather startling. I've found that the showing to the patient or the family is often as helpful as was the writing to begin with."

Still, it's not a bad idea for doctors to "get away from it all" from time to time, and appreciating a good book or a fine painting serves that purpose as well. As long ago as the late 19th century, Sir William Osler, one of the most influential teachers of medicine of his day, was preaching the value of the humanities as part of the care and maintenance of a good doctor.

"While medicine is to be your vocation or calling," he wrote, "see to it that you have also an avocation -- some intellectual pastime which may serve to keep you in touch with the world of art, of science, or of letters. . . . When tired of anatomy, refresh your minds with Oliver Wendell Holmes; after a worrying subject in physiology, turn to the great idealists, to Shelley or to Keats, for consolation; when chemistry distresses your soul, seek peace in the great pacifier, Shakespeare; ten minutes with Montaigne will lighten the burden."

And no, watching "Scrubs" or "ER" won't do the trick. •

Ranit Mishori, a physician at Georgetown University Medical Center, last wrote for the Health section about problems encountered by obese patients.