A sketch by NYU med student Michael Malone who takes an art and anatomy class.

Those who oversee medical education now recognize the benefits of exposing their students to the arts. Before graduating, today’s future doctors will be required to take a heavy dose of coursework in the social sciences. The New York Times reported on April 13, 2012 that the Association of American Medical College’s has revised its medical school admissions test (MCAT), and as a result, colleges are seeing increased enrollment by pre-meds in courses other than hard science and math. To prepare for the test, which will include areas like “ethics and cross-cultural studies,” students are lining up for courses like the history of modern science taught by Professor Piers J. Hale, who teaches at the University of Oklahoma. “Enrollment doubled and I had to turn 20 away,” Hale told the Times. “But what’s really exciting is not that taking this class will get these kids into medical school, but that it will help them become better physicians.”

Dr. Charles Hatem, a professor at Harvard Medical School and an expert in medical education is less certain that the changes on the MCAT will impact the delivery of healthcare, but acknowledges the general need for more empathic doctors. “Yes, we’ve fallen in love with technology, and patients are crying out, saying, ‘Sit down and listen to me,’ ” he said. “So what the MCAT is doing has a laudable goal. But will recalibrating this instrument work? Do more courses in the humanities make you more humane? I think the best we can say is a qualified maybe.”

Many medical students are also now encouraged to take up the practice of art making, doing courses in drawing, painting, and reflective writing. The Wall Street Journal ran an article on February 1, 2011 describing arts-based programs in medical schools at Brown University, New York University and the University of Iowa. According to instructor Hedy Wald, a clinical assistant professor of family medicine at Brown, the goal of Brown’s required “Doctoring” course is to help students cultivate empathy, think critically about diagnoses, cope with uncertainty, and deal with the ethical dilemmas of their profession. “The act of writing helps you build reflective capacity so you can better understand the patient’s story and integrate it with everything you know as a doctor to have a more patient-centered-care relationship.”

“Patient centered care” is a term often used in the Arts In Healthcare community. In fact, the title for the 2011 Society for the Arts In Healthcare’s conference was “Advancing Patient-Centered Arts.” As an artist in residence in the Arts In Medicine program at Shands Hospital at the University of Florida, patient-centered care is something I am asked to embody. But what exactly does it mean?

Ideas about “patient centered care” began showing up in medical journals in the early 1990s, and doctors, academics, and policy makers continue to refine the definition and how it is used.

In an August 2010 column on the medical blog, KevinMD.com, Christine Cassel, President of the American Board of Internal Medicine, offers this definition by The Institute for Healthcare Improvement: Patient centered care considers “patients’ cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient and their loved ones an integral part of the care team who collaborate with health care professionals in making clinical decisions… [and] ensures that transitions between providers, departments, and health care settings are respectful, coordinated, and efficient. When care is patient centered, unneeded and unwanted services can be reduced.”

In a 2001 article, “Towards a Global Definition of Patient Centred Care” for the medical journal, BMJ, Moira Stewart—Professor and Director of Centre for Studies in Family Medicine, Department of Family Medicine, The University of Western Ontario, London, Ontario, Canada—cites studies that suggest patient centered doctors display a “flexible” style while working with patients.

Communication and understanding are key, she writes. When patients are heard and their individual concerns are addressed, evidence shows a “tangible benefit: patient centred communication is positively associated with patient satisfaction, adherence, and better health outcomes.” Stewart reminds readers that patient centered care cannot be easily broken up and examined. While classifications may be useful for teaching and research, “patient centred clinical practice is a holistic concept in which components interact and unite in a unique way in each patient-doctor encounter.”

Patient centered care envisions a real collaboration between patient, family members, and healthcare providers and ultimately seeks to move control of healthcare into the hands of the person receiving it.

Though I’m not a physician or member of a hospital’s medical staff, I believe the concept is worth applying to my work as an artist in residence. Doing so requires me to take the patient’s lead in everything I do, from entering a room to recommending an activity or art project.

Photo by Emily Friedman

Across the United States, cancer was the second leading cause of death in 2007, according to the Centers for Disease Control and Prevention.  On January 1, 2008, there were approximately 11,957,599 men and women alive who had a history of cancer (5,505,862 men and 6,451,737 women).  This year, The National Cancer Institute estimates that 1,596,670 men and women (822,300 men and 774,370 women) will be diagnosed with and 571,950 men and women will die of cancer.

One oncologist at Johns Hopkins Kimmel Cancer Center is using art’s potential to help patients deal with physical and emotional challenges brought on by the dreaded illness.  In his essay in the Journal of Clinical Oncology (2011)  “Art in Oncology: How Patients Add Life to Their Days,” Dr. Evan Lipson writes about the ways patients use art to transform their lives post-diagnosis.  Lipson writes that part of his role as a physician is to find ways for his patients to live full lives within the context of cancer.  He does this, in part, by encouraging them to tell stories and make art. “People living with a serious illness develop novel, often overwhelming feelings that defy expression by the usual means.”  Art, Lipson writes, helps patients communicate their feelings in ways words alone cannot.  Art also offers benefits beyond self-expression.  “For some patients, art is a way to leave behind something tangible, a palpable reminder, perhaps. For others, art is an escape, a brief vacation from the roller coaster.”

Dr Lipson has also created a website called SeizeTheDays.org that features short audio clips (usually 2 or 3 minutes) of cancer patients describing how they are making the most of their lives during and after cancer.  All of the patients featured on the website are doing “positive, meaningful things” said Dr. Lipson in a recent phone interview. Patient stories on seizethedays.org represent the complicated ways cancer impacts people’s lives.  Many people on the site have dealt with multiple diagnoses and faced a number of personal challenges after receiving their life-altering diagnosis.  They have lost time at work, had disrupted relationships.  Yet all speak eloquently about how they are moving forward with their lives in the present moment irregardless of the circumstances.

Dr. Lipson’s essay and website have been an important find. His essay confirms the power of individuals to transform their experience of illness through art.  His website offers examples of patients and families who have positively reimagined and changed their experience of life post-diagnosis.  Their stories may be useful to the patients I see in a variety of ways.  Dr Lipson said they may feel less isolated by listening to the experiences of others:  “I’ve had patients get on to the site and say it showed them ‘I wasn’t alone.  I wasn’t the only one dealing with this.  I wasn’t the only soldier in this battle.’”  The stories also offer hope.  Patients can hear that “people are still able to find positivity in what is otherwise a horrible journey.”

For more about Dr. Lipson and his website, see this story by NPR.

In February 2011 I ran across an article in the New York Times by Pauline W. Chen, M.D. that helped shore up my ideas about the potential for art—particularly storytelling—to effectively promote public health. Chen, a surgeon, author and columnist, revealed the findings from a trial published in the Annals of Internal Medicine that examined the effects of storytelling on patients with high blood pressure. Researchers observed 299 African-American patients with controlled and uncontrolled hypertension. At 3-month intervals, half of them received DVDs featuring patients with similar medical conditions telling stories about their experiences. The most significant improvements were seen among patients with uncontrolled hypertension at baseline who listened to the narratives. The editors of journal report concluded: “Storytelling can be an effective way to teach patients about hypertension and improve blood pressure control.”

Echoing the editors findings, Chen suggested that storytelling can work in two fundamental ways, by reducing stress and teaching patients how to take better care of themselves. She began her article by telling the story of a liver transplant recipient who was afraid of the surgery’s potential hazards. But after speaking with other transplant survivors he came to believe he would be O.K. “You doctors have answered all of my questions, but what I really needed was to hear the stories about transplant from people like me.” This patient’s stress was alleviated after speaking with those who’d had the same procedure. The hypertension trial also suggested that people would change their lifestyles after hearing other people’s stories. Chen: “Whether among patients in peer support groups or between doctors and patients in the exam room or even between doctors during consultations, stories are an essential part of how we communicate, interpret experiences and incorporate new information into our lives.”

Chen points out that storytelling works in a variety of ways according to experts in narrative communication. For starters, stories can help offset denial, a major problem among patients receiving a new diagnosis. Other people’s stories are naturally more engaging, so people are more likely to pay attention to them. Patients may also identify with the storyteller. Chen interviewed Dr. Thomas K. Houston, lead author of the study and a researcher at the University of Massachusetts Medical School in Worcester and the Veterans Affairs medical center in Bedford, Mass. “Telling and listening to stories is the way we make sense of our lives,” he said. “That natural tendency may have the potential to alter behavior and improve health.” Dr. Houston is engaged in more studies examining the use of storytelling in patient care.

A growing number of studies show that people—including those dealing with physical illness—who use expressive writing have seen positive results. Expressive writing differs from other sorts of writing mainly in the level of openness required on the page. Participants are asked to write about their innermost thoughts and feelings regardingtraumatic and stressful experiences.

Dr. James W. Pennebaker, who chairs the psychology department at the University of Texas, Austin is, perhaps, the most active researcher on the topic. In Pennebaker’s first expressive writing study published in 1986, forty-six healthy college students were divided into two groups and asked to write for fifteen minutes on four consecutive days. One group was asked to write about the most traumatic events in their lives, the other on inconsequential topics. Students who wrote about traumatic events were in better health six months after the experiment. They used a pain reliever less often and paid fewer visits to the campus health center. The authors concluded that “writing about earlier traumaticexperience was associated with both short-term increases in physiological arousal and long-term decreases in health problems.”

In 2005 Advances in Psychiatric Treatment published a survey of the literature on expressive writing to date. The authors Karen A. Baikie and Kay Wilhelm’s report showsboth the benefits and limitations of expressive writing. They note that although many participants in expressive writing exercises experience short-term distress, negative mood, and physical symptoms, longer-term benefits seem to make up for initial discomforts. Expressive writers show fewer stress-related visits to the doctor, improved immune system functioning, reduced blood pressure, improved lung function, improved liver function, improved mood/affect, feeling of greater psychological well-being, etc. They are absent from work less often, enjoy quicker re-employment after job loss, have improved working memory, improved sporting performance, and higher student grade point averages. Benefits of expressive writing have been seen in people with the following illnesses:asthma, rheumatoid arthritis, cancer, HIV, cystic fibrosis, and others.

In their article, Baikie and Wilhelm also describe why expressive writing seems to work. Emotional catharsis is an ineffective explanation. Instead, those who confront previously inhibited emotions may reduce physiological stress through cognitive processing. Developing a coherent narrative may help to reorganize and structure traumatic memories, resulting in increased ability to adapt. Some evidence also suggests that repeated exposure may help eliminate negative emotional responses to traumatic memories. The authors conclude by advising clinicians to use expressive writing as adjunct to standard medical and psychological treatment, not a replacement, despite it’s demonstrated benefits.  Research is ongoing…

I’ve had two, what I would call, “rockstar experiences.”  The first was during the ’96 or ’97 H.O.R.D.E Festival in northern California when Lenny Kravitz took the stage.  He was dressed in a skin-tight, silver, sleeveless jump suit that glinted sunlight as he moved.  I had seen him swing his dreadlocks on TV, but seeing him work in real time was something else altogether.

At one point, he quit playing suddenly and back away from the mic.  ”S$&#,” he said, “I almost got electrocuted.”  A brief pause followed.  I was afraid he’d been injured, but he went back to playing soon after a few roadies came on stage and tinkered with the equipment.  The mishap just made him seem cooler.

I was 23 or 24 years old and had been to a lot of other rock shows, in both auditoriums and tiny dives.  But Lenny’s performance was different.  He seemed to blast through whatever conventions I was trying to live up to.  His performance was energetic and primal.  I now have a bit more compassion for those young women screaming after the Beatles.

My second “rockstar experience” actually took place at a poetry reading.  That night, however, the feeling was transformed into something more important and lasting–an appreciation of art that required effort.

This was in the early spring of 2001 or 2002, which would have meant I was 28 or 29 years old.  That night I sat in the balcony of the Babson College’s Sorenson Theater.  I had gotten there early so I could get a good seat.  I wanted an unobstructed view of my favorite poet, CK Williams, the evening’s featured reader.  At one point, I looked at the row of chairs below me and there he was, walking up the center aisle towards the stage.  It was cold out, deep winter–February, I think–and he wore a thick drab-colored coat.  He looked tall and thin, his arms hung loose from his shoulders.  I fought back feelings of rockstar admiration for him, which were entirely unexpected.  But the emotion quickly changed as soon as he started reading.  I was not bowled over by sound and imagery.  I had to listen up.  And his words immediately appealed to my intellect and its complex, subtler set of emotions.

William’s poem, “First Desires,” speaks to the challenges and frustrations we must endure to appreciate art.  (Read it on the New Yorker’s website.)  When first listening to classical music, we try to “get it” beyond the welling up of emotion.  At first, “there are only volumes and velocities thickenings and thinnings…”  These “touch within you, through your body, to be part of you/and then apart from you.”  You want to learn more, but even when you do get something, “the grainy timbre of the single violin, the/ardent arpeggios of the horn,” there are still “uneases and confusions left, an/ache, a sense of longing…”  You want to blame “a flaw of logic in the structure, or in (you knew it was more likely) you.”

CK William’s poem both embodies the struggle and rewards of art.  Any appreciation of art demands effort on the part of the viewer/listener/reader. Our initial emotional responses quickly fade unless we are patient and cultivate a kind of deeper understanding. I often feel incapable of moving beyond the my initial experiences with a work of art, especially if I don’t seem to “get it.”  I may even blame the work when it presents a challenge.

Poetry can be like that for me. I love poetry, even try and write it sometimes, but it’s often so hard to grasp, and I get lazy.  But poetry rewards are many.

For the past several months, I’ve been enrolled in Goucher College’s MFA in creative nonfiction writing program.  Last semester, my advisor was Richard Todd.  He announced at the start that we would be reading and discussing poetry instead nonfiction by saying the language would be good for us.  Read for pleasure, he said, and get the voices the best users of our language into your heads. “This is very purifying diction,” he said.  ”It washes out some of the toxins.”

Since I was small, I have wanted to paint. But I waited until I was thirty before I actually took up a brush. Why? The simple answer is fear. There are many visual artists in my family. I was afraid I would never measure up to their standards. It was safer not to try.

I write because I have to. I’ve been writing poems and stories for as long as I can remember. Writing has much to do with how I functioned in the world, connect with friends and family, make choices, and make a living.

Being a visual artist is still important to me, so I continue my drawing and painting practices.  I also play music.  I recently started taking drum lessons. I’m not proficient as a painter or a drummer, and I may never be. I still believe filling your life with many different types of creative processes has merits.

And I’m not alone.

Finding the book, Writer’s Brush a few years ago was a turning point in my thinking about incorporating multiple arts into my life. It continues to bolster my confidence in making visual art especially. Editor, Donald Friedman presents a catalog of visual art by famous writers—Mark Twain, Maxine Hong Kingston, Flannery O’Connor, Sylvia Plath, E. E. Cummings, Derek Walcott—and often includes excerpts of commentary by them about their drawings and paintings.

E. E. Cummings reminds readers that every authentic “work of art is in and of itself alive and that however the arts may differ among themselves, their common function is the expression of that supreme alive-ness which is known as beauty.”

In an excerpt from “The Nature and Aim of Fiction,” an essay published in 1957 and reprinted in Friedman’s book, Flannery O’Connor writes that her main task as a writer is to make the reader see, and she recommends the visual arts to other writers. “Any discipline can help your writing: logic, mathematics, theology, and of course and particularly drawing. Anything that helps you to see, anything that makes you look. The writer should never be ashamed of staring…I know a good many fiction writers who paint, not because they’re any good at painting, but because it helps their writing. It forces them to look at things.”

The last part of O’Connor’s quote—the part about the writers she knows not being any good at painting—has shored up my resolve to keep drawing and painting even when the images I make look like hell, which is most of the time. If I’m too tired and frustrated to aim for Cumming’s spiritually elevated “supreme alive-ness” I can still tell myself I’m reaching for something a bit more useful: painting is good for my writing.

Speaking on the same wavelength, Friedman quotes Derek Walcott who describes his own unsentimental approach to visual art-making: “No seasoned artist ever expects trumpets and a visionary light saying, ‘Go now to the studio.’ You just get up and you do your work as if you are a mason and a carpenter…you get an immense kick out of painting for ten minutes, and then you realize it’s hard.” Writes the editor, Friedman: “Artistry is not a matter of inspiration for Walcott, but of craftsmanship.” It’s that way for me too. Just doing the work is my primary mode of operation, if I have one.

One final note: It helps to have a purpose in making art, especially when creativity seems in short supply.  For me that purpose has been community.  Art brings us together in unique and important ways. It helps us communicate, honor one another’s experiences, and move forward together peacefully. Making art–no matter what it looks like–brings you into the conversation. Your voice matters.

Art making is often a solitary business. In fact, many choose to become artists precisely because they enjoy working alone. That is true for painter Chuck Close. In a 2007 television interview with Charlie Rose, Close described the working methods that have allowed him to continue to paint with minimal assistance from others after a spinal artery collapse in 1988 left him paralyzed from the neck down. After a brief period when he thought he would never paint again, physical therapy helped Close regain the use of his arms and hands, but he no longer enjoyed the same freedom of mobility. Close is known internationally for his enormous, nine-foot portraits of human faces—often of personal friends—on canvas. Prior to becoming paralyzed the artist painted with the help of a forklift truck. As a result of his impairment, however, he needed a new working method. Maintaining Independence and solitude were primary goals. “You become an artist because you wanted to be in a room by yourself,” he says. “And all of sudden you’re handicapped and you need help. Well, you want to make it as much like it used to be as you can…” Close’s solution has been to work in a two-story studio where he can move his paintings vertically through a hole in the floor.

Though Close enjoys the seclusion of the art-making process and tries to work unassisted as much as possible, his paintings express the personal connections he shares with other human beings. Close was born with Prosopagnosia, the inability to recognize faces. He has said that the disorder is part of what motivates him to paint enormous portraits of friends and family members’ faces. Through his paintings he hopes to etch the details of people’s faces onto his memory so that when he meets with them again “face-to-face,” he will know them more deeply.

Close’s work reminds us that regardless of how it gets made, all art is done in the context of the community in which it is made. Art—whether it is painting, music, poetry, or dance—speaks through self-expression and shared transcendence. It is a byproduct of human relationship.

I recently thumbed through my copy of the book, Art and Fear again. Authors David Bayles and Ted Orland offer artists one of the best recourses I’ve found for advice on continuing a healthy art practice.

In one of the books most famous sections (noted by bloggers like Jason Kottke) the authors share this parable on perfection:

The ceramics teacher announced on opening day that he was dividing the class into two groups. All those on the left side of the studio, he said, would be graded solely on the quantity of work they produced, all those on the right solely on its quality. His procedure was simple: on the final day of class he would bring in his bathroom scales and weigh the work of the “quantity” group: fifty pounds of pots rated an “A”, forty pounds a “B”, and so on. Those being graded on “quality”, however, needed to produce only one pot — albeit a perfect one — to get an “A”. Well, came grading time and a curious fact emerged: the works of highest quality were all produced by the group being graded for quantity. It seems that while the “quantity” group was busily churning out piles of work – and learning from their mistakes — the “quality” group had sat theorizing about perfection, and in the end had little more to show for their efforts than grandiose theories and a pile of dead clay (29).

It’s pointless to strive for perfection since humans, by nature, are imperfect. Why should we expect something different from our art? In fact, imperfection is an important ingredient in art. “Ansel Adams, never one to mistake precision for perfection, often recalled the old adage that “the perfect is the enemy of the good…’”

It is also fruitless for us to force ourselves to understand our art practice outside of the actual work itself. You come to make what you make by making it. Well, you might say, I haven’t any talent. Hogwash. “Talent is a snare and a delusion. In the end, the practical questions about talent come down to these: Who cares? Who would know? and What difference would it make? And the practical answers are: Nobody, Nobody, and None.”

We sometimes put a lot of unnecessary pressure on ourselves to fit a mold, any kind of mold. But art is too complex, too big and too rich to be labeled or constrained.

Bayles and Orland are not saying we ought to take our artmaking or the ideas behind it lightly.  On the contrary.  As we work, we should keep asking ourselves why our art matters. “In making art you declare what is important (108).”

Question yourself about your art practice, locate in it what is most important to you—careful always that the questioning comes through the making.

This month’s creative activity is featured in my forthcoming e-book, 31 Days to a More Creative You: Keep Your Day Job, Banish Perfectionism & Play More. It is Day 1.

Each day this week, spend 5 minutes writing in your journal. If you don’t own a journal, any simple notebook will do.

Fill two pages of your journal with stream of consciousness writing. Give yourself absolute freedom to write about anything and everything, even if you think it has nothing to do with a particular topic. Just keep writing.

Try starting with an image (a storm cloud, a bushy-tailed cat), a quote or line from a poem (see below for links to poems) and let the words flow without stopping them.

Practical writing is fine, of course. Even your (late) Christmas shopping list counts as writing, but only if it arises naturally. You may also find yourself writing useful material for work or school projects. Wonderful! Just keep writing.

When your fifteen minutes of free-writing are up, and only then, feel free to go back and collect chunks of useful text. Plop them into your work report, term paper or new novel. But remember, the point of your journals is “play,” not “work.” If what you write seems like gibberish, don’t be dismayed. Just keep writing.

When I lead writing workshops, I try to emulate one of my most important teachers, Pat Schneider. Pat founded Amherst Writer’s and Artists (AWA) and developed a method for writing that she fully describes in her book, Writing Alone and With Others. Pat says, “Every person is a writer, and every writer deserves a safe environment in which to experiment, learn, and develop craft.”

I was a member of Pat’s writing workshop for several years. She often encouraged us to respond to prompts through free-writing as a way to break through creative blocks.

Author Julia Cameron also uses free-writing in her book, The Artist’s Way.  She encourages readers to write daily “morning pages” to reconnect to their creative selves.