Abstract
The Medical School at Bristol University is noted for offering, and in some instances requiring, its students to work creatively with medical themes. Students, artists, educationalists and a web designer have worked to create an on-line exhibition of the resulting creative output. This can be viewed at www.outofourheads.net. This site is a themed repository of poetry, prose, drawings, paintings, cartoons, films, music, dance and rap. Most works come with commentaries that can be as illuminating as the works they describe. The site invites comment and welcomes new postings from anyone connected to medicine. As an alternative to the conventional pedagogical report, and in keeping with the subject matter, in this paper we tell the story of this unique educational enterprise through the narratives of four of its principle architects. The ‘Teacher's Tale’, the ‘Designer's Tale’, the ‘Curator's Tale’ and the ‘Artist's Tale’ offer different, personal, tellings of how the site came to be. Each tale contains hypertext links to notable works on the site some of which have become teaching resources within the institution. This paper is of relevance to anyone who seeks to explore and champion the human insights of this privileged community.
Prologue
The Medical School at Bristol University is noted for offering, and in some instances requiring, its students to work creatively with medical themes. Medical students, artists, educationalists and designers have worked together to create an on-line exhibition of the resulting creative output. This can be viewed at www.outofourheads.net. As an alternative to the conventional pedagogical report, we tell the story of this unique educational enterprise through the narratives of four of its principle architects.
The teacher's tale
I am a medical doctor and educationalist. In 2003, we started asking students to submit creative work on medical themes as part of a first year teaching unit. The ‘rationale, recipes and results’ of this initiative are unpacked in an accompanying paper (http://www.med-ed-online.net/index.php/meo/article/view/5394). In brief, we postulated that asking students to work creatively with medical themes would help develop their sense of the individual in a curriculum centring on the generic, encouraging them to savour and express their emotional reactions and experience the intrinsic pleasure of creativity.
The quality of the submitted work was often arresting in terms of its artistry or the poignancy of the issues with which it tried to grapple. A student would, for instance, write with honesty of their stubborn denial of incipient diabetes or submit a photograph of a snowman that they had crafted for a terminally ill patient who was unable to get outside in a Gloucester blizzard. Another dreamt her way into the synaesthetic world of severe autism (Box 1).
I judged many works deserving of a wider audience and began planning a paper anthology. But we were receiving submissions in every conceivable medium. Poetry and prose work fine on paper, but mime and rap and sculpture do not. Though I realised the obvious benefits of a web-based anthology, the technical challenge felt daunting. In addition, we had several thousand works to consider for inclusion. The idea seemed stalled when several unexpected things happened. The first was a chance meeting with an established artist with academic credentials and considerable sensitivity in working with ‘non-professional’ art. Her Doctorate in Education had involved the artistic work of special needs children. Catherine Lamont-Robinson quickly grasped the spirit of the enterprise and has been shaping it ever since. The second was connecting with one of our medical students who had, in a previous life, been a professional web designer. Danny van de Klee married industry-standard technical ability with an artist's eye for uncluttered design. Technical and financial backing from the University's eLearning team suddenly created the possibility of progress.
My artistic work can't get going unless it has a name, a central brightness around which the rest can gather. The project title ‘Out of Our Heads’ has an enjoyable ambiguity. It has enough druggy counterculturalism to cause a university webmaster to question its suitability. The student is immersed in other people's knowledge, the possessive pronoun asserts ownership: our heads, not anybody else's. Medics spend a lot of time in mental activity, but if we are Out of Our Heads, where are we? In our hearts?
We wanted to give these student artists the pleasure of seeing their works reach a wider audience. We also wondered if putting medically themed art into the public domain might positively influence public perceptions of medical education. Included in that public are potential medical school applicants and their parents. Might the discovery that the art of medicine has a place in the curriculum encourage students who had thrived in the humanities? We also had less utilitarian motivations. What insights would these fresh minds draw from their close and privileged exposure to the medical universe? We were interested, in particular, in what light they might shed on patients’ experiences, their critiques of medical culture and their reflections on their emerging professional status.
We needed to create a site that expressed within its form the nature of the work we were hoping to curate but, visually, it was hard to know where to begin. We could agree on three firm design principles. The form of the website needed to emerge from the artistic material rather than imposing on it. The student community would not only supply content, but be central to design decisions. Thirdly, the site would be iconic (i.e. visual) rather than textual in its presentation.
Our poly-vocal team established a written design brief. The site would host text, image, video, sound and flash files. Each media object would be associated with the artist's reflections on the context, the creative process or both. This was important as some of the most impactful work might be judged as artistically naive but tackled issues of utmost poignancy. The Facebook generation doesn't just wish to look, they want to interact. Visitors needed a means of making publicly visible comment and a mechanism by which new works could be submitted for inclusion. They also needed lots of flexibility in searching the site (by artist, title, subject, etc.).
We had to deal early with permissions and confidentiality issues. The former were complicated because many student artists had already graduated and were out of easy e-mail contact. We sought ethical advice about the inclusion of works detailing patient predicaments. We did not seek permission from patients. Occasional names were removed or changed, as was other identifying information. Most tales were generic, but some were so specific that a patient stumbling on the site might recognise themselves. We judged this to be an acceptable risk given that, in such cases, the students’ treatments were invariably sympathetic.
The designer's tale
Near the end of a long and labyrinthine journey through the Bristol medical curriculum, I found myself by a railway track digging on an allotment plot with Dr. Trevor Thompson. Discovering that prior to medical school I was once a professional web designer, he started talking about an idea for ‘Out of Our Heads’ – a web-based archive of medical student creative work. He wondered if I could help realise this dream.
At first I had reservations about returning to that stark internal landscape of hexadecimal and Boolean algebra. But it seemed this project might provide me with some sort of creative and emotional resolution in combining my disparate identities of artist, programmer and now doctor. The curator, Catherine Lamont-Robinson, was, by her own admission, wary of a ‘techies’. But we soon found ourselves engrossed in the challenge of inventing a ‘look’ out of nothing, sprawled on the floor, drawing and playing with bits of plasticine.
We wanted the student artwork to speak for itself through a simple, uncluttered, design. Additionally, we wanted the user interface to be minimal, playful and reveal itself rather than be obvious from the outset. After an initial idea for an interface using different shaped pills was abandoned, a tree was suggested. This provided a visual metaphor for the organic creative process, the complex branching systems of nerves, vessels and other structures within the body and a reference to the arbor vitae.
The animated eyes, hanging like bizarre fruit from the branches, came from wanting to express the notion of mindful watchfulness. Medicine, it seemed, involved a lot of uneasy watching from one side or other of the medical fence, as patients, practitioners and third parties, such as students or relatives, peruse the unfolding drama. The eyes also suggest introspection and reflection and their uncanny juxtaposition against the outline of the tree is meant to be un-nerving (sic), mimetic of such feelings often encountered when dealing with mortality and the body.
We found an archive in the university library of anatomy and medical texts dating back to the sixteenth century. These crumbling treasures provided a rich visual language and their intricate line drawings of things such as the vessels of the head and twin birthing conformations are used extensively but subtly in the design. These provide a reference to the continuum of medical education in Bristol and beyond. This is also mirrored in the choice of the phrenological head as the logo for the site, highlighting medicine as one of the healing arts, and the diverse cultural and historic background informing its practice today.
The collaboration with Catherine and the rest of the team was fruitful. Catherine encouraged the artist in me, I the designer in her. Trevor was keen to expand on novel features like sound effects, which is something I resisted, knowing from previous experience that there is a fine line between playfulness and annoyance. My focus was to get a functional, meaningful archive first and then develop these ideas later. I think we came to a happy medium, as the student artwork is itself full of humour and the site design does not detract from the stars themselves.
The curator's tale
As a creative facilitator in widely divergent communities and with a passion for the auto-biographical voice, handling suitcases full of raw data sparked both my narrative Citation1 and aesthetic sense of adventure. Gems were uncovered at each immersion and very few student works were without a glint of engagement beyond the requirement to submit.
My job was to select the works for inclusion on the site, long before its design had taken form. Not wishing to be either hasty or woolly in my choices, I established ‘definite’, ‘maybe’, ‘not quite sure why I am keeping this’ categories, and I began a parallel journal to document my thought processes as I continued to sift Citation2.
So, what were the criteria? At root, a sense of integrity in the pieces, a particular insight, a breadth of perspective and, albeit only surfacing, an Aesthetic integration, often hard-won.
A sheet of lined-paper with spidery, almost indecipherable, text, set my heart pounding, swiftly executed pieces astounded me with the quality of their insight and resonance, while some beautifully presented and mannered works would deliver little of substance.
We decided from the outset to present works according to emergent themes (rather than according to our own pre-determined categorisations Citation3). The process of identifying these, which now seem so obvious, was a challenge, as was the attribution of any single work to one theme only. Sharing complementary creative fascinations and educational values, Trevor and I crafted the over-arching concepts (such as Home Front or Doors of Perception) and sub-themes (such as My Family and Wounded Healer) and devised category descriptors to illuminate the grouping of work. These are included in Box 2.
The four themes of the homepage are introduced with an arc of blinking eyes. Rolling over any of these reveals further optical accoutrements providing cues to what lies beyond. Clicking on a blinking eye reveals a filigree of cerebral vessels, foregrounding the generic icons of the next level, inspired by student Nina Beck's painting of a rose.
Rolling the mouse over any rose, individual icons appear that are drawn from works residing in that particular category. Clicking on these icons reveals the actual works, displayed against a complementary background. For example, the category ‘Who Am I?’ was matched with an anatomical thumbprint from the archives. Other backdrops range from technical drawings of early surgical implements to current electromicroscopic imagery.
One of our early visitors commented, ‘What I think is important is that I really enjoyed rummaging around and was constantly surprised by the things I found’. This response highlights an interactive fluidity and playful ethos in the design. I added a Curator's Tour to facilitate navigation for those not inclined to go it alone. This includes insight into my own ethical journey. Respect for artists and their subjects is key to the delicate process of curation. Students share aspects of their their lives in a secure group context, or even privately for the eyes of their tutors alone. Though general consent had been obtained at the time of original submission, we wanted to be doubly sure that students were comfortable about public exhibition. In response to my enquiries, several wanted their works rendered anonymous, and very few withdrew altogether.
Throughout the development, we sought support and responses from others, including those outside medicine, academic colleagues and students. Dr Louise Younie, a GP and lecturer in Bristol, helped me track student artists who had been through her elective module in the ‘Creative Arts’. Such students had often gone much further in developing their artistry (see for instance this), and reflected deeply on the process (and this). We convened informal focus groups of students to help us gauge the anticipated peer-group response and referred back regularly to the perspectives of Will Duffin, the student artist in the design team who guided us through the subtleties of what might and might not be ‘cool’.
Medical staff from clinical departments have also voiced their appreciation of the opportunity to stand behind the creative lens of their students. One senior teacher confided that he had come across on the website creative work by a male student with whom he had had recent dealings of a disciplinary nature. The creative work showed him a sensitive side of that student which he could hardly have imagined, causing him to view the student in a different light.
After attending a presentation about the developing website, a retired obstetrician was prompted to contribute some poetry he had written as a junior doctor (Matthew John – died aged 9 days) and several general practitioners have enquired about submitting pieces. Patients involved in a creative arts group at a local surgery, where I have been working as artist in residence, have shown a critical interest in the students’ interpretation of medical conditions and remarked on the universal nature of the themes. On viewing the drawing ‘Reassurance’, one of the patient-artists observed ‘this is a mirror of my life at the moment – I am the hand being held – passive and unable to give anything back’. Some other responses to the website are included in Box 3.
The artist's tale
I always wanted to be a professional violinist. My ‘fallback’ option of going into medicine was born out of the stark realisation that in order to make a living in music, I would need to be either extremely good or extremely lucky. I was neither of these. As a medical student at Bristol, I began to embrace my new identity as a scientist of the human body. However, simply discovering where everything went, what it did and what happened when it went wrong, proved wholly unfulfilling. I found myself losing the ability to feel, to empathise and to truly connect with the subject matter.
I could hardly believe it when I looked at the lecture timetable and saw that sandwiched between pathology and biochemistry was a session on the ‘Art of Medicine’. We were being asked to produce something with a medical theme and share it with our colleagues in a group session. It's fair to say that most people had serious reservations about this compulsory creativity. Some were abhorred by the idea that they should be forced to produce a haiku or a watercolour, when this time could be spent memorising the divisions of the facial nerve. People came along to get their name on the register, as another hoop to jump through. We all expected it to be dire.
The collective astonishment was palpable. We were amazed by the diversity of talent, from rap music and dance, through to huge oil paintings, which explored challenging and evocative themes. Classmates revealed hidden depths: the ‘jack the lad’, known for throwing paper planes from the back of lectures, stood and delivered a mournful and poignant poem about sibling love and loss of innocence. It soon became apparent that while everyone was pretending not to care, they had been secretly and ferociously painting, drawing and composing.
When I learned that Trevor Thompson was planning to anthologise and showcase this wealth of creative talent, I was keen to be involved. We needed to make it accessible, non-pretentious, without having an obvious Faculty presence. The work had to be freshly presented and ordered into engaging themes. I wanted to see a site that was inclusive and open for comment and new contributions. In my book, the finished product has achieved all of this. Presenting the work in this format is a crucial step in creating a broader culture of creative expression in the medical community.
The work produced shows medical students becoming intimately involved with the plight of patients they have met. Hayley Penhale's ‘The Bold Explorer’ depicts a man newly diagnosed with prostate cancer as a small yellow figure navigating a bleak landscape of shattered white fragments, tentatively planning his next, potentially perilous, step. Emily Ashworth's painting ‘The Struggle’ is of a dancing couple: the male, powerful and commanding, takes the lead over the fawning female figure, representing the irrepressible dominance of physical illness over a patient's life ambitions.
Now that I am finally a doctor, I can appreciate more than ever how vital it is for people to nurture an outlet for the powerful emotions and dilemmas that practicing medicine evokes, through music, art, drama or whatever form this takes. Failure to value the people and their unique stories beneath the disease processes is what ultimately leads to burnout and boredom.
Epilogue
Johanna Shapiro, a pioneer of creative approaches in medical education, highlights in her writing the ‘inevitable distance between doctor and patient’ Citation4. This distance, which seems to grow rather than shrink through the clinical years, stems, she argues, from our collective discomfort with the sick. The sick remind us of what we don't want to be. Medical education should help us to recognise and process this gulf through approaches that emphasise our common humanity.
Our aspiration, in bringing creative endeavour to the Bristol medical curriculum, has been to foster student awareness of the human stories that are everywhere in the enterprise. Patient stories, doctor stories, student stories, stories of systems going well and systems going to pot. In creating settings for students to divine these stories, and to reflect on their significance, we thought to at least forestall their empathic decline.
Key to this process is the sharing of artistic work between students in established tutorial groups. This demands some risk taking on the part of the student. At most, they may reveal a poignant personal narrative and, at least, some form of emotional response to a medical predicament. Such revelation is, of course, what we regularly expect of our patients and demands of the listener a willingness to authentically witness whatever it is that has to be shared. These group encounters do then model many of the features of the sensitive consultation.
Of the several thousand artistic works that have been submitted by Bristol students, we have judged some as extraordinary through their artistry or their ability to illuminate some awkward corner of the medical universe. Through the www.outofourheads.net website, we have sought to bring these particular works to a wider audience. On the one hand, much of the emotional power is lost outside the context of the groups where they were first revealed. On the other hand, the website gives the viewer time to reflect, savour and compare.
We are now developing the site as an educational resource where students in different clinical specialities can link quickly to artistic works that foreground common themes. For instance, we have this and this on issues in early pregnancy and this and this on dementia. We have set students assignments to post considered responses to particular works and then used these responses as the focus for further discussion in tutorials. Using works created by other students adds interest and authenticity to these exercises. The website is also a source of inspiration when ‘compulsory creativity’ is demanded.
Anthologies of the creative work of a learning community are nothing new and the pleasure of seeing your own work in a real book is hard to better, but there is much to commend web-based curations. These allow exhibition in various media, including film, dance and rap, as well as the more typical poems, prose, cartoons, drawings and paintings. Visitors to the site can respond to the works and submit their own for consideration. The site can grow organically and be referenced in its entirety without the chore of tracking down paper copies.
This site came into existence due to an unheralded synthesis of artistic, technical and academic passions. An example of this is the weaving throughout the site of images plucked from the University's collection of sixteenth and seventeenth century illustrated texts. These collaborate to create an intentionally disconcerting interface that seems to look out as much as invite you in, a world as peculiar as medicine itself.
And where from here? We have secured funding to help us gather contributions from former students, current Faculty, NHS patients (it's only fair!) and invited artists. We are forging links with other institutions and investing in elective modules where gifted students can develop ideas and nurture techniques under the supervision of professional artists.We are curious about how to research the messages these artistic works convey about the medical universe as viewed from the shifting neutrality of the student gaze, but mindful too of the ethical complexities of offering up the stories of others for such scrutiny.
The insights conveyed on www.outofourheads.net are things at once peripheral and utterly central to the business of medicine; those moments, realisations and connections that lift us out of the mundane and highlight the privilege and poignancy of the enterprise.
Conflict of interest and funding
The Out of Our Heads Project received funding from University of Bristol Alumni Foundation and funding and technical support from the University of Bristol Centre for Medical Education. We wish to acknowledge the particular contributions of Jane Williams, Miranda Whinney and Dominic Alder.
References
- Alberty B. A documenter's perspective. Qualitative research and evaluation methods. Patton MQSage. Thousand Oaks CA, 2002; 589–98.
- Coffey A. The ethnographic self. Sage. London, 1999
- Young K, Saver J. The neurology of narrative. SubStance J. 2001; 94/95: 72–84.
- Shapiro J. Walking a mile in their patients’ shoes: empathy and othering in medical students’ education. Philos Ethics Humanit Med. 2008; 3: 10.