Touching Portraits

In 2005 the artist James Esber produced a line drawing of the turbaned bearded face of Osama Bin Laden. He subsequently sent a photocopy of his sketch to nearly one hundred friends, inviting each one of them to reproduce it on tracing paper and enhance the work to their liking with shades of black and red ink. The compiled results form the heart of his exhibition “You, Me & Everyone Else” currently on display at the Pierogi gallery in Brooklyn.

Some of Mr. Esber’s friends were members of his own family. Some were professional artists in their own right; others had no previous artistic training. Yet they all succeeded in expressing themselves in a unique way. In Mr. Esber’s words, “personal touch becomes paramount.” Each person possesses a unique touch, which under the proper circumstances can be drawn out.

When I step into an exam room to see a patient, I enter another world. I offer a greeting—an invitation of sorts—create an ambiance, ask a question or two. If the chemistry is right, the patient begins to talk, expressing concerns, fears, pain; sometimes hope, even joy. I provide the framework, the blank canvas, on which the patient might choose to render a drawing, a portrait—a blend of some segment of existence.

I recognize that any narrative might be slightly different depending upon the nature of the interaction. The technique works best with gentle guidance. As with any work of art, it fails miserably with inadequate time and attention to detail.

Thoreau writes: “It is something to be able to paint a particular picture, or to carve a statue, and so to make a few objects beautiful; but it is far more glorious to carve and paint the very atmosphere and medium through which we look, which morally we can do. To affect the quality of the day, that is the highest of the arts.”

Perhaps, like Mr. Esber, that is what we who work in the helping arts are tasked to do: to draw out the unique touch of those whose lives we touch every day.

The last time I saw Paris

We build our temples for tomorrow, strong as we know how, and we stand on top of the mountain, free within ourselves.       —Langston Hughes

The last time I saw Paris was this past Wednesday night when PBS aired the documentary, Paris: The Luminous Years.  This was a small miracle in itself, because my wife usually co-opts the TV remote and calls the shots.  She’s not particularly enamored with French culture.  But for once I had my way.

From 1905 to 1930 Paris became the gathering place for avant-garde artists from all over Europe, Russia and the United States.  It was here that modern art, poetry, dance, music and architecture evolved, beginning with the initial Fauvist exhibitions and ending with the advent of jazz.

Many of these early artists formed ad hoc bohemian communities and fed off one another’s work and ideas.  They found the open ambiance to be energizing, stimulating, liberating.  Paris was the place where many of them found themselves.

In 1923 Langston Hughes arrived in Paris from America with seven dollars in his pocket.  He knew no one in the city and had no letters of introduction.  He soon found a job as a bus boy in a jazz club and proceeded to write the poetry for which he would become famous.

In those days Paris was color blind.  Americans who had served in the European theatre in the First World War were eager to return to Paris.  These expatriates rejected their parochial roots and set out to find themselves in the big city.  Paris was where it was at.

Thoughts of that Parisian era swam through my head as I drove to work the following morning.  What it would have been like to amble down the street or sit in a café and mingle with the likes of Duchamp, Breton, Picasso, Braque, Chagall, Apollinaire, Miró, Joyce—a heady feeling at the very least.

My morning reverie dissipated as I started in with my patients.

A pair of new patients appeared on my schedule.  An adolescent boy and his younger sister needed physical examinations to matriculate in the local school system.  I met their aunt, who was in the process of adopting these two children, both of whom had come from the big city.  They had been placed in her care three weeks ago when their mother succumbed to a stroke at age 45 on Thanksgiving Day.

The boy was tall, athletic and polite.  “I’m sorry to hear about your mother,” I told him.

He shrugged his shoulders.  “She had high blood pressure, diabetes and asthma; but she didn’t take care of herself.  She smoked two packs of cigarettes a day and drank coffee all the time.  We figured she wasn’t going to last long.”

I asked a few questions to flesh out the past medical history and proceeded to the exam.  “So what do you like to do for fun?” I asked him as I looked into his ears.

“I like to drum,” he said.  “Down in the city I was part of a drum corps.  We were hot.  We took first place in the statewide competition last summer.”

“Wow, that’s pretty impressive!  Will you be able to continue your drumming with the group now that you’ve moved away from the city?”

“Don’t know.  But I’ll find something else to do.  Maybe I’ll try out for the football team.”

“Did you play sports in the city?”

“No, I wanted to, but there was always a transportation problem.  My mom didn’t drive and we didn’t have money for the bus.”

“Maybe you’ll have more opportunities now that you’re living with your aunt.”

“I hope so.  I’m so glad to be out of the city.”

There you have it, I thought, the great transmigration, only this time it was from the big city to a small provincial town. Maybe this would be the ticket this boy needed to help find himself.

Paris is Paris, no matter where you encounter it.

The Art of Medicine: Learning to capture the human figure

In his series of articles on the art of drawing, artist and author James McMullan speaks to that intuitive intelligence which the visual artist needs to cultivate in order to capture forces inherent in the human body:

Once we tune into these cooperative forces that animate the body, they seem obvious; yet opening up the kind of intuitive intelligence we need in order to see these forces is difficult when we are so used to relying mainly on the simple scanning operations of our eyes. As we draw, we need to record pressures and not just edges, and we need to see relationships between parts rather than just pieces of the body.

Reading these words, I was struck by the similarity between the art employed in drawing the human figure and the art of the practice of medicine. Both require the use of intuition to recognize the forces in play before the eyes of the observer.

In his approach to the patient, the medical student tends to dwell on organ systems—parts or pieces of the human body. This stance follows immediately from the way in which gathering the medical history is taught.

First, the patient’s chief complaint is identified. Many times it centers around pain. The student probes the patient to develop an understanding of the pain itself: its character, its location, its radiation, its severity, its timing—all necessary elements to round out a description that might fit a pattern consistent with a known clinical entity.

The physical examination serves to develop and substantiate the final diagnosis. Sometimes further testing—lab studies, imaging studies, tissue sampling—is deemed necessary to clarify the problem. Throughout this entire process, bits and pieces of data are gathered and assembled into an impression to describe the whole.

Although the master clinician gathers data in a similar fashion, at the same time he or she does more than just probe with questions and scan with the eyes. Intuition comes into play, albeit subtly, informing the clinician on a deeper plane, allowing him or her to discern the complex relationships between the pressures and forces that impact the functioning of the human being before his eyes.

In McMullan’s words, the clinician perceives that “significant energy relationships in the body are often not right next to one another.”

McMullan maintains that “You have to be alive to the possibilities of each pose as you encounter it, and be willing to be surprised and to surprise yourself.”

It is important “to identify the central aspects of a pose in order to give yourself a theme that helps you to organize your thoughts and the order in which you tackle the different parts of the body.”

“The best drawings of the human figure seize on its life force.”

In McMullan’s opinion, “all of these practices will lead you to empathic thinking,” a perspective which benefits both clinician and patient as well as the artist.

McMullan’s line echoes Tolstoy in his essay, What is Art? — “it is upon this capacity of man to receive another man’s expression of feeling and experience those feelings himself, that the activity of art is based.”

Historically, artists have studied anatomy to assist them in their understanding of the rendering of the human figure.

Perhaps clinicians need to consider the perspective of the artist to further an empathetic understanding of the patient.

A Pupil of Picasso

“I’m worried that my son might have a lazy eye.”

Seated in the chair by the exam table, this mother wears a concerned look as she produces a photograph from her purse.  “There—you see what I’m talking about?”

She points to the left eye in her son’s recent school picture.  By a narrow margin, it appears to be slightly smaller than the right one.  I study the color portrait and note that the light from the camera’s flash reflects off each cornea at the exact same spot.

The medical assistant has already checked the boy’s visual acuity on the Snellen chart:  20/20 vision in each eye.

“Anyone with lazy eye in the family?” I ask, reaching for a penlight to peer at the boy’s pupils.  “No?  Anyone in the family ever have eye muscle surgery?”

I ask the boy to follow the light: over, up, across, down, back to center.  I check for lid lag; I perform a cover test.  Finally, I use the ophthalmoscope to peer through the boy’s pupils to study his retinas.

The entire exam is normal.  I expected as much when I first glimpsed the photograph.

I find such encounters gratifying, because I’m able to reassure families that everything is fine purely on the basis of a thorough clinical exam.

“Then why does his one eye look smaller than the other?” his mother asks.

“It has to do with the distribution of the fatty tissue below the surface of the skin around the eyes,” I tell her.  “Have you ever studied Picasso’s works?  If so, you know that Picasso almost never rendered his subjects’ eyes as mirror images of one another.  They are usually of different size, location and proportion in his drawings and paintings.”

The mother seems pleased with my explanations.  She’s also happy that there is nothing wrong with her son’s vision.  All in all, it has turned out to be a good visit—for everyone.

In the Adventure of the Copper Beeches, Sherlock Holmes remarks: “To the man who loves art for its own sake, it is frequently in its least important and lowliest manifestations that the keenest pleasure is to be derived.”

Over the years I have taken keen pleasure in the art of medicine—and in the art of Picasso as well.

The Naïve Narrative

In his recent column In Defense of Naïve Reading, Professor Robert Pippin speaks to the state of literary criticism as it is taught on university campuses. His contention is that, although the current trend is to scrutinize the literary arts through the lens of the natural scientific research model — with the ultimate end of developing a “science of meaning” — creative works themselves were never crafted to serve research. Rather, their authors penned them as works of art, works meant to speak to us at the deepest level of our being.

In Pippin’s words: “Literature and the arts have a dimension unique in the academy, not shared by the objects studied, or ‘researched’ by our scientific brethren. They invite or invoke, at a kind of ‘first level,’ an aesthetic experience that is by its nature resistant to restatement in more formalized, theoretical or generalizing language.”

Pippin goes on to say: “Likewise ─ and this is a much more controversial thesis ─ such works also can directly deliver a kind of practical knowledge and self-understanding not available from a third person or more general formulation of such knowledge.”

I was reminded of these words during small group discussion at our recent Cell2Soul gathering on Nantucket. One of the presenters, a young physician, published author and director of a narrative medicine course, put forth his observations on illness. Illness, he maintained, separates us from our bodies. Illness diminishes us physically and morally. Illness alters the way we perceive the world and our place in it. Illness threatens us at the core of our being.

This young physician examined illness in various spheres of influence: illness and the self, illness in the doctor-patient relationship, illness and the family unit, illness and the community. He is working to formulate a theory of illness and its impact on the individual, the family, the community and society, in part to provide a framework for and justification of the study of narrative medicine in the medical school curriculum.

I applaud his efforts. In academic settings it is always necessary to justify what students need to learn to become competent in their chosen careers. A well-developed theory lends credence to academic study — and ultimately, acceptance of the particular discipline. In Pippin’s words: “We certainly need a theory about how artistic works mean anything at all, why or in what sense, reading a novel, say, is different than reading a detailed case history.”

When I engaged him in further discussion, the young physician maintained that the illness narrative could not stand alone by itself. It is too soft a subject to garner academic recognition.

Personally, I believe that narrative, like art, whether in written, cinematic, poetic or visual format, is sufficient to speak by itself. Although narrative understandably deals with the particular, it encompasses the universal, and so becomes relevant on a profound level.

Simple vignettes, simple narratives, in the hands of a skilled teacher, can be used to impart universal truths — scientific or moral — which every clinician needs to learn.

To Thine Own Self Be True

When Kristina Joyce was a little girl, she told her father that she wanted to become an artist when she grew up.  “Better a doctor,” her surgeon father told her, “than a starving artist.”

Kristina’s father was a pediatric surgeon who specialized in resecting tumors in children.  Her mother was a nurse.  Her grandfather and grandmother were both physicians.  They established the first hospital in Flagler, Colorado.  From the time she was a child, the family expected that she would pursue a career in medicine.  But Kristina had other dreams.

In 1986, Kristina became the first woman to attempt a series of scuba dives into the depths of Walden Pond.  She was interested in documenting the underwater flora and fauna of Walden, and wrote to the Commonwealth of Massachusetts to request permission to make the dives.  As a result of her studies, she was able to document a number of freshwater plants like nitella and quillwort and several species of fish that inhabit the depths of Walden.

I marveled at Kristina’s slide show, “Underwater Walden,” which she presented at the Concord Free Public Library, as well as her artwork in the exhibit “All the Earth is Seashore,” currently on display in that institution through September, 2010.

At this year’s annual gathering of the Thoreau Society, Kristina accompanied us on one of the early morning nature walks to the cliffs above Fairhaven Bay on the Sudbury River.  She told me about the art classes that she’s offered to the children of local residents in her home over the decades.  A number of her students have gone on to careers as professional artists.  Kristina described the joy she derives from teaching young people to express themselves artistically.

If you happen to be in the Concord area this summer, make it a point to stop by the Concord Free Library to see Kristina Joyce’s exhibit.  Her drawings and calligraphy are exquisite.

If she had listened to her father, perhaps she might have followed in Frank Netter’s footsteps as the next medical illustrator par excellence.  Had she pursued that path, undoubtedly she would have realized a handsome income.  As it is, she contents herself with her work, knowing that she’s nurtured the artistic lives of her students.

I can’t help thinking that her father would have been pleased at the way things worked out.

The Scottish Artist

I met him at table in the basement of the Masonic Lodge after the morning bird walk at White Pond.  How did he, a Scotsman, come to know the writings of Henry David Thoreau?

Through an obscure reference in a treatise penned by Robert Louis Stevenson, he told me.  “It was actually derogatory in nature,” the Scotsman said.  “Stevenson quoted another author as referring to Thoreau as a scoundrel.  It piqued my interest.  So I set out to learn if it were true.”

The first book he got his hands on was A Week on the Concord and Merrimack Rivers.  After that he read Walden.  By then he knew that Thoreau was no scoundrel.  On the contrary, he found solace in Thoreau’s writing.  “So much of what he wrote resonated with me in my soul,” the Scotsman told me.  “Money and material things aren’t everything.  These days I try, as much as I’m able, to live a simple life.  My needs are few.  Besides,” he said, paraphrasing Thoreau, “a man’s life is rich in proportion to those things that he can afford to live without.”

I asked him what he did for a living.  “Now I’m retired,” he told me, “but I had a career in telecommunications.  When I was a young man, I served in the armed forces as a paratrooper.  I spent some time on deployment in the Middle East—special services,” he said with a wink.  “Afterwards, my wife and I settled in the Wansbeck Valley, ‘dwelling midst woods and waters,’ as our motto says.”

“And how do you spend your days now?” I asked him.

“I rise early and watch the dawn come up over the valley and the river beyond,” he told me.  “I ramble through the woods and fields.  Lately, I’ve done a little column for our local gazette on natural history.  I also paint—birds mostly—working in gouache.  And then there’s my book collection.”

I merely had to wait for the narration.

“I’ve collected over a hundred books dealing with Thoreau alone,” he told me.  “I’ve got several first editions of his works published in Great Britain.  Walter Scott publishers picked him up in the 1880s.  In some of the books the pages weren’t even cut.  I had to go through them with a penknife.  I believe a book should be read, not just put on the shelf.”

And what brought him to Concord year after year?

“Wall, it’s good to rub shoulders with like-minded individuals, you know,” he said.  “And I bring poppies to place at the graves of British soldiers who died in the American War of Independence.  I place two at the graves at Old North Bridge, two in Lincoln, one at Meriam’s Corner and one at the marker by the Colonial Inn in Concord,” he explained.  “The war was really just a family feud.  And these poor lads have been sleepin’ beneath the soil over here so far from home for over two hundred years.  It’s the least I can do for ’em,” he said.