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THE ART OF |
A "Heart Smart" Program at a poor elementary school where the thrust is on prevention and education about proper food, exercise and rest to promote cardiovascular health. 780 children get a Federally funded free lunch, and half also come for a free breakfast. Eating is very serious. No child, even the smallest, drops a tray and all trays are returned to the kitchen with empty plates. The cafeteria is quiet and it seems to me unnatural. There is not the ordinary playing around, the jostling or socializing that I would expect among children. The program works with the school nurse and cafeteria manager to give the children low fat and salt lunches with fruit and vegetables to encourage health food choices. At gym, the jump ropes are the only equipment. Jumping and running are the exercises. But what those children can do with the jumping ropes! There are no guns on the school grounds which reduces tension and fear and the children bring home their lessons about food and teach the parents. A small step toward a healthy future, and a "big step" for mankind's health budget.
Professor: "Who else do we have?"
Student: "We have 'Willy Jones'; he had a pleural effusion."
Professor: "How do we know?"
Student: "Well, he had 75,000 poly, ILD is 85."
Professor: "Did you get a PH on him? I would assume it would be low with 75,000. Did he grow anything out of there? So he had normal renal function when he came in and sometime after that he had renal failure requiring dialysis?"
Student: "And they kept saying perhaps it was due to hypertension. I looked at all the blood pressures and there was not one that indicated hypertension."
Professor: "So how do you approach somebody with acute renal failure?"
Student: "You look for possible drug problems."
Professor: "Even before that. How do you divide up patients by the cause of acute renal failure? You usually divide up into three categories. You can ask consultants if you need to. Is it renal or is it post renal? So how do you rule out the post renal? How do you do that? In the male, that's not an unusual thing, so how do you rule that out? "Usually prostatic hypertrophy and how do you find out if this person has bladder outlet obstruction? What would be the best way to rule out whether this guy gets bladder outlet obstruction? Give me a single test? Something you can do at the beds." And so the professor went through each students' notes on each patient they had examined on the wards. They will accompany him as he examines the same patients. This is the way they develop judgment to integrate the facts they have learned from books and laboratory results.
The Professor of Medicine says, "As medical science and its miracles advance we are going to be faced with increasing numbers of very knotty ethical issues. As our population ages we are going to be faced with learning how to care for the very old, and of course, at the other end, we have to worry about the large numbers of crack babies who will probably always be outcasts of society. We are beginning to pay more and more attention not to just keeping people alive but in looking at the quality of their lives. It has been mentioned that 60% of the health care dollars in this country are spent keeping people alive in their last year of life and I think we have to look carefully at that. Whether or not that is a justified utilization of our resources. If we address the pathos of what we have created with out medical progress, it could send a very strong message not only to the profession but potentially to the public as well."
The red glow of the only bulb and the green flashes from the 800 taps of the footpedal of the laser beam gave a Rembrandt chiaroscuro to the operating room. The pediatric ophthalmologist and his assistants are actually garbed in surgical gowns very much like the 17th Century ones and are dark with the side lighting of the bulb and the lightning of the laser. The patient is a premature of 26 weeks whose lungs and brain are not well developed and the blood vessels in the retina have not disappeared. The procedure is to burn off the area around the blood cells so that they can not grow and pull the retina off, causing blindness. The laser beam goes directly from the head piece of the surgeon through the lens he holds at the eye, to the retina, "inside out," an advance over the cryon beam which freezes a larger area than necessary. It is precise and tedious work. Afterwards the surgeon walked with me to the female locker room and proceeded to tell me about his wife and sons and daughter and where they were at college, what they majored in, one in film directorship, another in computers, and I wondered why he was spending so much time with me. We were both so tired; it had been a pitiful afternoon. We never said anything out loud, but it surely would occur to anyone in that O.R. that this was all a mistake! It was a powerful argument for the pre-natal care for teen-aged mothers, and this one had taken crack. The physician had needed time to "change gears," so to speak before he could come down to the level of parking garages and traffic home. An ounce of prevention, yes. But, there is no lifetime of cure for this baby.
Apart from the computer programs and standardized patient/actors, used in medical school teaching, the human contact still remains as the basis for healing. When the physician is called upon to see more and more patients, quickly, he reaches a saturation point. There is still a human frailty that one can only encompass a certain number of people before one "turns off." Could the emphasis on the mechanical procedures draw the doctor away from human feelings about his patients? And being seen quickly in large numbers, will the patient also lose human compassion for his physician?
This is the large weekly teaching conference for doctors-in-training and faculty -- called grand rounds. It's held in the old amphitheater of the public hospital, an austere place with brown, wooden bleacher seats whose tile backs seem to rise straight up from the floor, creating a cavelike atmosphere. Originally, this room was an operating room, designed to be hosed down with water after surgery. This was more than seventy years ago, during the time of Dr. Rudolph Matas, a professor at the medical school and a pioneer in vascular surgery. During the 1930s, when Dr. Alton Ochser was professor of surgery, it was nicknamed the "bull pen" for good reason: as a resident took center stage, to begin the ritual of presenting what he believed were the pertinent facts and findings in a patient's case, the prospect of being examined by the faculty in front of his colleagues made him feel like a bull in an arena. My husband and father both had vivid memories of this experience. Today's conference starts with a young doctor's description of the patient's illness and medical and family history. The doctor then reviews the results of his examination of the patient. As he shifts from human social history, his language shifts into the coded medical data of percentages, equations, and statistics. From this a diagnostic picture emerges that even I understand. The patient's liver feels like a large stone pressing into the right side of his abdomen. The diagnosis of cancer of the liver is ominous enough, but in addition he has pulmonary tuberculosis, as shown by the large white blob on his chest x-ray. The overhead lights are now turned off to show the slides from a biopsy of the patient's liver. A strange rose and purple-gray hue from the projector's light floats across the room, and suddenly all the doctors appear to have red halos, which splash on the gray tile walls. Next the view box shows a CAT scan. The curve of the bleachers is the same as that of the ribs on the film. And the shape of the lectern imitates that of the vertebra. During the ensuing discussion, the pulmonary specialist on the faculty argues that because the tuberculosis is advanced it should be treated before the cancer. Most participants agree. When the hands of the old clock in the front of the room reach noon, the hall rapidly empties. Only an ambulance siren penetrates the silence. Somehow it would be more appropriate to hear the bells of the horse-drawn ambulances in use when the room was built.
I am reminded of a James Ensor print entitled Myself in the Year 1960. He made it in 1860, and his image of himself was a skeleton! This etching -- my first -- was done about twenty-five years ago. I began with a dried-out skeleton. I remember that while in sizing the plate, I saw my face reflected in the mirror of the polished metal. Tilted upward, my features seemed askew and somehow frightening. Afterward I added the image of a mother and child. And many years later, I added a title, The Four Stages of Human Life, refering to the four stages of my own life: child and mother, mother and child, myself, and the skeleton I would become.
The mother and child remind me of a squatter family I drew forty years ago. They and three other families -- the homeless of that era -- were living on a Mississippi levee in World War II army tents. The etching was part of my senior thesis at college, a pictorial documentation of their lives accompanied by some text, consisting of what they told me about themselves as I drew them.
So this project has its precursor. Once again I'm living with a group of people, recording what they say to me, drawing them at work. Only this time, the group is far more privileged. Yet they are like a family too, united by a common commitment. And like a family, the doctors, staff, researchers, and support groups are of all ages -- from very young to very old.
Years ago I understood that I worked best when I became so completely identified with what or whom I was drawing that I forgot myself. Then I could discern the harmony of parts, the design of the whole. That is what I am trying to do today.
The infants in the neonatology intensive care unit create a impression far beyond their minuscule size. I associate them with Alberto Giacometti's toothpick sculptures. Even when living beings are reduced to a minimum, they don't lose their human appearance. A thousand grams, a little more than two pounds, contain our whole essence.
These infants and the equipment used to treat them affect me profoundly. For example, it takes me many days to assimilate the inch-long needles. My brushstrokes become short, stiff, more delicate and detailed. I even dilute my black ink to make it lighter. Before me these scrawny red babies lie naked in what look like brightly lit cake boxes. Their eyes are covered. They're breathing fast, with so much effort to live.
A few babies die. A newborn transferred from another hospital has just died from an aplastic lung. Another died yesterday of a beta strep infection. Some staff members said that if he had reached the unit sooner, he might have been saved. His doctor kept waiting for him to get better.
A mother of one of the prematures comes to the nursery to read her baby's chart. She notes an episode of missed breathing. Because she's a nurse, this mother understands more than the other mothers. I wonder whether ignorance, if not bliss, is at least kinder than knowledge.
Here is a drypoint engraving printed in color of Dr. Paul Crandall's operation to insert electrodes into the brain. A mathematician had frontal lobe seizures, and the surgeons were implanting electrodes to attach to the EEG machine to locate the trouble in the brain. The print shows the professor on both sides, as the engraving is done progressively; that is, I began at 10:00 A.M. when he first began on the patient's right side and then he continued to his left side. I included Eddie, who made measurements on the x-rays with a plastic ruler, and Jim, with his arms folded in the upper left of the print, who recorded EEG tracings from the depth electrodes during the following six weeks. The professor's hand was done twice, once feeling the tip of the drill at the patient's skull and then two hands on the drill. All around Dr. Crandall were the onlookers; other surgeons and residents, medical students, and nursing staff. It was interesting to note that the ones not actually involved have a much lessened intensity in their postures, down to the circulation nurse who even faces the other way. I made the color soft, because I sensed the delicacy of the procedure and also the strain of the hours (I left at 3:30 P.M.). I appreciated the professor's talent and was impressed by the total orchestration of his staff.
This was an operation to drain a hematoma from a kidney of a fifteen-year-old boy. The patient was first diagnosed as having pneumonia, before the trouble was found to be a hematoma from a football injury. Much blood was lost, and once the oscilloscope did not register his pulse. Two pints of whole blood were pumped in. The surgeon's gum chewing stopped. The glass of the dome separated us as well as gave us a feeling of participating. It was how one had just felt watching Robert Kennedy assassinated on the TV screen. We responded to the event but were unable to help. We felt paralyzed. In a matter of seconds, the patient's heartbeat again registered as a trace sweeping across the oscilloscope screen. We sighed audibly as though we personally had contributed. Then we quietly realized how much "we" freshmen did not know.
As an artist, I found the scene below me was impressive because of the precise positions of the staff around the operating table: the nurse had to be where she was, the anesthesiologist had to be where he was . . . a certain beauty to the efficiency. The doctor holding the retractor assumed the same pose as Michelangelo gave the Libyan Sibyl in the Sistine Chapel. The classical poses seemed like a group sculpture.
I stayed on in the dome after this operation, and the room was readied for a liver transplant to a two-year-old child. The "last ditch" procedures were done in the afternoon. The anesthetist watching the operation alongside me commented that the answer to so many surgical exercises was in prevention. "Only we don't know enough yet about how to prevent."
[From: The Art of Learning Medicine, figure 269, page 301]
There is a basic tenderness between the large and small forms, teacher and student, their hands and the patient's eye, which produces a rhythm of composition. This is in contrast to angular forms and jagged shapes which are a part of unhappy lives and unresolved social conditions. The old woman was able to converse with her doctors while the cataract was being removed, and she was constantly being reassured all was well. The voices were hushed in the room because the patient was conscious. The professor quietly and patiently assisted the resident. The procedure was done through an operating microscope which enlarged the eye sixteen times. The lens is frozen and then removed.
[From: The Art of Learning Medicine, figure 271, page 305]
Unfortunately, an integral part of most clinic visits is an interminable wait. In the emergency room many nonemergency patients and their relatives also waited. The expressions and postures seem to be the same at all medical centers . . . some playing with a child, others eating, many silent and worrying. In the same part of the hospital were also the clinics for pediatric, orthopedic, and mental retardation patients; I got such a feeling of apathy, I had to go to a busy restaurant to get enough life to finish the plate.
[JAMA cover, 2 September 1992 (reprinted with permission); also from: An Artist in the University Medical Center, plate 14, page 23]
The Women in Medicine Society provides camaraderie for women medical students and meets their special needs, such as child care. The society has twenty members, six of whom are gathered together here. At each meeting a speaker discusses issues of concern to women in medicine. The scheduled speaker this noon is an internist. She's discussing her own practice and its effect on her two children and their effect on it. In addition to having speakers address them, the members try to help female patients, such as battered women.
A professor tells me, "The situation here is changing. The younger faculty as well as many of the older professors are much more sensitive to women's issues. Why, look at the big change in the number of female medical students. For example, in our department, we've two females for every six male students. In my opinion, the women are easily as good in every way as the men."
"I keep warning our women students and residents not to compete as males," the dean remarks. "I'm always worried about their trying to become one of the boys. I say to them, 'Be yourself because your qualities as women are unique. You bring to medicine a certain healing quality.'"
U.S. National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894 National Institutes of Health Department of Health & Human Services Copyright, Privacy, Accessibility Last updated: 8 May 1998 |
