In her critically acclaimed book, Middlemarch, 19th century writer George Eliot, a.k.a. Mariane Evans, wrote: "Medicine is the most scientific of the humanities and the most humane of the sciences." Eliot's observation proves as true in the 21st century as it did in the 19th. The arts and medicine are inextricably linked. Why? Dr. Tublu Chatterjee, who teaches the Introduction to Physical Diagnosis for Duke's first-year medical students, believes it's because practicing medicine is such an emotional experience. "Often as physicians, we have to hold our emotions in check," Chatterjee says. Writing is an avenue for physicians to explore and make sense of their complex emotional reactions to profound questions about life, death and what it means to be human.

"As a doctor," Chaterjee says, "one knows people from all walks of life. Each patient we see in the examining room is a short story."

Famous playwrights and authors Anton Chekov and William Carlos Williams were doctors, as was the English poet John Keats. History's most revered visual artists, such as Leonardo Da Vinci, often knew as much about human anatomy as their physician contemporaries. Dutch master painter Rembrandt and 19th century American artist Thomas Eakins both achieved notoriety for their depictions of medical training and practices. Rembrandt's "The Anatomy Lesson of Dr. Nicolaes Tulp" is one of his more famous paintings. Eakins' unsparing depiction of surgery in "The Gross Clinic" and "The Agnew Clinic" stirred controversy among the art aficionados of his day.

Dr. Gregory Ruff, a plastic surgeon and assistant clinical professor in Duke's Division of Plastic, Reconstructive and Oral Surgery, is a sculptor and two-dimensional artist with a keen appreciation for the visual and literary arts. "I'm always intrigued to read physicians' poetry in the Journal of the American Medical Association (JAMA)," Ruff says. "When you deal with the complexities of the human body and how people respond to physical problems, sometimes in the darkest of circumstances, you have penetrated the human soul as much as anybody ever does. The work of a physician lends itself to introspection and insights that very few people are privileged to have."

Teachers singled out Ruff's talent for drawing when he was in elementary school. Through college and medical school, he set aside his artistic ability but, Ruff says, "when I went through general surgery into plastic surgery, I found that having this capacity [to draw] served me well. A lot of things we do in plastic surgery are things that can be found in tables and books of numerical standards. But I don't feel like I have to look up the appropriate distance between a person's eyes to see that the patient doesn't meet the normal standards ... There's a limit to what you can measure."

Curves, for example, are difficult to describe mathematically. "But if you can draw," Ruff says, "a picture is worth a thousand words. When a patient comes to me and says 'I want bigger cheek bones,' I have some reference, but where on the cheekbone do you measure? I find it's easier to convey these things with pencil and paper.

"Symmetry is an important part of beauty in the face and human form," Ruff continues. "A lot of the things we consider beautiful are also structurally sound. When you're dealing with facial surgery, it's important to have a good sense of construction (what's underneath the skin) in order to do reconstruction."

In Ruff's office hangs a photographic print of a medical illustration by Bill Bruden depicting two dissections of a young woman's face, the superficial aspect done in sepia tones, the deeper structures in watercolor. Dr. Russell Woodburne, former chairman of the Anatomy Department at the University of Michigan Medical School, commissioned the art. Bruden told Ruff that Woodburne had waited for a subject who was youthful and attractive. The young woman who was dissected had been killed in an automobile accident. The result of her tragedy is a work of art that, according to Ruff, is both poignant and beautiful.

Visual art also has made its way onto the covers of medical journals. Nearly 40 years ago, the venerable JAMA replaced its traditional table of contents cover with one showcasing works of art. Since 1974, Dr. Therese Southgate has been selecting JAMA's cover art, often writing an accompanying essay about the cover. Two volumes of JAMA's cover art together with Southgate's essays have since been published, primarily at the urging of loyal readers.

In her preface to the first volume, Southgate writes: "As distant as the two notions---medicine and art---may at first seem, they do share a common goal: the goal of completing what nature has not. Each is an attempt to reach the ideal, to complete what is incomplete, to restore what is lost. The search is for harmony as well as for form." In a human being, that harmony is health. In art, it's the interplay of color, form and line. It's Monet's luminous water lilies or Van Gogh's vivid self- portraits.

In the second volume, Southgate explores further the connection between physician and artist: "If art reminds us of our human condition, even more so does the practice of medicine, in which we recognize that all---patient as well as caregiver---are afflicted beings. But not without hope ... The very act of painting a picture signifies hope, as does the act of treating a patient. That is why painters paint and physicians practice medicine."

Perhaps the most obvious connection between artist and physician is in the power of observation. Keen observation is critical to outcomes - for the patient being treated or the art being created. This observation ranges, Southgate notes, from the way a physician listens to the patient and watches facial expression and posture to the way the artist's eye takes in the play of light on water or the thickness of paint on canvas. But there's an additional element: the act of paying attention to, of beholding, the subject of one's observing.

It is this act of paying attention that concerns Chatterjee as she grapples with new ways to teach Duke medical students how to be keen observers. "The physical exam is difficult to teach, because it really is about honing your senses," Chatterjee says. Traditionally, the only way to teach observational skills has been to get students involved with patients. "The pitfall," Chatterjee explains, "is that there is a huge power differential between patient and physician. It is not uncommon for young physicians to have biases and to make judgments based on first appearances." So Chatterjee tells her students: "Don't jump to conclusions." But how does she ensure her message gets through and is put into practice?

A novel way of getting students to hone their observational skills while withholding judgment came via Duke's Museum of Art and its university and community educator, Adera Causey. Causey had read an article in the New York Times about medical students at Cornell and Yale visiting museums to learn to be better observers by observing art. She sent a letter to a number of Duke medical faculty suggesting a similar collaboration with the Duke University Museum of Art (DUMA). Chatterjee and Elizabeth Lentz, the administrative director of Practice, responded.

"My feeling is that the process of viewing art is not dissimilar to the process of viewing a patient," Chatterjee says. "One has to approach the viewing with care and thought and initially just describe what one sees and then go through a careful process of analysis before making inferences."

Chatterjee adds that she sees art as an effective way of presenting a complex whole, which is how she views a patient. "To see that the whole is greater than the sum of its parts takes care, practice and discipline," Chatterjee says.

For first-year medical students, the two-week physical diagnosis class is an intensive learning experience. In January, students spent the first afternoon of the course at the DUMA-on a Monday when the museum is normally closed.

After meeting as a group to get their instructions, the students were asked to choose three from a group of pre-selected paintings to observe and analyze. Each student was given a printed sheet as a guide for analyzing the paintings.

"We selected figurative, signed paintings with something in them that students might miss," Causey explains, paintings such as Laura Wheeler Waring's "Portrait of Anna Washington Derry." A first impression might lead one to believe that the older black woman with the lined face is a laborer, servant or former slave. Closer observation reveals that she's wearing expensive clothing and her hands are smooth. In fact, she was a member of a wealthy black family from Philadelphia, proving Chatterjee's point that it is easy to mischaracterize patients based on their appearance.

Anne-Caroline Garnier, a first-year medical student, found the experience enlightening. "The instructors were trying to get us to look closer, deeper and think more and not rely on that first impression," Garnier says. "A lot of diagnoses can come from intricate details that might not be picked up right away if you're not paying attention."

Once the students had jotted down their observations about the paintings---details such as costume, hands, facial expression, skin---they gathered in small groups with art experts to discuss and analyze what they'd seen.

"In my group," Garnier says, "we discussed a painting of two men at the Moulin Rouge. One of the men was speaking to a woman. The interesting thing about the painting to me was that the women in the background were painted in vivid colors while the men in the foreground were painted in gray tones." A lively discussion ensued about what the artist meant to convey in using a different color palette for the women.

"I looked at the scene from the point of view of the women," Garnier recalls, adding that she thought the men might appear gray to the women performers, because the women were used to being propositioned by the men and all the men began to look alike. Others interpreted the somber color of the men as an indication that what they were doing could be morally questionable, assuming the men had just seen the show at the Moulin Rouge and were trying to proposition the women.

"One of the best things about the experience, even for the people in the class who didn't have that much to say about the art itself, was that it left us with something to think about," Garnier says, adding that students talked about the experience afterward in their social circles outside class. "In my group of friends," Garnier says, "we talked about reconciling the idea of not making generalizations while at the same time making guesses about the lives of the people in the paintings."

First-year student Quintin Quinones recalls the initial group meeting and viewing a portrait: "He was a Sigmund Freud-looking type of guy," Quinones says, "who turned out to be a famous surgeon, the point being that on first impression the person may not be who you think he is." Quinones adds that he found it difficult to suspend judgment and remove himself from his cultural background, especially when viewing religious paintings. Though not everyone was able to bridge the two worlds of medicine and art, Quinones says, overall the exercise was successful in getting the point across.

Lentz, who is an artist herself, worked with Chatterjee and Causey to design the museum experience for the first-year students and collected the feedback afterward. "Student response was quite varied, including one student who e-mailed me that it was a total waste of time" Lentz says, adding that most students said they enjoyed the experience and that it will likely be repeated with next year's class. Chatterjee says the museum "was a wonderful place for students to practice learning how to describe what they were viewing and then to be careful about the inferences they made from their descriptions."

The Duke medical students' experience is part of a growing trend in medical education to include the humanities as an integral part of a physician's training. Dr. Rita Charon, who holds both an M.D. and a Ph.D. in literature, is professor of clinical medicine at the College of Physicians and Surgeons of Columbia University, as well as the director of the Program in Narrative Medicine, which she launched in 1996 as the Program in Medicine and the Humanities.

As part of their medical training, students at Columbia are required to take a number of seminars in humanities. Charon notes that in the spring semester of the second year, students must take a humanities seminar---in literary studies, contemporary poetry or modes of listening (taught by a Russian literature professor who is also a pediatrician). Also offered are courses in figure drawing, with live nude models, or drawing from classical Greek and Roman sculptures at New York's Metropolitan Museum of Art, as well as a photography seminar. "What I can do," Charon says, "is signal to the students that these skills in reading, writing, beholding and creating are part of their equipment as doctors."

"We scholars of the 21st century didn't invent the relationship between medicine and literature," Charon says. "If you look closely at Hippocrates, he tells stories about the particulars of individual patients. Eternally, there's been a tension between what doctors know about the human being in the abstract and what medicine needs to know about this particular 67-year-old diabetic woman sitting in the office whose mother died from diabetes and who has started smoking again." Charon adds that there's never been an effective means of bringing together the abstract and the particular.

One example: the directive that doctors should have empathy. But what exactly does that mean? "Until recently," Charon says, "We've been short on the method of how to do that. We end up with these sappy exhortations to doctors to be good people, be humanistic, be empathic. To my mind the real radical contribution that the humanities have made to medicine is to give medicine methods---a tool kit for doing the things we've been exhorted to do."

The tool kit Charon refers to is filled with what she calls narrative skills---the skills used when one learns to read and write. "When you read Huckleberry Finn, what you're doing as a reader is you're entering this narrative world, and provisionally you accept the point of view," Charon says. "You naturally follow the narrative thread.

"This turns out to be revolutionary in medicine," Charon adds. "You sit with a patient in a room and say nothing except 'but' and 'then' and respect the powerful narrative that comes to you. It's not always literary, but visual---what the patient is wearing, his or her expression.

"To be effective as a doctor," Charon continues, "you have to be open to and absorb all the news you get, so that you're listening in an attuned, skilled way. And you're beholding the patient."

The concept of 'beholding' is key to Charon's philosophy of medical education and what makes a good doctor. Charon says, "Part of the equipment of an effective doctor is to be able to behold a patient, to be able to absorb both the said and unsaid things about what you're beholding and in some way to be moved by what you see. If you're being effective, you're moved toward acting on behalf of the patient."

Charon says the increasing focus on medicine and the humanities, and especially narrative theory and medicine, is not an American invention. In England, for example, the general practitioners got the scholars involved, whereas in the United States it was the reverse. "It's an exploding area," Charon says, adding that the use of narrative theory in medicine is growing in Canada, France, Australia and Saudi Arabia. Charon is on her way to a conference on the subject in London, jointly sponsored by New York University and the University of London Hospital.

Journals such as Literature in Medicine and Medicine and the Humanities are another outgrowth of the burgeoning interest in the intersection of art and medicine. "I think it's succeeding and growing, because we've finally found a way to talk very practically about the things that appear to have been missing from medicine," Charon says. "That's why it works." Additionally, there are humanities masters programs being developed for physicians. The University of Texas at Galveston and Drew University in New Jersey now offer a Ph.D. in medical humanities, which includes not only literary studies but also history, visual arts, philosophy, anthropology, theology and qualitative social sciences.

Like most of Chatterjee's students at Duke, Charon's students at Columbia have embraced the concept of using art and narrative as a means to hone their clinical skills and become more compassionate and effective as caregivers. Several students are signing up for intensive work in the fourth year: One of Charon's students is writing a play and several are writing narratives about their experiences in caring for patients.

"For years, I've been having third year students write about their patients," Charon says. "I call it the parallel chart, and I told them that some things that are important in the care of the patient don't belong in the hospital chart, but they have to be written down somewhere." Charon instructs her students to write about their personal responses to patients and their colleagues in the parallel chart. Once a week, students meet to read to each other what they've written. "They write of their deep feelings of victory when things go well, of anger when they don't, of disagreements with other doctors," Charon says. "When they read this aloud, it does two things: It develops a different agenda for training (giving the students a means of dealing with their feelings of grief, sadness and attachment in working with patients) and it helps them feel they're not alone. It's been a tremendous treatment for the feeling of isolation that tends to occur in medical training."

Anecdotally, the parallel chart worked well, but Charon wanted a more tangible measure, so she selected 100 students and randomly assigned half to write the parallel chart and half who served as controls, finding students who had similar undergraduate majors. She pre- and post-tested the students, using psychological scales of empathy and ability to cope with death, as well as faculty ratings of the participating students. About half the findings have been collected, Charon reports.

"Even on the quantitative findings," Charon says, "there are statistically significant differences between the experimental students and the controls." For example, the faculty rated the experimental students higher on their therapeutic relationships with patients and the students' ability to take histories and perform physicals. There was no difference between the two groups in fund of knowledge.

"So there are outcomes to narrative training," Charon says. "When students evaluated themselves, they were statistically higher on things like, 'I feel confident in caring for dying patients or in giving patients bad news.'"

As to why this trend toward integrating medicine and the humanities is gaining momentum now, Charon says it's because there's a burst of new scholarship in narrative theory and knowledge about what happens in the brain when one hears or makes up a story. "The interest in narrative theory really began in the 70s," Charon says. "But it took a while for the scholarship to percolate into medicine and law."

Additionally, she says, "The narrative failings of medicine have become more urgently apparent in the midst of dazzling technical feats such as liver and heart transplants and the disparities in who gets what." Advances in medicine and genetics have created thorny ethical questions about nearly every aspect of patient care, from beginning to end of life. Consequently, the field of medical ethics has matured to the point that that a new branch of medical ethics has evolved called narrative ethics.

"The traditional legal methods we've used for dealing with these issues are not enough," Charon says; "we are realizing the terrible dilemmas we find ourselves in, and we need ways to take individual patients into account."

Training medical students to pay more attention to the plight of individual patients raises the question of how, in an era of managed care, doctors can take the time needed with each patient. To this question, Charon replies: "It helps doctors to recognize what they've lost. I predict that doctors increasingly will say no to the ludicrous practices emerging from managed care.

"Every doctor has it within his or her power to restrict the number of patients he or she sees daily, assuming that doctor is willing to take a lower salary," Charon continues. If doctors say no collectively, Charon believes they can and will be heard.

Narrative medicine may also provoke risky conversations about health care in this country and address questions that are now answered only on an ad hoc basis. "What prevents our doing this thoughtfully is that we don't have a way to talk about it," Charon says. Narrative skills provide doctors a way to meaningfully engage in the debate.

In the end, Charon says, "All these skills increase the joy of being a doctor and the satisfaction of patients."

A new book by documentary photographer Meryl Levin, Anatomy of Anatomy in Images and Words (Third Rail Press, New York), illustrates the kind of collaboration between the arts and medicine that brings deep meaning to the experience of studying medicine. Levin embarked on a journey, along with the Class of 2001, through an anatomy course at Weill Medical College of Cornell University. She photographed cadavers, students and instructors and interwove her full-color images with the medical students' journal entries and artistic anatomical illustrations. The work is presented temporally, from the introduction to the dissection lab to the final exam and the student-led memorial service.

Physician-writer Abraham Verghese wrote the foreword to the book, describing the journey as "the living studying the dead. The dead instructing the living." Levin dedicates the book to those who donated their bodies and writes: "I have never before witnessed a gift that is honored, respected and consumed so completely."

As an on-line reviewer remarks, Levin's photographs "are not for the squeamish: for example, the double amputee pelvis prosection on page 103 or the multiple images of flayed skin or limbs tied to supports." Other images remind the reader of the once living person now represented by the dead: "pink fingernail polish on a female cadaver or a heart palmed by a student."

The student journal entries are honest, sensitive and thoughtful and contemplate their discomfort with certain dissections, such as the pelvic region, and their growing awareness of their own bodily functions through what they're learning in the dissection lab. They write about their relationship with the cadavers, their gallows humor and uneasiness with the humor, as well as how the experience with dissection sets them apart from those who will never have such an experience.

A reviewer comments: "two fathers (Rajiv and Michael) reflect on a renewed sense of privilege and intimacy when holding their children's hands after leaving the hand dissection session. '[My daughter's] hand is soft and warm despite the January cold. This is what life feels like, I say to myself. I have learned something about the human touch. I will never hold someone's hand the same, old, ignorant way again.'" (Rajiv, p. 36).

More profoundly, the body bazaar is encouraging us to think of ourselves in purely utilitarian terms. "Body parts are extracted like a mineral, harvested like a crop, or mined like a resource," observe the authors. We are in danger of becoming commodified and reduced to objects, not people.