Art and Medicine

Art and Medicine 2020

At our Family Medicine Residency Program, we are starting a Medical Arts and Humanities Fellowship in collaboration with the Intermedia Program at the University of Maine.  In order to fully participate as a faculty in this program, I felt I needed to participate in some of the courses our fellows would be taking; hence, I find myself this semester in Intermedia 501 – the History and Theory of Intermedia.  Our first subject is Dick Higgins, the person who coined the term intermedia, and a person whom our professor, Owen Smith, knew well.  Owen delivered a lecture of Higgins at his memorial celebration.

Higgins wrote a book entitled Horizons, which was published originally by Roof Press in 1998, and republished by /ubu editions in 2007.  He opens with an interesting quote by art critic, Rosalind Kraus, spoken at the University of Iowa in April 1981.  She said, “I am devoted to the idea of burying the avant-garde.”  Later Higgins wrote about the important role of the avant-garde in exploring the fringes of what may become, so I found it curious that he would open with a critic who wants to destroy them.  We have the avant-garde in medicine, too – those who imagine a different future than the status quo and try to make it so. I have been in that fringe – those who imagine moving what was fabulous about indigenous medicine into our future.  We also talked about implementing a psychobiosocial model or a holistic model or an integrative model, but we were all careening and ricocheting in an obscure future in which we cannot imagine what will ever become.  Higgins talks about this for art – the role of the avant-garde in exploring what might become.  Comets are worlds that didn’t quite form.  They have their own beauty as they rush around the universe, but they are not planets. Some of the avant-gardes are destined to be comets.  Some will become planets. Only the future will know. It is the same in medicine, though its avant-gardes have fared less well than those of art.

Higgins said that avant-garde thought minimizes conventional forms and thereby tends to be an active, dialogical interrelationship between the form which a work assumes and the material of which it consists. He says that the avant-garde focuses upon the “up-to-now-this-wouldn’t-have-been possible.”  I see this as well in medicine and psychology, though each of these movements stand in direct risk of annihilation.  The mainstream, like Star War’s Empire, is strong.  It is all too easy to destroy a few rogue rebels.  So, we toil quietly in the shadows of the mainstream, slipping beneath the gaze of Big Pharma, hoping to acknowledge what is good about conventional medicine and to discard that which is solely commercial or anti-human. 

Higgins contrasts the avant-garde with the pop-garde, which is the follow-the-leader world of charm, including fashionable but safe dissent and high style.  Within medicine, yoga has entered the arena of pop-garde.  Yoga, itself, of course, is fabulous, and anyone can and should do it, but pop-garde yoga is chic and expensive and full of beautiful, rich people.  It’s not the yoga for the people, for example, that is advocated by Diamond Dave Phelps (DDP-Yoga) who worked with decrepit wrestlers (Jake the Snake, for example) and crippled former paratroopers, to bring them back to function.  It is the yoga taught in the fancy studios of New York and Los Angeles and Kripalu.  The pop-garde co-opts the discoveries of the avant-garde for profit.

Next, Higgins discusses conservative artists, who stick to the tried and true.  These constitute the bulk of the art world as they do the world of medicine.  They do what they’re told.  They follow the algorithms without question.  They faithfully implement the guidelines, whatever they are, without questioning the origin of these guidelines.  These are conservative doctors, similar in attitude to conservative artists. Higgins distinguishes between conservative artists who use materials in prescribed ways with avant-garde artists who allow the unique characteristics of the material to speak to them. The parallel for this in medicine is the application of the same algorithm to all patients while avant-garde physicians allow the being of the patient to guide and shape the treatment.

Higgins continues to define a good critic.  He says that a good critic points out the implications of the material and the work, forming a relationship with the material and the work in which any theory developed arises from the ensuing dialogue.  In medicine, we have no good critiques.  We are expected to mindlessly follow the dictates of the various professional organizations who rule the roost.

Higgins creates a term, “exemplative art,” in which the work is not a definitive realization of something, but one example of a sample of possibilities.  His term “allusive referential” refers to a displacement between what one expects to see or what one would logically regard as normative and what one does, in actuality, see or hear or read.  This displacement factor can trigger all the emotional responses associated with art independent of the artist. We have that in medicine. I am reminded of a 96-year-old man who was snow-blowing his driveway and got exhausted and bent over and passed out.  That would seem ordinary to me, but in our algorithmically driven Emergency Department, it triggered a $30,000 stroke work-up. The man was already on anticoagulants for his atrial fibrillation, so our work-up would not have changed anything in his treatment, but it is required by a protocol which we must blindly follow.

Instead of the modern/postmodern division (which Higgins places in the mid-1950s), Higgins prefers to make a cognitive/post cognitive distinction with the term “cognitive” referring to the sense of self or personal identity of the artist or the viewer of the art. I take this to mean that around the mid-1950s, the opportunities for creating identity dramatically multiplied. Before the mid-1950s, people’s identities were largely constructed by their context and rarely did people leave that context (family, community, church/temple).  Around the mid-1950s, people began to be more mobile.  In North America, we witnessed the birth of the car culture in which most people had one or access to one.  People became able to leave the context in which they had grown for a context of their own choosing. The rise of technology created jobs that had never existed previously.  The manufacturing and mining/farming industries began to decline in relation to the service/technology industries.  This has only continued until the present time.  If identity is more fluid and we can have agency in constructing and even changing our identity or holding several identities for the multiply different contexts in which we find ourselves, one could say we are post-cognitive, because our identity is no longer fixed and immutable. Higgins says that a post-cognitive perspective allows us to journey backward into works from the past without having to make elaborate justifications for doing so.  As someone outside the art world, I would not have known that such justifications were required in a modernist or cognitivist perspective.  Higgins says a post-cognitive perspective allows us to put the artists into a neater lineage as to how they feed into contemporary avant-garde practices. In medicine, a post-cognitivist perspective allows us to see the folly behind many of our algorithms, but that perspective is not rewarded.

Higgins uses the cognitive/post-cognitive distinction regarding the material of an artwork.  The cognitive artist uses expression to reveal his or her subjective persona.  The post-cognitive artists allow the material of the artwork to express itself. The parallel in medicine is that the cognitive physician imposes him or herself on the patient.  The post-cognitive physician is patient-centered and listens to the patient to collaboratively create a point of view.

Higgins says that the desire to fuse seems to be a part of our biological nature as living beings.  Certainly, we are all seeking that sense of belongingness and opiates work most powerfully on the neural circuitry of social relations and belongingness along with oxytocin (the social relations hormone). A number of religions seek a transcendental fusion with divinity or a spiritual realm.  We all need to belong and in an intensely connected way.  People fuse, he says, not just when they have sexual intercourse, but merely by being in love, and certainly a clinical literature exists on the dangers of fusing while in love and losing one’s own personal boundaries.  Historically, this tended to be more common for women than men due to differences in socialization to the roles we play in love relationships, and this is also currently in flux.  Higgins says that people even fuse in friendship to some extent, with the give and take of relationships and the deep involvement people have over the course of a lifetime. Higgins says that this desire for fusion is a basic hunger within us, which reflects how important belonging is for survival.  Humans survived by banding together in groups.  Without groups, we are vulnerable and easily defeated. We are incomplete without belonging. This need for fusion exists everywhere, and medicine can either contribute to it or detract from it. Conventional biomedical medicine detracts; patient-centered medicine contributes.

Higgins next criticizes structuralist and post-structuralist theory and cultural criticism.  He believes they lack any scientific validity and calls them science-as-metaphor rather than science-qua-science. I think Higgins lacks an understanding of what happens behind the scenes in science; that so many of the elaborate explanations are simply metaphor disguised as truth.  He elevates science-qua-science perhaps inappropriately. We are all trying to invent a story to explain “what is,” and science provides just one more story as does Levi-Strauss, Jacques Lacan, and Roland Barthes.  Higgins criticizes Barthes for writing about one work, a short story by Balzac, but Higgins also talks about exemplifying work, which provides an example of a type of work, which is just what Barthes is doing. I read Higgins as emphasizing keeping theory grounded in “the thing itself.”  When it becomes too abstract, theory suffers.  He criticizes the pretentions and limitations of academic thought and art criticism. He opines that the critic can contribute by identifying works that are unique and characteristic of our current era, because the only art we will ever know firsthand is the art of our current era, with avant-garde art containing the art of the future, albeit indeterministic of what it shall be.  This brings us to what he is calling intermedia, art that falls between established and conventional media.  He mentions concrete and visual poetry as an example.  He turns to painting, which was the elevated art of the past, which has migrated off the canvas in the world of visual arts, entering the world outside of itself, interacting and fusing with other media to form visual poetry, visual music, and more.  Higgins calls for a pluralistic approach, recognizing that a horizon has many points along with it, perhaps even an infinite number of points. 

Next Higgins returns to history, writing that the concept of the separation among media arose in the Renaissance. He says that the social problems that characterize our time, as opposed to the political ones, no longer allow a compartmentalized approach.  He thinks we are approaching the dawn of a classless society, which I reject.  Class seems stronger in America today, than during Higgins's time.  Pop art for Higgins is dead, bland and pure, but impotent.  The notion of a pure medium is depasse.  He invokes Duchamp’s pieces as being truly between media, between sculpture and something else, while a Picasso is readily classified as a painted ornament. The ready-made or found object is intermedium because it was not intended to conform to the pure medium, and therefore suggests a location in the field between the general area of art media and those of life media.

Higgins talks about how painters of the 1950s began to make work that adds or removes, replaces or substitutes or alters the components of a visual work but placing increasing incongruous objects in the work.  For example, Rauschenberg called his constructions “combines,” and went so far as to place a stuffed goat-spattered with paint and with a rubber tire around its neck onto one.

Higgins then turns his attention to the theatre.  He wants a theatre in which time and sequence can be utterly suspended, not by ignoring them, but by systematically replacing them as structural elements with change. Lack of change, he says, would cause his pieces to stop. He mentions his 1958 work, Stacked Deck, in which any event could take place at any time, as long as its cue appeared, provided by colored lights. This led to a happening, in which external events controlled the cues. The happening was an uncharted land that lay between collage, music, and the theatre, not governed by rules, each work determined by its own medium and form according to its needs.  In intermedia, the visual element (painting) is fused conceptually with the words. 

Higgins says there is always avant-garde in the sense that someone, somewhere is always trying to do something unique which adds to the possibilities for everyone else. These artists question established forms and media.  But if avant-garde is successful, it will become the new medium for its great significance, becoming truly important to large numbers of people. He says that one regrets the adherence of an artist to a set of dogma. 

Higgins's explorations of art can help us explore medicine.  Many of the same forces are at play.  The dialogue between the powerful and the powerless remains. The forces of the establishment and the radical extremes remain. The avant-garde exists in every field, trying to determine what will come next, though the orthodoxy usually prevails. Ultimately, the stakes are lower in art.  No one dies. Art, therefore, is allowed more possibilities which is why we in medicine should study it.

Day 6 of the Australian Journey 2012

Today we arrived at Boole Poole, the ancestral land and burial grounds owned by the aboriginal cooperative for the formal start of Culture Camp 2012.   Several of us were wearing Culture Camp 2011 T-shirts in bold red, black, and yellow, the colors of the Australian aboriginal flag.   Boole Poole is only accessible by boat which was a rough ride in a rainy sea.   Flocks of pelicans sailed overhead, experts at riding the currents of wind.   Black swans floated gracefully on the swells, while young cormorants appeared to be walking on water as they got out of the way of the boat, flapping their wings faster than imaginable.   The rain had begun as we unloaded the boat at the pier.   By the time we had pulled the trolley with our things to the house, it was a downpour.

The food at Boole Poole is continuous and one meal runs into the next.   Looking for an alternative to eating, I decided to interview Miriam, the newest physician to work for the Aboriginal Cooperative and their first and only full-time physicians.   My colleague, Rocky, had already spent time with her on his last journey to Australia when he consulted to the physicians who worked for the Cooperative.    The rain drummed on the roof as we talked in the living room of the house while most everyone else watched films of aboriginal dancing from the community at Mullingimby, the home of Shadow and Lily.

"How long have you been at the Coop now?" I asked.

"Since last August, 2011.   Now, it's six months."   Miriam answered.    She had trained in Brazil and had practiced for some time with aboriginal people there.   In Brazil she had a catchment area of 4000 people.   She worked for the public medical care system.   In her clinic, she had four health workers, one nurse, and her.   I wondered how it was to have that many families under your care.   She said it was a matter of doing the match.   In any given month, one expects 4% acute care visits.   She used the morbidity tables for the percentages of chronic diseases in her practice to calculate how much time to allocate for chronic disease care.   Time was very scientifically managed.   Next I asked her what was her biggest challenge in coming to the Coop in her first week.

"My first week was one of introductions and cultural awareness.   I was taken to the different sites I needed to know about; taken to meet the people with whom I would be working and whom I would be calling. They (the coop) introduced me to elders.   That first week was also an introduction for the community to me.   It was a pleasure.   They believed it was fundamental for me to understand the geographical space in which the patients lived.   They were open to all my questions.   They introduced me to all the places that were important to know.   The two aboriginal health workers did that -- Shane and Judi Ann.   Judi worked with the midwife and could bring her all the issues with pregnancies in young people and what they need, their expectations.   That was my first week." I was impressed with how culturally sensitive the Coop was to Miriam.   I hoped we had contributed something to that awareness. Then I asked Miriam about her second week.

"During my second week I was in the unit of my mentor, Dr. Jane Greason.   She was able to introduce me to the program and what they had been doing in the community.   She has been there more than 12 years."   Then I asked her what other doctors work for the Coop.

"Dr. Greason is my supervisor.   There is Dr. Gene Wofurt who was raised in Bairnsdale, then Dr. Schoefeld, and Dr. Black.   We have two offices at the health center.   Usually only one session or two sessions occur at the same time."   I learned that the other doctors had contracts with the Coop and did their own billings.   Miriam was on a salary.

"My challenge is, not by the production, but to help people get well.   I am not billing medicare like the other doctors who have to see patients one after the other, 1, 2, 3, 4.   I have A, B, and C consultations.   An A consultation is scheduled for 10 to 15 minutes.   B is 40 minutes and C is one hour.   Because we have the other doctors, if I have another doctor at the unit, the other doctor does their patients and I do the health assessments with the aboriginal health worker and do the gp planning."   I hadn't heard the term "gp planning" so I asked what that was.   Assessments are always category C consultations.

"After the assessment, you have at least some idea of the risk factors, medications, and social information.   That supports the gp planning.   We identify the patients with the chronic disease and the special needs.   After that, you have to work in a way that you agree with the patients and negotiate with them what can be done and how.   We set some goals between us.   I have to write this down.   That is the product we call GP planning.   The Coop is a very special situation because they have more than just general practice.   They have the family service, the alcohol and drugs follow-up, the midwifery service, and many more community outreach services.   With these special services, it's easier for us to go further than a simple gp plan in mainstream medicine.   There they have hard work because they don't have the facilities to refer as I have here.

"When I arrived in the heatlh center, I realized some of the aboriginal health workers were not having time with the doctors.   Every doctor had a small time with the patient.   I started doing the health assessments with the aboriginal health worker and the patient together.   I also did the gp planning with the patient and the aboriginal health worker together.   This seemed like a natural way to do this. It would be a longer appointment if we did it together, but we would get so much more done.   It is the job of the aboriginal health worker to visit the patient in the community and to make sure the plan that we have negotiating is being implemented.   If I cannot finish the gp planning with the patient, I will finish it with the aboriginal health worker.   Sometimes that's necessary because I didn't have all the necessary background.

"We have a clinic coordinator who is a nurse practitioner and we have Leslie who is a nurse practitioner who is more responsible for immunizations and wound management.   She's a more unit centered nurse.   Another nurse does diabetic education.   We have another midwife who works with Liz Boyer, who is one of the doctors responsible for antenatal care and deliveries at the hospital.   The midwife is a nurse, too.

"After gp planning, I keep in contact with the aboriginal health worker to be sure every action that we have planned is happening.   In that stage I had some concerns because the aboriginal health workers belong to the families.   If I have a male patient, they have male business and they will be ok with these patients, but if they belong to other families, maybe they will not be ok.   We lost one aboriginal health worker because she couldn't do the male business.   Judi worked with the midwife and had good support in the women's business.   It's very hard because you know they belong to their families and sometimes they don't want to get involved in other families' business.   I have to be very careful, because I don't know where I am walking.   Some of them are close to these patients.   I have to be very respectful.   Once I went to aboriginal health worker and said what I wanted to do with this patient and he said, doctor, I prefer not to work with this patient, because she is my wife.   He could help her as a husband but not as a health worker.

"Patient confidentiality is minimal.   Everybody is a relative.   You have to be very careful what you have as a goal.   What we have to do is ask the patient.   I have the opportunity to talk with the patient myself before we discuss things with the aboriginal health worker.   I explain what is a good aboriginal health worker and they agree with me.   Then I ask them if they are ok with who will be assigned to them.   Some of them don't accept the aboriginal health worker."   I asked Miriam about the challenges to health in the community.

"People in the community want to be heard.   They have a hard time with drug addiction, alcohol, domestic violence, but when you open the door, they go through it.   If you listen to them, they will tell you things which will give them some relief.   I remember one patient who was very upset.   In their community, it's not normal practice to have an elder in a retirement home.   She was very upset with that.   She came for high blood pressure.   She was very upset.   She was fighting with the family because one of the sisters got the guardianship of their mother.   The sister wanted their mom in this specific retirement home.   I started to treat her blood pressure but I knew the stressful situation was    part of what was raising her blood pressure. Part of my job was to be a problem solver strategist.   To help her make small changes to cope with the situation was what I needed to do.   She is still working through her issues but she is changing.   She asked me to support her with her alcohol issue because that was why her mother was in the retirement home.   She was not able to take care of her mother because of her drinking.   She was then able to go to alcohol treatment.   She could choose an alcohol counselor. " I have this problem and how can I solve with the resources we have here.'   Now her mom is in the retirement home and she is struggling to cope with alcohol problems and she accepted the situation as transitory because she wants to recover so she can take care of her mother.   She is in the middle of her process now.   She has access to the consultations.   Every time she needs to contact me, I have an agenda for her to come every week as a crisis like, trying to support her in this journey.  

"Second I have a list of resources we can present to the patient.   Patients can choose what they want.   If it's housing, I have people who can help with that. One of her [the above patient] issues was that she didn't have a house.   She got connected to the aboriginal legal services and I could do a letter supporting her for housing.   It was important for her for the crazy stress.  

"The aboriginal health worker is very important, because they know how to work the system.   If the patient doesn't allow me to contact the aboriginal health worker, I have the list of the resources and I ask the patient how to help them.   Sometimes they say it's impossible.   They give me the limitations.