Art for better health and wellbeing
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5353 (Published 21 December 2018) Cite this as: BMJ 2018;363:k5353
- Bastiaan R Bloem, professor of neurology1,
- Ilja L Pfeijffer, Dutch poet and writer2,
- Paul Krack, professor of neurology3
- 1Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Nijmegen, Netherlands
- 2Genoa, Italy
- 3Department of Neurology, Centre for Movement Disorders, Inselspital, Bern University Hospital, University of Bern, Switzerland
- bas.bloem{at}radboudumc.nl
“The time has come for the line between literature and science, a purely arbitrary line, to be erased.”
William Burroughs, US writer and visual artist, cited by Andrew Lees in Mentored by a Madman1
At first sight, the world of medicine and the world of art and culture could not be more different. Medicine is, almost by definition, rather conservative—just think of the ancient adage primum non nocere (first, do no harm)—and its profession is bound by regulation and guidelines. In contrast, art and culture are characterised by creativity, imagination, and liberal thinking, with little formal supervision.
Yet we would argue that these two worlds are closely intertwined, perhaps even inseparable. As with other historical couples who seemed to be an unusual pairing at first sight but were highly successful (think of the painters Diego Rivera and Frida Kahlo), we believe that a closer collaboration between the two could improve the future of care for our patients. Here we offer some examples, drawing from our experience in neurology and beyond.
Dopamine, creativity, and Parkinson’s disease
The tight connection between art and medicine takes many forms (table 1). It’s fascinating that the neurotransmitter dopamine binds both worlds together by its diverse actions: a lack of dopamine leads to debilitating motor and psychiatric symptoms (apathy, depression, anxiety) in patients with Parkinson’s,2 whereas adequate dopamine levels are associated with creativity and art.3
Illustrations of interactions between the world of art and culture and the world of medicine
Dopamine’s role in creativity seems causal: when patients with Parkinson’s receive dopaminergic medicine to improve their mobility the treatment also stimulates curiosity, motivation, and even creativity in as many as 10% of patients.7 Some develop beautiful art, even if their creative intelligence had never expressed itself before.89 Other patients change their existing artistic expressions under dopaminergic stimulation, sometimes strikingly.310
Perhaps even more provocative is the recent finding that healthy people who had chosen an artistic profession early in life had a reduced risk of developing Parkinson’s disease.11
Artistic expression
The recognition that art can serve as treatment for patients is growing. Dance and music can help patients with Parkinson’s to overcome their characteristic loss of automated movements.121314 We’ve seen compelling examples of patients using artistic expression—paintings, drawings, books, poetry, music—to provide positive connotations to their disease (fig 1). These include the creativity unleashed by dopaminergic medicine which, if not excessive, can improve the patient’s wellbeing, allowing physicians to exploit this as part of their therapeutic repertoire.15
Compelling examples of art work by patients with Parkinson’s. A: a painting of the human brain by Sibolt Hulsbergen, who has Parkinson’s disease. B: a closer look reveals that the gyri and sulci display the local functions of specific brain areas. (A film on YouTube describes the making of this painting and highlights all details that can be observed: https://youtu.be/-dZFhzCziQE.) C and D: sculptures as a remarkable example of a newly developed artistic expression, unveiled in a patient with Parkinson’s under the influence of dopaminergic medicine. Photos courtesy of Dominique Guillaudin. (Further beautiful examples can be found at: http://musee-sciences-medicales.fr/ouvrage-parkinson-creativite-dopamine/.)
Such positive effects of art remind us of a new definition of health, formulated as the ability to adapt and self manage.16 Given that art can be a powerful and highly personalised way to support patients in self management, we urge governments to keep investing in art and culture to help support the population’s health.
Improving communication
How does one describe pain? It’s one of the most difficult symptoms to express in words. Yet doctors and patients discuss pain constantly. The efficiency of this interaction depends on whether they understand each other. Poetry can help us to find words for specific types of pain. In talking about pain, doctors and patients express themselves in metaphors and similes. (“Is it like a knife being stuck in your back?” “‘No, it’s more like a continuous grinding of sandpaper.”) Metaphors are the realm of poetry. And poetry can help to improve patients and professionals to find the right words and improve communication.
Art can also help patients in more profound ways. Even if physicians and patients alike prefer not to talk much about death, illness can confront patients with their own mortality. Being treated for a serious disease inevitably raises questions about life, death, and the meaning of it all.
Ignoring these questions is unnatural and helps neither the cure nor the care. Art is a way of confronting them, as it has dealt with the deeper questions of life for millenniums. A patient undergoing all necessary mechanical interventions, like a sink waiting for a plumber to finish the job, is often vexed by a restless and anxious mind left entirely alone by the treating physicians. Art can take care of that tormented mind. It can offer answers, acceptance, fighting spirit, and consolation.
Building education and empathy through art
Artists might also help to inspire and even lead the medical world in making the necessary changes towards personalised care. Often more open minded by nature, artists can offer a complementary source of truth and reinstall the power of imagination. In doing so they can present fresh and unbiased visions that may help to shape necessary transformations in healthcare.
We foresee important roles in various areas. For example, artists can improve the quality of the medical curriculum by teaching students to make unbiased clinical observations—a key element of the true art of medicine itself (fig 2).1718 Similarly, writers and poets can help scientists to supplement scientific jargon with a more accessible writing style. Recognising this potential, universities are incorporating artists into their medical curriculums,19 such as teaching interns to make observations through the eyes of an artist. (“Paint what you see, not what you think you see.”)
Teaching young doctors the art of careful clinical observation by observing art together with, and through the eyes of, an artist. Photo courtesy of Bert Beelen.
Art itself can facilitate medical training. Leonardo da Vinci used his anatomical skills to identify the thyroid gland and his artistic skills to draw the first depiction of it as an organ.20 In the 19th century famous neurologists such as Jean-Martin Charcot not only observed their patients carefully but also portrayed them in great detail in paintings or sculptures, to better educate their students.
Similarly, illustrations by Frank Netter, a surgeon and artist, can still be seen in doctors’ offices and medical books around the world, decades after his passing. Netter believed that physicians should be able to sketch at least a rudimentary scheme of what they were trying to convey to their patients. And a recent example is Oliver Sacks, a physician with a humanitarian approach to medicine who not only made astute clinical observations but also described them meticulously in books.
Finally, artistic training can help young clinicians to deal with situations of ambiguity and uncertainty21 which, although poorly accepted by the medical community,22 are common challenges in clinical practice.
Individual needs
We see a critical need for healthcare to shift from treating symptoms or signs towards focusing on people with individual needs and preferences. Indeed, current medicine is obsessed with rapidly finding diagnoses and initiating treatments, but this may be at the expense of humanistic, individualised, empathetic, patient centred care.22
Evidence based medicine and findings from large trials dictate medical decision making, leaving little room for intuition and adaptation to an individual patient’s context. This threat is further aggravated by the advent of computer algorithms using big data analyses to overtake these traditional medical skills. The need to analyse scientific literature will soon lose significance too, being replaced by neuronal network algorithms that can outsmart any human brain in memorising even rare diseases.
But the challenge is that computers have no intuition and are not good at helping patients by using empathy. To avoid care becoming depersonalised, medicine should concentrate on skills that seem to have been lost, such as taking the time to listen to patients to understand what really matters to them. Working with artists can help young clinicians to “zoom out” and better recognise the total clinical picture, including the person behind the complaints.23
As art can help us to understand the human condition better,24 should medical universities consider forcing their students to read a novel every month? Perhaps the greatest value of literature is that it teaches empathy. Reading a novel is a way of living other people’s lives, thinking their thoughts, looking through their eyes, and following a logic that may not coincide with one’s own. The quality of empathy is fundamentally important in any physician. An inspiring example is the career of Andrew Lees, the most prolific scientific writer in the field of Parkinson’s disease, who was inspired by reading non-scientific literature that opened his mind to new ideas and boosted his imagination.1
A merging road ahead
Many centuries ago medicine was considered an art, and its predecessor—“healing”—has been an art for much longer than it’s been a science. So, the origins of medicine and art were as one, and their present separation results only from our normative and cultural need for labels, structure, and silos.
Healthcare professionals are often specialists with deep expertise in one area of medicine, but this shouldn’t keep them from partnering other specialists from the world of art to optimise patient outcomes. In an era when modern technological developments threaten to drive these two fields even further apart, we believe that it’s time for medicine and art to come back together so that patients and society can benefit from the best of both worlds.
Acknowledgments
We thank Valentin Bejan and Susie Sainsbury for their valuable comments on an earlier draft of this manuscript.
Footnotes
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: BRB currently serves as associate editor for the Journal of Parkinson’s Disease, serves on the editorial board of Practical Neurology, has received honorariums from serving on the scientific advisory board for Zambon, Abbvie, Biogen, and UCB, has received fees for speaking at conferences from AbbVie, Zambon, and Bial, and has received research support from the Netherlands Organisation for Scientific Research, the Michael J Fox Foundation, UCB, Abbvie, the Stichting Parkinson Fonds, the Hersenstichting Nederland, the Parkinson’s Foundation, Verily Life Sciences, Horizon 2020, the Topsector Life Sciences and Health, and the Parkinson Vereniging. ILP reports no conflicts of interest. PK received grants and personal fees from Medtronic, Boston Scientific, UCB, and grants from St Jude Medical France, Annemarie OPPRECHT Foundation Parkinson Award, Edmond J & Lily Safra Foundation, French Ministry of Health (PHRC), INSERM (French National Institute of Health and Research in Medicine), France Parkinson, Swiss National Science Foundation, Roger de Spoelberch Foundation, Centre National Recherche Scientifique, Orkyn, Homeperf, Bertarelli Foundation, outside the submitted work.
Provenance and peer review: Commissioned, based on an idea from the author; not externally peer reviewed.