Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff.
If you've ever been to our website, you've probably seen the Journal's tagline, “Illuminating the art of medicine.” This phrase, “the art of medicine,” is commonly used when people want to point out the importance of skills and attitudes toward patient care that aren't highlighted in traditional medical school clinical curricula. The relationship between art and medicine is assumed to be collaborative, with each field contributing their own unique worldview to the practice of healing and good care. However, it's easy to misconstrue the relationship between art and medicine to which this phrase refers.
To many, medicine is an inherently scientific, objective, and evidence-based practice. Any art of medicine, therefore, would need to be the set of things that are not scientific and that are left up to individual clinicians. Illuminating the art of medicine, then, would be reduced to highlighting idiosyncrasies of individual clinicians' practices. After all, someone might say if the art part of the practice were as scientific as the medical part, it would just be called “medicine.”
In this dualistic view, medicine is rigid; art is fluid. Medicine is scientific, and art is emotional. Medicine is intervention, and art is compassion and support through illness experiences. But social and cultural context, including arts and arts-based research, contribute to the development of scientific knowledge and its application to helping patients.
Artist, researcher, and teacher Dr Mark Gilbert has long problematized dualistic separations of art and medicine and suggests that this line of thinking doesn't give enough credit to medicine or to the people who practice it and places outsized importance on the arts as a unique source of compassion and empathy for patients, and underemphasizes it as a source of robust, rigorous research that motivates innovation in patient care.
Mark Gilbert, PhD: That has a slightly jaundiced or cynical view of medicine, and at times, I think it has a slightly inflated view of the arts. Whatever capacity I have for empathy or compassion, I have that capacity not because I went to art school, but because of what medicine has given me these last 20, 25 years working in this process. And so, these collaborations, if they're going to be a genuine collaboration, then both parties have to be changed by or at least have to be open to be changed.
Hoff: Art, in this view, is not a separate sphere augmenting medicine, it's another tool clinicians can and likely should use in the practice of medicine, in the very act of diagnostic and prognostic inquiry, and in patient care.
In this episode of the podcast, we'll be talking with Dr Gilbert, associate professor in the School of Art and Art History at the University of Nebraska Omaha, and participating faculty member in UNO's Medical Humanities Program about arts-based research: what it is, who it's for, and why we should be paying more attention to it as a method of research.
Dr Gilbert, thank you so much for being on the podcast today.
Gilbert: Thanks. No, it's lovely to be here, Tim. Thank you. [music fades out]
Hoff: So, when people first hear the phrase or read the phrase in our issue this month, “arts-based research,”rdquo; most people think of things like film criticism or art history, where the arts are the subject of research rather than the method of research. So, can you introduce our listeners to what arts-based research is and especially how it relates to health care research specifically?
Gilbert: I mean, really, arts-based research kind of recognizes that the role of the arts—the arts in all their forms, whether it be the visual arts, music, dance, even poetry, and many others—it recognizes how these can be forms of research and that they can kind of, they can engender modes of representation that have the potential to create statements and insights that otherwise, in other ways and other methods and other mediums maybe can't, wouldn't be expressed or documented or shared. And I think it's important to realize, at least for me anyway, I'm always, you know, as an artist, I'm always…I'm always acutely aware that any form of art, in its own way, even if it's not being done explicitly as a research method, is research.
Gilbert: So, before I became an artist working in collaboration with medicine and working on all the research studies that I've worked on—and I started doing that 25 years ago—10 years before that, for 10 years before that, I was working in almost isolation painting a small cohort of models and sitters who were kind enough to come and sit for me. And each one of those pictures, each one of those paintings that I did then in its own way was a form of research, you know? I think we underestimate…we underestimate the rigor, and we underestimate the empiricism that there is in the arts.
Gilbert: And in the same ways, we also underestimate the artistry in the sciences and the artistry, frankly, the artistry and the creativity that's required in medicine.
Gilbert: And as I say, I think that's the, you know, and I think even, sometimes I think people who are working in medicine underestimate the creativity that's required bearing in mind. And so, for me, anyway, at least speaking from my own research method, my own research perspective, a great deal of what I'm, with the work I do in collaboration with medicine is really kind of using the arts as a way of exploring these kind of relational elements. And then whether that relationship is between an artist and a sitter or between a patient and a doctor, that relationship is an inherently creative endeavor. And with that creativity comes uncertainty. And these are all elements that both as an artist, and I think from my experience of working with physicians and caregivers and patients and so on, these slightly hard to, certainly hard to teach and sometimes hard to engage with elements of these relational elements and really looking at the nature and form of relationships. And again, being able to address and recognize and embrace the creativity with all the challenges that come with that. I think the arts can give a, you know, can help in a medical context in an amazing way. It kind of offers a safe space in which to engage with these kind of, with these themes that I think to a certain extent can get squeezed out of the medical curriculum these days.
Hoff: Mmhmm. Yeah, I appreciate you highlighting the rigor of arts as a method of research since I think so often, people approach this conversation thinking that art and arts-based research is an inherently less rigorous and perhaps ultimately less useful method of inquiry for people who practice in the “scientific” space of medicine. So, can you tell me a little bit more about what arts-based research is like? For example, how does patient participation in arts-based research differ from more traditional research methods?
Gilbert: So, no, I think that's certainly, from again, just reflecting on my own, from my own perspective, I think that's a terrific question. And it's something that I'm acutely aware of about the role of the participant, and to a certain extent, the relationship I have with the people who participate in my studies as maybe slightly different from the more traditional model of researcher/participant. And so, as a researcher working as an artist, when I'm creating a picture, I'm not just, when I'm painting somebody, whether that be a patient or whether that be a partner in care or a professional caregiver, I'm not really, you know, there's always that balance between the kind of being objective and subjective, and that's always there.
Gilbert: That's there in everything that we do. And so, nothing's purely one or the other. But I am acutely aware of, you know, I'm not detached when I'm painting somebody. There's a relationship. There's an instant intimacy that's engendered when you start to, when I start to, work with a participant, when I start to draw a participant. And then the relationship that is so fundamental to the work that I do then is developed out of that intimacy. That intimacy may feel a little bit burdensome or a little bit awkward or even maybe even threatening at the beginning. But it's amazing how both myself and the participant kind of ease ourselves into the process.
Gilbert: And so, it really is one of collaboration. It's not just a case of that the participant needs to, all the participant needs to do is kind of sit still and allow me to get on with the picture. It's much more, there's much more complexity to the relationship.
Gilbert: And so, I do get to know the participants incredibly well. There's moments of silence, which carry their own deep communicative benefits and values. And there's a lot of, there's a lot of discussing back and forth and a lot of reflection, either side of the easel. And so, it really is, you know, I aspire for it to be as collaborative as possible. And when I'm working on a picture, I really kind of almost paradoxically, I have to make sure that I'm paying more attention to the person that's in front of me than I am to the picture. So, I care deeply about the picture. I want it to do justice to who or what I'm painting. At the same time, it's very important to realize that my focus and the majority of my focus has to be on the subject. And that's important not just in a research capacity, but just in an artistic capacity. That's something I teach my art students all the time that they have to, they can't fixate on the picture. They have to be responsive to what it is that they're responding to.
And then ultimately, the picture, the results, the data, I mean, there's different data that I collect. So, there's the pictures themselves.
Gilbert: I record all the verbal back and forth that happens during the sittings, during the portrait sessions. And I keep journals and so on. So, there's lots of journal, but ultimately, part of that data collection is the image themselves. And I don't pretend, you know, I'm not being a fly on the wall here. I realize that ultimately, the actual, the final, the finished picture is, to a certain extent, is being seen through my lens.
Gilbert: And there's a decision I've made, the decisions, multitudes of decisions that have been made, explicit and implicit, decisions I'm maybe not even aware of doing that are happening. And so, there's a great deal. So, even though I'm the one sitting behind the easel with the brush in my hands, the participant still brings a great deal to the process. And ultimately, and it's important to realize this—so, my challenge is to make sure I can still be creative, that I can still be making these decisions—but ultimately, it's important that my voice as the artist-researcher doesn't overpower the voice of the sitter. So, ultimately, when people look at the, you know, when people engage with the paintings, hopefully initially they're engaging with the participant first, they're engaging with who the picture is of. And then they might then start, they might be, if they didn't know who the artist was, then they might be curious to find out who it was. They might want to know more about how the picture was painted. But ultimately, the participant is front and center.
Gilbert: But there is that element that, you know, I, I… The arts-based research, as I say, especially when it comes to portraiture, is all about the relationships. And so, we're not just kind of, it's not, I'm not just doing, I'm not just developing research into the participant.
Gilbert: The research is really all about, it's scaffolded on that relationship, and that relationship has to be recognized and described as richly as possible as well.
Hoff: Mmhmm. Your mention of the value of even those moments of silence in the creative process, it brought to mind the experience that you had with Anthony, which you captured in an article for our June 2020 issue on portraiture as a research method, which you guest edited. And for folks who are interested in more descriptions of these artist/sitter relationships, that issue is definitely one to go check out.
As you note, there are a number of challenges in the portraiture process. There's first establishing a relationship with the new sitter. You need to balance their experience with what you bring to the process as an artist. What are some of the specific benefits of portraiture as a method of research?
Gilbert: I mean, I think what portraiture does, because you're using portraits as a research method, I think, as I say, a great deal of it is to do with the relationships and the generation of that relationship. And of course, that parallels, that immediately then opens up, and has opened up for me then. I will have been able to then use that research relationship that I engage with and then be able to kind of use that as a kind of way of exploring even more the doctor/patient relationship or the health, the clinical interaction. And so, my research has shown that by working on a portrait, for both the artist and the sitter, we have to engage with abundant uncertainties. We're all engaging with uncertainties. There's the uncertainties that the patient participant, for instance, may have to do with a diagnosis, the prognosis.
Gilbert: Creating artwork is an inherently uncertain endeavor. It's creative, and therefore it has that uncertainty. And many of the people I've worked with haven't been painted before or drawn before. So that again, it's something, they're taking a step into the unknown. So, there is no, you know, so we all engage in this process not knowing the end at the beginning. And then the relationships, again, as I say, that we're able to, the relationships within themselves are creative endeavors. And so, but being able to have those relationships, to be able to work in such a way that we can have those relationships, the relationships I have nourish the research I do. And frankly, they nourish me. They allow me to continue and to ease my own, frankly, anxieties at times. Because it's a vulnerable process for both the participant and myself. And so, again, we help each other through that process.
It's also a process that requires a great deal of reflection from both the artist and the sitter. So, the reflections are profound for the sitter, almost as they kind of sit in either silence reflecting on their lives or by looking back in their lives through the conversations. And there is just the sort of storytelling element. I want to know their story as we're working. And frankly, they want to know my story.
Gilbert: And as a result of that, as a result of engaging with those uncertainties, the reflections that it engenders, the relationships that hopefully develop, having that opportunity to express themselves and be heard, my studies have shown that that can help us feel a little bit stronger. The participants and myself, to a certain extent, then feel a little bit more empowered, maybe a little bit more, you know, maybe even at times, it's maybe engendered a little bit of a healing process one way or another. And so, these are all things that I think, as I say, because the nature, because portraiture is really all about that artist/sitter relationship, then it's very easy to kind of recognize or to kind of compare that relationship with other types of relationships, for instance, in the clinical sphere.
Gilbert: But the arts in all their forms, as I say, have that, still have all that. Those emergent themes, as I said, they're pertinent to the clinical interaction, but they're also salient to any compassionate interaction that any of us may have. And we're all going to be patients and caregivers at some point in our lives. But these are all things that the arts—the uncertainties, the reflection—these are all fundamental to the arts in all their forms.
Gilbert: And so, it opens up this window for, whether it be music, dance, and so much more, to be able to, again, to provide a sort of safe space to be able to engage with these processes, and to a certain extent, I think we tend to avoid.
Gilbert: But whereas if we do engage with them, there is an element of discomfort, but it does make life richer. It does kind of illuminate aspects of our lives that are important. And that benefit is when we do engage, sometimes these challenges, by engaging with the challenges, it can be incredibly powerful and even ultimately, maybe even enjoyable. And it just makes life richer.
And I heard the other day somebody said that when you draw something, just taking that time in silence just to draw, just attend to something with care, we so often don't give ourselves the opportunity to just kind of be quiet and engage in a way like that. And it can, and what they said is it helps you fall in love with the world again. And I think to a certain extent, I think there's a truth in that. We don't give ourselves these opportunities. And the arts…the arts, I think, can do that. And again, recognizing the artistry that really, I think, is often spoken about, but maybe not necessarily addressed in medicine at times like that, then I think it behooves, it would benefit medicine a huge amount to talk about the art of medicine and seek it out even more.
Gilbert: And obviously then, that opens a door for the arts to inform medicine, and frankly, for medicine to inform the arts. So, it's not one-way traffic here. Yeah.
Hoff: Mmhmm. So, given that it's not a one-way street and that both arts and medicine have much to offer each other, how can arts-based research be integrated into medical education, and what should students and trainees know about how to use what they learn through arts-based research in their own practice?
Gilbert: Gosh, that's a great question. And there's a lot. I mean, I can talk about how we've used the arts in different ways within medical education. So, we've kind of, you know, in the past, we've used it as, for instance, the act of drawing, encouraging students to draw and delivering drawing workshops or engaging with the visual arts, we've used it to help augment the powers of observation. We've used it as a way of being able to illuminate the importance of being able to engage in critical thinking.
Gilbert: Again, it gives students a sort of safe place to be able to immerse themselves with the creativity and the uncertainties that I've already spoken about and then be able to kind of allow them to be able to weave or to recognize where this applies to their own work. So, now, we've used artmaking and engaging with the arts, whether it be, I'm thinking of a specific study working with a physician when I was up in Canada. We used music, we used film and visual arts as a way to engage students into different ways or to make them aware of the risk of medical error.
Gilbert: And so, being able to make them realize that medical error isn't necessarily because…it occurs not necessarily because somebody doesn't know what they are doing or hasn't learned properly what they ought to be doing. But it tends, it comes from more, from maybe not think-, not maybe thinking properly, you know? So, the arts, I think, are a terrific way of illuminating the risks of, and familiarizing one with, our own internal schema when we're trying to address things like, for instance, biases and so on that can be so.... You know, if we're not aware of our own biases, if we're not aware of where we take shortcuts, if we're not aware of where we might make dangerous assumptions, these are all things that can impact on medical decision making.
And I think, again, the arts kind of open up because of that creativity that it demands of us, either by being in the audience or through engaging with or actually creating ourselves. Then I think it's a great way of being able to eliminate that, frankly, where art and medicine, I think, work most purposely together is that we're challenged by the same things, and that's basically to maintain and sustain a sense of curiosity.
Gilbert: And with that sense of curiosity, with that curiosity comes emotional engagement, comes compassion, comes a capacity to be able to kind of jettison or hopefully at the very least, be able to recognize our own biases in a way that can then help augment our powers of observation, our capacity to make critical decisions, and so on.
And so, it's interesting. I mean, so much of the work that I do is, you know, we think about, for instance, the medical humanities as trying to make better doctors, using arts as a way of being able to kind of help future doctors, future nurses, future health care workers, and so on. And to a certain extent, that's, you know, and I believe passionately that's possible. But at the same time, to a certain extent, I often flinch a little bit because I end up thinking that has a slightly jaundiced or cynical view of medicine. And at times I think it has a slightly inflated view of the arts.
Gilbert: And I know from my own experience, whatever capacity I have for empathy or compassion, I have that capacity not because I went to art school, but because of what medicine has given me these last 20, 25 years working in this process, working in these research studies. And so, I passionately believe that actually, the reason the arts and medicine can kind of work so well with each other and inform one another so well is that we're challenged by the same things. And frankly, to put it kind of, to simplify that, I think it is that kind of challenge, and it's a deep challenge for all of us, to be able to maintain and sustain that sense of curiosity with everything that comes with that.
And also, what comes out of that is also meanings, new meanings. Because you're trying to keep your perspective as broad as possible, then it becomes, whether in medicine or whether in the arts, it means that you're then more open to discovery. It becomes a much more interesting process. And with that discovery…with that discovery comes new meanings.
And I think, you know, and the other aspect of this that I haven't really touched on is the risk of things like burnout and so on is so prevalent. And with my experience, when it comes to burnout in medicine, it's not really just to do with the quantity of work that one has to do, although that's part of it. A great deal of the time when you speak to people who are living with burnout, who have suffered from burnout and so on, it's because they've lost touch with those elements, those elements of medicine that inspired them to go into medicine in the first place.
Gilbert: So, they've kind of lost touch with these motivations. They've lost touch with these elements of medicine that can nourish them even at the most challenging of times. And I think so often that can be, burnout can be engendered because we've lost touch with what's important with the essence of ourselves and also the essence of medicine. And again, I think that the arts are a terrific way of being able to engage with the most challenging aspects of medicine in such a way that it can help us cope better with them. [theme music returns]
Hoff: Dr Gilbert, thank you so much for being on the podcast with me today and for all of the work that you've done helping pull this issue together.
Gilbert: Thanks so much, Tim. It was great speaking with you.
Hoff: That's our episode for this month. Thanks to Dr Mark Gilbert for joining me. Music was by the Blue Dot Sessions. To read the full issue for free, visit our site, JournalOfEthics.org. For all of our latest news and updates, follow us on Twitter and Facebook @JournalOfEthics. And be sure to check out our other podcasts, including our Author Interview Series, short, 5- to 10-minute episodes featuring the authors in each month's issue discussing the main ethical arguments and takeaways in their article. We'll be back next month with an episode on iatrogenic harm. Talk to you then.
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