A Poet in the Practice? The Role of the Arts in Health Care

Summary of talk given by Dr Gillian Rice to the Bristol Medico Chirurgical Society on 8 January 2003

Lets think about the healthcare environment first of all. In the 1980s hospital planners began to recognise that the hospital environment can bring anxiety and disorientation to patients and visitors, as well as stress to staff, and design teams started to explore the notion of using the arts to create an environment in hospitals that is more welcoming and pleasant for those who work, visit or receive treatment there.

A fantastic example of how the arts have been used to create such an environment is The Chelsea and Westminster Hospital in London. The hospital was unusual in Britain in commissioning numerous works of art at the drawing board stage. There are also paintings, drawings, prints and photographs enlivening the walls of wards and public areas. The hospital has embraced performing arts as well. Weekly live performances are held on the wards and in public areas such as the main stage. The City of London Sinfonia completed a four year residency at the hospital, and the Medici String Quartet have also done workshops and concerts.

Closer to home, here in Bristol, we have another wonderful example of the arts being used to enhance a hospital environment in the new Childrens Hospital. Theres the wonderfully up-beat neon lollipop sculpture, by Andrew Smith, outside the hospital entrance, and inside another artist, Ray Smith, worked on the colour scheme throughout the public areas on all levels. The hospitals Prayer Room, has a stunning glass window by Catrin Jones. A beautiful wood and cast glass table was also made for the room, and a calligrapher inscribed excerpts of a specially commissioned poem on the walls.

Not all areas of the hospital are vividly coloured. The hydrotherapy pool room is largely monochromatic, so that staff who spend a long time in the room arent overwhelmed by strong colour. Nevertheless, the pictures and poems can distract bored children. I think you can see that the arts have helped to create an environment which is different, distracting, even joyous and that this kind of environment may well relieve worry in children and their families, helping them to forget the illness thats brought them into hospital and instead focus on something stimulating and diverting.

I believe we can use the arts to similar effect in primary care. Visual art and poetry can help take patients minds off their ailments and it isnt necessarily expensive to provide such diversions in the waiting room. Theres even a free scheme for surgeries called Poems in the Waiting Room that provides pamphlets containing a selection of old and contemporary poems. Of course GPs could be even more adventurous in the way they incorporate the arts into their surgeries and my partners and I certainly hope to stick our necks out as we design our new practice which should be built in Bedminster in the next two years. In order to make it feel imaginative and vibrant as well as welcoming and soothing, we have involved an arts consultant to help us integrate the arts into the fabric and the culture of the new surgery.

The second area I want to discuss is how the arts can be used as therapeutic activities for patients. I became interested in this area a few years ago when I heard about a scheme run by the Poetry Society in which poets were going into different workplaces from a chip shop in Wigan to the head office of Marks & Spencer to see how they could contribute to the working environment. If poetry could prove useful to people in small businesses or large organizations, I thought, why not in a GPs surgery? The Poetry Society provided funding and so it was that Rose Flint, a published poet from Bath, took up residency for six months as our Poet for Health.

For the first couple of weeks Rose joined me in my consulting room while I saw patients. Everyone was asked if they minded a poet sitting in and, much to my surprise, almost no one objected. We offered certain patients one-to-one sessions with Rose, so they could talk about current problems or troubling past events and eventually write poems about their experiences and feelings. Rose also started up a poetry writing group for patients suffering from arthritis. Rose saw less than 20 patients but everyone whod spent time with her completed an evaluation questionnaire after the residency had ended. The response was uniformly positive. We also received some individual letters of thanks which made us feel that for some patients poetry had proved to be a very effective medicine.

We were also lucky enough to be approached by two arts psychotherapists who worked with us for 12 months and provided one-to-one sessions for a small number of patients throughout that time. Patients were encouraged to use painting, drawing, or sand and clay work to explore heir feelings in these sessions. Again, patients seem to have found the arts therapy very helpful.

So my practice has just been feeling our way into the whole area of therapeutic arts but there are hospitals and community groups around the country who have used a wide variety of art forms as forms of therapy for patients. It all sounds great fun, but is there any evidence that using the arts to enhance the health care environment, or as forms of therapy for patients, can improve their health in any way? Going back nearly 20 years, one classic American study looked at 46 patients undergoing cholecystectomy. Half were kept in hospital rooms with a pleasant view looking out over trees, the other half had rooms looking out over a brick wall. Those who had a room with a view needed fewer doses of potent analgesics on average, and left hospital almost a day earlier a 10% shorter stay than those faced with a brick wall.

In 1996 Robin Philipp reported on a small qualitative study looking at responses from members of the public as to whether reading or writing poetry might benefit peoples health. 6.6% reported that theyd been able to wean themselves off benzodiazapine tranquillizers or antidepressants as a result of discovering poetry for themselves, 75% said that writing poetry reduced stress and anxiety, and 65% said that reading poetry had the same effect.

In 2002 David Evans in Australia carried out a systematic review looking at the effectiveness of music as an intervention for hospital patients. The results suggested that music played via headphones reduces anxiety of patients during normal care delivery (eg awaiting, or recovering from, surgical procedures). It has no impact on anxiety of patients undergoing procedures such as bronchoscopy, sigmoidoscopy or surgery with a spinal anaesthetic. Music produces a small reduction in respiratory rate during normal care delivery but little effect on other vital signs including systolic blood pressure. Music also appears to improve the mood and tolerance (to unpleasant procedures) of patients, although the evidence is limited.

The most comprehensive study of the effects of the arts in healthcare is still ongoing at the Chelsea and Westminster Hospital. (Results from various phases of the studies were shown). The rest of the results are due to be published in the next couple of months.

Theres a third area Id like to explore thats the value of the arts for healthcare professionals. The Chelsea and Westminster Hospital study looked at the response of doctors, nursing staff (and administrators) to the arts programme in the hospital; their findings suggest that the arts might help with recruitment and retention of health professionals. And the arts can have a direct therapeutic role for doctors and nurses. A number of hospitals and hospices around the country have held arts-based workshops for staff to attend. One workshop for doctors and nurses working in oncology used the visual arts to explore their feelings about death and dying. Many of the participants said they had found it an incredibly useful way to understand and deal with the emotions that arose within themselves in the course of caring for terminally ill patients and their families.

I can thoroughly recommend the courses run by the Centre for Medical Humanities, part of University College London. Reading literature and looking at paintings can help us understand other peoples perspective - on illness, disability, dying, whatever - without having to take responsibility for them (which is what we naturally tend to do with our own patients). It can also help us ponder on issues more deeply than we might be able to in the course of our day-to-day work.

The ability to understand other peoples perspective should be cultivated at medical school. About 30% of American medical schools include instruction in literature in the curriculum and some British medical schools also now offer Special Study Modules in arts and humanities. But we have a long way to go before the full value of the arts in medical education is recognised.

Talking of education, theres one more role the arts can play in health care and thats to help the public understand medical and health issues. One example is the "Saving Faces" art exhibition which is currently touring the country. Its the brainchild of Iain Hutchinson, a consultant maxillofacial surgeon, who commissioned a Scottish artist, Mark Gilbert, to paint a series of portraits of his patients to both educate the public about modern reconstructive facial surgery, and demonstrate that people with facial disfigurement do lead full and happy lives.

One of the portraits from the exhibition shows Henry de Lotbiniere, a remarkable barrister who died last year, aged 57. When he was 42 he was diagnosed with salivary gland cancer. Over the next 15 years he had most of the left side of his face removed and had extensive facial reconstruction carried out. He exuded an air of joie de vivre and often reminded people that " what you look like is a seriously minor part of the person you are". The way this portrait shows de Lotbiniere staring unflinchingly at the artist reflects his determined outlook on life.

A second portrait shows another man called Henry - a 34 yr old forensic mental health nurse. Originally from Nigeria, he developed an osteosarcoma and his upper jaw, sinus and nasal support on one side had to be removed. No surgical reconstruction was carried out, but he wears a large denture or obturator to fill the space. The fact that hes been painted with his young son helps us to see him as a parent trying to bring up his small child, not just as a man with a disfigured face.

Another exhibition called the Tree of Life uses a wide range of different art media to depict the beauty of the human heart and its blood supply. One piece by Alan Evans, part copper, part steel, shows the healthy coronary vessels of a non-smoker on one side and the diseased vessels of a smoker on the other. Another artist, Stephanie Carlton Smith, used pieces of stained glass to depict normal and abnormal blood flow to the heart muscle. The exhibition also contains a wonderful wood sculpture by William Fairbank in which hes used 108 separate pieces of yew to form an enormous heart. He says that he hopes that if people can touch the sculpture then the sculpture will touch them.

I was greatly cheered to read a recent editorial in the BMJ by its editor, Richard Smith. The headline declares that if we "spend (slightly) less on health and more on the arts, health would probably be improved". Not everyone will agree with him - some people might think it trivial to be concerned about whats hanging on hospital walls when there are bed and staff shortages and long waiting lists to deal with. And why bother with creative therapies when weve got SSRIs and CBT to treat anxiety and depression? Well, I think we should bother because modern medicine often fails to even notice, let alone nurture, the human spirit in patients, their families and in us the health care staff. The arts offer a way in helping us to understand how we, and those we care for, react to illness, to treatment and to death. If we truly want to offer holistic, high quality care to our patients, I believe the arts have a big part to play in helping us achieve that.