Marie Allitt reviews Alan Bleakley’s Educating Doctors’ Senses Through the Medical Humanities: “How do I look?” (Routledge: 2020).
Building on many years as professor of medical humanities in medical education, Alan Bleakley’s Educating Doctors’ Senses Through the Medical Humanities: “How do I look?” argues for dedicated education of the senses in medical training. Bleakley’s focus is directly on pedagogy, demonstrating the manifold ways in which arts and humanities can contribute to this fundamental aspect of medical practice. Bleakley argues that modern medicine, in both its practice and its training, is increasingly disembodied, leading to insensibility and insensitivity: the increasing use of ‘cold’ technologies as opposed to warm “hands on” examination, for example, contributes to a widening a gulf between practitioner and patient.
Medical education, and by extension medical practice, develops habits and relies on establishing behaviours. Knowledge is based on pattern-learning, consultation to a repository of knowledge, and recall to identifiable examples and case studies. There is a reduced focus on response to sensory stimuli grounded in perceptual learning: Bleakley argues that there are far fewer opportunities for medical students to actually interact with real patients, with the result that learning to diagnose takes place before witnessing the illness first hand. To counter this, Bleakley draws on Martina Kelly’s work on ‘body pedagogics’: an embodied practice that must be truly embedded and engrained in today’s medical curricula. Bleakley maintains that one of the major barriers to embodied practice is increased recourse to simulation, such as mannequins, patient actors, or more complex simulation technologies. Consequently, the student has little opportunity to ‘make sense’ of the basic examination through their own bodies: the student does not have much chance to practice their examination technique, let alone practice real-life sensory encounters, although many medical schools would probably dispute this.
This is not a historical or philosophical study of the senses, although it can usefully contribute to scholarship in these areas. Instead, Bleakley’s approach embeds interesting aspects of sensory histories and philosophies to foreground examples of the value of sensory engagement, which medicine cannot afford to lose. Having made the case for the value of medical humanities elsewhere, Bleakley’s priority here is to argue that an education, any education, of the senses needs to be taken seriously. The humanities provide ample opportunities for doing so, as the examples and case studies demonstrate, but this doesn’t have to be the only way to integrate the sensory approach. Any medical professionals and educators reading this will no doubt identify examples throughout the book that ring true for themselves and for their students. Those still sceptical about the importance of the humanities may in the first instance be drawn to reinstating a focus on smell, touch, sound, vision through more comfortable or traditional means, but it will quickly become apparent that the best way to integrate this pedagogy and generate the skills desired is to employ humanities approaches. The sooner it is recognised that humanities can be instrumental in the sensory education, the sooner this pedagogy starts to pay off. Consequently, the sensory pedagogics may in the long term provide a gateway to convincing sceptical medics, and funders, of the importance of integrated humanities.
The book is structured around the senses: while chapter 1 addresses the use of sensory networks, chapters 2-9 address individual senses. Bleakley admits that this mirrors a ‘false compartmentalising of the senses’ but, on this occasion, it is most convenient. Elsewhere such compartmentalising can be frustrating, but in this work, it is logical, in part because, while Bleakley subverts the hierarchising of the senses, he does not attempt to flatten them, nor does he pretend there is not a Western ocular-centrism. Chapters 2 and 3 address smell, in the context of disgust and abjection; chapters 4 and 5 focus on sound and listening, and chapters 6 and 7 explore the visual, centring on the act of looking, the medical gaze, and aesthetics. Somewhat surprisingly, there is only one chapter, 8, dedicated to touch. If parts of this book feel familiar to readers, it is because earlier versions of some of these chapters, particularly chapters 6 and 7, first appeared in Bleakley’s Medical Humanities and Medical Education How the medical humanities can shape better doctors (2016). The concluding chapter, 9, revisits sight in terms of identity creation and performativity, asking ‘how does the doctor want to be seen?’, which treads the path for further engagement with the meaning of ‘professionalism’ (a term mentioned throughout, but not explicitly interrogated).
Addressing smell and sensory assault, chapter 2 argues that the current direction of medical education that moves away from hands-on experience in, for example, cadaver dissection, generates a mishandling of disgust. Bleakley asserts that students need to learn to control their senses, overcoming disgust and repulsion. This move away from dissection results in losing sensitivity to the smells and textures of the body, which may offend or disgust, but ultimately help develop complex relationships with the abject and subjectivity. Bleakley adopts a psychoanalytic model, addressing not only abjection, but introducing the complex negotiations of repression, assimilation, and sublimation, which are all part of continual functionality. Students must learn to tread the delicate line between coping with both sensory and affective impacts, without losing sensitivity to the patient.
Developing the focus on smell specifically, chapter 3 also reinforces the larger issue at stake in a dedicated education of the senses, that of diagnostic acumen. Bleakley convincingly argues for the attuning of the senses, emphasising how using smell, especially, requires imagination. Together with the emphasis on de-odorising and neutralising clinical spaces, smell is no longer regarded as vital in medical education, resulting in a deficit of skills to harness or translate the signs. In order to notice and communicate a significant sensory marker, the clinician needs the vocabulary, memory, and capacity to analogise, compare, and contrast; whether it is recognising the odour of liver failure, or distinguishing between different kinds of infection. This is one of many cases where the humanities really prove their worth, demonstrating the vitality of the clinical imagination and the ways this can be nurtured and reinforced through creative and critical skills.
In chapters 6 and 7, Bleakley argues for encouraging students to move from looking to seeing, training them in aesthetic judgement and visual cues. Building on this, Bleakley suggests that it is one thing to educate on focused looking, but it would be more effective to prepare students to recognise and challenge the structural, and masculine, gaze of medicine. Bleakley expands upon the value of looking at, and seeing, art, to address the fact that there is an ethical urgency to challenge existing power structures. He establishes a critique of the ‘gaze’, and sets it in contrast with the phenomenological concept of the ‘glance’. Where the gaze penetrates, the glance surveys. Here we can recognise the necessary challenge to racial and cultural biases that pervades medicine. This takes on further prescience given recent efforts, for example, by medical student Malone Mukwende to address the shocking shortcomings of medical textbooks and educational structures, by creating a handbook to highlight how clinical signs appear on black and brown skin. While this is certainly an issue of representation and speaks to a wider race problem in medicine, this is also a lesson in training students to navigate from looking to seeing, to action and critique.
Perhaps unwittingly, Bleakley’s work here supports further need for a history of medical education, to help us educate the senses and educate through the senses. We need to look to the past in order to recognise how medical education and practice has got to where it has today. We need to explore how medical knowledge has been acquired and constructed through sensory engagement. There is a need to return to the basics of the examination technique, which is most useful if recognised in combination with how those actions developed in the first place. Are there forgotten details of earlier medical education that we could usefully adopt? Are there attitudes to the senses that we have misjudged or underestimated? By re-examining what the sensory engagement doesin training, we can begin to notice what aspects have been lost, the consequences of this change, and what we need to bring back.
The month and year of this book’s publication, February 2020, is notable. There is no escaping the fact that the realities of the COVID-19 pandemic has given whole new meanings to closeness in medical encounters, and sensory absence more generally. Further research that develops from this book needs to consider the role and education of the senses when it comes to telemedicine which, while never a substitute for face to face examinations, is a reality of medical practice going forward.
At times Bleakley acknowledges cultural differences and the impact this has on senses and practice, for example drawing upon aspects of Chinese medicine as a way to rethink western practices, identifying the very recent inclusion of cadaver dissection in some parts of the world, and references the fact that in some countries and cultures eye contact is perceived as a mark of disrespect. However, there does need to be further consideration for how different cultural traditions may produce different attitudes to or histories of the senses. Any harnessing of embodied learning and sensory networks must not only accommodate but actively involve cultural differences and attitudes to the senses. We also need to consider such pedagogic intent which is fully inclusive and attentive to disabilities, ensuring that sensory differences are not discriminatory, as well as recognising that the senses might carry alternative meanings and do different things for different people.
This is vital reading for all involved in humanities in medical education. But I also urge all medical educators to read this, with an open and curious mind, to reflect upon their own learning and practice in light of the points raised here. There is much inspiration here to necessarily disrupt and challenge educational practices in the UK and further afield. This is not a guide or textbook for how to embed medical humanities or the education of the senses into medical curricula: it is closer to a manifesto for centralising, or at the very least acknowledging, the role of the senses at the heart of medicine, and establishing a conscious sensory pedagogy.
Dr Marie Allitt is a Humanities and Healthcare Fellow at the University of Oxford, on the project ‘Advancing Medical Professionalism: Integrating Humanities Teaching in the University of Oxford’s Medical School’. She is also the Postdoctoral Research Assistant for the Northern Network for Medical Humanities Research, at the University of Leeds. Marie completed her PhD in English Literature at the University of York in 2018, focusing on experiences and representations of spaces and senses in First World War medical caregiving narratives.
Marie can be followed on Twitter at @MarieAllitt.