We submit to the doctor by quoting to ourselves a state of childhood and simultaneously extending our sense of childhood to include him. We imagine him as an honorary member of the family.

John Berger

Over the past twenty years or so, in medical schools in Ireland, the UK and the US, as part of an academic movement commonly referred to as ‘medical humanities’, students have increasingly been studying literature and creative writing. Much to the satisfaction of medical educators, these tailored arts and humanities offerings have proved reliably popular, particularly in the first two years of a medicine degree, before the more intense phases of clinical placements have begun. For the new recruits there seems to be something natural as well as novel in the undertaking. The explorations and discussions involved tend to be genuinely stimulating, in addition to being a counterbalance to a curriculum that typically presents major challenges.

In Ireland, if you ask medical students their opinion about the value of reading and writing poetry as part of their training, one likely response is that the validation of such things within the medicine curriculum, along with the opportunity to develop an artistic interest, comes as a great relief. On entering medical school, many students begin to rally themselves for extreme exam preparation. A combined vision of endurance and success can come into play, as they tell themselves a limiting story; namely, that they must be prepared to block out all distractions, all temptations, and almost all extracurricular interests for the sake of the job at hand.

Being given an outlet that is arts-based, and being required to slow down and reflect, are not unwelcome, and neither are study requirements that are enjoyable for their novelty and sociability. But such things as enjoyment and artistic ambition are not often uppermost in the thoughts of the people responsible for curricular developments in medical schools. Certainly, behind the bulwarks, a concern for the wellbeing of medical students exists. The idea that medical training is at times unnecessarily demanding is not a contested one, and neither is the idea that something should be done to ameliorate the built-in stresses of the student experience. Some academic doctors write about their students in compassionately holistic terms. Since the advent of medical humanities, there have been calls to use literature in medical training as a counter-cultural force, as a way to tackle the forms of medical inhumanity that too often alienate the trainee. There has been some powerful writing this year questioning the presumption that medical students should volunteer themselves as frontline workers, and about the phenomenon of graduations being fast-tracked as a way of addressing personnel shortages. In an article emphasising the risks posed to students’ mental health by pandemic unpreparedness, the risk of what has been termed ‘moral trauma’, and the untried altruism of the students themselves, one fiery commentator wrote, ‘No more should be expected of medical students than of the general public.’

Viewpoints of this kind reflect a lesser known culture of advocacy, and an established sensitivity to the phased transformation of medical students from members of the public into medical professionals, things which tie in with arts and humanities initiatives in undergraduate medicine. But the main reason student doctors have been encouraged in recent years to read and write creatively is that a belief that it might make a difference to the patient’s experience of healthcare has begun to take root in the pedagogical ground of medicine itself.

Such things as curiosity, and a willingness to try to relate to the patient, to listen to them, and to interpret their symptoms in the light of their experiences, together with an interest in the nuances of language and expression, have attained importance, and it is for the sake of these virtues that many medical schools have sought to make budding writers and critics out of their new recruits. In a recent New Yorker interview, Johanna Shapiro, the director of the University of California Irvine’s medical humanities program, framed the link between literature and the doctor-patient relationship in striking terms:

You think a patient is going to be like a well-organized essay, but what you really get is a poem … You’re not sure what they mean, and they don’t tell you everything all at once, up front.

Embarking from this image of a doctor palpating a sonnet, I’m going to explore two recently published poems by Irish poets: Mary O’Malley’s The Heart Man, from her 2019 collection Gaudent Angeli (Carcanet), and Stephen Sexton’s #7 Larry’s Castle, from the collection If All the World and Love Were Young (Penguin), also published in 2019. On their own terms, both poems are engrossing and impressive, and I will try to identify some of the technical secrets behind their respective powers. The fact that both have illness, healing and healthcare among their themes allows an additional approach. By looking at The Heart Man and #7 Larry’s Castle in the light of the idea of a medical poetry audience, one that wishes to embrace literature as a means for doctors to become better attuned to the individuality of their patients, as well as a medium through which new insights into its institutional biases and hang-ups might be attained, I will be trusting an unusual critical angle, but one that I’m confident will help to reveal something of the true depth and substance of the poems. Ultimately, mindful of the shadow of the coronavirus pandemic, I want to attempt to illuminate something of poetry’s value as an offering to the doctors of the future, those for whom that same shadow is likely to become a kind of professional habitat.

Possessed by an idiosyncratic counter-cultural spirit, Mary O’Malley’s The Heart Man catches the medical humanities eye in the way that it excludes mainstream medicine and science from a story of illness and healing, almost to the point of casting imagination as the primary carer. Through a third person narrative mode, articulated from the perspective of a wry speaker, we meet a male patient, the eponymous heart man, who is remarkably self-possessed in the face of a serious condition. The poem begins with the pursuit of a diagnosis:

… When he is asked

to picture it he sees a dark space

a metal wrapping locked tight

to protect it from the touch of ravens

and whatever else is there.

There’s a valuable strangeness in this depiction of the patient’s insides as spacious, a place populated by ravens and other shadowy presences. The opening lines of The Heart Man hold a metaphor for the ways that our sense of ourselves and our relationship to our physical bodies are often inseparable. Patently, if this was a real patient’s response to a real doctor’s question, the doctor would have to try again in order to extract a more medically relevant answer. As requested, the heart man has taken an inward view, but he has failed to anatomise himself. His heart has clouded his tongue, and made it over-figurative. Or to put it another way, his personal poetry is at odds with the prose of science. It’s as if he cannot speak without reflecting a dream perspective. Importantly, that perspective is expressed in matter-of-fact terms. O’Malley has given her readers no verbal cue that she wishes the poem to be read as particularly high-pitched. This adds an appealing tension, and the sense of an ironical leaning towards transcendence.

Quite sensationally, though again O’Malley’s diction is without showiness, the heart man puts himself in the care of a shaman, who in turn applies an intense visionary treatment. This involves the ailing heart being flooded with ‘the healing breath’ of love, and a quasi-surgical attempt to expose ‘all that raw flesh’ to the ‘pulsing red light’ of the shaman’s ‘inner eye’.

These efforts fall short. Instead of a manifest recovery there is a creaking sound inside the heart man’s chest. This might represent the fact that the illness is persisting; or it might suggest a biological willingness to meet an ancient therapeutic method halfway, a kind of murmuring identification. Whatever its significance, the heart man now feels exhausted. The following morning he wakes with a vision of self-healing. He feels that the shaman’s efforts have helped him to locate his heart more precisely, and he has a new set of approaches. He resolves to relate to the embattled thing beating in his chest as if it were a bird, and to breathe upon it. He also decides to try to banish the ‘rust’ from his circulatory system.

These memorable images of an improvised, questing, non-scientific medicine are carried forward in the closing two stanzas of The Heart Man. Our patient has had some success, he is out of the woods, and his next step is to return to a way of life that is at once nourishing and celebratory. With a logic that connects to a number of other O’Malley poems – most significantly the Gaudent Angeli poem A Jig in Spacetime, and Uileann from her 2016 collection Playing the Octopus – he goes to a traditional music hotspot, a pub where he further revives himself by listening to a live performance which stands as another alternative practice, a veritable tonic that ‘lifts the heart and makes time fly’. By the end of the poem, his condition temporarily forgotten, the heart man has begun to dance.

There is something undeniably surreal in the shift from the shaman encounter and the efforts of self-healing to the setting of the pub. But O’Malley has tonal control. Ultimately, this odd segue allows a deeper version of the shamanism theme, lending as it does a special form of credence to ritualistic medical practice, before arriving at a more humane evocation of acceptance and strength in the face of death. This is another selling point for The Heart Man as a medical school poem: death is not a subject defined by fear or sorrow, and it is not a matter of medical futility or failure. At the close, conventional thinking and assumptions have been side-lined. We’ve been transported to a secure place of wonder; and from that vantage point, mortality looks different.

In the following, the final verse of the poem, Madame Bonaparte is a reference to a hornpipe tune, often played on solo accordion –

He was dancing with Madame Bonaparte

when it cut out. He folded so quietly that

the music played on, nice and stately.

Nature has run its course. A man appeared to get a new lease of life, and he made the most of it. The poem almost seems to say to the reader: that is all you need to know. But the description of the musicians, oblivious as they are to the presence of a dead man in their midst, as their playing continues ‘nice and stately,’ seems to go further. An uncanny view of life’s continuity is suggested, together with a community that accommodates death, and a consciousness that seems willing to confront the fact that a heart, like an engine, can ‘cut out’, on radically accepting and imaginative terms.

Confrontational in other ways, Stephen Sexton’s If All the World and Love Were Young is a formally strict sequence of poems that explore the poet’s memories of his mother’s death from cancer. Innovatively, the turmoil, sorrow and grief, as well as the love and courage that belong to the experience, are presented as part of an exploration of Super Mario, the classic Nintendo platform video game. The Nintendo atmosphere of the sequence draws on a palate of nostalgic fandom and retrieved innocence. Throughout the book, Sexton plays with the visual aspects of the hierarchical worlds of the game and the mythic and heroic implications of its quirky and complex story lines. In the context of his mother’s illness and decline, Super Mario is an escapist medium for the poet’s younger self, a kind of self-anchoring through recreation, as well as an assertion of the stuff of boyhood and adolescence in the face of an oppressive reality. But the great poetic resonance of If All the World and Love Were Young depends on what cannot be escaped: the emotional demands and consequences of a core experience. A path of fear, longing and questioning must be walked; a trial of holding on and letting go must be endured.

A number of the poems dramatise time spent in hospitals, with particular attention drawn to the conflicted role of being a visiting relative in a clinical environment. In the following lines, from the poem Valley Fortress, the vending machine conveys the limitations of the setting, while the fact that commas have been exiled from the page represents a form of driven memory heightening the sense of a filial bond in extremis, one that is all the more compelling for the way the son’s attempts to reassure his mother are blended with a primal argument against her suffering –

My head is heavier than stone. I read yesterday’s newspapers

eat crisps from the vending machine I want to die is what she says

not either asleep or awake let me please die is what she says.

It’s me I’m here is what I say but I am not since she is not.

Then she says I want to go home once more for one once more one night

and I say you can’t go home now she says I know not now after.

The granulated syntax in this passage is representative of the book as a whole. In part, this style prevents a demarcation between the speaker’s inner world and the unfolding action. But by communicating a sense of living thought, it also creates moments of contrast between the son’s mind and the ambivalent order of the hospital.

This same contrast is an explicit theme in two poems which mention one of the great classical sources of medical ethics, Hippocrates II, the Greek physician and writer who produced the endlessly adapted principle, ‘First, do no harm’, and whose name endures in the Hippocratic Oath. Hippocrates is Sexton’s nickname for an otherwise anonymous doctor who, if not quite aloof, appears reticent when he brings the protagonist news about his mother in the poem Chocolate Fortress. But the unflattering portrait contains no ordinary sense of grievance. What comes across instead is a graphic take on the function of medical communication skills –

… With his stethoscope slung around

his broad shoulders like an athlete with a towel Hippocrates

says for now the pain must stay here in the small room without flowers.

If these words evoke a tide of inconsolability beneath the surface of the exchange, the closing lines of the same poem carry forward the sense of an unsettling power dynamic, mixing them with a set of irrational hopes that draw on the pixelated beauty of Super Mario worlds –

In the forbidden pharmacy he goes about the magic task

of grinding down a rhino’s horn to infuse with ground down rubies.

In #7 Larry’s Castle, the inscrutable athletic doctor returns: ‘Hippocrates arrives again and I ask him what will happen.’ These words are more alive by virtue of the fact that they are preceded by a concentrated sense of a vigil.

No clock ticks in her room but if one speaks light fluently one can

tell the time by the shadow the fountain casts across the courtyard.

The uncanny directness with which the notion of speaking light fluently is expressed locates the reader squarely in the protagonist’s thoughts. Because we are, in one moment, made to identify with that aesthetic peak, when the doctor answers the question in the next, he sounds all the more remote. The poet’s mother is close to death; she might die that very day. The single additional piece of clinical information is provocatively concise: ‘… asleep he says but still aware …’ These words mark the end of a dialogue and the beginning of a passionate passage where the poet recounts his efforts to make sense of this update. He asks two questions of himself: ‘what am I say to her …’ and ‘what kind of story do I tell …’

In response, the poem concludes with a dual intention: to narrate the mother’s life beyond its natural limits, and to attempt to rejuvenate her through a boy’s unshakable faith in the Super Mario apple, a symbol of restored health and delight. As such, where the doctor dryly accepts the futility of further treatment, the son cannot –

what kind of story do I tell apple is the longest story

I know let’s see how does it go again apple apple apple.

There is great tenderness in these lines. At sea in a palliative care scenario, the son’s instinct is to spend an eternity saying goodbye. When John Berger says ‘we submit to the doctor by quoting to ourselves a state of childhood,’ he captures the fact that we often have no choice but to trust that doctors contain within themselves a ready impression of who we truly are. We must trust that our vulnerability has a power over them, that they perhaps understand it with their own hearts. This trust, of course, is sometimes misplaced, and the systemic picture is always sobering. The coronavirus pandemic has introduced a terrible new logistical pressure that will result in fractured and impersonal healthcare. But the art of the face-to-face encounter and the deep literacy that pertains to true healing are not forgotten. The doctors of tomorrow, as they prepare to enter a troubled arena, are also, in their idealism, picturing themselves as warm communicators and as wordsmiths.

To be like the son at the bedside in #7 Larry’s Castle, to find yourself in that isolated position, and then to hear words that let you know your predicament has been recognised and understood, is to benefit from an ecosystem of care and imagination that is always under threat, and always within the realm of the possible.