Summary of the impact

Research in Medical Humanities, including a distinctive input from English Studies, has influenced the working practices of a wide range of individuals and groups, both in the arts and in medicine, at regional, national and international levels. Beneficiaries include medical professionals and writers, artists and museums. The impacts on medical practitioners have been: to influence professional conceptions of medicine, illness and the body; to influence policy and training through collaboration with the Royal College of General Practitioners; and to alter medical perceptions of consultation in general practice. The impacts on creative work have been: to inspire and promote specific works in creative arts; and to shape the exhibition policy of the Royal College of Surgeons in bringing their art collection to public benefit.

Underpinning research

The underpinning research has been a collaborative venture between a specialist in medieval literature and culture (Professor Corinne Saunders, English Studies, appointed 1997) and a professional clinician and academic (Professor Jane Macnaughton, Centre for Medical Humanities, Durham University and Associate Researcher in English, appointed 2000). In 2000 Macnaughton founded what became the Centre for Medical Humanities (CMH); Saunders has been closely involved since 2000. Since 2008 Saunders has been Associate Director of CMH, and Macnaughton Co-Director.

Much research in Medical Humanities has tended to favour medical education and the history of medicine; in contrast, Macnaughton and Saunders have argued that the divergence between scientific and experiential views of human nature has deleterious effects on healthcare, policy and human flourishing. They show the dynamic and mutually-influential relationship between creativity, arts and humanities and the medical discipline.

Macnaughton's approach combines clinical and literary expertise (her publications discuss modern literary texts within the clinical context), while Saunders offers a long cultural perspective in her exploration of medieval literature and the history of ideas. The collaboration has helped to show how understandings of medieval attitudes and concepts can enhance and challenge contemporary understandings of well-being. Its focus has been on the notion of embodied experience, and its particular insights are:

(i) The interdependence of mind, body and affect or feeling. All experience is affective, shaped by bodily senses and cognitive elements, and registering in both the body and the mind; emotion is both affective and cognitive. Saunders's work shows that pre-modern literature has a special ability to express this interdependence (see section 3.2)

(ii) Transhistoricism. Saunders argues that pre-modern studies offer important insights for our understanding of embodied experience; and that only an understanding of the long-term, dialogic interactions of arts and medicine from classical to contemporary periods can realise the full potential of Medical Humanities for all its partners (3.1).

(iii) Clinical Generalism. Macnaughton addresses the problem of practitioners facing an increase in `multi-morbidity' (where patients suffering from more than one chronic illness present an array of symptoms). `Clinical Generalism' emphasises the need for practitioners to understand the person holistically, in terms of the interdependence of mind, body and affect, and in a wider cultural context, especially in the face-to-face context of consultation practice (3.5). It also underlines the need to recognise the practitioner as embodied, and so stresses the complex interrelation of physical, mental and affective elements of practice (3.4). The co-authored essay, `Cool intimacies of care' (3.6), links notions of the embodied expert practitioner to generalist and holistic care. Macnaughton's work uses literary ideas relating to multiple authorial perspectives to examine shifts and changes in object/subject status during a single consultation for both patient and doctor.

The underpinning research has emphasised the perspectives on embodied experience offered by the imaginative worlds of literature, and the corrective these imaginative perspectives offer to bio-medical perspectives. It has centred around three major public lecture series, all held in Durham and resulting in co-edited volumes. (i) `Madness and Creativity: The Mind, Medicine and Literature' (2001-2002; see 3.1) demonstrated the ways that literature offers alternative perspectives to biomedicine, setting against the notions of asylum and confinement an interest in mental illness as a fundamental aspect of the human condition, with the potential to stimulate and influence creativity through actual or imagined experience. (ii) `Flesh and Blood: The Body and the Arts' (2005-6; 3.2) focused on the body as inspiration, subject, symbol and metaphor, and medium. Literature was explored as a medium for shaping and probing the nature of the embodied mind and the crucial role of the body in human experience. This work pointed to continuities between a pre- Cartesian perspective, which emphasised the mind-body continuum, and recent neuroscience, which argues that affect is crucial to cognition. As Saunders's research shows, medieval writing enriches and challenges current understanding through key insights into the lived body, the integration of body and mind, and the profound physical consequences of emotion (3.3). For instance, her work explores the responsibility for primary care taken by the pre-modern social community and the crucial role played by empathy (3.6) —significant issues taken up by Macnaughton in her analysis of practitioners, patients and carers. (iii) Their recent co-authored study of embodied experience has focused on the changing manifestations of ideas of beauty in medicine and the arts. The series `The Recovery of Beauty' (2011-12) brought together creative artists and specialists in medicine, cultural history, literature, theology, philosophy, gender studies, art and architecture, and will result in a co-edited book (Palgrave, 2014). This work challenges bio- medical assumptions by arguing for the importance of cultural and aesthetic perspectives in understanding embodied experience, in which the perception of beauty plays a crucial part.

References to the research

Markers of research quality: All items are published by international peer-reviewed journals and publishers; the lecture series `Madness and Creativity' and `The Body and the Arts' were co-funded by the Wellcome Trust. CMH was established by a Wellcome Trust Strategic Award of £1.9M.

Details of the impact

The research has been disseminated to, and generated interaction with, diverse clinical and creative audiences and partners, through live events, web-based discussion, and publication in targeted journals.

(i) Since 2009, the CMH Blog and Twitter feed have facilitated dialogue with academic and non- academic partners and the public, so that the events described below have reached as wide an audience as possible and attracted additional feedback for further work. There has been a growing readership for the blog (10,000 page views per month from 165 countries, as of July 2013) and twitter-feed (over 1,500 followers). [5.1] Contributors include artists, writers, clinicians and community arts-in-health practitioners who work in schools.

(ii) Conferences and lecture series have enabled partnerships to emerge from the research. The lecture series `The Body and the Arts' (described in section 2) led the Association of Medical Humanities Conference, held in Durham in July 2009, to adopt the theme `Taking the Body Seriously'. As well as academics, the 80 delegates included medical practitioners, creative artists and writers, arts-in-health practitioners, therapists, nurses and members of the general public. Discussions following this event led to a more focused Arts in Health Critical Mass Meeting (June 2011), with leading practitioners from the UK, Australia, South Africa, USA, Mexico and Ireland: two-thirds of the delegates were health professionals. Macnaughton led discussion on the relationship between embodiment with clinical expertise and artistic creation. (iii) Medical professionals were targeted through articles in The Lancet, which has a weekly print circulation of 30,000 and 1.8 million online users (82% of readers are medical practitioners). One co-authored Lancet article by Macnaughton, Saunders and others [3.6], exploring the tension between empathy and distance in clinical encounters past and present, led directly to invitations to Macnaughton to contribute to two conferences for general practice trainers, held in Darlington in September and November 2012, which in turn led to an invitation to organise a Medical Humanities research day at the Royal College of General Practitioners (see below).

This dissemination policy has facilitated mutually influential relationships between health practitioners and medical organisations, and writers and artists, with impacts in both areas:

(a) Impact on Medical Practitioners

Engagement with the Royal College of General Practitioners (RCGP) led to the establishment of a special interest group of 10 practitioners —including the then President of the RCGP and the Chair of RCGP Scotland —who took part in an initial meeting with Macnaughton in London in September 2011 to establish areas of common interest between working clinicians and the medical humanities. Key themes that emerged included the relevance of literary critical perspectives to the training of clinicians, the nature of `clinical generalism', and articulating the complexity of interpersonal relations in the clinical encounter. These key themes drew substantially on material in references 2, 4, 5, 6 and 7 listed in section 3 and discussed in section 2 (iii).

The meeting demonstrated to the clinical group the new perspectives that Saunders's and Macnaughton's research might bring to their practice, leading the group to host a workshop for GPs across the UK. Consequently, Saunders and Macnaughton designed the programme for a Medical Humanities Training Day held at the RCGP on 14 March 2013. Both presented their research on `clinical generalism' and the other themes raised at the initial group. Macnaughton explored the potential for this Medical Humanities approach to redress the impoverishment of evidence-based medicine, and the ways that GPs might lead in articulating a new ethos. Saunders explored different models of experience, care and empathy presented in medieval literature and the resonance of these for current practice, both in terms of holistic understandings of experience and wider responsibility for care. The Chair of RCGP Scotland stated in his closing remarks that Saunders's research on medieval attitudes to care and practice had brought caritas back into medicine. [5.2] All 60 participants read the co-authored Lancet article. The meeting was validated by the RCGP as Continuing Professional Development for clinicians and all 60 practitioners who participated received CPD points. In feedback, 100% of respondents stated that the underpinning research `posed a serious challenge to conventional medical practice' and directly addressed `the way I practice medicine'; 90% stated that the training day had altered their understanding of Medical Humanities. [5.3] The former President of the RCGP has recognised the importance of the underpinning research: it `deliberately seeks to accommodate the front-line medical perspective'; through collaboration with CMH; she herself has made `a definite shift in [her] approach to patients'. [5.4] The Chair of RCGP Scotland has stated that Durham's CMH has been `crucial in driving forward' recent changes in understanding the relationships between clinicians and patients. This has now become `central to our professional role' and is `hugely important to our future as medical generalists'. [5.2] As a result of this workshop, Macnaughton and Saunders have been invited to contribute half-day sessions to a regional `day release programme' for GP trainees and to a `Training the Trainers' programme (to be held May 2014 and December 2013). The impact, then, has been to promote the holistic and cultural approach of embodied experience and clinical generalism within medical practice, providing RCGP training in Medical Humanities where previously there was none; to influence RCGP strategy; and to alter the practice of RCGP leaders.

(b) Impact on Creative work in Art and Literature

CMH research meetings regularly include creative writers —whose work has informed the research of Macnaughton and Saunders —who reflect on and explore research questions in their art. Both Gwyneth Lewis and Kathleen Jamie were involved in this way, before becoming CMH Visiting Fellows in 2011 and 2012 respectively. Each presented their work at public readings to audiences of 50-100 (Jamie, February 2010 and 2012; Lewis, May 2011, followed by workshops).

(i) Lewis's epic poem about caring for her husband, A Hospital Odyssey (2010), engages with the underpinning research in confronting bio-medical conceptions of the body and illness, and explores the history, practice and experience of medicine. She writes that her collaboration with Macnaughton and Saunders has `changed my understanding of a subject [the nature of poetry] I thought I knew well', helping her to see that medical humanities is `philosophically completely tied in to the forms of art themselves'. She is currently writing a play commissioned by the National Theatre of Wales that draws on her engagement with the underpinning research. [5.5]

(ii) CMH helped establish a creative collaboration between the poet Kathleen Jamie and the visual artist Brigid Collins that would lead to the publication of Frissure (August 2013), which combines visual and verbal images of the scar left by Jamie's surgery for breast cancer. A CMH workshop on `The Recovery of Beauty' (February 2012), brought together Jamie and Collins to discuss their initial thoughts and illustrations. Jamie commented, `It's wonderful to have one's hesitant first explorations confirmed as valuable'; and Collins wrote, `this has helped us both to see the importance of this work'. This is how `the idea for a book with the scope of Frissure came into being' (Collins). Macnaughton helped secure Wellcome Trust funding, and the book was launched at the Pittenweem Arts Festival (2013). The project addressed Macnaughton's and Saunders's understanding of embodied experience, exemplifying how `new imaginative perspectives can transform attitudes to the body, illness, medicine and health' (as they write in their preface), while uniquely exploring the meanings and possibilities of beauty. [5.5]

(iii) Perceptions of beauty and injury have been influenced by Saunders's work on war, disfigurement and empathy, and by Macnaughton's research on the development of plastic surgery after WW1. This recent work persuaded the Durham Book Festival to adopt `The Recovery of Beauty' as one of its themes for 2011. The writers Ali Smith and Geoff Dyer created and presented newly-commissioned work on the subjective quality of beauty, engaging with metamorphosis of the body and the danger of beauty respectively (they gave readings on 22 October 2011). Their original fictions will be included in a forthcoming volume co-edited by Saunders and Macnaughton.

(iv) Saunders and Macnaughton developed `The Recovery of Beauty' through a co-organised exhibition of drawings by Henry Tonks, an artist-surgeon in the First World War who worked with the originator of cosmetic surgery. The exhibition, `About Face', was held at Durham Light Infantry Museum, April-May 2012. It began a partnership with the Royal College of Surgeons (RCS), who own the Tonks drawings, and Durham City Council. Tonks's drawings were complemented by a modern photographic exhibition and accompanied by a series of free public talks exploring the possibilities of literature and art to change understandings of injury, surgery, identity and empathy. Among these was the first public reading by Pat Barker from her new novel (partly about Tonks), Toby's Room. The audiences included NHS staff, local book clubs, Friends of the Museum and retired soldiers. The exhibition was organised as Barker was in the closing stages of writing Toby's Room. Barker, a Booker Prize winner who has been affiliated with CMH since 2001, writes that its research `has had an important and beneficial impact on my work as a novelist'. [5.5]

The exhibition had 4,700 visitors, generated £3,000 for DLIM, and has led the RCS to stage a national tour of the Tonks drawings and re-model its exhibition strategy. [5.6] The RCS Director of Museums and Archives states that `the CMH link and the history of collaboration has been crucial in fundraising for this project', helping secure £5,000 from the Knott Trust and £20,000 from Arts Council England. More significantly, `the RCS has derived lasting benefit' from its collaboration with Macnaughton and Saunders, which `formed the foundation for RCS programming' to mark the centenary of the 1914-18 War. `War, Art and Surgery' will begin at the DLIM in summer 2014 with associated public events in partnership between CMH and the RCS. This collaboration `has embedded within our strategic development a heretofore unrealised regional focus' which will have lasting benefit. [5.7]

Sources to corroborate the impact

5.1 http://www.dur.ac.uk/cmh/. Breakdown of CMH blog figures from HEI.

5.2 Testimony from Chair RCGP Scotland.

5.3 Feedback from RCGP training day.

5.4 Testimony from the President, RCGP (2009-12).

5.5 Testimony from writers and artists. More information on Frissure is here:
http://medicalhumanities.wordpress.com/2013/08/13/launch-of-frissure-a-collaboration-between- kathleen-jamie-brigid-collins-and-cmh/

5.6 Exhibition figures provided by Durham Light Infantry Museum.

5.7 Testimony from Director of Museums and Archives, Royal College of Surgeons.