474 July-August 2006 Family Medicine

Literature and the Arts in Medical Education

Johanna Shapiro, PhD

Feature Editor

Editor’s Note: In this column, teachers who are currently using literary and artistic materials as part of
their curricula will briefly summarize specific works, delineate their purposes and goals in using these
media, describe their audience and teaching strategies, discuss their methods of evaluation, and speculate
about the impact of these teaching tools on learners (and teachers).
Submissions should be three to five double-spaced pages with a minimum of references. Send your
submissions to me at University of California, Irvine, Department of Family Medicine, 101 City Drive
South, Building 200, Room 512, Route 81, Orange, CA 92868-3298. 949-824-3748. Fax: 714-456-7984.
jfshapir@uci.edu.

The “Bad News Scene” as Clinical Drama

Part 2: Viewing Scenes
Catherine Belling, PhD

(Part 1: Writing Scenes was pub-
lished in the June 2006 issue
of Family Medicine (Fam Med
2006;38(6):390-2.)
Life itself is a dramaturgi-
cally enacted thing.
Erving Goffman, The Presen-
tation of Self in Everyday Life
(page 72)
The nature of bad news in-
fects the teller.
William Shakespeare, Antony
and Cleopatra
The dramatic characteristics of
giving bad news are already im-
plicit in clinical recommendations,
which often assume a theatrical
component, speaking of “setting
the scene,” “following a script,”
and so on.1-3 Focusing explicitly
on the performative and narrative
aspects of the “bad news scene” in
(Fam Med 2006;38(7):474-5.)
From the Institute for Medicine in Society, Stony
Brook University, Stony Brook, NY.
film might awaken students to the
particular responsibilities of being
both a central character and, to a
limited extent, the director of this
scene. At the same time, this focus
reminds them that in the life drama
of the patient, the physician’s role
is crucially important but com-
paratively small. When the bad
news has been given, the films we
view follow the patient/protagonist
rather than the physician, whose
role is limited to providing crucial
information and acting as a sound-
ing board for the patient’s first
emotional response, be it despair,
anger, or equanimity.
In part 1 of this article, I de-
scribed a writing exercise I use as
part of a medicine and film elec-
tive. Fourth-year medical students
recall an instance of conveying bad
news and write it up in the form
of a film scene. After discussing
their dramatizations, we move on
to viewing some actual “bad news
scenes” from films, beginning with
three short clips. The first two are
both bad news scenes from the
1993 film, “My Life.” In the first
scene, the oncologist tells Bob and
his wife that the chemotherapy for
Bob’s stomach cancer is not help-
ing. In the second scene, set several
months later, a different physician
tells them that the cancer has spread
to his brain, and he has no more than
a few weeks to live. Both scenes are
structurally important in the film’s
plot. In the first, Bob reacts with
hostility, accusing the doctor of
destroying his only hope; in the
second, he has begun to accept his
approaching death. We discuss both
words and images (the first scene,
for instance, begins from Bob’s
point of view, the camera panning
up the doctor’s imposing desk, set
up as a fortress from behind which
he gives the bad news. The second
scene begins with a longer shot that
takes in the couple and their doc-
tor in one frame, presenting them
as linked rather than separated by
the doctor’s professional role). We
talk about elements in the scenes
that echo the choices made by the
students in their writing, and we
explore the role of sympathy and
point of view: how is an audience
intended to feel about each physi-
cian?
Literature and the Arts in Medical Education
We then view part of the film
“My Life Without Me” (directed
by Isabel Coixet, 2003) in which
a young woman, Anne, is told that
she has advanced ovarian cancer.
In this unusual scene, the doctor
clearly suffers too and is candid
about his helplessness, admitting
to the patient that “I can’t sit down
in front of someone and tell them
that they’re going to die. I never
have been able to. The nurses are
beginning to mention it.” Expecting
her to see this as a sign of his in-
adequacy as a doctor, he says she’s
welcome to get a second opinion.
Her response both reprimands and
reassures him: “Someone who tells
me the exact same thing as you
but looks me right in the eye?” He
turns to her and their eyes meet,
a powerful image of the two, side
by side, connecting in the face
of something that threatens them
both, in different ways. The scene
poignantly conveys the physician’s
own vulnerability and the way his
admission of it helps the patient.
His own sadness makes him both
more sympathetic as a character
and, arguably, less professional as
a physician (“The nurses are begin-
ning to mention it.”).
This leads to an ongoing ques-
tion we consider as we view several
more scenes over the following
days: as these films show it, a
good doctor is one who shares the
patient’s suffering in the face of
bad news. Does this expectation
extend from the film to the clinic,
where repeated such encounters
may threaten to overwhelm the
sympathetic doctor? What does this
mean for medical students?
In the class sessions that follow,
we watch entire films, expanding
our view beyond the bad news
scene but keeping our attention on
the ways in which film constructs
certain views of health care and
illness. When a bad news scene
arises, we stop, watch it twice,
and continue the discussion begun
on the first day. For example, in
“Ikiru” (directed by Akira Kuro-
sawa, 1952), a paternalistic physi-
cian lies to a patient who already
believes (correctly) that he is dying
of stomach cancer, saying it is noth-
ing but an ulcer. This protects the
physician but not the patient, who
is left isolated and abandoned in his
unacknowledged suffering. In “The
Doctor” (directed by Randa Haines,
1991), a surgeon becomes a patient
when he learns, from an overly ef-
ficient and matter-of-fact colleague,
that he has laryngeal cancer. In
“Wit” (directed by Mike Nichols,
2001), a literature professor is told
she has advanced ovarian cancer by
an oncologist who seems to assume
that, as a fellow researcher, she does
not need the compassion that other
patients might merit. In all three
scenes, the viewer is led to sympa-
thize with the patient and to deplore
the physicians’ various failures. In
class we examine both words and
camera work (how close-ups show
patients’ apprehension of the news,
for instance). We also speculate
about how the doctor may be feel-
ing in each scene and then how the
filmmaker could have him or her
act differently to make the scene
less painful for the patient.
Given more class time, it would
be valuable to add scenes from
some recent medical television
series, where clinicians rather than
patients are the central characters
and therefore receive both more
sympathy and closer exploration of
their motives and experiences. For
instance, a recent story on “ER”
concerned a technically skilled
but interpersonally inept resident
and included a scene in which she
blurted out bad news to a com-
pletely unprepared patient.
Approaching the bad news con-
versation as a scene may help physi-
cians develop a kind of necessary
distance, not from the patient and
family, but from themselves and
their anxieties. Viewing themselves
as part of the patient’s drama, with
a responsibility to make this turn-
ing point in the story as positive as
possible, they can see themselves
as actors in a role to be performed
Vol. 38, No. 7 475
as well as possible for the patient.
The white coat’s theatrical mean-
ing as a kind of costume is relevant
here, as John Stone’s brilliant short
poem on giving bad news shows.4
“Acting” here never means be-
ing dishonest, or insincere, or
following a prepackaged script
inflexibly.5 But it does mean that
physicans must not be expected
(or expect themselves) to suffer
in the same way that each patient
inevitably suffers when bad news
is given. They should be expected
to imagine, rehearse, and play their
crucial part in each drama in such
a way that when the patient and
family return in their memories
to this scene—as they will, over
and over—what they remember
will be a moment of pain but also
one of growth and learning, of
reassurance and the promise of
companionship and help. The phy-
sician, director/actor in repeated
and varied iterations of this scene,
must be able to remove the white
coat and go home, but that does
not diminish the importance of
performing the part that goes with
that coat as well as possible, to
begin to palliate the patient’s and
family’s suffering even when the
objective information seems inca-
pable of anything but causing pain
and admitting defeat.
Correspondence: Address correspondence to Dr
Belling, Stony Brook University, Institute for
Medicine in Society, HSC L3-086, Stony Brook,
NY 11794-8036. 631-444-2765. Catherine.
belling@stonybrook.edu.
REFERENCES
1. Shapiro J, Hunt L. All the world’s a stage:
the use of theatrical performance in medical
education. Med Educ 2003;37:922-7.
2. Rosenbaum ME, Kreiter C. Teaching deliv-
ery of bad news using experiential sessions
with standardized patients. Teach Learn
Med 2002;14:144-9.
3. Holleman WL. The play’s the thing: using
literature and drama to teach about death
and dying. Fam Med 2000;32:523-4.
4. Stone J. Talking to the family. In: The
smell of matches. Louisiana State Uni-
versity Press, 1972; Shapiro J. Commen-
tary on Talking to the family. Acad Med
2005;80(10):909.
5. Persaud R. The drama of being a doctor.
Postgrad Med J 2005;81:276-7.