Those of the arts and health movement seeking to enter the realm of medicine face a dilemma. How do they gain access? How do they prove that the arts in health are worth funding, especially when resources are scarce? How do they perform before the gaze of the medical audience? This is the gaze of the medical scientist, the gaze that requires proof, factual confirmation and hard virile evidence. The choice faced by artists is whether they choose to gain credibility within the rules set down by the medico-scientific discourse or do they try to challenge that discourse from an alternative paradigm.
If artists choose to seek integration within the boundaries of the medico-scientific discourse they face a difficult task. In the world of health, medical professionals, in particular doctors, have been assigned the role of being the arbiters of truth. Evidence-based medicine seeks to distinguish therapeutic interventions that are proven to make a difference from those laden with false promise. Not only must those seeking to promote their therapy prove that their potion is efficacious, they also must demonstrate it is ‘value for money‘. Evidence-based medicine has achieved great strides ensuring that patients only receive interventions that will actually benefit their health. According to this paradigm, artists must prove firstly, that art in health settings makes a difference and secondly, that it also represents value for money.
If the arts do choose the route of seeking affirmation within the medical gaze they choose a dangerous course. When assessing evidence one can choose either to use that evidence to assess the truth of a proposition or else to simply bolster one’s preconceived position. Those seeking truth will weigh up the strength and validity of the evidence; those seeking support for their position often fail to distinguish the chaff. Those at the vanguard of the arts and health movement need to be careful that in their zeal they do not proffer every shred of possible evidence that supports their position and ignore evidence or common sense arguments incompatible with their beliefs.
Within evidence-based medicine there are three differing perspectives as to the type of evidence required. Firstly, hard line quantitative scientists will demand numerical objective proof demonstrating art in health settings produces defined health outcomes (e.g. the presence of murals in a burns unit resulted in significantly less patient reported pain intensity and less anxiety). If one does seek hard evidence for the contribution of the Arts, there are two interesting examples of movements that sought validation within the medical community which bear comparison.
The first example offers hope. Communication skills have been recognised as being increasingly important over the last half century. However, many doctors, while professing a recognition of the importance of communication, believed that its value lay in improving the experience of patients rather than improving their health. However, studies have shown that communication skills decrease hospital inpatient stays, improve blood pressure and diabetic control and speed up recovery from hip operations among other outcomes. This has led to a heightened respect for communication skills and has resulted in training in communication becoming a central component of health education.
A less hopeful story it that of how the psychotherapy community sought an evidential basis for what they perceived as the great benefits to be accrued to their clients. Numerous studies were done to demonstrate that clients needed to consult doctors less often, required less medication or showed improvement in mood as assessed by standardised depression questionnaires. Unfortunately, the gold standard medical arbiter, the Cochrane Database (where all studies on a particular subject are collated, assessed and their results combined so as to gain an overall picture of what the evidence on that subject suggests) concluded that ‘in the long term, counselling is not any better than GP care…although some types of healthcare utilisation may be reduced, counselling does not seem to reduce overall healthcare costs.’
The danger is that the arts and health movement would broadcast findings related to health outcomes without assessing the strength of the evidence. For example, there have been trials on drama therapy with people with schizophrenia which have had promising results. However, when the Cochrane database reviewed the area they found that ‘studies have been successfully conducted in this area but poor study reporting meant that no conclusions could be drawn from them. The benefits or harms of the use of drama therapy in schizophrenia are therefore unclear.’ The reality is that the evidence on what outcomes arts in health, while it exists, it is limited. There is very little evidence as to whether the arts provide ‘value for money’.
The second type of evidence relates to patients’ valuation of the presence of art programmes in medical settings. The danger on relying on this type of evidence is that it may imply the arts are a luxury and that in times of recession, money will be directed towards activities that are seen to produce tangible outcomes.
The third research route is that of qualitative research. While medico-scientists tend to prefer the quantitative method, qualitative research has a strong healthy tradition in the social sciences and has gained increasing respect within the health community. In my opinion, qualitative research offers the best avenue for artists to explore the impact of their work on patient care.
The danger for the arts is if they rely exclusively on the evidence based route to promote their worth they face a real possibility of discovering they make little difference to patient outcomes and that while most patients may value the arts within the medical setting that they will not see the arts as ultimately being important to their health.
An alternative approach is to challenge the medico-scientific discourse. The spaces where medical professionals practice are glittering, glowing, germless, unsoiled and unsullied. I spent my early childhood in Crumlin hospital, which was designed so as to ensure that infection did not spread through its occupants. Most rooms were single so as to allow isolation, surfaces were designed to be easy to clean and sterilise. The disinfectant smelling bare walls and floors echoed the sounds of children crying for their parents. The rooms were free of sentimental objects which could interfere with the objective scientific gaze.
The art in my surgery seeks to humanise the space, to fill those bare walls and floors of my childhood. When I first moved into the surgery thefts were common. Phones, bags, money, prescription pads and toilet rolls all made their way out my surgery door. When I did up the surgery and put in over thirty paintings and sculptures I was told I was mad as they would disappear. Not only did they not disappear, other thefts ceased. By showing respect to my patients and by humanising my surroundings they returned the respect.
I also use the arts in educating medical trainees. The use of the arts challenges students personal preconceptions, stereotypes and attitudes towards the world and its inhabitants; it enables an exploration of narrative approaches to understanding ill health, and promotes awareness of the moral, ethical and philosophical issues that pervade their work as medics and healers. I have found it a powerful, transforming educational approach.
It is in these arenas that the arts can challenge the medical paradigm. Humanising one’s experience in a healthcare setting is a worthwhile aspiration irrespective of whether it reduces the length of inpatient stays or pain intensity. Life is to be lived, not survived. Using the arts to challenge the stultifying, dehumanising, unwritten medical curriculum offers a rich education vein to be mined.
The most likely scenario is that the arts will use both arguments to ply their trade within the medical community. It is only right that questions as to whether the arts promote healing in its more holistic conception are explored. However, it would probably be wise that they equally, if not more strongly, stress the non-evidence based reasons for having art in hospital; the transformation of an intimidatory, cold and clinical environment into one where patients can engage with their surroundings on a human and empathic level.
If I may make one last observation which deviates from my main text. As one who works in a deprived community yet inhabits one of the middle-class islands in the North Inner City, it has often seemed to me that the arts pander to those moneyed classes. Poverty is the biggest predictor of poor health. If art does want to make a difference in health settings it should focus on those settings in areas of deprivation. Let art not be yet another affirmer of Tudor Harts infamous Inverse Care Law i.e. ‘the need for health care is inversely proportional to the provision of health care’.