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The editor of the JRSM challenged me to write this book review as a follow-up to a mischievous paper I published couple of years ago with the title `Evidence-based Art'.1 To give the flavour of my thinking, here is the final paragraph:
`The humanities and the sciences have their particular roles in the practice of medicine. The notion of evidence-based art is as absurd as an Impressionist school of science.'
To begin with I thought that the book, The Healing Environment,2 would offer support for my view that the medical humanities movement, of which I am a fully paid up member,3 is in danger of losing its way. In the preface Professor Carol Black, PRCP, states that the arts and humanities are of `immeasurable importance', and this I took to mean not lending themselves to measurement. Yet, Lara Dose, director of the National Network of the Arts in Health, states in her excellent foreword, `Money will only be forthcoming once the evidence of the efficacy of arts-based health interventions is available. Whilst many working within this field view the results of their work as self-evident, it is now clear that funders... do require a persuasive evidence base before they will commit any money.'
Fine, I can accept the need for well-designed experiments to test the usefulness of art or poetry therapy before we start employing poets and painters in residence—but must we invoke the same principle to justify a beautiful and quiet environment in which to care for the sick? Hospital wards and corridors are public places. They are also the temporary homes of our medical charges. Which other public places are denied natural light, an interesting view or at least walls punctuated with works of art? How many of us have homes that are empty of pictures. with walls an institutional cream colour? The benefits of art, literature, poetry and music are givens within our culture, experienced by all: and their life-enhancing effects are common experience. Very probably, the resultant sense of wellbeing is associated with beneficial physiological changes such as a decline in blood pressure, a rise in the lymphocyte count or endorphin release—subjects well worthy of research—but these are surrogates for the real outcome.
I was nearly half way through the book before I fully understood the significance of the subtitle, Without and Within. In all innocence, I had assumed we would be learning about the importance of architecture and art in providing the right environment for clinical staff to do their work of healing. As it turns out, about half the book is devoted to the patient's `internal environment'—defined not in physiological terms but in a metaphysical manner somewhere in the realms of `spirit' or `soul'. Despite my natural sympathy, I was irritated by the chapter in which John Fox, a certified poetry therapist, indicates that failure of doctors to accept such metaphysical models signifies spiritual stunting. Yes, many working environments are brutal and, yes, many clinical practices appear inhumane. But he would be wiser to start from the default position that all medical practitioners are decent and cultured folk and that their deficiencies are traceable to their mode of education and a health service that understands the price of everything and the value of nothing.
What we end up with are twelve essays, most of them well written and some deeply moving, which are only tenuously linked. About half address the outer environment and the others consider the spiritual dimension. Where experimental evidence is presented, assessment is hampered by inadequate description of the methodology or obvious design flaws. This is illustrated by the two chapters relating to the Chelsea and Westminster (C&M) Hospital Arts group. In the first, `Integrating the arts into health care: can we affect the clinical outcomes?', Rosalina Staricoff and Susan Loppert declare, `The need for a rigorous evaluation of the effects of the arts in health care is widely recognized and the Chelsea & Westminster provides an ideal setting for such an evaluation process'. As far as the latter assertion is concerned, I could not disagree more strongly. The C&M is a one-off showplace that was built way over budget and consequently destabilized healthcare in West London—as I learnt to the cost of my personal health, when the future of the Royal Marsden Hospital was placed in jeopardy. The C&M, with its spectacular interior and fine commissioned works of art, bears as much relation to the average NHS hospital as St Peter's Rome does to your parish church. That aside, consider the rigour of their evaluation of art and music. For the most part, the qualitative responses of the public were in favour of beauty – hardly a surprise. The experimental studies can be judged by statements such as `The small size of the sample made it impossible to detect significant differences' or `This was a pilot study with 34 patients in the control group and 54 in the study group... results suggest a tendency to lower levels of blood pressure...'. Clearly, before embarking on further work they should learn more about randomization techniques and take statistical advice on power calculations. Similar criticisms apply in the linked chapter by Jane Duncan attempting to evaluate the impact of a gorgeous set of murals and ceiling paintings on a blank and forbidding hydrotherapy unit. The quantitative results were disappointing and she attempts to rationalize them away. Jane, take my word for it: your work is beautiful and my life was enhanced even by the reproduction in the book.
Since this book is replete with illuminating anecdotes, I feel I have the right to offer one of my own that at the same time illustrates the strengths and the weaknesses of this collection of essays. One Friday evening a few days before Christmas last year, Annie, my Geordie mother-in-law age 96, had to be admitted as an emergency to our local hospital with acute viral pneumonia. Until then she had had `all her marbles' and played a mean game of contract bridge. The ambulance arrived promptly and she was delivered to the subterranean A&E department. After a reasonable delay she was medically evaluated and admission to the ward was arranged. For the next six hours she lay on a trolley in a featureless and windowless room getting more and more disoriented and frightened despite the presence of my wife and me. At last she was admitted to the receiving ward—another blank featureless room with four beds. In one corner was a comatose and dying woman with a grieving family at the bedside. In the next corner was a demented old lady screaming non-stop abuse and exposing herself to all comers. And, finally, in the bed next to Annie, was a middle-eastern lady, surrounded by an affectionate family who came and went in droves treating the place like a souk. All of these patients had their own needs for `healing environments' yet all were denied them. The Arab lady deserved to be embraced by her loving family, but not at the price of peace and quiet for Annie to recover. The demented old lady was denied the dignity of succumbing to or recovering from whatever had precipitated the acute episode. whilst her family should have been spared the mortification of her public behaviour. Finally, the family of a dying woman should have been allowed their vigil in peace. And, for everyone's sake, flowers, potted plants, walls of warm and friendly colours and pictures filling in the gaps would have helped to lift the grim pall that hung over the ward. Thanks to the devoted care of an understaffed ward of nurses (not an Anglo-Saxon face among them by the way), Annie returned to her cozy warden-protected accommodation on New Year's Day.
This now leads me to what I believe is the best chapter in the book, `Healing by design: feeling better', by John Wells-Thorpe. In this he evaluates a `natural experiment' whereby patients in an orthopaedic unit in Poole and a mental health unit in Brighton were translocated to modern architect-designed facilities at about the same time. The new facilities were designed to centre activity on patients' needs, whereas the old units are described as places where `the hospital bed can be perceived by patients not as a safe haven, but rather as a medium of containment which renders the patient as a passive object of clinician's activity'. The study impressively confirms what might seem obvious—that light, colour and a view from the window help recovery. But the unpredicted outcome, considered far and away the most important by the consumers, was the manner in which the new environments enabled or inhibited privacy or sociability.
By the way, my local hospital, the Royal Free in Hampstead, is home to the centre housing the editors of The Healing Environment. Perhaps before proceeding further with work on art appreciation, creative writing and poetry therapy, they should see what can be done about the gruesome external environment of the wards of that hospital, with its debilitating effects on patients, families and staff. The Royal Free, with its unlovely structure, has far more relevance to the NHS as a whole than does the Chelsea and Westminster.
I believe that the humanities in general enhance our daily lives and make sense of our very existence. As such they should not be denied us when we are sick and dying. Furthermore they should not be subject to audit. At the same time, any activity with `therapy' in its title should be subject to critical evaluation with sound experimental design. There can be no compromise even if the therapy is art based. Finally, I believe that these aspects of medical care should be included in undergraduate and postgraduate medical curricula, providing that they are subject to the same monitoring as any other educational intervention.4