Full transcript
0:04[music]
0:09[music]
0:18Hello everyone. I welcome you once again
0:20to my NPTL course introduction to
0:22medical humanities. Now before we begin
0:25today, let us take one moment to think
0:28who is our favorite doctor because I am
0:31going to talk about doctor patient
0:33relationship and with that respect I am
0:36going to take up two films that I have
0:38chosen for analysis. The title of my
0:40presentation today is trusting doctors
0:43and empathizing with patients. And while
0:46we go through the at least theoretical
0:48framework of what I am going to speak,
0:50you think about what is the quality that
0:53you like in the doctor you have chosen
0:55as your favorite.
0:57Quick overview. I am going to talk about
1:01the dual pillar of trust and empathy in
1:05clinical encounters. Explore the empathy
1:08gap.
1:09Talk about how
1:12important it is to emphasize the
1:14narrative around patients. Take up
1:17Munabhai MBBS and Dr. G as our case
1:20study and follow it up with the final
1:23theoretical model in which cinema
1:26education is a pedagogical catalyst.
1:30Let us begin with the first theoretical
1:32model that we choose in which we talk
1:35about the empathetic nature of clinical
1:38trust. Now within the spectrum of
1:42patient doctor relationship, we find
1:45that trust is a quotient which cannot be
1:49compromised with. And why is it that?
1:52Because when we think about health and
1:54its different markers,
1:57physical, mental, emotional,
2:00in front of a doctor, all this lays bare
2:04and anything, any space that requires
2:08this kind of uh vulnerability of
2:12just opening up, you need extreme trust.
2:17So how does that build? So the first
2:20point that I would like to make in this
2:22regard is on your screen consensual bond
2:25of doctor patient relationship. Now the
2:28moment you walk into the clinic of a
2:31doctor, you walk into the OPD of a
2:34doctor, there is certain amount of
2:38leap of trust you give and vice versa is
2:43also true. In the absence of trust,
2:47there is no diagnosis happening. There
2:49is no healing possible. And therefore,
2:52the expectations of patients of
2:54receiving
2:57any kind of prescription from the doctor
3:00has also a little bit of alignment with
3:04the trust quotient. So that is something
3:08we begin with. The second point that I
3:10want to make here is that of the
3:13dimensions of trust. Quinnho makes this
3:16uh point. Uh she surveyed over 3,000
3:20patients. I'm sorry that is 3,000 and
3:23not 300. Uh so three she surveyed over
3:263,000 patients and found two qualities
3:30that all of them said are something they
3:34are looking for in their doctors.
3:36Benevolence and competence. So
3:39competence to make the diagnosis if I
3:42can broadly speak and benevolence to be
3:45kind because the moment somebody is
3:49unwell they are looking for an
3:52empathetic
3:54gaze.
3:56The third point here is biocschosocial
3:59diet. Now this is a shift shift from
4:04what? shift from caveat emper to credate
4:08enter. Now caveat empter is let the
4:12buyer be aware. So you are aware of that
4:16situation what it is like you know that
4:19but credit emptor says let the buyer
4:22believe or have trust. So same space
4:26with different kind of meaning will
4:28generate different kind of result and
4:30that is why it's not just a physical
4:32space you are sharing but also a
4:35psychosocial space. So if you look at
4:37this word it has three words into it. It
4:40has biology, it has psychology and it
4:44also has the social aspect. So it's a
4:47permon word. It is a combination kind of
4:49a word which has been taken up by
4:51Everett Hughes. You can read more about
4:53it in the material that I have shared.
4:55The reciproxity of doctor patient
4:57relationship is also important to the
5:00construct of how empathetic nature and
5:03clinical trust builds. In this the trust
5:06becomes a dynamic bond and viewing the
5:10sick as a complete individual with
5:13feelings, desires and need becomes
5:16essential to how you can be empathetic.
5:21The second part that I would like to
5:25make in terms of theoretical framework
5:27is the aspect of clinical empathy. Now
5:29when you want to build the trust when
5:32there is a trust quotient that we are
5:34talking about empathy also clinically so
5:40to feel the pain to feel the misery all
5:44these aspects also come into play. So
5:47the first thing is cognitive versus
5:50effective. What does this mean? This
5:51means that it involves understanding
5:54patient experiences to communicate back
5:57to them. This is different from sympathy
6:00because it literally expects the
6:03clinician or the doctor to step into the
6:07shoes of the patient and
6:11think of or visualize the disease as the
6:14patient is feeling or suffering from. So
6:18the narrative of the patient here
6:20becomes central to how the clinical
6:24empathy gaze will happen. Additionally,
6:27it is intersubjectivity because when you
6:30think about a disease,
6:33there is a clearcut objectivity to it.
6:36So you can actually in in a very
6:39mathematical term you can make 2 + 2 is
6:42equal to four out of it. It's very
6:44quantifiable diagnosis oriented. But
6:47when you come to the subjectivity of the
6:50illness experience, this is vague
6:53because it involves individuals will
6:55respond to same disease in different
6:58kind of ways. Hence, customization
7:00becomes important and that is where you
7:03can think of clinical empathy to be
7:06playing an important role in deciding
7:09the doctor patient relationship. The
7:11third is the narrative competence and I
7:13have earlier spoken a lot about it. This
7:16is a skill better acknowledge, absorb,
7:19interpret and act on the stories of
7:21illness. So when a patient says that he
7:24or she is not feeling well or they are
7:27not feeling well, now that unwell has to
7:30be interpreted
7:32and for that different other narratives
7:34from the patient has to be listened by
7:37the doctor.
7:39Now the third uh and perhaps the final
7:41before we jump to making analysis of the
7:44films that we have chosen is the crisis
7:47of the devil in the third year. Now in
7:51the making of a medical doctor
7:55the process is through many experience
7:59and exposure of mortality,
8:03dead body, disease and so what happens
8:06that by the time they reach the third
8:08year they are getting very mechanized to
8:13the responses that will generate in
8:16their mind. So they talk about it in
8:19terms of empirical decline which says a
8:22significant drop in empathy scores of
8:24medical students transitioning into
8:27clinical rotations has been documented.
8:30So a study conducted suggests that by
8:32the time these students reach their
8:34third year there is a significant drop.
8:38So they start feeling less for the same
8:40situations that had affected them
8:43earlier. The second point you can take
8:46up is anatomy of clinical gaze in which
8:50Michelle Fuko describes this as
8:53objectifying perception that opens the
8:56patient to see a lesion rather than the
8:58soul to look beyond that kind of goes
9:01absent. So you just see the patient as a
9:05disease. You just want to identify that.
9:09Now there is sensory reliance which
9:11means that you rely a lot on
9:14investigative technologies. This
9:17replaces hands-on care leading to a
9:19state of institutionalized stability. So
9:23say for example somebody has fever you
9:25put a thermometer it indicates that's so
9:29even fever may vary that is something
9:32that is we are mentioning here.
9:37Now when you study these approaches you
9:41find these three theories
9:45important to what you will analyze. The
9:48first is simulation. What is the word
9:50simulation mean? The word simulation
9:53means imagination.
9:55So it's an imaginative act of
9:59visualizing oneself in that position. So
10:02what does the doctor do? The doctor
10:04imagines oneself in patient's position.
10:07Like I said, you put yourself into the
10:10person's shoes and then you find where
10:13it takes, where it pains, where it
10:14burns, all those things. There is a
10:16drawback as well because it fails in
10:19crossgender or cross-cultural encounters
10:23because the doctor merely projects their
10:25own limited view. In case of India,
10:29language also is important. So if I
10:32don't know Canada and somebody is
10:34speaking in Canada, how will I
10:35understand completely?
10:38So even linguistic barriers come in
10:41places which have like linguistic
10:43diversity but primarily uh uh you can
10:47broadly categorize it into crossgender
10:50and cross-cultural encounters. Uh so uh
10:53simulation uh does play a role but uh it
10:56is limited uh is how you approach
11:00empathizing with patients. Narrative
11:02humility that is another framework that
11:05Saiani Daz Gupta has coined this term
11:08and she talks about it in terms of how
11:12this
11:13particular phenomena destabilizes the
11:16doctor as expert hierarchy and
11:19constructs healing as a collaborative
11:22meaning making process.
11:25So the recuperation of a patient also
11:29depends on
11:31how and what kind of equation that
11:34person shares with the doctor. So
11:37healing and not cure depends on the
11:43collaborative effort of the patient and
11:45the doctor. There is interaction theory
11:48in which they mention Hardy mentions
11:51patient be understood through second
11:53person engagement which means that a
11:57space a community space that gets
12:00created where the doctor's medical
12:02expertise and the patients lived reality
12:06meet. Now
12:09for the same kind of disease how do two
12:12patients respond? One doctor can have
12:15one diagnosis but different kind of
12:18other suggestions depending on what the
12:21resources of the patients are. So
12:23something like that gets created in
12:25interaction theory.
12:27Let us come to the two texts that we
12:29have chosen. The first is Munabhai MBBS.
12:32I am sure everyone in this class has
12:34seen this film. If you haven't, it's a
12:37good watch. Please go ahead. Now this
12:40film came out in 2003. It's a Hindi
12:44language film. I reiterate, I am taking
12:46most of my cases from Hindi films
12:49because that is the language I know. But
12:51you are absolutely free to use the same
12:55framework and analyze a film that is in
13:00the language that you know. In fact, it
13:02will build your corpus and maybe uh in
13:05the feedback session you have something
13:07more to add to what I had to say. So in
13:10this film you find Murali Prasad Sharma
13:14better known as Munabhai and he's a
13:16gangster and some u I mean because he
13:20wants to show his father that he's a
13:22doctor and not a gangster he by some
13:24fraud he enters into uh MBBS college and
13:27in fact when he goes there he challenges
13:29the very uh cold mechanical
13:33medical system through empathy based
13:36care and human connection. something
13:39that we were talking about earlier. So
13:42there are more films that talk about uh
13:45empathy based care but this film is
13:49quite popular and quite central and
13:52brings it to focus without any other
13:55paraphernelia as to how empathy based
13:58care and human connection is central to
14:02the entire doctor patient relationship.
14:05The film portrays the central conflict
14:07as compassion centered care of Muna
14:10versus the dean who's there
14:12eminence-based medicine of the dean Dr.
14:15Astana. So the the conflict it is
14:18between two people Munabhai and Dr.
14:22Astana and they both come from different
14:25school of ideology. Here there is no
14:27degree here very eminent degree. Here
14:31you find empathy and here you find
14:33excellence. So what does doctor patient
14:36relationship theory say? There has to be
14:38a merger of emotion and excellence.
14:43Either of the two. No, there has to be a
14:46combination.
14:48Let us come to uh one episode that I can
14:51discuss from the film. It's the power of
14:53therapeutic touch. In fact, if you read
14:56many of these uh ancient uh texts, you
15:00will find that uh tactile traditions
15:02have been there in India.
15:06So the whole idea of touching a patient
15:10and finding what is the disease it's um
15:13it's very much there in sahas as well.
15:17So the first thing uh that we are going
15:19to see is two scenes here. If you see
15:22Munabhai is hugging Zahir who is a
15:25terminally ill cancer patient and uh
15:28there is Dr. Astana conversing about
15:30different views. So even here the touch
15:33is there. So what happens touch is used
15:37as the cornerstone of physicians
15:39reportire before technological
15:41mediation. So all these technologies
15:45came much later. In fact, there are many
15:48films that you will find in which
15:54this whole idea of touching and finding
15:58out or touching and making the diagnosis
16:02uh was there. So, it's a tactile
16:05tradition that we are we have followed.
16:08But when technology came, it just
16:11reduced
16:13and now almost gone the whole human
16:16touch over there. And that's why the
16:18magical hug or the jaduki juppy becomes
16:21the metronym for connection. You find
16:24this throughout the film and uh it's a
16:28ritual of trust and non-verbal
16:30communication. Like I said, how
16:33important it is to build the quotient of
16:36trust in the doctor patient relationship
16:38that is reflected in this particular
16:41film. Additionally,
16:44when they show that there is a touch
16:47that is happening, a hug that is
16:49happening, it also shows a physiological
16:53impact. Uh what happens? It reduces
16:56hormones. It boosts the immune system
16:59and endorphin release. This also has
17:02been uh validated through research and
17:06additionally what it does it challenges
17:09the rigid institutionalization
17:11and the conventional
17:15structured kind of relationship between
17:17the patient and the doctor. Other than
17:20that one aspect of Munabhai MBBS which I
17:25find is worthy of discussion here is how
17:28the rigid hierarchies of doctor centric
17:32model break which is something that we
17:35are also finding in the health care
17:37system now in fact also in nomenclature
17:39of medical and health. So health
17:42humanities is a more inclusive academic
17:45area of research. uh medical humanities
17:49is more around what I am discussing
17:51around one disease, one illness or the
17:53other. So in uh this film you find that
17:58they challenge this hierarchy where a
18:01clinical doctor is at the supreme and
18:03that is something that I will discuss
18:05also in the later part of my slides. But
18:07in this film what happens there is a
18:10democratization. So if you see this
18:12particular uh scene on your screen, you
18:14will find that Munabhai is embracing a
18:17sanitation worker in the hospital.
18:20So there is a doctor and there is a
18:23sanitation worker but the doctor is
18:25giving a hug. Jaduki Japi as they call
18:28it in the film throughout. Additionally,
18:30hospital became a space of relational
18:33care. So everybody is kind of coming
18:35together a kind of a team uh a feeling
18:37of solidarity, a feeling of family is
18:39there.
18:40What happens? Muna treats the ward boys,
18:44sanitation workers and patients as equal
18:46participants in healing and not as
18:49support staff. So while they function as
18:53support staff, Munabhai in his approach
18:56of empathy makes them all part of the
19:00healing system and that is how he
19:04democratizes the aspect of care.
19:07Institutional authority and rigid
19:09hierarchy is countered with emotional
19:11connection and care reflective
19:13throughout the film where he listens to
19:15all the patients first place which many
19:19of them have been perhaps longing for uh
19:22and that leads to entire change in the
19:25way
19:26their body starts responding their mind
19:29starts responding in a positive way. It
19:32is also about humanizing the clinical
19:35practice. Many of you must be using AI.
19:37It calls about how AI is humanizing now.
19:41So similarly clinical which was going
19:44very you know biology based
19:46science-based also needs humanizing and
19:49that is where these films intervene and
19:52they say no there has to be humanizing
19:55alignment to the clinical practice where
19:58the ward uh I'm sure you know the I mean
20:01hospital has wards so that ward becomes
20:03a space of relational care rather than
20:06the procedural strictness. So there are
20:08procedures no doubt but there is also a
20:11relational care that is there which
20:14means that everybody is a kind of a
20:15family. Now contemporary research argues
20:18that the doctor centric model can be
20:20detrimental to patients well-being. So
20:23very strict just clinical aspect might
20:26be problematic is something that has
20:28been researched. Application of
20:30narrative medicine this is a term I have
20:33already used where other factors become
20:35important. So you have honoring the
20:37patient story. So there is a there is a
20:39patient named Anand who is in a
20:41vegetative state uh and he's treated as
20:45a you know a passive subject but Muna
20:47doesn't uh care for this. He takes him
20:50for a walk, he talks to him and uh
20:53suddenly you know um there is uh so much
20:56of life uh in the scenes even though we
21:00know that the patient is in a vegetative
21:02state. Again go back to the metaphor uh
21:05that I had used when I was talking about
21:09illness and metaphors.
21:11Narrative competence. He uses personal
21:13stories and jokes to stimulate them.
21:15Again a way in which you enhance the
21:20narrative capacity of what you are uh
21:23talking about and it challenges the
21:25medical gaze in which it is strictly
21:29biology or science-based.
21:34The second film of analysis is Dr. G.
21:36It's a Hindi language film directed by
21:38Anubhuti Kashup and came out in 2022 and
21:42it follows uh the story of Udai Gupta.
21:45Now um it's a very interesting story
21:48because there is this male medical
21:50student aspiring to be an orthopedic
21:53surgeon but his rank is uh not enough
21:57for him to get orthopedics. So he gets
22:00gynecology and uh many of you might
22:03relate to it because uh many times uh
22:06the branches we choose are not about the
22:09choice we make but the rank we get. So
22:12what happens when he comes to something
22:14which is considered to be woman's
22:17department. He gets very uncomfortable
22:20and the film foregrounds the sensitivity
22:24in that doctor patient relationship and
22:26how Ud Gupta as a doctor overcomes this
22:34conditioning of being to certain extent
22:37biased towards the gynecology department
22:40as somewhere he doesn't fit as a male
22:43doctor. So quite a few times you will
22:45find the phrase losing of the male touch
22:48and I use it as part of how I go about
22:52uh discussing the theoretical model. So
22:54the first point that I want to make here
22:57is the myth of manly specializations. So
23:00how does that take place that there are
23:02certain disciplines because clinical u I
23:07mean disciplines also create some kind
23:09of hierarchy. So there are manly
23:11specializations. So orthopedic is a
23:14manly specialization compared to
23:17gynecology which carries a baggage of
23:20meanings related to sexuality that often
23:23triggers social taboos for male
23:25practitioners. So that is what we see
23:29the myth of manly specialization is
23:31broken. Now the humanistic sensibility.
23:35What does this mean? That male touch is
23:37not about male as such. It's about
23:41sensitive and insensitive. You know that
23:43is how the film projects and the
23:45protagonist is reprimanded to lose the
23:47male touch and focus on caring for the
23:50patient instead of his discomfort or ego
23:54so that he treats all the patients as
23:56the same. Uh narrative humility is here
23:59as well. So you find uh Udai Gupta
24:02surrendering to the gendered bias he
24:05because he's biased he
24:07performs his duties as a doctor and
24:11listening to his patients need but he
24:14has to go beyond that. Therefore he
24:17begins to listen and understand the
24:19perspective of his mentor colleagues and
24:22family. So you see Uda is asking the
24:25nurse to treat the patient. You see the
24:28scene here and Udai being hesitant in
24:31treating a female patient. So he's kind
24:32of hesitant. Yeah, you can see the face
24:35of Aayush Man Kurana here very tense as
24:38to where have you put me in a kind of a
24:40face. So in the patient fair first
24:43realization
24:45he develops that empathy and here it's
24:49about recognizing that the other is not
24:51an extension of our own needs or social
24:54categories. that other person is also
24:56me. Other person is also somebody who
25:00who is a patient and I as a doctor I
25:03cannot uh discriminate. I do not have
25:05any bias. So he learns to communicate
25:09with rather than performs procedures on
25:12the female patients in his care. And a
25:14very iconic kind of a scene happens a
25:17little later. So here so how he now
25:21turns into a medical citizen. So what
25:23happens? There is uh a cousin of Udai
25:28who has attempted to force a high-risk
25:30abortion on an underage pregnant girl to
25:33save his reputation. Her name is Cavia.
25:36See uh he's taking her to the hospital.
25:38She's underage but she's pregnant and
25:40now there is this miscarriage that has
25:43happened. So how is that dealt by Udai?
25:46Uh it's very sensitive. You find that
25:48Udai helps in crisis and chooses to
25:52confront his cousin for his action like
25:55he is his family but still you find that
26:00he is reprimanding him and saying that
26:03this is not legal. By recognizing his
26:07moral debt to the patient, he outweighs
26:10familial bonds and evolves into a
26:12medicali citizen who actively resists
26:15systemic injustice. So that is how the
26:19film represents the transition of Ud
26:21Gupta and it is this incident in which U
26:26finds the right touch and the loss of
26:28the male touch that was earlier
26:31mentioned and runs as a parallel
26:34narrative throughout the film. You do a
26:37comparative analysis you find that in
26:39Umunabhai MBBS the protagonist is
26:41outsider whereas in Dr. The protagonist
26:44is medical intern. There is source of
26:47empathy purely instinctual. It's not
26:50based on any u training and here it
26:54comes over a period of time. He
26:58overcomes his internal gender bias and
27:01stereotypes and that is how in this film
27:03you find it is in opposition to the
27:05medical clinical setup lacking human
27:08sensitivity. Whereas here it's about
27:10transformation. the transformation of
27:13the character arc and how he learns
27:16narrative competence and humility. But
27:19what do both films do? They democratize
27:22the clinical practice shifting from
27:24authoritative medical gaze to a more
27:27inclusive tenderminded model based on
27:30the foundation of trust and empathy.
27:34So cinema education, cinema education is
27:37one word as a pedagogical catalyst. I
27:40will talk about how comics has been uh
27:43employed to decimate the information of
27:46covid-19 during pandemic. But for the
27:49time being you also understand this
27:51model. This is a again a combination
27:53word of cinema and education where
27:56cinema is employed to educate. What does
27:59it do? It helps to view patients as
28:02complex individual instead of just
28:05clinical cases. It experience high
28:08emotional stake and primary response
28:11without immediate burden of clinical
28:13responsibility. It encourages students
28:16and viewers to reflect on their own
28:18biases and perspective. Visual
28:21storytelling's unique capacity to
28:23represent empathy and trust. And finally
28:27leads to a better understanding of
28:29biocschosocial model of health. This
28:32means if you I put it all together into
28:35one uh line, it means that cinema is
28:40employed as a medium to educate about
28:45stories of medicine or narratives of
28:48medicine or issues of medicine. Not from
28:52the perspective of science alone but
28:55from the perspective of how society
28:58assigns certain kind of meaning to these
29:00kind of disease. How your mind as a
29:03patient respond to it and what is the
29:07diagnosis the uh doctor is going to
29:09make. Uh finally uh is this is we are
29:14living in the age of uh technocratic
29:16efficiency and therefore there is huge
29:19amount of requirement to go ahead and
29:22humanize it and that is what uh these
29:25two films do. They add the
29:28quotient of individuality
29:31and personalization so to say into the
29:35whole domain of medicine and finally
29:37talk about the trust and empathy which
29:40remain the dual pillars to ensure that
29:43care remains patient centric. On that
29:46note I will take your leave and I we
29:48will meet soon in the next class where
29:50we'll we will talk about other important
29:52issues in the field of medical
29:54humanities. Thank you.