AnArtomy: Arts, Anatomy and Medicine - Human Beings Being Human

This article was migrated. The article was marked as recommended. Background The study of anatomy underpins medical education and is an important facet of clinical practice in various diverse disciplines. We explored the dynamic relationship between arts, anatomy and medicine, along the continuum axis of anatomy, medicine, healthcare and art. Aims 1. to foster and gauge artistic and creative expression within the context of medical science and practice. 2. to generate representative artwork examining the relationship between art, medicine and healthcare. Methods Two purposefully open and expressive creative workshops were held within the cadaveric dissection laboratory of the Queen’s University Department of Anatomy; with awide variety of artistic substrates available for faculty and student participants. Themes included: the relationship between art and medicine, the impact art and science have upon each other and the effects of creativity on wellbeing. Accompanying questionnaires included a quantification of perceived relationships between art and medicine; with an estimation of connectedness to feelings. Qualitative items within each questionnaire also addressed key humanistic questions. Comparative analysis of quantitative results was by Student’s t-testing; statistical significance being p values <0.05. Results, Summary and Conclusions There was a statistically significant increase in “connectedness to feelings” amongst participants over the course of the workshop. There was a trend for participants to agree or strongly agree that art and medicine were important to each other. Qualitative responses changed from specific, task-oriented hopes to responses more aligned with social/gregarious themes and those related to higher order functioning. Humanistic responses changed across the entire group from a largely fixed inclusion of the concept of emotions to broader, more altruistic visions; inclusive of communal, social views. There was a noticeable shift in emphasis from succinctly defined descriptive terms to more expressive terms; reflective and inclusive of caring, holistic practice. The most arresting and compelling results were those of the resulting representative artwork.

Introduction "Medicine is not only a science; it is also an art.It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided" -Paracelsus "Wherever the art of medicine is loved, there is also a love of humanity"-Hippocrates Anatomy is a science, medicine less so; healthcare even less again.
The knowledge and principles of anatomy as a grounding for clinical learning in healthcare cannot be overstated (Sbayeh et al,2016) The study of anatomy underpins medical education and is a key central feature of the practice of surgery and radiology, as well as forming an important facet of clinical practice in a diversity of disciplines such as internal medicine, anaesthetics and neurology; to name but a few specialties.
Much of anatomical learning is based around imagery and the rendering of representative detail, which often leads students and practitioners of this science into the creative realm of artistic portrayal.The teaching of anatomy is underpinned by the work of key individuals, such as Frank Netter (1906 -1991); often referred to as "The DaVinci of Anatomy".Netter was a surgeon and medical illustrator, who produced circa 400 illustrations, which featured in key anatomical texts.His work was compared to and superseded by the epochal illustration of Andreas Vesalius (1514 -1564) and Leonardo DaVinci (1452DaVinci ( -1590)).Vesalius was a surgeon, anatomist, artist and scientist, whose artistic output was both voluminous and hugely influential.Da Vinci's artistic background informed his illustrations of cadaveric dissection, imbuing these with dynamics and life.It is in the interface between his inhabited worlds of art and science that his phenomenal creative output proves most fascinating.Later, the illustrated works of Henry Gray (1821 -1865), an anatomist and surgeon became a central feature of anatomical and surgical texts, including his own seminal publications Anatomy of the Human Body in 1918 [more commonly know as Gray's Anatomy] (Gray, 1859).
Medicine deals with the human condition, often at it's most fragile, dealing with the wide range of the human condition; encompassing suffering, illness and death or recovery.This spectrum of the human condition contains the central substrate for the production of all forms of art (Walsh 2017).The dynamic and mutually beneficial relationship between art and medicine has been increasingly recognised and explored, particularly over the last several years.Cole et al (2015) believe that arts and humanities can contribute to "cultivating personality, intellectual curiosity, emotional honesty, social awareness and the exercise of sound judgement and moral imagination -virtues and skills indispensable to good doctoring (Cole et al, 2015)16.The ability and potential of art to comfort, heal, and help individuals find hope in illness and suffering has become recognized as a role for art in healthcare (Hanna, Rollins and Lewis, 2017).
It was with this dynamic relationship between arts, anatomy and medicine in mind that we embarked upon this project; recognising and exploring the continuum axis of anatomy, medicine, healthcare and art.

Methods
An open invitation was sent to all first and second year undergraduates at Queen's University Belfast during the Development Weeks part of their study program (this is a typically fallow period between the commencement of main curricular studies, wherein students and teaching faculty are encouraged to volunteer for additional teaching and learning activity to broaden their academic experience at the university).Students registered online for 2 consecutive daily workshops, which were designed by the Artist in Residence (AS) at the Department of Anatomy.
All creative activity took place within the cadaveric dissection laboratory of the Queen's University Department of Anatomy.All participants were briefed at the outset on the principles, regulations and legislation relating to the Human Tissue Authority, as pertinent to the venue.
The workshop design was purposefully open and expressive, with a wide variety of artistic substrates being made available for both faculty and student participants.In addition to resources such as drawing materials including paint, pencil, crayon and ink printing blocks, all participants were given free access to a wide range of additional materials with the potential for artistic deployment.These materials included substrates such as willow, wire, foliage, plumage, cardboard and aluminium.
At the start of the first day of the workshops, the lead artist demonstrated techniques for working with the materials supplied, including demonstrations in the safe deployment of wire cutting tools, ink printing and methods for entwining willow, together with sculpting techniques.
Participants were encouraged to work in groups and discuss their direction of creative travel before engaging with the materials.It was explained to all involved that the first two hours should be spent in acclimatising and growing accustomed to the various resources and how best to interact with them.Faculty freely circulated amongst participants, answering questions and providing anecdotal narratives to inform artistic construction.Themes raised included: the relationship between art and medicine the impact art and science have upon each other the effects of creativity on wellbeing All participants were asked to complete a questionnaire (Appendix 1) at the start of the day one workshop and a separate questionnaire at the end of day two.These questionnaires were designed to gather information on participant demographics, current academic status and previous experience with artistic endeavour, together with Likert scale quantification of participant's perceived relationships between art and medicine; with an estimation of connectedness to their own feelings.The key qualitative questions, as free text responses included in the questionnaires were: What are you hoping to personally gain from this workshop?What do you predict or hope will be the result(s) of the workshop?What does "human being" mean to you?What does "being human"mean to you?What does "being a doctor"mean to you? Quantitative questions and statements (Likert Scales) were based on three key statements: Art is important to medicine Medicine is important to art How connected to your feelings do you feel right now?

Data analysis
Likert scale responses were coded and exported to standard (Excel) spreadsheet format, wherein descriptive and comparative statistical analysis was undertaken.Comparative analysis was by Student's t-testing, with statistical significance taken at p values <0.05).
A variety of artwork forms were created by the participants, largely working in teams which formed and developed throughout the workshops.Accompanying explanatory commentary and narrative was encouraged in the production of this artwork, to delineate the genesis of each piece.Such commentary was guided toward the above themes, as they emerged and evolved.
Digital photographic representation of artistic activity in progress and upon completion of all creative artefact was undertaken throughout the workshops, deploying designated digital photographic equipment designated to the Department of Anatomy in line with Human Tissue Authority regulations and legislation.

Results/Analysis
The results have been divided into: (1) Demographic results (2) Qualitative results derived from questionnaire free text responses and direct verbal comment during workshop activity.
(3) Quantitative results -derived from analysis of Likert Scale responses to the three key statements.
(4) The multifarious artworks produced by participants.Representative explanatory commentaries were aligned with each piece to provide context and narrative.

Qualitative Results (questionnaire responses)
Exemplar questionnaire responses are represented in Table 1 (Appendix), with a delineation of these between those immediately before the workshop began and those at the end of all creative activity:

Quantitative Results
Analysis of the Likert Scale responses to the key statements are illustrated in Figure 1.
There was a statistically insignificant trend for participants to agree or strongly agree that art is important to medicine (p = 0.4) and that medicine is important to art (p = 0.3).In contrast, there was a statistically significant (p = 0.03) increase in "connectedness to feelings" amongst participants over the course of the two day workshop.

Artistic Artefact
The resultant artefacts took the form of sculpture, often accompanied by contextual narratives; the latter of which provided rich descriptions of each artwork's genesis, evolution, construction and creation.These narratives and the artworks themselves also included and provided significant personal back stories from the participants; as each creative exercise allowed back stories and context to emerge.Sharing of experiences during such creative activity was an invaluable aspect of the entire activity and helped forge both collaborative efforts and subsequent friendships, as alluded to in Table 1.
A selection of the creative works are shown in Illustrations 1-6.
Illustrations 1 and 2 show representations of the human heart and lungs, fashioned from tape, plastic conduit tubing, surgical gauze and plaster of Paris.The structures are visually arresting, especially with the strikingly vivid representation of blood and blood vessels in "Heart", which are roughly representative of the vessels of the adult coronary artery circulation.These artworks, created by medical students, are both somehow anatomically correct, yet emotive.Illustration 3 (The Body and Nature) is arresting in its'imagery, combining substrate from nature (foliage) with typically inert material (wire) and medical matter (gypsum; "plaster of Paris").Again a representative heart, replete with great vessels coronary arterial supply entwines and contains a deeply olive green branch and still-living leaves.The inscription could be considered a subtext for the entire project: "exploring anatomical connections abstractly; linking with natural forms".
"Leg Within a Leg" (see Illustrations 4 and 5) encompasses and expands a personal narrative.The medical student sculptor explained that her contribution was inspired by the story of her brother, who had undergone amputative surgery of his lower limb as part of the treatment for his osteosarcoma.The student was privy to information relating to prosthestics in light of this personal connection, together with her knowledge accrued during her anatomical and medical studies.Through the creation of this striking sculpture of wire mesh and gypsum, she was able to articulate feelings relating to her sibling's disarticulation, simultaneously expanding on the technical challenges of prosthetic design.
"Flower Lungs" (Illustration 6) represents an innovative use of willow, surgical tape, foliage and various brightly coloured fabrics, caged within wire mesh.The resultant sculpture is a representation of the adult human trachea (together with cartilaginous [willow] rings), bronchi and lungs.The concept of lower airway branching is represented by actual branches of verdure and the "floral" lung substance somehow suggests the breath of life.Discussion Medicine can at any one time be referred to as a discipline, a profession, a subject, a field, a specialty, a career or a practice (Walsh, 2017).The practice of medicine is deployed within the arena of healthcare provision, wherein it is now recognized that human factors play a hugely influential role, both in terms of efficacy, efficiency and safety.Such human factors include technical skills, behavioural skills and encompass human-human interactions, together with ergonomics (human-machine and human-environment) interactions.Humans are the central feature of medicine and healthcare; in the form of professionals, patients, relatives and carers.Effective and compassionate healthcare should embrace and incorporate this tenet, always being mindful that medicine is not wholly a science, nor entirely an art; but occupies a variable position on an axis betwixt the two.The oft-quoted "doctor-patient" relationship is essentially a humanistic construct and is considered a central pillar of clinical practice.Within healthcare provision, particularly in the welcome era of multidisciplinary practice, the relationship between healthcare professionals is, by necessity and definition, also enterprisingly humanistic.
Art-mediated peer learning has been shown to enhance both an appreciation of both the value of the doctor-patient relationship and holistic care, with the potential to educate on the humanistic aspects of clinical practice (Potash and Chen, 2014).Our workshop facilitated human-human interaction and human-material interaction in an open, safe and supportive environment which was truly interdisciplinary; with faculty representation from domains such as visual Illustration 2. "Heart": art, music, surgery, anatomy, physiology.Likewise, the student participants hailed from diverse fields such as medicine, law, biomedical and biological science, as well as astrophysics and engineering.The qualitative feedback results indicated that there evolved a sense of teamwork, camaraderie and friendship -all aspirational qualities of effective and caring healthcare teams.The participant groupings which developed were variform in terms of: (1) vertical integration; there was distinct representation across the undergraduate-postgraduate-faculty continuum and (2) interdisciplinarity; horizontal integration of participants occurred effortlessly amongst subjects and disciplines as diverse as physics, law, biomedical sciences and english.

Questionnaire Responses
The preliminary items on the questionnaires were directed towards the participant's aspirations for the workshops.It can be seen from the responses before and after the workshop, that these aspirations distinctly changed from specific, taskoriented hopes (e.g."insight into anatomy and medicine in creative form"; "learn more about the human body and how art relates to the body"; "improve my manual dexterity"; "learn how to do more 3D work") to responses more aligned with social and gregarious themes, as well as those related to higher order functioning (e.g."friends, meeting new people, having fun"; "people have a good time, teamwork established and new friends are made";"a closer relationship to my lecturers";"inspiration and insight"; "build creativity";).It is encouraging to note such a change, especially as such would be considered as conducive to communal and supportive learning.
Subsequent questionnaire items allowed for exploration and examination of views on humanistic concepts and the relationships betwixt arts and healthcare.Views of what it means to be human and what human beings are defined by varied amongst participants, dependent upon their academic background.When asked to define "human being", there was no noticeable difference in responses at the beginning and end of the workshop.Those participants with a greater scientific background weighting tended to be provide responses associated with positivist language (e.g."higher organism"; "living creature"; "a species; something that can be studied"), whereas those with a less scientific background tended to respond with constructivist/creative language (e.g."being alive"; "ability to think"; "living";"soul, love").However, when asked about "being human", responses changed across the entire group from a largely fixed inclusion of the concept of emotions (Being alive, having consciousness, emotions, feelings"; "having emotions"; "being emotional, achieving things, thinking, feeling...") to broader, more altruistic visions ("being part of something more"; "how you live your life"; "having a life worth living").The latter responses were again more inclusive of a communal, social view ("experience new things and build relationship"; "our human nature).Again, this is a welcome observation and one which bodes well for interdisciplinary learning.
When asked about what 'being a doctor" meant; as the artistic collaborative activity progressed, there was a noticeable shift in emphasis from succinctly defined descriptive terms ("fulfilling the requirements/principles of what it means to be a doctor", "being safe and hopefully knowledgeable", "someone who has a degree in medicine") to terms which were more expressive, reflective and inclusive of caring, holistic practice ("to save people", "having empathy, being a listener and carer to those in need", "curing the body or aiding it in death -providing comfort").
It may well be that engagement with, and immersion in, artistically creative activity fostered these changes in perspective; allowing broader thinking to emerge when considering key features of the human condition.A similar process may have underpinned the shift in perspective of participants when considering the cardinal features of a doctor, as it was apparent that a greater consideration of higher order functioning such as empathy, caring and healing had come to the fore.An additional factor in such shifts may have been the influence of collaborative working.Free conversation and open thinking was encouraged amongst participants from disparate backgrounds; perhaps allowing for a greater understanding of healthcare professional roles as historically typical interdisciplinary barriers lowered organically.

Quantitative Results
Figure 1.shows that, as the creative collaborations developed, there was a statistically significant increase in the extent to which participants felt connected to their feelings.
In essence, this was an unstated aim of the project; as we negotiated the complex pathway between science and art, there was somehow a tacit agreement amongst all involved that we were exploring something connected to both feelings and higher order functioning.This was expressed in some of the questionnaire responses discussed above (c.f."contemplating Illustration 4. "Leg Within a Leg": surroundings at a higher level", "having thoughts, feelings and emotions") and such responses may have indicated an evolving awareness of feelings as a central feature of both the workshop.It was hoped that the questionnaires themselves would prompt reflection, discussion and an appreciation of the emotional landscape.This may explain the genesis of the encouraging and significant (including statistically) results.The increased identification with feelings may also have been augmented by the collaborative nature of the creative activity, wherein free conversation and discussion of topics such as feeling and emotion were fostered and encouraged.

Artistic Artefact
For all involved, the most arresting and compelling results were those of the resulting representative artwork.The nature of the production and creation of this work was entirely organic.Themes emerged within groups and minimal direction was required from faculty to progress any of the work.There was an initial hesitancy at the outset of the creative activity, as participants grew accustomed to the variform artistic substrates and materials.However, once the basic material handling skills were explained and demonstrated to the participants by the artistic director (AS), creative activity quickly got underway.Each completed work was largely the result of group activity, especially amongst the student body.Faculty participants tended to work solo, although free conversation and collaborative comment was clearly evident as work progressed.It is perhaps this collaborative facet of the project which proved most fruitful.It is difficult to envision that such arresting artwork could have resulted from efforts in a non-networked environment.On the subject of environment, this workshop was particularly unique by it's setting within a cadaveric dissection laboratory.Such environs would not be immediately clearly evidenced by the resultant artwork.It is hoped that this unconventional setting itself provided food for thought and consideration as collaborative creation progressed.This is discussed in the final paragraph.
Placing the scientific and medical alongside the creative allows for a uniquely fertile soil.Participants may come to realisations hitherto unknown or unrecognised; whereby the similarities and common ground of the art of medicine and the science of creativity may come to light.This is the arena inhabited by the polymath giants such as Vesalius, Da Vinci, Gray and Netter, as described in the introductory section.We replicated such a propagative environment on a microcosmic scale and contend that the results were fruitful in terms of supportive creativity and producing representative artistic content of worth.
Several authors have commented on the potential for engagement with arts and humanities to enhance imagination and empathy in healthcare, as well as linking emotional and rational brain functions (Katz and Khoshbin, 2014;Riess, 2010).It has also been demonstrated that facilitating undergraduate medical students to examine fine art allows them to become more observant, self-caring and empathetic (Hojat et al, 2009).
Within the critical realm of patient safety in healthcare, it has been argued that immersion in arts-based activity may enhance self-awareness and recognition of the impact of emotions on clinical judgement (Potash et al 2014).
Art can also effect culture change, especially around health provision issues such as literacy, understanding and trust, thus affording opportunities for prevention and cure (Bonder & Martin, 2013;Govindasamy et al, 2014;Sonke & Lee, 2016).A more humanistic approach to the practice of healthcare has become increasingly evident, relevant and welcome in recent years and holistic care has now been recognised as the aspirational standard for modern healthcare provision in the modern (Serlin, 2007) Within this holistic paradigm, the arts can uniquely provide an environment and opportunity to create environments conducive to recovery, healing and health for both patients and carers alike (Hanna et al, 2017).
In relation to medical learning within a cadaveric dissection setting, George Dickinson eloquently opined" Medical training is more accurately characterized as a process of socialization, that medical students are not only "passing through" an experience intended to refine previously established values, but that those previous identities must be repudiated and new and countervailing identities assumed..." (Dickinson et al, 1997).We have thus explored this arena specifically within the unique setting of an anatomy dissection laboratory; an environment typically and traditionally associated with sterility and the scientific approach, conjuring up stark, dispassionate imagery.The results of this project; particularly the life-imbued artefacts which were produced, have demonstrated that such a setting need not necessarily be stagnating, but can be creatively invigorating.Such environs are necessarily associated with the human condition, particularly dying and death.We argue that this association may render such spaces as distinctive places for learning, collaboration and creativity.

Conclusion
The full spectrum of the human condition is encountered in healthcare, which thus contains the central substrate for the production of art.Fostering artistic and creative expression within the context of medical science and practice allows for a holistic approach to science and health, whilst similarly providing a uniquely humanistic climate for artistic creation.Exploring stark, singular spaces such as the cadaveric dissection laboratory we housed this study in allows for rich, experiential, creative learning and attitudinal change.

Take Home Messages
Art and medicine are uniquely placed as overlapping, potentially synergistic disciplines Artistic and creative expression within the context of medical science fosters a holistic approach Medical science allows access to key features of the human condition, which is the central substrate for art Typically stark scientific surroundings such as anatomy dissection laboratories can provide uniquely inspirational and creative learning environments

Notes On Contributors
Mr Ian K Walsh is a Clinical Academic and Urological Surgeon at Queen's University Belfast, Belfast Trust and Kingsbridge Hospital.He is Chair of the Northern Ireland Healthcare Human Factors and Transatlantic Arts, Humanities and Health groups.
Dr Joseph Quinn is a lecturer in anatomy at Queen's University Belfast, who teaches anatomy, physiology and neuroanatomy.He champions scholarly support and leads student development.He has published widely in international peer-reviewed journals; ranging from neurosciences to medicinal chemistry.
Andrea Spencer is Residential Artist at the Department of Anatomy and active member of The Renal Arts Group at Queen's University Belfast.Her prolific body of work references the human condition, expressed through teh poetics of glass; utilising a visual language common to both science adn art.
Dr Helen Noble is a Senior Lecturer at Queen's University Belfast, where she chairs the Renal Arts group.Her research explores creative activity in palliative settings and she leads the Mindfulness and Resilience support and research group.

Declarations
The author has declared that there are no conflicts of interest.

Trevor Gibbs AMEE
This review has been migrated.The reviewer awarded 3 stars out of 5 An interesting paper to read, although I am a little unsure what this really adds to our thinking about how the humanities can our future thinking about educating our new students and how the humanities fit into our new curricula.I was very impressed by the "sculptures" created by the students and would very much agree that there was a clear development of team learning and an expression of the students inner-self and their ability to look at the human through rather tangential eyes -I think the paper could have been improved by allowing a more discussive process, post making the sculptures, so that the students could explain the why, what and their inner feelings.If this was done it should, I feel, be better included in the paper.I was also a little confused with the pre and post questionnaires-there appears to be no matching of expected and actual outcomes, which again I feel might have improved the results.Saying all that, I did enjoy reading the paper and its innovation.One big question, how do we take these findings into the curriculum -having such a course as a stand-alone activity I am not sure gives it the value it deserves.Should the authors follow this group of students through the early part of their course?Its good that the paper creates more questions than answers.
Competing Interests: No conflicts of interest were disclosed.

P Ravi Shankar American International Medical University
This review has been migrated.The reviewer awarded 4 stars out of 5 This is an interesting paper describing a creative workshop conducted at Belfast University, Northern Ireland.The workshop was successful in helping collaboration between the participants and increasing their understanding of the links between medicine and art.The photographs of the creations by various groups are interesting.I would be interested in knowing more details about the workshop.There were 28 participants in the workshop.Was 28 kept as the upper limit for the workshop?Did the cadaveric dissection laboratory provide sufficient space for the workshop?How many hours a day did the participants spend working on their projects?How many groups were there?How were the groups selected?Who were the faculty members?How were they selected?Did faculty participants also create artworks?I am not completely sure about the last sentence in the Conclusion section.The authors encountered rich creativity and learning among the participants but a causal relationship may be more difficult to prove.A similar result may have been observed in a different setting outside the laboratory.The workshop opened up pathways for connecting between students and faculty members in various professions and areas of study.The article would be of interest to all medical educators.
Competing Interests: No conflicts of interest were disclosed.

Illustration 5 .
"Leg Within a Leg" (close-up view of narrative):

Illustration 6 .
"Flower Lungs": Ethical Approval was granted for the Human Beings Being Human project by Queen's University Belfast Research Ethics Committee(reference no.15.47v3) This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.