RE-EMBODYING MEDICINE: WILLIAM CARLOS WILLIAMS AND THE ETHICS OF ATTENTION
Britta Gustavson
William Carlos Williams (1883-1963) spent nearly every waking hour of his adult life dancing between his career as a physician and his career as a writer. His mission, one about which he frequently wrote and which he continuously updated, critiqued, and revised, was at its core a simple one: to find a way of using everyday language on the page to grasp, reimagine, and give back to the reader what he observed and experienced in his surroundings. The evolution of medicine and medical education over the century since Williams himself studied medicine has brought about remarkable advancements in how we can care for patients. However, modern medicine, with its emphasis on progress, efficiency, and technology, has made the misstep of disembodying the human experience of medicine. Williams practiced at a time when medical technology was imagined more than realised, making his ability to observe and listen to patients paramount for his ability to treat them. In his autobiography, Williams writes that the poet is “not to talk in vague categories, but to write particularly, as a physician works upon a patient, upon the thing before him, in the particular to discover the universal” (Williams "The Autobiography of William Carlos Williams [Electronic Resource]" ch.58). Through a selection of Williams’s poems and prose, I aim to highlight how close reading of his literary works can help return physicians to the importance of such attention and ground us in our bodies and our environments. Engaging with Williams’s works can help us as readers, physicians, and medical trainees to re-embody medicine by better observing our surroundings, better empathizing with patients, and better reflecting on our own human perspectives.
Acts of Outward Attention: Patients
Williams’s career as a rural physician allowed him intimate access to the lives of the people among whom he lived and worked. Williams’s literary career was equally entwined with his local environment, thus grounding Williams’s writing in his present-day American reality. In this respect, Williams was unlike many of his literary contemporaries, who were altogether more concerned with a distant European aesthetic. Williams was committed to creating a new kind of American poetry – a kind of poetry that rejected unrooted artistic abstractions, focusing instead on an immediate, tangible reality and the way that, for Williams, abstract “ideas” are derived from tangible “things.” In his poem Paterson, Williams emphatically writes “Say it! No ideas but in things -,” capturing this focus on material realities (9). Weaver comments on this divergence of Williams from his contemporaries, writing that “[T.S.] Eliot in London was abstracting spiritual values, or an absence of them, from the air; Williams, in the physical waste-land of his own part of New Jersey, detected an irrepressible force in the soil” (Weaver 44). Weaver’s language emphasises the sense of rooting and groundedness in American life that is evident in Williams’s writing. The keen attention Williams gave to observing his surroundings was undoubtedly influenced by his early medical education at the University of Pennsylvania. Medical education in the early 1900s was experiencing a shift away from wholly didactic lectures to more hands-on laboratory sessions and teaching in the clinics and wards. The faculty aimed to teach medicine “as an application not as an abstract science,” echoed in Williams’s “No ideas but in things - ” (Pennsylvania 279; Williams et al., "Paterson" 9). The practice of medicine helped Williams to hone the skills of observation and attentive listening, which we see reflected in his approach to poetry.
Observation and Listening
Observation is a skill central to the practice of medicine. To reunite medicine with the body we can look to ways Williams’s writing can help us “train” our senses. For Williams, a focus on sensory particulars in order to “discover the universal” was a key foundation for both his medical practice and his writing ("The Autobiography of William Carlos Williams [Electronic Resource]" ch.58). In medicine, to forget the particulars is to miss crucial medical signs, while to forget the universal is to overlook the patient and miss the aim of medicine altogether. Williams created poems that were often centred around his rendering of a precise snapshot of something he observed. Moreover, he created poems that were themselves to be observed on the page. Williams wanted the particulars of his lineation, syntax, and layout to be attended to for both their effect on the meaning of the poem and their effect on how the poem appeared.
In one of Williams’s best-known poems, “The Red Wheelbarrow”, we see this emphasis on observation and poetic form and how it contributed to decisions about the visual layout of his poetry. In the poem Williams plays with the enjambment of lines and individual words. This “word-splitting enjambment” serves “momentarily” to “magnify the discrete parts of which the whole is composed” (Cushman 26). Williams enjambs words like “wheel/barrow” and “rain/water”, asking the reader to momentarily see these words as their constituent parts and likewise see their physical reality as constituent parts too (Williams et al. The Collected Poems of William Carlos Williams. Vol.1, 1909-1939 224). Many readers of Williams undoubtedly cannot now see a wheelbarrow without thinking of “wheel” and “barrow” as separate entities. Medical trainees are taught to summarise a patient’s case by distilling the history and physical exam into its simplest expression. The simplicity of Williams’s poems, like the sixteen-word “The Red Wheelbarrow,” parallels this crucial skill of formulating a patient summary. Even with his economical approach to language in “The Red Wheelbarrow,” Williams presents the reader with a crisp snapshot of a rain-glazed wheelbarrow. Comparably, in the clinic we aim to be able to observe and summarise in such a way that our colleagues can see the “image” of a patient’s case just as crisply as if they too were interviewing the patient.
Williams did not just want his poetry to be read, but he wanted it to be observed. “11/2 [Dahlias]”, for instance, undulates on the page like the edges of a flower while “An Early Martyr” appears boxed in to represent the institutionalisation of the ‘insane’ (Williams et al. The Collected Poems of William Carlos Williams. Vol.1, 1909-1939 377-378). The shape on the page is significant both for its visual effect and its implications for the distribution of lines and words within the poem, as evidenced in “The Red Wheelbarrow.” The visual nature of Williams’s poems became even more accentuated in the latter half of his career. In “The Yellow Flower,” the poetic speaker asks:
What shall I say, because talk I must?
That I have found a cure
for the sick?
I have found no cure
for the sick .
but this crooked flower
…………………………
[This]
is that sacred
flower!
(Williams et al. The Collected Poems of William Carlos Williams, Vol.2, 1939-1962 257).
The reader is asked to reflect, why are lines split as they are? Why are there questions and exclamations and unconventional intralinear spaces? To what effects? It is no coincidence that Williams then writes:
I have eyes
that are made to see
…………………………
[and]
through the eyes
and through the lips
and tongue the power
to free myself
and speak of it,
(Williams et al. The Collected Poems of William Carlos Williams, Vol.2, 1939-1962 259).
Yes, profound concepts arise in the text of this poem, ones about the tension between elevated and ordinary, between power and powerlessness, between isolation and unity, but by designing the poem as he has, Williams is asking for observation not just reading. The techniques he uses serve to defamiliarize the practice of reading, encouraging readers to pause and observe poetry as they ordinarily would not. Williams’s poetry leaves spaces both visually and metaphorically for the reader to reflect on the meaning behind his choices with form and how they impact the overall interpretation of his work.
Florence Nightingale noted that “Observation tells us the fact, reflection the meaning of the fact” (Nightingale et al.). Instead, Williams encourages simultaneous observation and reflection, something more akin to Charles Peirce’s concept of “abductive reasoning” (Peirce et al.). In Educating Doctors’ Senses Through The Medical Humanities, Alan Bleakley discusses how abductive reasoning, “reasoning in the senses” or “reflection-in-action,” can be a useful framework in medicine (31). Through his work Williams demonstrates that observation is a dynamic process requiring a self-awareness about the process of observation. Williams’s poetry, in particular, encourages the reader to exercise a sort of reflective, active observation. Close reading of poems like “The Red Wheelbarrow” and “The Yellow Flower” helps medical students to consider how we observe.
Williams was not only committed to creating work centred around observations of his surroundings; he was also committed to creating poetry that used everyday language. William Osler is quoted as saying “Listen to the patient. He is telling you the diagnosis” (Pitkin). Listening to Williams’s work and attending to the choices he makes with language is a way to help medical trainees learn to be more aware of the choices patients make with language when narrating their own illnesses. This aforementioned present-day disembodiment of medicine involves not just the hyper-centrality of objective facts and clinical signs, but it also involves the loss of the patient’s own voice. What Williams was doing for poetry in the mid-1900s was reuniting the poetic voice with the poetic subject, both of which he aimed to root in American life. For medical trainees, reflecting on Williams’s work can help focus our attention on reuniting our observations of the physical patient with the patient’s own “voice” – even their “lyric voice.” Much as lyric poetry registers and engages a particular emotion or state of mind for the reader and facilitates understanding, paying attention to the patient’s voice can encourage physicians to connect with the important affective experiences of their patients.
Williams’s “day job” as a physician was a grounding force for his literary career; the voices and stories of patients provided insight into something of a collective, largely rural, American psyche. He sought to integrate the pattern and motion of American speech into his literary work. Williams was attuned to the voices of the people around him and used the “American voice” as another “thing” in which to root his poetry. In his writing “you hear the rhythmic envelope of American utterance, Variable Feet and all” with this variable foot serving as “a manifestation of the American Idiom” (Kenner). Throughout his career as a writer Williams experimented with the tension between the way his poems sounded and the way they looked on paper (Kenner). In the second stanza of the poem “To A Poor Old Woman” Williams plays with how lineation can affect the meaning of words and phrases. His poetic speaker comments on the plums:
They taste good to her
They taste good
to her. They taste
good to her (Williams et al. The Collected Poems of William Carlos Williams. Vol.1, 1909-1939 383).
Williams tests out on the page which break suits his poetic goals and, more importantly, which break conveys the meaning as it relates most to the old woman whom the speaker observes. Williams’s shifting lineation contributes to a sense of voice in the poem. While “They taste good to her” has all the cadence of normal speech, Williams poeticises the sentence in order to ask the reader to think as much about words, their meaning, and how they sound as he does. There is a sense in this poem that the poetic voice is something intimately shared between the poetic speaker and the old woman. This interplay feels much like how a doctor works with a patient to collaboratively come to understand an experience in a way that encompasses both the professional “doctorly” observations and the patient’s own personal history. Through techniques like the one demonstrated in “To a Poor Old Woman,” Williams prompts us not just to engage in close reading of his work but he also models how to listen to a poem and how the act of listening can help us to understand the old woman’s experience of the plums or, likewise, a patient’s experience of their illness.
Imagination
Engaging with literature can be seen as a way of affirming our sensory realities in ways that are enlivened by imagination. Williams’s two careers were mutually informative; his cultivation of the imagination as a poet, in turn, influenced his ability to treat and empathise with patients. In Spring and All, Williams explores the meaning and importance of imagination in his literary work. He presents imagination and reality as fused entities, insisting that “it is the imagination on which reality rides” (Williams et al. The Collected Poems of William Carlos Williams. Vol.1, 1909-1939 225). Williams muses that “As birds’ wings beat the solid air without which none could fly so words freed by the imagination affirm reality by their flight” (Williams et al. The Collected Poems of William Carlos Williams. Vol.1, 1909-1939 235). As medical trainees we are taught by experienced physicians to “see” things that are not overtly present and “hear” things that are not spoken aloud. This is an important though somewhat elusive task for the inherently inexperienced student. What Williams suggests is that it is the imagination that can help bridge the gap between keen sensory observations and the multitude of elusive “clinical senses” in medicine. Much as a bird in flight affirms the existence of air, a patient’s illness affirms the existence of some cause, elusive as it often may be. As Williams uses words, the imagination is required to engage our senses more fully with reality and embrace what is unseen, contributing to the general task of re-embodying modern medicine. In a field where evidence and efficacy are so highly valued, training students to exercise a sort of poetic imagination is rarely done. But as Hallyn writes, “a poetic imagination [refers] to the possible rather than the evident” (16). Staying open to the possible facilitates comprehensive patient assessment and promotes patient safety, by avoiding things such as premature diagnoses for example. This imaginative openness is a critical skill for medical trainees.
Empathy and Sensibility
How to teach and maintain empathy are further challenges of modern medical education. While physician empathy has been shown to improve medical care in terms of patient satisfaction, adherence to therapy, and clinical outcomes, physician empathy has also been shown to decline even in the short time between starting and graduating medical school (Batt-Rawden et al.; Di Blasi et al.; Kim et al.; Neumann et al.). Bleakley discusses the importance of ‘sensibility’ and ‘sensitivity’ in medicine. Sensibility refers to “sensitivity to sensory stimuli,” much as how Williams’s poetry encourages a re-embodiment of medicine through keen observation and active listening (Bleakley 2). Sensibility, however, is “oriented to quality in relationship and emotional or affective response” (Bleakley 2) . The imagination, as Williams describes it, has an important place in everyday patient interactions. Neither the experienced attending physician nor the new medical student will have lived each patient’s experience. Therefore it is the imagination that allows us to maintain our ‘sensibility’ towards patients and better empathise with their situations. In Williams’s poem, “The Young Housewife” the poetic speaker imagines the subject of the poem moving “about in negligee behind/the wooden walls of her husband’s house”(Williams et al. The Collected Poems of William Carlos Williams. Vol.1, 1909-1939 57). The speaker then imaginatively “compare[s] her/ to a fallen leaf” before observing the “crackling sound” as he passes “over/dried leaves” (Williams et al. The Collected Poems of William Carlos Williams. Vol.1, 1909-1939 57). It is with these small acts of attention that Williams both observes his surroundings and uses the imagination to impart meaning and context to his observations. Williams’s speaker is both separated from the subject of the poem, passing her in his car, while also offering fleeting contextual observations of the housewife’s solitude and neglect, made possible only by engaging with his imagination.
Acts of Inward Attention: Physicians
Introspection
We previously spoke of re-embodying medicine for the patient, but what Williams’s writing also encourages is a re-embodiment of medicine for the physician. Introspection is in many ways an ultimate reunification of the self. In the preface to Paterson Williams writes “we know nothing pure and simple beyond our own complexities” (3). Where Williams’s poetry was focused on an outward gaze towards his surroundings, his prose encourages a reflection inwards on the self. In the foreword to Williams’s book The Doctor Stories, Atul Gawande remarks that the stories encourage us to reflect on who we are and what we are capable of doing, “good and bad” (Williams et al. The Doctor Stories ii.). For each short story Williams writes a doctor-narrator who is convincingly human – a doctor who exposes his prejudice, a doctor who uses violence to restrain a child, a doctor whose substance abuse seeps into his practice – combined with the more typical doctorly messages of empathy and healing. Williams’s ‘Doc Rivers’, for example, is a man made of contradiction. Williams’s narrator reflects, “I tell you there was a howl about the town: another decent citizen done to death by that dope fiend Rivers…And yet the man could be – often was – kindly, alert, courteous…He could be cruel and crude. And like all who are so, he could be sentimentally tender also, and painstaking without measure” (Williams et al. The Doctor Stories 22-23). Through Old Doc Rivers Williams asks us to think deeply about how far we might go to excuse someone’s shortcomings, how we might reconcile the fact that Rivers is a brilliant physician and an addict, how we would act as a bystander of his actions, or how would we act if we had Rivers’s same struggle? As is written in the introduction to the book, Williams uses the particulars of these stories to help the reader discover the universal in themselves. These murkier aspects of being a doctor, while in many ways dramatized for each short story, are not absent in modern practice. Medical students are not explicitly taught how to handle the human aspect of being a physician, how to navigate moments of malice, prejudice, or weakness within ourselves. Williams’s prose gives us the opportunity to ground ourselves in our own bodies, to our own biases, and to approach medicine in a more ethical and embodied way. When we read Williams’s doctor-narrators we are asked to be better aware of these aspects of ourselves and of others and to have more open discussions about how they can be managed throughout a career in medicine.
At its core, medicine is about human interaction. Doctors, patients, families, and ancillary healthcare providers interact with the shared goals of healing and relieving suffering. Despite over a century since Williams embarked on his medical education, with the advent of thirty tonne MRI scanners, automated colonoscopies, robotic surgeries and the like, the interaction between doctor and patient remains the essence of medicine. 21st century medical education practices, shifts in the way clinics and hospitals are run, and the feats of new medical technologies have contributed to a generalised disembodiment of what is fundamentally a bodied experience. Williams’s literary work encourages an embodied awareness of both the patient’s body and the physician’s own self. While engaging with literature cannot directly heal or relieve suffering, what it can do is produce more attentive, reflective physicians who are grounded in this embodied experience. Close reading of Williams’s poetry and prose can help train physicians to be rooted by the things around them, to observe the particulars and acknowledge the universal, to listen patients tell their stories, to begin to imagine a patient’s struggle, and to reflect on their own human perspectives.
Works Cited
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Britta Gustavson is a third-year medical student at McGill University. She previously studied Neuroscience at McGill University and completed a Masters in Brain Sciences at University College London. Gustavson enjoys investigating the links between clinical practice, patient narratives, and literature. She would like to thank Professor Miranda Hickman for her guidance and expertise throughout the writing of her paper.