cyber-Medicine.org

Team Collaboration, Crossing Disciplines, and Medical Informatics

by Kim Solez[1], Nicole Olson[2], Sheila Moriber Katz[3] and Christine Borland[4]

Department of Pathology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada, Simon Fraser University, Vancouver, British Columbia, cyberMedicine Joint Venture, Gladwyne, Pennsylvania, USA, and Glasgow School of Art, Glasgow, UK

Art and the art of medicine are quite separate entities, as are the science and practice of medicine. All interrelate and all can be enhanced and linked in beneficial ways through the new tools of the digital age and medical informatics.

Mixing art and medicine brings a desirable humanism to the healing profession but also a sense of the surreal. Great advances are made in medicine and in art through the surreal, the juxtaposition of elements no one else had thought to juxtapose before.

Collaboration between people from different disciplines has a similar beneficial effect, as Bono of the musical group U2 says "bringing people together who have no business being in the same room together."

Medicine requires predictability, standards, pursuit of tried and true methods, but advances in medicine require lateral thinking, new ways of looking at things, and cross-fertilization, exactly what cross disciplinary initiatives and collaboration can bring.

Key Words: Collaboration, Crossing Disciplines, Surreal, Laboratory Medicine, Conceptual Art, Virtue Ethics, Virtual Reality, Holographic Telepresence, Mixed Reality, Pathology, Roy Calne, Thomas King, Charlie Kaufman, Barry Schwartz, Leonard Cohen, Chelsea Hotel, Outliers, Genius, Exquisite Corpse.

In 2007 and 2008 a number of scandals emerged in laboratory medicine in Canada. They were isolated incidents of frequent misdiagnosis, high error rates, sloppy, apparently inaccurate work on the part of a few individual physicians. But because there were multiple incidents around the country it suggested a systematic problem of low self image, work satisfaction, and attitude toward work among at least some laboratory physicians and led to articles being written with titles like "What's Ailing Pathology?".

One of the striking things about the physicians involved in these scandals is the way in which they worked alone without collaboration, had limited insight into exactly how their work fit in the larger picture, and were not assisted by computer tools that would check and strengthen their work.

This is an essay on Team Collaboration, Crossing Disciplines, and Medical Informatics. Under other circumstances these might seem rather dull topics, but upon reflection we think the reader can see how they are directly relevant to the prevention of the types of problems noted above and to significant improvement in the practice of medicine overall.

Collaboration in this essay means not only the working together of people from different areas of medicine, but also the working together of people from inside and outside medicine, and the working together of different new communication technologies, some of which the reader may not be aware of. Collaboration often results in lateral thinking, in approaching a problem with a fresh new perspective.

Surreality refers to the practice of juxtaposing elements one would not usually think of juxtaposing, and engaging in non-linear creative thinking. Leonard Cohen referred to the first author as "great master of the surreal" and Arthur Miller referred to the Chelsea Hotel where some of this essay was written as "the high spot of the surreal".

Medicine is serious business. Yet to be most effective medicine needs to incorporate a tincture of the un-serious, humor and the humanities, art, music, literature, in just the right amount with just the right timing, just the right balance. Whimsical humor and the surreal in art are sometimes just the right counter-argument to the absurdity of illness and bring understanding to situations that otherwise cannot be understood.

We are not lacking for examples of talented individuals who mix medicine and art. There have been many physician writers writing for the general public. Daniel Bryant provides a list of over 1000. Here is a smaller but still impressive list:

Chekhov, Sir Arthur Conan Doyle, John Locke, Oliver Goldsmith, Keats, Somerset Maugham, Rabelais, Schiller, Maimonides, Oliver Wendell Holmes, Robin Cook, Roget (Thesaurus), Michael Crichton, Virgil, Michael Palmer, William Carlos Williams, Arthur Schnitzler, Lewis Thomas, William H. Drummond, M.J. Beechwood, Gottfried Benn, Robert Colfelt, Michael LaCombe, Richard Selzer, David Hilfiker, and Vincent Lam, all writers, all physicians. And Goethe, Charles Darwin, John Donne, Coleridge, Ibsen, Joyce, Gertrude Stein Somerset Maugham and Walker Percy all began to study medicine but then abandoned it.

It follows then that it is difficult to write about medicine and art for a physician audience. The general public might be fascinated, even thrilled by the idea of a physician writer. But many physicians went into medicine exactly because they were renaissance men and women. To them there is nothing particularly notable about a physician writer, many physicians have abundant talents outside of medicine.

Confident and capable as a group, many physicians might even believe for instance that Michael Crichton would have led a more interesting life if he had stuck to medicine. They would be wrong. But they might hold that belief.

Similarly the first author has come to know Sir Roy Calne, a remarkably gifted surgeon responsible for many firsts in transplantation who is also a remarkably talented painter and sculptor. He was knighted by the Queen in 1986. While the general public would be impressed by this honor, many physicians would be of the opinion that there should be a good number more physicians knighted than there are.

So on the one hand there is a question how unusual it is for physicians to have notable artistic talents outside of medicine. Perhaps it is not very unusual.

On the other hand it is not unusual for physicians to become highly specialized, to delve very deeply into one narrow area of medicine, to the exclusion of other pursuits and interests.

It follows then that to combat this narrow superspecialized perspective collaboration between disciplines both inside and outside of medicine needs to be encouraged, to conceptualize the larger picture. Advancing new communication technology makes such collaboration easier and more efficient, and the options and power of these new technologies is constantly increasing.

As noted above, in this essay we define collaboration in the broadest possible terms to include not only collaboration between people and groups inside and outside medicine, but also collaboration among different media, different forms of dissemination to get the message out.

Successful medical care has much to do with communication, and so the way to be a successful health professional in the future has many analogies with the way to be a successful writer. Patrick Tucker has suggested that to be a successful writer in the 21st century one needs to use multiple different channels and media, blog at least 5 hours a week, consider having one's own radio program. It is necessary to fully embrace the Internet, text messaging, Twitter, and whatever else comes along in new communication technology to get the message out, as well as low tech means including lectures and social interactions at parties and other gatherings.

Doctoring in the future, future health care, will be similar to that. It will include full community engagement using every communication tool you can think of including holographic telepresence.

True collaboration in its broadest sense involves not just working with other people, but also employing many different types of media and means of dissemination to fully engage the community in thinking about and discussing the matter at hand, full contact communication.

This essay goes beyond traditional scientific collaboration within disciplines which is well described in the recent book Scientific Collaboration on the Internet.

Laboratory medicine is by definition medicine practiced in the laboratory, where the patient is usually not present. Laboratory physicians and technical staff may each contribute to the care of 3,000 or more patients a year, often a much larger number than their clinical counterparts take care of, but without ever seeing the patient face to face. In such a circumstance it is possible to partially lose the big picture, the sense of personal responsibility to the patient and fail to experience the good feelings that come from personally helping another human being.

Teamwork is seldom emphasized in laboratory medicine and in particular the partnership between the patient and the laboratory health professional is often forgotten. Bringing the artist into the medical arena opens up new potential communication pathways both within the hospital context and beyond. In the UK, several important funding agencies recognize and support the possibilities offered by this kind of collaborative work, the National Endowment for Science Technology and Art, NESTA and the Wellcome Trust

,which operates in both a historical and contemporary context. Dr Ken Arnold, Head of Arts at the Wellcome Trust, "We want to encourage imaginative and unorthodox arts projects that will engage audiences and inspire them to think about the wider impact of biomedical science upon our lives”.

Particularly over the past 5 years, since The Human Genome Project has excited such great public interest, many important international touring exhibitions have presented artworks exploring these themes.

Gregor Mendel, The Genius of Genetics by Caterina Albano and Marina Wallace with contributions by Kim Nasmyth, Luigi Luca Cavalli-Sforza and Martin Kemp ISBN 3-9501590-1-0

The senior author, artist Christine Borland, whose work has been central to this debate, spent a week in the University Of Alberta Hospital, producing a piece of work to be presented in the exhibition ‘Imagining Science’ at the Art Gallery of Alberta. Working with 2 patients having kidney biopsies, the artist took photographs at the start of the procedure to remove their biopsy samples under mild sedation. She then accompanied the tissue to begin its journey through the many processes of the Pathology Laboratory. Throughout the week the artist tread a path between the lab and the wards, building an intense, personal relationship with the patients and staff at each end. For the patients the ‘end product’ was a 10 minute long, self-running PowerPoint presentation of the hundreds of images documenting their journey through the hospital and laboratory system. As the patients watched this for the first time, entirely absorbed while it was presented to them on the artist’s lap-top, they were filmed from a tiny camera embedded in the frame of the laptop screen which captured their reactions and expressions in the most non-mediated way possible.

The presentation of the work in the art gallery was pared down and minimal, utilizing the techniques of Conceptual Art, which emphasizes the importance of primarily conveying ideas, rather than indulging in an appreciation of medium or technique. Removing or erasing material to discourage an ‘easy’ or literal reading of these idea is another device commonly used in Conceptual Art.

‘It is frequently the case in Christine Borland’s work that deliberate excision - something missing or taken away – tantalises or disquiets, since its presence remains powerfully implicit’ Ruth Richardson ‘The Soul Cleaveth to the Dust’ P84 – 87 Christine Borland ‘Preserves’ The Fruitmarket Gallery

One important aspect was removed in the gallery viewer’s experience of the final work; they had to ‘read’ the whole process by watching the faces of the patients who were watching the images, inserting themselves into the patients position rather than adopting the role of passive viewer.

By first bringing the patient (not just the patient’s sample) into the laboratory and the experience of the laboratory to the patient, a new sense of pride and purpose is to be had by the laboratory physician and technician and a sense of completeness to the patient, who is now able to see images of the miraculous journey the parts of his/her tissue takes on the way to a diagnosis. It also extends the possibilities for greater empathy and understanding of both with the viewing public in the gallery, who are of course the past, present and potential future patients.

The Beneficial Influence of the Surreal and Virtue Ethics - Charlie Kaufman and Barry Schwartz

Charlie Kaufman is an advocate and creator of what many characterize as 'surreal'. While many diverse styles embody what one might call surreal, there is one common thread running through the movement itself, that being an appeal to the illogical (but not necessarily unfavorable) aspects of human experience. Encyclopedia Britannica writes that surrealist work " aims to provoke a sympathetic response in the viewer, forcing him to acknowledge the inherent "sense" of the irrational and logically inexplicable".

Charlie Kaufman believes that one's perspective on a situation, subject, or phenomenon is limited when one's artistic gaze is too structured. That 'the world opens up' in response to a more unpredictable method. But could this approach really benefit medicine?

The main counter-argument one might raise is one of quality control. Standardization of method is an effective way to control quality. As Barry Schwartz pointed out at the TED conference in early February 2009, we standardize because we don't trust that quality will be maintained if we don't—doctors need rules in order to make the right decisions, to be able to uphold the interests of the profession and practice in general. When doctors are left to their own devices, without strict guidelines, the medical experience becomes increasingly diverse and difficult to control the quality of, so the argument goes.

Is argument this correct? Well, it depends. More and more in medicine, and other disciplines such as education, there has been a shift in professional ethics towards what is called 'virtue ethics'. This approach in ethics dates back to Aristotle, and suggests that the best ethical behavior emerges from those endowed with practical wisdom, not those given a list of rules to follow.

But what is practical wisdom? As Barry Schwartz argues, wisdom is knowing "when and how to make the exception to every rule". Also, a wise person "knows how to improvise". He goes on to assert that "real world problems are often ambiguous and ill-defined and the context is always changing", that "a wise person is like a jazz musician, using the notes on the page, but dancing around them, inventing combinations that are appropriate for the situation and the people at hand".

The doctor's approach, if somewhat 'surreal' or 'jazz-like'-as described above, will ultimately compliment the more rule driven aspects of medical practice. That is the argument here, which is consistent with a virtue ethics approach to professional ethics pointed out by Schwartz.

Our interest in this essay is to suggest how this approach can be enhanced via new technologies. The surrealist approaches flourishes when collaboration takes place. The Internet and new communications technologies make working together much easier, and are changing the face of collaboration.

The practice of medicine requires predictability, standards, pursuit of tried and true methods, but advancement of the science and art of medicine requires lateral thinking, new insights and ways of looking at things, exactly what art and the surreal conveyed by technology can bring.

Many aspects of interdisciplinary collaborative practice could be compared to the ‘Exquisite Corpse’ game, invented by the Surrealists.

It is played by a group of people who each draw a portion of a human body (usually head, torso and lower extremities) on a piece of paper, which is folded to conceal all but a tiny portion of the previous participant’s contribution. The reconstructed corpse, revealed at the end of the game can offer us all new ways of seeing and thinking about fundamentals.

The humanising possibilities for art in medicine are suggested, possibly for the first time, by the illustrations in the first anatomical atlas, ‘On the Fabric of the Human Body’ ‘De Humani Corporis Fabrica’ by Andreas Vesalius.

The detailed engravings of the dissected body throughout the seven volumes are by no means ‘straight’ representations. Many of the figures strike allegorical poses, surreally set against a landscape, or in dialogue with architectural features. Both Andreas Vesalius and the artists of the early Renaissance whose great advances in depicting perspective and drapery made his atlas possible, were looking at and recording the body with fresh eyes;

‘Even thought they had begun to open the body, there were still many things Renaissance scientists could not see. To see is clearly not only a physical faculty; it is just as much a psychological and cultural one….The modern, enlightened and classifying gaze, that gradually replaced the curious gaze in the seventeenth century, was by contrast a strict one. It was analytical and compartmentalising, extensively based on naked, empirical observation, in that respect it can be argued that it is a superficial gaze’ Ulla Angkjær Jørgensen ‘Curious Connections: A Modern Study of Anatomy and Botany, Christine Borland ‘Preserves’ The Fruitmarket Gallery

Vesalius was the first great Professor of Medicine to emphasis the importance of being ‘hands on’ with the dissections, which were more commonly left to assistant surgeons. By contrast, there is a current debate on whether anatomy by dissection should be practised at all in contemporary medical schools.

In 2002, the Peninsula Medical School, Cornwall became the first in the UK to teach Anatomy without using the cadaver. The reasons for this decision, are that the availability of sophisticated, three dimensional models and new medical imaging techniques and simulations mean that ethically, the emotional trauma of the dissection process for young students cannot be justified. In addition, the cadaver, preserved in formalin is very different to the living flesh on which they would operate as surgeons. However the absence of the real human body and the increasingly ‘hands-off’ nature of simulated learning mean that students are increasingly distanced from the uniqueness of each human body and the ‘exquisite’ possibilities in medicine. Dr Alan Bleakely from PMS suggested in his presentation to the AMH Conference in 2008, that the role of the artist could re-illuminate the many areas in medical education which have become 'obsessed with function and instrumentality rather than form’.

In recent film works ‘SimMan and SimBaby’ presented in her exhibition ‘SimBodies and Nobodies’ the gaze of Borland’s camera dwells and pans across the full body mannequins of the human manipulated simulators of the same name.

The camera languishes on the folds and creases of the body drapes in the manner of Rennaisance painter Andrea Mantegna in his ‘Lamentation over the Dead Christ’ (painted approximately 40 yrs before Vesalius’s Fabricus was published) The slow observation, and appreciation of these mannequins, transforms them from the realm of caricatures, demanding to be treated with respect rather than with the ridicule often afforded them by nervous medical students in simulated encounters.

Playing the game of the surrealists and offering up our own body of knowledge to be juxtaposed with that of peers from out with our own disciplines can help us step outside the classifying, ‘contemporary gaze’ and recapture the ‘curious gaze’ of the Renaissance pioneers.

This haunting line from Thomas King’s “The Truth About Stories” is meant to stress how the stories we tell about the world become our reality in such a way that we are unable to step outside them, nor into the stories of others. Not easily anyway.

The ethnographic experience of Daniel Everett in Don't Sleep, There are Snakes: Life and Language in the Amazonian Jungle exemplifies Thomas’ point. Everett spends time with the Pirahã Indians, a hunter-gatherer tribe in the Amazon. The Pirahã have what Everett calls the ‘immediacy of experience principle’ in their language. As Andrew Anthony explains:

“Pirahãs have little interest in that which they cannot directly verify, thus they communicate through a sequence of simple declarative assertions, negating the need for embedded clauses.”

For example, the tribe lost interest in hearing about Jesus when they found out that Everett had never met him.

Science and Medicine surely could not function with a language like this, nor could most of us! In industrialized cultures, people benefit greatly from learning about things outside of their immediate experience. We don’t need to have met Edison in order to be interested in his principles!

But how far outside of our own direct experiences can we correctly perceive? Getting back to what King says, the answer is ‘not very far’.

Doctors often experience this barrier when attempting to treat patients. The personal experience of the patient is removed from the doctor in such a way that the doctor must make well calculated inferences into what is unsaid.

Patient histories are essentially stories, medical email discussion groups exchange stories. When we collaborate we share stories. Stories are the stuff of medical communication.

Collaboration often involves the sharing of expert opinion. Where does expertise come from?

In medicine as in other areas of human endeavor expertise comes from 10,000 hours or more of practice of the necessary skills. Malcolm Gladwell's recent book Outliers: The Story of Success renews interest in this "magic number for true expertise" although the idea has been around for over fifteen years. For Gladwell, a person only needs to be ‘smart enough’ to become an expert. If a person meets the minimal threshold of natural talent, the hours one puts in are what make or break the achievement of expertise.

Many true experts in medicine develop diverse interests outside of medicine as a defense against the boring homogeneity of only doing one thing for 10,000+ hours. Famous transplant surgeon Roy Calne referred to above is not only an accomplished painter and sculptor but also for many years was a champion tennis player amongst his medical colleagues.

Dean Keith Simonton's new book Genius 101: Creators, Leaders, and Prodigies provides a very different perspective on this question. Simonton tends towards the belief that inheritable traits play a substantial role in the cultivation of geniuses, a more substantial role than Gladwell recognizes. He argues that only those with high IQs rise to the top and become the experts. Practice is important, but of weak currency if our genes are not built in a certain way.

Simonton notes, for instance, that top scientists tend to have an IQ of one-hundred and fifty, which is fifty points higher than the IQ of the average person. Plus, he says, there are certain personality traits beyond IQ that contribute to making one an expert, such as being “open to experience, introverted, hostile, driven, and ambitious”. Simon contests that IQ is 80% inherited, and personality substantially so as well.

Many of us would like to believe it is our own efforts that carry us to the successes we have, but sometimes that just isn’t true!

Most discussion about collaboration deals with how to do it, but these genius and expertise considerations relate to the quality of the input obtained by collaboration, and what factors influence that.

Collaboration in creation of real physical things requires all collaborators to be in the same place in the same time or to ship things. Collaboration in the virtual world has no such limits, there can be as many copies made as the situation requires, each identical to each other. The ease of sending text and files over the Internet greatly facilitates team collaboration and crossing disciplines.

In the last decade, the word 'virtual' has become ubiquitous in academic literature. From virtual community to virtual banking, many people are now operating within and thinking about the virtual realm.

One criticism directed at anything virtual is say that it is inauthentic and of lower value than 'real' life. Along these lines then, are virtual communities a poor excuse for community, a representation of the crippled sense of community in the individualized industrialized West, or something equally as meaningful and important as real communities?

When it comes to philosophy, there is a metaphysical distinction to be made between the real and virtual world. The two can be distinguished based on physics. The virtual world is by nature an abstraction of the real world in that it is premised on computational representations rather than on things of matter. A virtual tree is made up of ones and zeros (implemented on a physical device), rather than of chemicals, particles etc.

This distinction, however, is less important when one is at the level of language, since language is already ‘non-physical’ by nature. An email for instance is barely different from a fax, which is barely different from a letter. At the level of language, the exchange back and forth is more or less fluid between real and virtual versions.

But whether at the level of language or not, things virtual often have the same ‘effects’ as their real counterparts. Neuro-scientific research suggests that imaginary experiences trigger the same responses in the brain as the real experience. The parts of the brain stimulated in certain types of online gaming often mirror those in real life. Not surprisingly, virtual educational systems have been shown to be effective.

Also, virtual experiences can feel very real. A virtual friendship elicits similar emotions and behavior as does a real friendship. In the Fall of 2008, for example, a women divorced her husband in real life because he had a virtual affair in Second Life. Virtual events can have the same effects as real world events, and vice versa.

As we move into the digital age however, there seems to be persistent skepticism towards the value of virtual experiences in general. But is it always the case that the virtual experience is of lesser value than the real one? Could it not be the other way around? Rather, are there some cases where virtual experiences are better than real life experiences in a general sense, not just in convenience and efficiency?

On Sept. 7, 2001 the first author gave a talk in Banff on "Imagery, Hope, and Health". The next to the last slide in the PowerPoint presentation showed simulated sea anemones created on a 3D rendering program; the last slide showed a beautiful picture of real sea anemones taken by Norbert Wu, with the inscription "An infinite difference! Real life is still better!"

The talk was well received overall but the audience reaction to these last two slides was quite surprising. The digital artists in the room were quite upset with the blanket statement about the superiority of real life!

Now seven years later one can see their point. Everyone is aware of virtual experiences that are almost as good as real life face-to-face ones, or fictionalized virtual experiences that are better than real life because of the fiction. We are starting to talk about Second Life as if it were a better place for meetings than real cities are, but there is still a fictional element there in the avatars and virtual real estate.

What is striking in medicine now is that it is clear that in many instances the non-fictionalized virtual is superior to real life, medical "truth" online in digital form is often easier to quantify, assess and make use of for diagnosis and treatment than tangible medical "truth" in something you can hold in your hand like an xray film or a microscopic slide. One can only wonder in how many other fields this is the case now, and in how many others it will be the case soon.

Gene chip technology is also being applied to pathology material and so now medical truth may lie in a genomics "heat map" rather than in a conventional microscopic image. These developments pose important philosophical questions about what we mean when we say we "see" evidence of disease and what "real" medical data is.

In the end the genomics heat map you view on the computer screen is probably as real as the microscope slide you can hold in your hand and may contain much more valuable information.

Sherry Turkle argues that not only does the Internet and other current technologies allow us to 'see' ourselves, they also allow us to explore the many facets of ourselves and be the many people that we really are. It helps us to understand postmodern theories, and human fluidity, variability. The experience of the Internet forces us to question the modern notions of the self, identity etc. She writes in Life on the Screen “in the emerging culture of simulation, the computer is still a tool but less like a hammer and more like a harpsichord…you don't learn from a rule book but from playful exploration.”

Real cats sleep 16-18 hours a day, if you were to make a virtual cat you would probably make it more active than that. Turkle talks of the "artificial crocodile effect" where the fake seems more compelling than the real.

So do we really have to choose between the virtual and the real? No, not at all. Increasingly there is recognition of "mixed reality" , such as that being explored by National University of Singapore Professor Adrian David Cheok, and the idea of the Virtuality Continuum extending from the completely real through to the completely virtual environment with augmented reality and augmented virtuality in between.

There are a lot of 'mixed realities' in everyday life that we already accept. For instance, the way things are presented on television or in newspapers online. We know that it is not always real, but we don't care, we enjoy it anyway.

In the end when it comes to reality there are a lot more choices than we ever thought!

[1] Department of Pathology, University of Alberta, Edmonton, Alberta, Canada

[2] Simon Fraser University, Vancouver, BC, Canada

[3] cyberMedicine Joint Venture, Gladwyne, PA, USA

[4] Academic Researcher, Glasgow School of Art