Introduction

The teaching of literature as a conceptual tool in the formation of undergraduate medical students already has a significant tradition which dates back to the pioneer course at the University of Pennsylvania School of Medicine, begun in 1972 ^1-3. At the beginning of the 21st century, 35% of the North American and European medical schools already had a regular course on this subject in their program curricula ^4-12, and the journal Literature and Medicine, published by Johns Hopkins University Press, has existed since 1982. I have more than 10 years of teaching experience in this area, teaching a course entitled "Medicine and its Relationships with Literature, Art and Philology", which is part of the Medical Humanities curriculum area at my school, for which I am responsible. This curriculum area is a made up of five required credits, divided as follows: the history of medicine (two credits), ethical dilemmas in contemporary medicine (two credits) and one credit for the previously mentioned course. Following, I will show the theoretical foundations and themes which have been developed.

Narrative as a medical reflection tool

Narrative fiction (stories and novels) constructs characters and human situations that recreate reality, but broaden it in its symbolic dimension and the variety of its meanings. This is what makes certain characters so unforgettable for readers, managing to penetrate people's intimacy and stay there forever. This capacity to generate knowledge and emotion come from the narrative's power to construct otherness (recognition of others) and establish authentic dialogues. Ever since Bajtin we have known that the modern novel is 'The dialogic perception of the world"¹³ and this generates the narrative "polyphony", which is simply the diverse perspectives of human life, as opposed to the one-sided discourse fed by totalitarian ideologies or single powers. In the medical context, narrative allows the recognition and comprehension of the sick person's and family's subjective perspective of pain, and teaches the social (sickness), personal (illness) and biomedical (disease) implications of disease. The existence of these three anthropological dimensions of the disease allow the student to understand that the biomedical explanation of the sick person's pathology is not enough for him to understand his ailment and that we must learn the language and symbolisms of the disease as a subjective and cultural phenomenon, and as a collective and social presence ^14,15. Classic works that serve for this simultaneous recognition of human disease include, among others, The Magic Mountain (1924) by Thomas Mann, The Plaque (1947) by Albert Camus, Cancer Ward (1967) by Aleksandr Solzhenitsyn, and a contemporary and Latin American novel like The Sickness (2006) by Alberto Barrera Tyszka.

The patients voice

There are narrations where the protagonism of the sick character is central and autonomous. This experience provides a great lesson in solidarity to the students and allows them to recognize the existence of the sick person who suffers, which will facilitate an attitude of respect and empathy in real clinical practice relationships. As correctly stated by Luis Montiel, professor of Medical Humanities at the Universidad Complutense de Madrid, in "great literature, the sick person speaks of his fears, his pain, his helplessness, his abandonment, his resentment, his hope. Anyone who has some experience of human pain knows that what this sick person says is true, universally true, although at the same time personal, private, intrinsic to the person who in some way has lived his fictional existence before us in the story." ¹⁶ In my teaching experience, the works that best emphasize this voice of the suffering sick person and are convincing include: The Death of Ivan Ilyich (1886) by Leo Tolstoy, One Flew Over the Cuckoo's Nest (1962) by Ken Kesey, The Bell Jar (1963) by Sylvia Plath, A Very Easy Death (1964) by Simone de Beauvoir, To the Friend Who Did Not Save My Life (1991) by Hervé Guibert, and The Diving Bell and the Butterfly (2009) by Jean-Dominique Bauby.

Fictional physicians and autobiographies of real physicians

Fictional physicians help students develop empathy with the profession and are a source of positive emulation, since most of them are heroic figures belonging to romanticism and who reflect rural or family medicine environments which inspire emotional closeness in young student readers. Among the classics are Dr. Andrés Hurtado in Tree of Knowledge (1911) by Pío Baroja, Esteban in El Médico Rural [Rural Doctor] (1912) by Felipe Trigo, Dr. Andrew Manson in The Citadel (1939) by A.J. Cronin, Dr. Carlo Levi (real and also as a character) in his autobiographical novel Christ Stopped at Eboli (1946), Dr. Michel Doutreval from Bodies and Souls (1943) by Maxence Van Der Meersch, Pedro in Time of Silence (1962) by Luis Martín-Santos, Juvenal Urbino in Love in the Time of Cholera (1985) by García Márquez, Roy Bash in The House of God (2002) by Samuel Shem, and the Stone brothers in Cutting for Stone (2009) by Abraham Verghese. There are also historical novels with invented or recreated doctors such as Sinuhe in Sinuhe the Egyptian (1945) by Mika Waltari, the evangelist Luke in Dear and Glorious Physician (1958) by Taylor Caldwell, Maimonides in The Doctor from Cordova (1977) by Herbert Le Porrier, Rob Cole in The Physician (1986) by Noah Gordon, and Avicenne in The Road to Isfahan by Gilbert Sinoué. These fictionalized historical physicians help understand the history of medicine in various time periods and these readings can be complemented with historical or biographical texts from the same period being analyzed. For example, Sinoué's novel can be read concurrently with Soheil Afnan's essays and El Pensamiento de Avicena [Avicenne's Philosophy] (1965), Miguel Cruz Hernández and La Metafísica de Avicena [Avicenne's Metaphysics] (1949) or Avicena by Rafael Ramón Guerrero (1996).

Autobiographies of real physicians generate a lot of discussion and reflection among the students and some of them are preferred even over other fiction books, perhaps because they become authentic models which students seek to imitate. The genre of scientific autobiography began with the work by David Hume titled My Own Life (1776) and is characterized by mixing personal life and scientific accomplishments in what is known as the context of discovery, which has been stimulated by science philosophers such as Thomas Kuhn in his famous book The Structure of Scientific Revolutions (1961) ¹⁷. Medical autobiographies incorporate the authors' clinical experience with sick people, and this aspect enriches the students' vision of the doctor-patient relationship and also of how some clinical discoveries resulted from reflecting on the clinical cases they had to treat. Classic autobiographies such as The Story of San Michele (1939) by Axel Munthe, or the trilogy of the Nobel laureate in Medicine Santiago Ramón y Cajal: Infancia y Juventud [Childhood and Youth] (1901), Historia de mi Labor Científica [History of my Scientific Work] (1923) and El Mundo Visto a los Ochenta Años [The World Seen at Age Eighty] (1934) combine well with contemporary autobiographical works such as The Statue Within (1987) by the French geneticist and Nobel laureate Francois Jacob, Uncle Tungsten: Memories of a Chemical Boyhood (2003) and the moving On the Move: A Life (2015), both by Oliver Sacks, or the recent Do No Harm (2016) by the English neurosurgeon Henry Marsh. Words like the following by Sacks, from his posthumously published essay titled "Gratitude" (2016), are a lesson in integrity and courage in the face of one's own sickness which provide life-long teaching for students: "At 81 years of age, I continued to swim one and one-half kilometers every day. But my luck has run out: a week ago I was told that I have multiple metastases in the liver. Nine years ago, they found a rare tumor in my eye, an ocular melanoma. The laser and radiation treatment to eradicate the tumor ended up leaving me blind in that eye. (...) I am thankful to have been granted nine years of good health and productivity since the original diagnosis, but now I see death face to face. Now I must decide how I want to live the months I have left. I must live them in the richest, most intense and productive way I can..." ¹⁸. And he concludes with these brave and profound reflections: "And now, weak, tired, with formerly firm muscles softened by the cancer, I find that my thoughts center ever less on the supernatural or spiritual and more on what it means to lead a good, worthwhile life, to achieve a sense of peace with oneself. I find myself thinking of the shabbat, the day of rest, the seventh day of the week, and perhaps also the seventh day of one's own life, when you have the feeling that your work is finished and that, with a clear conscience, you can rest." ¹⁹.

Anton Chekhov and the stories of medical doctors

The best example of a physician writer is Anton Chekhov (1860-1904), who practiced medicine for most of his short life and simultaneously wrote an immortal literary work, even being considered the precursor to the modern story in the West, alongside Edgar Allan Poe. In addition, his personal condition of chronic tuberculosis adds a dramatic component to several of his sick characters. A series of Chekhov's stories and plays with medical themes can be selected to give a course based exclusively on the Russian's literature. For example, the list would have as its central narrative the extraordinary story entitled "Ward Number 6", which describes the relationship between Dr. Andrei Yefimych Raguin and the mentally ill person with persecutory delusions, Ivan Dmitrich Gromov. Here the topic of empathy in the doctor-patient relationship as well as recognizing suffering in patients is masterfully discussed. This work continues to impact students and create many sensations and reflections. Other works by Chekhov with physicians and diseases which complement the course are: Dr. Tiletski from the play "Platonov", Dr. Lvov from the play "Tvanov", Dr. Astrov from the play 'Uncle Vanya", and Dr. Dorn from the play 'The Seagull", along with stories such as Perpetuum Mobile, Nerves, A Nervous Breakdown, Enemies, Typhoid, The Black Monk, The Wife, Three Years, etc. In all of Chekhov's work, there are 36 medical characters and 45 narratives with medical themes ^20,21. With good reason, Chekhov wrote the following in 1900: '1 do not doubt that my activities as a doctor have had a strong influence on my work as a writer. They have significantly broadened my field of observation, enriched my knowledge, and only people who are doctors can appreciate the value of all this. Medicine has also been a guide, and I have probably avoided many errors as a result of my close relationship with it." ²² Other courses dedicated to a single author could be the reading of novels and stories about the fictional doctor Sherlock Holmes by the Scottish physician Arthur Conan Doyle, which also allow a parallel reflection between art and clinical diagnosis and detective investigation ^23,24. In addition, the stories in the book The Doctor Stories (1995) by North American poet and clinician, William Carlos Williams, can be an interesting thematic course, which could be complemented with historical sources regarding the practice of rural medicine during the first half of the 20th century such as, for example, the evocative book of memoirs by the Colombian physician Jaime Mejía Mejía entitled Historias Médicas de una Vida y una Región [Medical Stories of a Life and Region] (1960).

Oliver Sacks and the invention of a literary-clinical sub-genre

Oliver Sacks, a neurologist who was born in 1933 and died in 2015, has been identified as the best contemporary clinical writer. His work is a fortunate fusion between the experience of a medical practitioner and his ability to narrate the patients' strange worlds. He thus achieves the humanization of the sick, since as he describes his personal life stories immersed in the patients' various diseases, the readers understand that the disease is almost always the obligatory bridge to pass over to another reality where each sick person must readjust his existence according to his new bodily limitations. In the prologue to his famous book The Man who Mistook his Wife for a Hat, Sacks summarized his clinical-literary proposal as follows: 'Tn a rigorous clinical history there is no 'subject'; modern clinical histories allude to the subject with a quick phrase ('albino female with trisomy 21'), which could just as easily be applied to a rat as to a human being. To place the subject in the center once again (the human being who grieves and struggles and suffers) we must deepen the clinical history until we make it a narration or story; only in this way will we have a ''who" as well as a ''what", a real individual, a patient, in relationship with the disease.. .in relationship with the physical and medical exam" ²⁵.

In other words, Sacks' work is proof that scientific rigor is made comprehensible and communicable with the full recognition of the rich individuality of each sick person. Thus, reading the clinical histories described by Dr. Sacks is a marvelous way for medical students to understand that clinical practice is the art of diagnosing and treating complex, unique persons whose signs and symptoms are better understood if we know about their personal life. Sacks called this new proposal 'Clinical Tales" ²⁶.

The course selects various stories from different books and the students, divided into groups, present each story, and, at the same time, explore the clinical and scientific aspects, using Harrison's internal medicine or Adams' neurology. An example of the series of stories selected is the following: 'The Man who Mistook his Wife for a Hat", 'Life of a Surgeon", 'The Case of the Color-Blind Painter", 'The Lost Sailor", 'The Visions of Hildegard", 'Musical Hallucinations", 'Phantom Fingers: The Case of the Pianist with only one Arm", 'Level", 'Hands and Prodigies", 'An Auditory World: Music and Blindness"", A Hypermusical Species: Williams Syndrome", 'The Landscape of Dreams" (they are also required to read the story by Jorge Luis Borges titled 'Funes el Memorioso"), 'The Last Hippie", and 'Seeing and not Seeing". The books from which these and other stories have been taken are: The Eyes of the Mind (2011), Musicophilia (2009), Uncle Tungsten (2001), The Man who Mistook his Wife for a Hat (2000), The Island of the Color Blind (1997), An Anthropologist on Mars (2004), I See a Voice: A Journey to the World of the Deaf (2003), Just one Leg (2003), Awakenings (1974), and Migraine (1997).

The sub-genre of 'clinical tales", is a source of humanist and medical richness which has been very well received by the students and has also motivated other physicians to express their clinical experiences in writing using narrative forms. I highlight another book here, titled The Man with the Iron Tattoo. Doctors Learn from their Patients (2009), written by the North American neurologists John Castaldo and Lawrence P. Levitt, who in the prologue of their book state that: 'As we learned more about neurologic disorders and how to treat them, we began to realize that our patients also gave us more wisdom - wisdom about how to live. We also learned a lot from the relatives who frequently faced heartbreaking changes in their loved ones and, therefore, in their daily roles and rhythms." ²⁷.

Other themes

The literature and medicine course can also be aimed at other relationships such as: the clinical descriptions of diseases in literature (Sach's Disease (1999) by Martin Winckler, The Posthumous Papers of the Pickwick Club (1837) by Charles Dickens, Doctor Faustus (1947) by Thomas Mann, El Enfermo de Abisinia [The Sick Abyssinian] (2007) by Orlando Mejía Rivera, etc.), the semiological interpretation of signs and symptoms described by the great masters of world literature, the perception of the vital stages of human beings, and the description of epidemics and pandemics (The Decameron (1350) by Giovanni Bocaccio, A Journal of the Plague Year (1772) by Daniel Defoe, Essay on Blindness (1995) by José Saramago, Doomsday Book (1992) by Connie Willis, The Andromeda Strain (1969) by Michael Crichton, Nemesis (2010) by Philip Roth, Plague and Cholera (2012) by Patrick Deville, etc.).

Films and medicine

Films are another interesting conceptual tool and students love them. The same objectives and themes from literature serve to teach about medical issues through films ^28-32. Several theme cycles can be offered and the ideal presentation space is the creation of a weekly, biweekly or monthly movie forum (sponsored by the faculty of medicine and the medical education office) and the movies are shown in a trans-curricular environment which motivates a variety of conversations among students from different semesters and professors themselves from different departments within the faculty. Bibliographic sources are recommended such as La Revista de Cine y Medicina [Journal of Movies and Medicine] (2005-2016) published by the Universidad de Salamanca (with several articles on the pedagogy of movies in medicine and recommendations of medically-themed movies), as well as theoretical books such as Med&Cine: Encuentros, tribulaciones y cortocircuitos entre cine y medicina [Med&Cine: Encounters, Tribulations and Short Circuits between Movies and Medicine] (1998) by Jordi Batlle Caminal; Médicos en el cine: dilemas bioéticos: sentimientos, razones y deberes [Medical Doctors in Film: Bioethical Dilemmas: Feelings, Reasons and Duties] (2006) by Diego Gracia and Sagrario Muñoz Calvo; Cine y medicina [Movies and Medicine] (2008) by Fernando Giménez Escribano; Bioética y cine. De la narración a la deliberación [Bioethics and Film. From Narration to Deliberation] (2011) by Tomás Domingo Moratalla; Mayores de cine. El cine como instrumento de aprendizaje en gerontología [The Elderly in Movies. Movies as a Learning Instrument in Gerontology] (2012) by Juan Dionisio Hernández Avilés; and Terapias de cine. 50 películas básicas en torno a la medicina [Movie Therapy. Fifty Basic Movies around Medicine] (2016) by Carlos Tabernero Holgado.

Of the English works which also substantiate various aspects of the movie-medicine relationship, the following are recommended: Psychiatry and the Cinema (1999) by Glen O. Gabbard and Krin Gabbard; Movies and Mental Illness: Using Films to Understand Psychopathology (2005) by Danny Wedding and Mary Ann Boyd; Medicine's Moving Pictures: Medicine, Health, and Bodies in American Film and Television (2008) by Leslie J. Reagan and Nancy Tomes; Legacies of Plague in Literature, Theory and Film (2009) by J. Cooke; The Picture of Health: Medical Ethics and the Movies (2011) by Henri Colt and Silvia Quadrelli; The Dark Mirror: Psychiatry and Film Noir (2011) by Marlisa Santos; Psychoanalysis and Film (2011) by Glen O. Gab-bard; Medical Visions: Producing the Patient through Film, Television, and Imaging Technologies (2013) by Kirsten Ostherr; Neurocinema: When Film Meets Neurology (2014) by Eelco F. M. Wijdicks; Movies and Mental Illness: Using Films to Understand Psychopathology (2014) by Danny Wedding and Ryan M. Niemiec; Neuroscience in Science Fiction Films (2014) by Sharon Packer; and Monsters, Demons and Psychopaths: Psychiatry and Horror (2016) by Fernando Espi Forcen.

Finally, the suggestions for beginning a course on movies and literature using a movie forum format with a biweekly movie on a variety of themes would be the following: Awakenings (1990) by Penny Marshall (based on the book by the same title by Oliver Sacks, which deals with the stories of a group of chronically ill people with neurological sequelae from the encephalitis lethargica epidemic of 1917-1928 and their transient improvement upon receiving the drug L-Dopa); Miss Evers' Boys (1977) by Joseph Sargent (recreates the terrible ethical violations against African American patients with syphilis who never received treatment with penicillin between 1932 and 1975); Wit (2001) by Mike Nichols; The Barbarian Invasions /Les invasions barbares (2003) by Denys Arcand and The Sea Inside / Mar adentro (2004) by Alejandro Amenábar (three notable contemporary classics on the dilemma of the terminally ill, palliative care and euthanasia); Philadelphia (1993) by Jonathan Demme (the topic of discrimination against AIDS patients at the beginning of the epidemic); The Elephant Man (1980) by David Lynch (the true story of Joseph Merrick and his suffering due to severe neurofibromatosis); My Left Foot (1989) by Jim Sheridan (the case of Christy Brown, a person with cerebral palsy); A Beautiful Mind (2001) by Ron Howard (about the life of John Forbes Nash, Nobel laureate in Economics despite his diagnosis of schizophrenia); Son of the Bride / El hijo de la novia (2001) by Juan José Capanella, Away from Her (2006) by Sarah Polley and Still Alice (2014) by Wash Westmoreland and Richard Glatzer (three good movies about patients with Alzheimer's dementia).

Conclusions

Literature and movies are powerful and convincing instruments in medical humanities teaching. They allow an intimate interrelationship with bioethical reflection, the history of medicine and medical epistemology and contribute to producing in medical students an attitude of solidarity with the patients, their families and colleagues. In summary, literary and film narratives are lofty tools for achieving recognition of otherness. As Ann Hunsaker Hawkins and Marilyn Chandler McEntyre said well, teaching literature to medical students 'is a unique pathway for imagining the other, for using the imagination as an instrument of compassion, for tolerating ambiguity, for dwelling with paradox, for considering multiple points of view and for recognizing the different truths that human experiences have" ³³.