Medicine Unboxed: Where arts and medicine meet

Dr. Sam Guglani, an oncologist from Cheltenham, UK, has been running Medicine Unboxed for ten sold-out years. His show examines the interface between medicine, philosophy, and the humanities through a series of speakers and performances. Here, he joins Gavin to discuss philosophy, "good medicine", and the show's move to London.

Find out more about Medicine Unboxed here:
https://voices.medicineunboxed.org/

Read all of our content at https://www.thelancet.com/?dgcid=buzzsprout_tlv_podcast_generic_lancet

Check out all the podcasts from The Lancet Group:
https://www.thelancet.com/multimedia/podcasts?dgcid=buzzsprout_tlv_podcast_generic_lancet

Continue this conversation on social!
Follow us today at...
https://thelancet.bsky.social/
https://instagram.com/thelancetgroup
https://facebook.com/thelancetmedicaljournal
https://linkedIn.com/company/the-lancet
https://youtube.com/thelancettv

Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello and welcome to The Lancet Voice. It's March 2023, I'm Gavin Cleaver, and we're very happy to have you with us. Medicine Unboxed is a series of events exploring the interface between medicine and the arts. After ten sell out events in the UK, the show moved for the first time to London this May.

Creator Dr. Sam Gaglani, who, as well as curating Medicine Unboxed, is an oncologist, Joins me today to discuss the event and the intersection between the humanities and medicine.

Dr. Sam Ghaglani, welcome to The Lancet Voice. Welcome. Thanks Kevin. Thanks so much for joining me. Now you're the creator of Medicine Unboxed, but perhaps you start off by introducing yourself. Tell us a little bit about your background and then tell us how Medicine Unboxed came about and kind of, you know, what it is.

So I'm a doctor, a medical 

Sam: doctor. I'm an oncologist and I work in Cheltenham looking after patients with brain tumours and lung cancers. I've been a consultant here for about 16 years. I qualified as a doctor back in 1995, having trained in London. I think it's true to say that all through my training, Also my life really, my personhood is the, the medicines really important to me, but also all along has been words, language, writing, thinking a bit about certainly as a doctor, not just what we can do, but what we ought to do for patients and what the whole business of good care actually looks like, good medical care.

So Medicine Unboxed, I think sprung from all of those different impulses and strands of thought and it arrived. Initially, definitely as a way of thinking about the arts and sciences together, but I think really in hindsight it was, it was recognizing definitely personally that in my day to day work as a medic, that the science and the moral reasoning only took me so far.

And maybe, I don't know, maybe some of the questions being presented to us by medical ethics formally understood also remain relatively narrow. I mean, there's a conference of interrogating. What good medicine is defined by. 

Gavin: So you have a series of individual speakers at these events. How do you choose the guests and how much, you know, how much do you know of what they're going to say before they, before they say it?

Yeah yeah, I mean, so 

Sam: the events are historically for 10 years, they were one day events in a theater in Cheltenham. With really lovely space, it's, it's almost in the round. It was a parabola, in fact, called the parabola theatre in Cheltenham. And this, this, it's interesting that business of the speakers that come, I mean, they come from a huge range of backgrounds, scientists, medics.

Patients, all of us are patients, by the way, philosophers, politicians, many writers, musicians. They kind of, this is an interesting process and it's the most fun bit of it for me, which is where we have a theme for the event. So for instance, mortality, wonder, language frontiers. And the only image I've got is, do you remember doing chemistry at school where you stick a crystal or something in a beaker?

Other crystals would gather around it. I'm sure there's a formal, there's probably a formal term for that. I ought to know the speakers kind of cohere around this idea. And in that happening, the idea kind of grows because, you know, I guess you can find yourself talking, for instance, next year's event is on the theme of matter and instantly the word becomes quite variegated.

And it's implications and reach. So once a sort of core number of speakers arrive and the idea starts to evolve, others start to then, I guess cohere around it in terms of what they're going to say thankfully I'm always surprised and sometimes shocked. So we try quite hard not to script it unduly.

And so that I. at its best. It has a life of its own. I can't play any instruments, but not a million miles, I guess, from jazz and improvising on a theme. I imagine and hope that for instance, in our upcoming events on matter, something that someone says earlier in the day will resonate and amplify in a, another speaker's talk or conversation.

So something hopefully becomes more than the sum of its parts. And in a way, therefore, you know, although originally medicine box did set out to. Present the questions primarily through the lens of the arts that has grown and changed. You know, I think it seems to me that as doctors, any vista of knowledge of which there are many that allows us to think about the humanity that we have a duty to and the planet surrounds that humanity permits it.

It's necessary, it's vital to looking after Mrs. Jones in bed three or wherever she may be. So it isn't narrowly the arts, although I do think they have a particular way of presenting us with questions and holding those questions, if not, if not giving us mechanical answers. 

Gavin: You, you mentioned your, your love of the arts, of course, and and your qualifications in medicine, being a doctor, but what first made you kind of want to Showcase the arts and medicine in this in this way.

Do you think it's kind of an underserved area? 

Sam: I think I think it is. Well, let's say this medicine is tussling with really central questions. What it means to be alive and mortal. So it turns out is religion. And, you know, fundamentally the arts are asking very similar central questions around the business of humanity.

So these ostensibly separate disciplines. are all fixated on similar questions with huge spheres of overlap around their concerns. So it's not so much that I think the arts are underserved as all of these are important means of addressing fundamental questions. Now, that isn't to say that faced with a patient in ED or on the ward in front of me, I sit down and kind of ruminate on, on Keats or whatever.

So much as a sensibility that is Permissive of wider spheres of knowledge is really important to my, to delivering well on my duty of care and the arts. I think if we were to be I guess mechanical about it, one are interested. So if we look at literature, really interested in the force and gravity of words and how they're presented, well, central to all medical communication.

They recognize that each of us contains multitudes. with a range of moral possibilities and good art, good literature will, I think, allow us to recognize our moral range rather than being mutually in their moral view. And in doing that, I think exercise our capacity for moral argument with ourselves, if not others.

And in a way, therefore, they really are demonstrating our continuity with one another. And I think, you know, empathy, this much contested term might flourish with that recognition. The, the, the recognition that not only that could be me, but in many ways that is me and generate or drive the will and the action to care better for others.

Gavin: You think there is a danger then that medicine can become too mechanical, too focused on a kind of notion of, of serving users, so to speak. 

Sam: I mean, I think it's difficult to answer that because It absolutely has to get the mechanical, technical bits of its job done well. There's, I think there is no excuse for a healthcare professional being shoddy in their technical skills and their mechanical approach to others.

It would be, it would be misguided for me as an oncologist to dismiss the appropriate dosing of Adriamycin or the, you know, the isodosis around a tumor in a radiotherapy plan. I think it's more not that those things aren't necessary, they're absolutely necessary, but I don't think they're sufficient to the whole business of good care.

Moral judgment, moral argument with ourselves and others is part and parcel of that, but in themselves they, they're not enough or sufficient. And we know this, don't we? Otherwise we wouldn't be surrounded by failures of care towards meeting other human beings as persons who we may well be.

Recognizing pain and suffering and feeling compelled to act on it in a way that is compassionate, empathetic and motivated. Now, of course, That motivation isn't just a Mrs. Jones in bed three, but if I'm saying there is a material continuity between myself and others and that we share similar similar capacity for suffering, fear, hope, then in fact, it isn't just Mrs.

Jones in bed three, but the treaties of medicine apply just as much to someone who might be living on an estate in another city, or indeed, frankly, those who aren't, haven't even got reach for oral rehydration in other parts of the world, as I glibly prescribe costly drugs in one part of it. So I think it instantly widens your 

Gavin: circumference of concern.

Do you think as an oncologist that this kind of sense of mortality is more, more apparent to you given the kind of the, you know, how many people die of cancer, what a common cause of death it is, and what a serious condition it can be. You know, there's so many, so many people's lives are changed in an instant when they're told that they have cancer.

Sam: So we're, we're very conscious within a specialty such as oncology of our proximity. the proximity of our patients to death, not necessarily universally. You know, so many impressive advances in the last 20, 50 years, which have meant that, you know, all sorts of tumors, which are once deemed either incurable or untreatable, that our approach to them has changed dramatically, survival of figures have improved, the range of therapeutic interventions at our disposal has extended.

you know, almost beyond recognition if I think back to when I was a houseman in oncology in the mid 90s nonetheless it remains true that large a large component of our intention with oncology is palliative, by which I mean with the hope of controlling or shrinking malignancies and improving symptoms and indeed prolonging life, but with no expectation of cure.

So we, we recognize that human finitude is very apparent to us every day. But it's interesting, this almost harks back to your other question is to what extent I suppose, Doctors and mechanics. So doing the mechanics well is important. I think in our encounters with death, it's really clear that the mechanics isn't enough.

And indeed a recognition of that mortality and the means by which it's navigated both with candor, but also compassion and truthfulness is really challenging in a world where ever more is possible. And I think it's really interesting to how much that recognition is lost in the narrative. So you find yourself either, of course, being an oncologist on the one hand, or a palliative care physician on the other, either prolonging life or palliating suffering.

But of course, these things run concurrently, don't they? And I think only with a bit more open recognition of our shared mortality. And the means by which truthful conversations are possible and care for others is foregrounded over and above the delivery of treatments, can we get to something that looks slightly more like what I would like to suggest is good medicine.

It's fascinating isn't it that we can live in a world with all this progress yet that that view or I guess that application of medicine will still only be true primarily for many in high or middle income countries that it can be concurrently true that I can administer life prolonging treatment yet not deliver analgesia or rehydration, simple treatment for large swathes of those on the planet.

Gavin: Yes, I was just going to ask you about that and how, I guess, kind of how that makes you, you feel, the kind of, the, the vast inequalities of medical care across the world. 

Sam: I think it leaves me troubled at this version of progress. I know that there's a risk of that sounding terribly naive. If we are interested in progress, and if we are ostensibly here to.

Persons to serve humanity, then and if we're interested in that being a rational morally sound response to that suffering, then it stands to reason it's bonkers for it to be possible that we have such extremes. Dare I say, you know, we ought to also similarly question our drive primarily, particularly given the crisis the planet's facing around other species and the warming of the planet, that our attention is primarily focused on humanity.

Now, that's not to say I need to Suddenly ramp up my skills on looking after small animals, but everything I do here will have an impact on wider life and the pandemic, you know, in many ways epitomize that didn't it? Our attention was primarily on gleaming ventilators in certain parts of the world rather than.

Good palliation or the care of those in nursing homes and similarly large amounts of plastics, PPE and the like were readily deposited into an already weathering 

Gavin: environmental landscape. Another thing that really struck me about the pandemic that's hits at themes that we've been talking about was the kind of dehumanizing nature of, of, of the kind of heavily medicalized deaths.

So many people died during the pandemic, you know, isolated completely from their family and friends, only able to see doctors heavily clad in PPE and only then for a short amount of time, given the incredible stresses on on the health system. How did your experience of COVID 19 kind of affect this, this kind of, the kind of nature of humanity and medicine that we've been talking about?

Sam: It's difficult, isn't it, because I'm, I'm wary of and conscious of sounding perhaps too damning, and I definitely don't mean to be, because it's a really hard thing to get right, definitely individually, and therefore the call, almost, I guess it's a political call, is for institutions to foster a more and be permissive of galvanize a more grown up conversation, perhaps about the value of medicine, the value of life, the limits of medicine, the absolute facts of our mortality and how we as a collective then articulate what good medicine ought to look like.

So for instance, over the course of a pandemic, although quite understandably and quite rightly, and who knows, you know, I'd be clamoring perhaps for the same, which is why we. ought to rely on institutions to be able to whom we can trust to allow us to hold these questions with us in a way that's better.

But whilst the clamor was rightly there for ventilators, vaccines and life, it, you know, it was clearly disconcerting that there were many who weren't necessarily. Many individuals weren't coming anywhere near a hospital for good reasons, for whom galvanized palliative care services, symptom control and support in the community just didn't have the same energy behind them.

You know, none of that seems necessarily Wise in hindsight, and although I was away from the, from the kind of crisp front line of ITU and ED, we had our own challenges in the regional cancer center in maintaining an immunosuppressed patient group as shielded from COVID whilst perpetuate, whilst continuing anti cancer treatments.

And certainly at the beginning with a very clear lack of data, just modeling to give us a sense of what that would mean for their. Cancer for the risks of immunosuppression from treatment with COVID, et cetera, et cetera. So there was a lot of uncertainty at the start, which I think was, was very challenging for us as a health community.

But interestingly, that uncertainty and the fear that is the corollary of it is in many ways, what. Our patients are facing every day, you know, deep uncertainty and fear that's, that compounds that. 

Gavin: I think it's, it's very easy as well to be too hard on ourselves in, in retrospect when dealing with such a incredible series of unknowns.

Sam: Absolutely. Yes, absolutely. And it's, I guess it's like all, it's like all learning in medicine, isn't it? It's what one can hope for is a culture that's open to reflection. Such that there's growth in a way that isn't unduly critical, but I suppose receptive to genuine reflection, but on a platform that is constantly trying to articulate the rightful goals of medicine ought to look like.

And I think that's something that, you know, understandably people tussle with, don't they? But central to that surely is both the fact of our mortality and visible. gradients of injustice across the planet. So if we accept those two givens, what's medicine's response? What would good medicine look like?

Now those aren't, those aren't technical questions. They're partially moral questions. They're, they're definitely political questions, but they're questions around citizenship, aren't they? As much as what Dr. X or Y happens to think in a practice wherever in the world. 

Gavin: Yes, I mean, that's fascinating, isn't it?

And that kind of hits at a real philosophical core of medicine because we can we can, you know, we, we can all learn the mechanical nature of medicine that we've been talking about, the, the vital interaction of drugs and doctor and patient. But when we ask a question like, what is good medicine? I think you're right.

We just, we can't answer that in a purely mechanical way. It has to, it has to invoke a wider humanity. 

Sam: Yeah, I think so. And I think, you know, it's interesting when we, when we have some of our ethics committee meetings around particular cases, it strikes me that it's less the case that there's one right moral answer, so much as the number of versions of what good might look like premised on sound reasoning.

So I, I think it's, It's okay for us not to say, right, here's the panacea, here's the holy grail, this is perfect medicine. At the same time, that oughtn't to, I think, have us retreat from the attempt at finessing what good medicine looks like. And my, I guess my fear at the moment is that most of that is premised on personalized molecular medicine and genomics.

That's the, that's the avenue upon which we're, it's the platform upon which we're defining good medicine, which of course is part of it and it's part of progress and technological development, but it is just a narrow version of what good medicines look like. And further to that, it might even be problematizing it because, you know, Day on day we can do ever more and alongside that capacity to do more, are we really asking ourselves vigorously about the wisdom of that whilst at the same time articulating to ourselves and the public that inevitably there are limits to what medicine can achieve and there are undoubtedly on the planet there are financial limits to what's affordable.

What sort of conversation do we want whereby we can really. ask ourselves, to what extent is evermore intervention desirable? To what extent is good end of life care a priority with community services, welfare, dare I say, even food for those who can't afford it in 2023? And I'll be really saying that isn't the province of medicine, that's for others to sort out, because I think, you know, we're really important to that debate.

Gavin: And to what extent, of course, each of these things matter, which leads me nicely on to talking about the theme for your event this year, how did the theme matter come about? And I, I guess there can be many different interpretations of the word, what kind of central kind of call would you like to come from the performances?

Sam: Yeah. Thanks, Kevin. I think you've hit on it already. It's it is. A bit primarily the theme came from a biochemist called Nick Lane who came to our event on mortality some years ago where he, he articulated to me that possibly a common progenitor for life on the planet had been a porous rock, a membrane across which chemical reactions were permissive of what we now describe as life and that I remember being really struck by that, the idea, and it wouldn't be surprising really, that at some point inanimate matter reached for animate matter and life.

To hear that a porous rock was very possibly the progenitor of life, I think is startling and humbling. And then of course, you know, it's interesting, and I know less about this than Others, but a virus isn't obviously either alive or not alive. It's a packet of material reliant indeed on other life much as we are to survive.

So this, it increasingly becomes the picture for me anyway, personally emerges of absolute continuity across life and the planet and forms of life and us as human beings with one another. And I really felt. Interesting to explore that and it's many facets and to perhaps not explicitly, but perhaps for a narrative to emerge from that around what does matter or to allow ourselves to think about it, I think.

And so over the course of this day in, in London, there'll be. Numerous short talks and conversations about everything from the nature of a cell to meteorites, to stories and how stories express the multitudes that we each contain, to how the color of our skin affects our engagement with the world to the Grenfell tragedy, fossils and deep time and rocks.

And it's going to be immersed in music and performance and enchantment and beauty, hopefully. 

Gavin: Wonderful. I think all that remains for us to say is the most important part. What date is it? When is it happening? And how can our listeners get tickets? So it's on 

Sam: Saturday, the 13th of May Medicine Unboxed Matter at King's Place in London.

And it'll run from about 10am to 6pm followed by an evening reception. And you can get tickets on Eventbrite or if you go on to medicineunboxed. org, it'll point you towards ticket sales and we'd love to see you there. Dr. Sam 

Gavin: Guglielmi, thanks so much for guiding me on the podcast. It's been a really fascinating chat.

Sam: Thank 

Gavin: you, Kevin. Thanks a lot for having me.

Thanks so much for joining us for this episode of the Lancet Voice. This podcast will be marking the Lancet's 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon.

Thanks so much for listening.