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Do we feel it – do we miss it?

The word unspoken but implicit;

the heart symbol drawn – unsaid;

thoughts of love, though not explicit.

Do we think it – do we believe it?

Connection lost behind jagged lines;

swirls of emotion – the ache of now;

the coiled snake, fearful signs.

Do we know it – do we see it?

The search for meaning making;

the desire to paint it, dance it;

aching for a way of speaking.

Do we hear it – do we perceive it?

Open the closed, find curved lines,

ways around to explore, to find;

clear the thinking with creative mind.

Do we read it – echo the song of it?

It’s powerful, this thinking out loud,

this music of freedom and life:

it’s straightforward and proud.

Do you sense it – are you stirred by it?


Congenital Glaucoma


She sat in bed, a room to drama given

Not often or of late. With her a throng

Of fellow teens, all smiles as if room seven

Were home, were Méjico, speaking the tongue

I’d learned one college summer with aims

Of studying pre-Columbian deities -

Those eyeless gods of stone and clay with names

Like Ixtacíhuatl, snow capped queen of trees.

Ciega. Blind. Mi chica had no sight.

I looked into her eyes and saw two suns

Of blinding white - atrophic holes, where light

Fell off the cliff to disappear, forever gone:

Her aqueous flowed but poorly from her eyes.

For Ixtacíhuatl, a maiden sacrifice.

Competing interests

None declared.

Provenance and peer review

Not commissioned; internally peer reviewed.



You spent most your life

with your head in the clouds

of smoke that billowed forth

from the O-shaped mouths

of the ones you love.

You never smoked

so much as one cigarette

in all your cloudy days

spent in places you came

to call bittersweet home.

Your parents and husband

fought for breath and coughed

blood before dying one by one,

leaving you and your

dear daughter all alone.

You lived on as a widow

who sold bright bouquets to

people who knew you by a

smoker’s cough, a cheeky smile, and

photos of your granddaughter.

When the time came for you

to fight for breath and cough blood,

you felt a poignant love

for the grand one who shaved

her tiny head for your cure.

The chemo made you

bald like your granddaughter

and vomit like your daughter

yet kept you alive...

Digital dust


A creature of clay. I am

Shattered so easily.

Delicate dust,

Facing Pompeii’s destiny.

A man of steel. I desire

An artificial heart.

Simulated soul,

Chasing the philosopher’s stone.

A ghost in a shell. I become

Deprived of my flesh.

Digital dust,

Dissolving under Icarus’ sun.

A creature of steel. I remain

Fragile undoubtedly.

Digital death,

Hoping for the Potter’s breath.

Competing interests

None declared.

Provenance and peer review

Not commissioned; internally peer reviewed.

An unpredictable vision


Unquenchable thirst,

draining sequelae,

a pervasive feeling of lethargy,

throbbing headaches are master now.

And then blurring of vision,

all is not what it seems,

sweats abound with unbearable discomfort,

a bruising encounter.

A brief hiatus.

Vivid dreams and a flurry of activity,

vision begins to clear and headaches subside,

but lethargy is new master now.

Good days intertwined with bad days,

beware vacillating tiredness,

hidden from outside but omnipresent.

Will this hidden metabolic assassin ever depart?


ARLM conceived the idea, wrote and reviewed the manuscript.

Competing interests

None declared.

Provenance and peer review

Not commissioned; internally peer reviewed.

Author note

ARLM is a respiratory consultant working and living in Bristol, UK. The poem is a reflective following the diagnosis of type two diabetes to give an insight into the experience of unpredictable yet debilitating apparently invisible illness.

The Gift


I want to give you a gift.

The side of her you could never see.

The sober moments when her addictions were briefly quieted.

She loved you, sobbed with shame and grief,

In the brief clarity of the hospital pulling herself together.

You’ll never know this.

Never see the side of her that ached for a normal life with you.

You know the cloud, the avalanche.

Gathering speed.

Fueled by the weight of your life as a ward of the state.

Gathering speed.

The inevitable end you would hear from a social worker.

But this gift, you deserve it.

To know there was a cement of love among the cracks.

Competing interests

None declared.

Provenance and peer review

Not commissioned; internally peer reviewed.



Red ribbons cut by the blissful sliver,

One of many trying not to quiver,

A grizzled man with cold dead steel,

The stain of death closes the seal,

Inky blackness all consuming,

Only feeling is slowly moving,

Closer, but just out of reach,

Light is back, dark thoughts impeach,

Take this hand and we shall see,

If the lock is lost and we’ve found the key,

For all is nought without this grip,

So squeeze these fingers and pray; don’t slip.

Competing interests

None declared.

Provenance and peer review

Not commissioned; internally peer reviewed.

The Evening Shift


the page bleeps relentlessly

a chain of patients still to see 

and the phone rings rings again

spot tests nebs bloods LP 

awaiting results but treat IV 

the page bleeps relentlessly

cannula fails dad complains

calm situation hit the vein

and the phone rings rings again

toddler bruising no history

parents aggressive contradictory

the page bleeps relentlessly

resus breathless call ITU in

no local beds or transfer ‘til ten

and the phone rings rings again

night reg sick no capacity

negotiate maintain endlessly

the page bleeps relentlessly

and the phone rings rings again

Competing interests

None declared.

Provenance and peer review

Not commissioned; internally peer reviewed.

The Seahorses


There is a secret self, a shadow

Relax your peepers and you’ll miss her-

Some say she’s not welcome here,

Others that she’s always been

Resting on gyri, enveloped in some sulcus,

She’s very small you know.

Her favourite thing is riding the opal-grey seahorses, over and over,

They watch her in wonderment, ache a little at her touch

Other times she sits in an oval orchard,

Feasting on almonds, leaving scatterings

When she is full she wanders along silvery-spindle tracts,

Until she reaches the cusp of the water and waits-

At the point of a kiss

Competing interests

None declared.

Provenance and peer review

Not commissioned; internally peer reviewed.

A visit to Brookwood Aslyum in the 19th century


During a visit to Surrey History museum, I reviewed a number of archived patient notes from the old Brookwood Asylum. Patient notes dating back to the late 19th century. Reading through these prompted considerable sadness as it became clear many patients were incarcerated for several years without contact from the outside world. Often these were patients who had nowhere else to go. One patient in particular stood out. A young boy admitted in his late teens, described as uncontrollable in behaviour, spent his life in the asylum. From reading the notes, he is likely to have had an intellectual disability and his parents were simply unable to cope or receive any support to help care for him, resulting in incarceration. The numbers of diagnoses were limited in the late 19th century and many were simply diagnosed with ‘mania’ or ‘lunacy’. As a result, he spent his life living in...

Editors note: shame, stigma and medicine


We are delighted to share this December issue of Medical Humanities, a special themed issue on shame, stigma and medicine. As the editors Barry Lyons of Trinity College Dublin and Luna Dolezal of the University of Exeter explain in their guest editorial, this project evolved from a conversation ‘about the politics of shame and humiliation within healthcare.’ I can think of no more appropriate and timely topic for the end of 2017. Shame and stigma, with their social, political and clinical impacts, ought to be critical foci for medical humanities; such topics remains especially important to the many health crises unfolding globally—and have particular significance to me, coming from the US context and its present problems of access.

The issue seeks, through the cogent and fascinating work of interdisciplinary scholars, to elaborate on shame and stigma from both historical and contemporary perspectives, and considers social issues as well as clinical ones. This is...

Shame, stigma and medicine


"As a young physician in the mid-80s, caring for people who had contracted HIV, I lost two of my patients to suicide at a time when the virus was doing very little harm to them. I have always thought of them as having been killed by a metaphor, by the burden of secrecy and shame associated with the disease".

         Abraham Verghese1

When, in the late 1980s, the psychiatrist Donald Nathanson organised a symposium on the nature of shame, it turned out to be the first such event to deal with the subject in the history of psychiatry or psychoanalysis on either side of the Atlantic. It seems strange that such a ubiquitous emotion had excited so little academic interest to that point, but as Nathanson points out—shame makes us so uncomfortable that we will go to great lengths to avoid it.2 Yet, despite...

Shame and the vulnerable self in medical contexts: the compassionate solution


Shame is a powerful experience that plays a vital role in a whole range of aspects of the clinical encounter. Shame experiences can have an impact on our psychological and physiological state and on how we experience ourselves, others and our relationships. The medical encounter is an obvious arena for shame because we are presenting (aspects of) our bodies and minds that can be seen as unattractive and undesirable, diseased, decayed and injured with the various excretions that typically might invite disgust. In contrast, experiences of compassion of acceptance, validation and kindness and can increase approach, openness and preparedness to engage with painful difficult scenarios. While shame is an experience that separates, segregates, marginalises and disengages people, caring and compassion facilitate integration, (re)connection and support. Given the potential opposite impacts of these different types of social experience, this paper will outline their evolutionary origins and compare and contrast them with particular reference to the medical context.

A dirty little secret: stigma, shame and hepatitis C in the health setting


While recent medical innovation shows great promise in treating hepatitis C (HCV), it remains a condition associated with profound stigma. HCV is a bloodborne virus (BBV) most commonly transmitted in high-income countries by injecting drug use, and it is the stigmatising association between the two which is deeply problematic for those with HCV. A qualitative study undertaken in 2002 found that disclosure in health settings places those with HCV in positions of pronounced vulnerability. Disclosure is a primal scene, an interface, where the stigma of HCV, replete with connotations of disease and deviance, potentially transforms those affected into shamed subjects. Standard precautions protect health workers and minimise the transmission of contagion, measures which, in theory, also mitigate the requirement of those with BBVs to unnecessarily disclose their blood status. However, questions on pre-employment health checks, concerns that health treatments might adversely affect the liver and an ethical need to pre-emptively inform healthcare professionals undertaking exposure prone procedures are occasions when those with HCV confront the decision to disclose their blood status. This paper employs Goffman's model of actual and virtual social identities, along with Douglas' notion of dirt and pollution, to examine the dilemmas around disclosure those with HCV negotiate within the health setting. Discriminatory responses by healthcare professionals elucidate the stigmatising potential HCV carries. The subsequent reticence by those with HCV to disclose their blood status risks less than optimum healthcare. Recent studies indicate that stigma occurring in health settings remains a perennial concern for those with HCV.

Shame, stigma, HIV: philosophical reflections


It is a distinctive feature of HIV that its pathology cannot be adequately grasped separate from a number of psychosocial factors, and stigma is widely seen as the most prominent. We argue that it is equally important to have an adequate understanding of shame, as the emotional response to stigma. We have identified five ways shame might negatively impact upon attempts to combat and treat HIV, which emerge from the stigma HIV carries and STI-stigma in general. In this paper, we draw out four insights from philosophical work on emotions and shame which we propose will improve understanding of shame and stigma. We conclude by briefly discussing how these insights might shed light on the negative role shame can play for a person living with HIV engaging with, or being retained in, care. We conclude by proposing further study.

'He would by no means risque his Reputation: patient and doctor shame in Daniel Turner's De Morbis Cutaneis (1714) and Syphilis (1717)


This article offers a historical corollary to the examination of shame in medical practice by considering the negotiation of shame in the treatment of a stigmatised disease at a time in which surgeons themselves occupied a highly ambivalent social position. It will focus on case studies provided by Daniel Turner (1667–1741), prominent surgeon and later member of the College of Physicians, in his textbooks De Morbis Cutaneis. A Treatise of Diseases Incident to the Skin (1714) and Syphilis. A Practical Dissertation on the Venereal Disease (1717). Turner demonstrates an awareness of the precarious position of both the surgeon and the syphilitic, and devotes significant portions of his text to advising the trainee surgeon on how to manage patients' reticence over disclosure of symptoms, expectations for cure and impudence towards medical authority. In turn, the trainee must manage his own reputation as a moral and medical authority who can treat all distempers, yet without condoning or facilitating the shameful behaviours associated with a sexual disease. Furthermore, shaming plays a key role in enabling Turner to fashion an ideal patient whose successful cure will both respond to and build the surgeon's medical authority and that of the medical field in general.

Pain, objectivity and history: understanding pain stigma


The primary claim of this paper is that understanding the stigma so commonly endured by chronic pain sufferers today in the USA and the UK is unlikely without proper appreciation of the history of pain. Ameliorating such stigma is an ethical imperative, and yet most approaches eschew even an attempt to trace connections between historical attitudes, practices and beliefs towards pain and the stigmatisation so many pain sufferers currently endure. The manuscript aims to help fill this gap by framing pain in the modern era in context of two crucial intellectual schemes that waxed in the 19th and 20th centuries: mechanical objectivity and somaticism. The analysis explains these frameworks and applies them to exploration of primary sources connected to contested pain conditions such as railway spine. By properly situating the historical roots of what it means to cite the ‘subjectivity’ of pain as a problem, the modern roots of stigmatising attitudes and practices towards chronic pain sufferers become much clearer. The manuscript concludes by suggesting that interventions expressly intended to target the root causes of such stigma are much more likely to be successful than approaches that proceed in ignorance of the historical forces shaping and driving pain stigma in the present.

The medical reshaping of disabled bodies as a response to stigma and a route to normality


Disabled people are said to experience stigma because their embodied presence in the world does not fit with how others interact and use their bodies to be social participants. In response they can turn to medical procedures, such as surgery or physiotherapy, in order to reshape their bodies to more closely approximate norms of social interaction and embodiment. This paper explores how medicine plays a role in attempts to be recognised by others as normal and acceptable by minimising disability. It will do so via a focus on disabled young people, in order to explore how their emerging identities and aspirations for the future influence how they think about their bodies, what normality means and their participation in multiple activities that work on their bodies. The paper draws from an Economic and Social Research Council (ESRC) project that used a range of qualitative research methods with a group of disabled young people. The project explored ways in which participants actively worked on their bodies to be more normal and examined the disciplinary and agency dynamics involved in this work.

On shame and voice-hearing


Hearing voices in the absence of another speaker—what psychiatry terms an auditory verbal hallucination—is often associated with a wide range of negative emotions. Mainstream clinical research addressing the emotional dimensions of voice-hearing has tended to treat these as self-evident, undifferentiated and so effectively interchangeable. But what happens when a richer, more nuanced understanding of specific emotions is brought to bear on the analysis of distressing voices? This article draws findings from the ‘What is it like to hear voices’ study conducted as part of the interdisciplinary Hearing the Voice project into conversation with philosopher Dan Zahavi's Self and Other: Exploring Subjectivity, Empathy and Shame to consider how a focus on shame can open up new questions about the experience of hearing voices. A higher-order emotion of social cognition, shame directs our attention to aspects of voice-hearing which are understudied and elusive, particularly as they concern the status of voices as other and the constitution and conceptualisation of the self.

Health-related shame: an affective determinant of health?


Despite shame being recognised as a powerful force in the clinical encounter, it is underacknowledged, under-researched and undertheorised in the contexts of health and medicine. In this paper we make two claims. The first is that emotional or affective states, in particular shame, can have a significant impact on health, illness and health-related behaviours. We outline four possible processes through which this might occur: (1) acute shame avoidance behaviour; (2) chronic shame health-related behaviours; (3) stigma and social status threat and (4) biological mechanisms. Second, we postulate that shame's influence is so insidious, pervasive and pernicious, and so critical to clinical and political discourse around health, that it is imperative that its vital role in health, health-related behaviours and illness be recognised and assimilated into medical, social and political consciousness and practice. In essence, we argue that its impact is sufficiently powerful for it to be considered an affective determinant of health, and provide three justifications for this. We conclude with a proposal for a research agenda that aims to extend the state of knowledge of health-related shame.

Vulnerability, survival and shame in Nina Raines Tiger Country


Shame in healthcare remains relatively underexplored, yet it is commonplace and its impact is significant. This paper explores shame in healthcare using Nina Raine’s 2011 play Tiger Country. Three manifestations of shame are explored, namely (1) shame in relation to professional identity and survival in the clinical workplace; (2) shame and illness as experienced by both patients and doctors; and (3) the systemic and organisational influences on shame within healthcare systems. I suggest that the theatre is particularly well-placed to elucidate shame, and that Tiger Country demonstrates the prevalence and impact of shame on clinical work. Shame has a fundamental and overlooked relationship with damaging and well-documented phenomena in healthcare, including moral distress, ethical erosion, compassion fatigue, burnout, stress and ill health. Attention to shame is essential for those interested in medicine and healthcare and must, I propose, include the experiences and perceptions of those who provide care, as well as attending to those who receive care.

Digital medical humanities: stage-to-screen lessons from a five year initiative


Translation of curriculum materials to digital formats has become increasingly common. Medical humanities, typically reliant on human interaction to generate emotional impact, represents an interesting means to study engagement with digitised content. While technology-enhanced learning may provide opportunities to integrate humanities into curricula, redesigning sessions for digital use can be resource intensive and ‘requires consideration of the affordances’ of different media.1 As previously reported in BMJ Medical Humanities, guidance for this process—beyond simply, ‘digitising existing content’—remains limited.1 We present a five year educational case study that outlines our successes and struggles with digitising a medical humanities session for undergraduate medical education.

Our model uses, Ed’s Story: the Dragon Chronicles, a verbatim play based exclusively on the journal of a 16 year-old boy with terminal cancer, and 25 interviews conducted after his death with his family, friends and interdisciplinary healthcare team.2 We have described the play’s development and...