Professor Rónán Collins is a Consultant Physician in Geriatric and Stroke Medicine at Tallaght University Hospital and National Clinical Lead for Stroke.
This conversation between Rónán Collins and Emma Eager was recorded in January 2020 and has been edited for clarity and length.
What was it that drew you to the area of Geriatric Medicine?
I love hearing interesting stories. First of all you get free lessons in life because there’s nothing that a person in their nineties hasn’t seen in their life, nothing that they’ve not come across that you’re maybe experiencing or that they haven’t some experience of, or very rarely at least. So you get a lot of free lessons and advice which generally enriches your wisdom if you choose to listen.
I’m also medically curious of course. Why do some people age so successfully and others not so? Why do you break your hip when you’re 70 and you don’t break it from the same fall when you’re 40? Why does your memory start to deteriorate? So there’s a degree of medical curiosity. And older people very often have three or four different significant issues going on and it’s teasing that out and problematically addressing it, that kind of inquisitive thing appealed to me too.
In what ways have you found the arts valuable within healthcare and how do you engage with the arts in the Age-Related Health Care Department?
Very often health is a very complicated subject for people to discuss. People feel either threatened by the science or feel they don’t know enough about it to voice their opinion or how they’re feeling about a particular health episode. I think sometimes the arts gives articulacy to that.
For example, The Diving Bell and the Butterfly is a very famous movie about stroke, a really beautiful adaptation of Jean-Dominique Bauby’s book. It allowed people not just to discuss stroke but to discuss severe physical impairment and what a personhood might look like in the context of having severe physical impairment. I don’t think the book glorifies in any sense that it’s some sort of wonderful situation to be in, it’s terrible. But you understood that even despite this huge physical impairment, that there was an intact personhood deep within and also that there were moments of great humour as well as great tragedy and powerful emotion. But that’s probably one of the more extreme examples whereby arts in health has helped create articulacy around a very difficult subject.
It’s almost like the arts giving permission for this to be discussed in an open, frank way. People feel more comfortable in that way to bring up the subject. Now the problem with it in a day-to-day consultation is that if you show a movie clip the patient automatically assumes, is he talking about me? There can be difficulty around that. But this can work very well in a group setting, in particular where many people might be experiencing a problem. So, for example, movies or clips about memory difficulties, around adjusting to life after a stroke in my own area of medicine can be very useful to allow people to say, ‘I relate to that, I’ve had similar problems like that’. Or ‘I wondered about that myself, it seems to be a common experience, I’m not alone’.
On a day-to-day basis, I use a lot of music for patients with dementia. People who are experiencing symptoms of delirium including restlessness and anxiety, I think I’ve managed to alleviate those conditions more often with YouTube on my phone than I have by ever giving a medication. A simple ice-breaker like ‘who’s your favourite singer?’ And I would play a bit of Hank Williams or whoever it was and a ‘healing’ chat would ensue.
Similarly, for patients who have significant memory problems and maybe are struggling to live in the here and now, we often use music clips and reminiscence therapy, drawing on the arts in order to allow patients, number one, to have a meaningful discussion and to partake in the here and now in a meaningful way, but also of course to add aesthetic quality and value to people’s lives.
A number of artist residencies have taken place in the Age-Related Health Care Department over the years. Can you tell me about some of those residencies and the work that emerged from them?
Well we had a poet working with us here in the hospital, the late Michael McCarthy, who was a fantastic poet, originally from Skibbereen and a priest in Yorkshire by day. Funded by the Meath Foundation we gave him a blank canvas but I said I’d like you to try and create a narrative around stroke and dementia, what it’s like for both patients and for staff working with patients, in whatever way it hits you. He became part of the medical team and did writing workshops with patients and staff, it was a great experience.
Michael was a great observer of human nature and he produced a wonderful anthology of poetry, The Healing Station. A closer examination shows his great insight and description of how as people we deal with ill health, our many reactions to ill health, and also the reactions of staff dealing with patients and how different those reactions can be in different settings. That can point very importantly to recognising that health and healthcare is not a unidimensional experience, either from patients or from staff, and it’s often a very complex engagement.
Similarly, we worked with Ian Wilson, a well-known composer. The idea I had at the time was that we would create a narrative of stroke and dementia through contemporary Irish music, literature and some form of creative art. Again, funded by the Arts Council and the Meath Foundation, Ian came to a blank canvas and he became part of the team. So he did ward rounds with us, had a staff ID badge, he was the composer in residence and it was all explained to patients.
The other observation I made from that project was that people spoke to Ian in a different way than they would have addressed me or other healthcare professionals. Now, I’d been aware of this phenomenon to a lesser level as very often when you meet patients, particularly older patients, they come with a pre-conceived notion about what this engagement with the consultant should look like, or what they can and cannot say, or what they’re willing or not willing to say. Then as soon as you’ve left the bedside, they’ll tell the real story to the nurse. Because they see the nurse as being more ‘on their side’ or somehow more intimate to them, or their confidant. And this dynamic is well-experienced by many doctors.
That was an even more exaggerated phenomenon when Ian and Michael were working with us. We would have the ward rounds and Ian and Michael would often go back and check how patients were doing and just discuss things. They would get into very different discussions with the patients and discover things that people were thinking about that never became evident to us clinically. And again that made me realise that the engagement from a clinician with a patient can become very stylised and limited by expectations on both sides and may not really address the full concerns of what’s going on in a situation. So it broadened my horizons, I learnt a lot from it.
Ian interviewed both staff and patients and listened to the ‘sounds’ of ill health. I don’t think we listen to the sounds of our hospital, the noise that goes on here. I think we become desensitized to it. The sounds of people calling out in distress or being agitated, shouting or using bad language. The sounds of weeping and crying as someone is dying; the sounds of laughter as there’s a lot of laughter in hospital, a lot of funny moments and a peculiar brand of dark humour, necessary to vent anxiety at times as well; the very human sounds of hiccoughing, coughing, flatulence. And then of course there is the sound of our ‘machines’, noisy MRIs, whistling nebulizers etc. All of these things must seem an incredible assault on the senses if you come in to this environment you don’t normally work in.
And like many others, I’ve always thought that healthcare institutions would really provoke the creativity in people and so it was. Ian did a lovely job, particularly with Bewitched which was his narrative of stroke. Getting the sounds of stroke, the narrative of what patients and staff were expressing and then putting it contextually and beautifully, by morphing into a series of Doris Day songs which thematically echoed the interviews.
You mentioned that Ian interviewed healthcare staff. How did they engage with the residency?
There’s a very nice interview with one of my colleagues which morphs into the song ‘Que Sera Sera’. In the created song, you can hear the self-reflection going on during the interview, this burden of ill health or of people suffering that you carry with you. You don’t really fully realise it until you sit back and reflect on it.
There’s a beautiful piece as well with a new mother in which the inexplicable realisation that she’s had a stroke is given expression amidst the joyful experience of her newborn ‘flying her to the moon’ and another song created from interviewing one of our speech and language therapists, where you hear the communication difficulty, where someone’s speech has been affected by a stroke, again morphing beautifully into Doris Day’s ambition to ‘shout it from the highest hills’. So I just thought the whole project was a very reflective experience for all, maybe even a type of practical wellness.
You’ve also brought a dancer in residence into the unit –
Dancer Ailish Claffey has done fantastic work with some of our more physically impaired patients, in order to allow them a medium by which they could express themselves through simple movement. Even it was just simple hand movement or the feeling of movement over them or the sensation of rhythm. Rhythms are very important in our lives. Physiologically of course we have sleep rhythms, we have heart rhythms, we have breathing rhythms. Subconsciously there’s the rhythm of our working day, you can sense when there’s a disturbance to that rhythm and its impact on you as well when things haven’t gone right, you can almost feel a shock to the rhythm of your day.
So I think working with a dancer made people reflect on that, about how we move, what our posture looks like, what looks friendly, what movements are calming and soothing or which might appear threatening or frenetic. It also showed us how important it is even when we move people passively who may not be able to move themselves, how that degree and the way that movement is performed can be healing for people.
What are important qualities for artists to have if they’re going to come into an environment like this?
I think first and foremost to have an open mind. Come with an open mind and a questioning mind and don’t be afraid to ask, why did you do that? Particularly ask the clinicians, why would you do that? Because very often there are things that would be very inexplicable to people who don’t work within the health service, or that we may not even be consciously aware of.
The second thing obviously is to be conscious that this is an environment where people’s innermost feelings and intimacies are exposed, where people feel very vulnerable and can be at their lowest ebb. So we always have to be conscious about doing our best to protect people’s privacy and to reassure them that that is so. Because when people see an artist coming and they’re at a low ebb and they’re vulnerable, they may voice fears like ‘I don’t want to be the subject of a book or a painting’, or whatever. And so respecting that vulnerability and the personhood and integrity of a patient is very important, realising that they’re not on a level playing field of engagement with you when they’re a patient, that they’re automatically a vulnerable person. And that equally applies to clinicians.
The experience also needs to be treated for what it is, a great opportunity to learn and experience a less-viewed side of life and a special privilege to be around people when they’re in very human states of vulnerability, because you know people are inviting you into their world in a way that they’ve probably never brought anybody else into their world, not even their children or their spouses maybe have seen them in such a vulnerable state.
I remember, for example, when I was working in England I had a little arts project that I was doing myself. I used to take a photograph of the World War Two veterans’ tattoos because my instinct at the time was that this was a body art that would die with the veterans. With their permission I would take a photograph of their tattoo and then ask them what was their best and worst experience of the war.
I got some great moments of humour, learned some astonishing things that I didn’t know about, heard some really horrendous things, and also on several occasions people told me things they had done or had experienced that they had never told anyone including their children or family. I remember one man being so emotional about something that happened to him during the war and it struck me that I will probably be the only person who’s been in this room with him hearing this discussion, and that was a huge honour and privilege. And I also understood on a very deep level the quiet suffering that sometimes goes on in people’s lives because of what they’ve experienced but cannot resolve or have not resolved. So there was a lesson in that as well.
So respecting the opportunity, the privilege, the honour of what people are going to share with you while at the same time reassuring them that this will be treated in a deeply respectful way that preserves their privacy is very important to impart to patients as an artist in healthcare. If I was to single out one key attribute, I would say to be kind. I think kindness is probably the most important trait because everything else flows from kindness. If you’re kind, you understand empathy, you understand privacy, you understand the honour it is to talk to people, you’re patient with people, you don’t get frustrated easily. You understand that the person is in a different place to where you are now while recognising it’s a place where you will likely be too one day.
What do you think are some of the biggest challenges of bringing the arts into an environment that’s designed for healthcare?
The biggest challenge is funding. In terms of health and safety and infection control, human resources, Garda clearance etc. I think they are possible barriers and delays but they are usually easily surmountable if you put a good structure in place. We’ve got a defined pathway within our own hospital. We take people through an induction programme. So I don’t think that’s a serious issue but rather just a process by which the hospital needs to have a defined induction which allows artists to integrate clinically.
The third issue is probably a double-sided apprehension. Artists who say ‘I’d love to work in that institution, but I don’t think I could or how could I ever go about that?’ So there’s a natural reticence to explore the possibility and a lack of knowledge on the access and role for artists in healthcare. And then on the other side, there’s the relative suspicion of clinicians about the role of arts in hospitals. ‘Why are you asking me to take an artist in here? What could this possibly do? How will the service or perhaps even me be perceived?’
But I think that is changing. More and more clinicians understand that if nothing else, bringing the arts onto campus gives people an aesthetic break from the daily deliberations about their own health and maybe takes them out of themselves a little bit, helping them more from a mood and psychological point of view. There’s an increasing recognition from clinicians of the importance of art and engagement with the arts from a patient perspective.
But also, and this is where we need to do a bit of work, maybe understanding ourselves what we derive from it. I think that’s what the dotMD conference [Festival of Medical Curiosity] is effectively about. It’s trying to say to clinicians, we can learn a lot from the arts here about how we treat our patients and look after our patients and we can do better. We’ve started in Trinity, certainly a nod to Des O’Neill [Professor of Medical Gerontology at the School of Medicine], pushing this agenda in starting to have lectures to students about the role of the humanities in health, be it in literature, painting, films, music, there’s great learning about health.
I often say this to med students, to understand what depression might be like, just read Manley Hopkins’s ‘No worst, there is none’. The last six lines of that are probably the epitome of what depression must be like to experience. There isn’t a finer description of it in any medical book.
O the mind, mind has mountains; cliffs of fall
Frightful, sheer, no-man-fathomed. Hold them cheap
May who ne’er hung there. Nor does long our small
Durance deal with that steep or deep. Here! creep,
Wretch, under a comfort serves in a whirlwind: all
Life death does end and each day dies with sleep.
That ‘cliffs of fall / Frightful, sheer, no-man-fathomed’ is a very powerful metaphor for how people feel when they’re depressed, that terror of being on the edge of something that you don’t necessarily understand or no one else has explored the depths of. There are similar examples in music and theatre, and great paintings as well of course. I think there’s so much in the arts people can learn about health and vice versa, if we just took a bit more time to engage together.
Do you think that if the arts were recognised on a policy level within the health service that it would help to create a sustainable structure for the work?
If there was an acceptance in the first place from all institutions that the arts have a role within our institutions and there was an arts committee set up of people who were interested and some degree of funding set aside, I think that would be a big help.
It’s a bit like ‘build it and they will come’. If you create the infrastructure, people will say, I’d like to contribute to that. There is an acceptance that the arts are important in our lives but I think the acceptance that the arts are important in our lives even when we’re a hospital patient is the key transformation needed here.
But also, the other way round, healthcare environments are important fonts of creativity by which people can tell us important things about ourselves. But that has to be dealt with carefully because these are vulnerable people that artists are coming to engage with and that needs to be understood. It needs to be very carefully managed with proper induction, ethics and consent structures put around it with proper explanations and goals as to what the projects are about, to avoid any notion of a voyeuristic Victorian curiosity.
All the projects we’ve done, which of course would have gone through an ethics committee and the arts committee here as well, the patients have really engaged with, at a level far beyond what I would have anticipated.
President Michael D. Higgins, Prof. Rónán Collins and Eilísh Hardiman, former CEO of Tallaght University Hospital, at the final recital of Bewitched by composer in residence Ian Wilson, the Royal Irish Academy of Music, 2012.
Looking to the future, what does an art friendly hospital look like for you?
I think an art friendly hospital would look like a place where there was an understanding that even though you’re ill, you’re still entitled to beauty and aestheticism in your life, that you still have something important to say and perhaps something more important than you ever said in your life before and that the hospital understands that about its patients. That’s the first thing.
The second thing is probably an infrastructural issue, our hospitals do need to be better designed so there is more space for patients to be creative. And that may include having little cinema rooms or free space rooms or reading rooms, having those facilities available to patients. That includes people who’ve got physical impairments so they can access arts, either by audio, by visual or by tactile means.
And then of course it needs a structure by which artists and the arts community can engage with the health community in a meaningful way. And that means having a structure around a committee and the procedures by which this can happen.
There is merit as well in something that you may do that while it may not individually benefit that patient, it may benefit us all by opening up a discussion in society. And I think many patients understand that and are very generous with that as a concept, because that’s the basis of medical clinical trials. Patients will very often go into clinical trials knowing that this will not benefit them personally but it may benefit the greater good. And similarly I think people in engaging with the arts may realise that by prompting this discussion, although it may not necessarily be of benefit to themselves, it may benefit future people in society.