Content of the Database

Briefly, the database catalogues works of literature, visual art, and film. The literary section (the only segment of the database examined in this review and by far the most extensive of the three) arranges annotated works of literature so that the user can search by genre, author, annotator, or keyword. Each of the works, even the poems, is annotated with a short "Summary"-a bare-bones plot synopsis-and a "Commentary" that ranges from astute literary criticism to such causal personal notations as "indeed, one is eager to find out what will happen next" about an 800-page 19th-century masterpiece of fiction. A few of the annotated works are linked via buttons to either a voice recording of the work or a Web site (for example, the Herman Melville Home Page or the Frankenstein Resource page) that offers the full text of the work or a more specialized database of literary criticism. Finally, a "Free Search" option allows the user to perform Boolean searches among keywords, authors, annotators, and genres.

The list of 33 genres includes anthologies, biographies, fairy tales, folk tales, plays, poems, and short stories. Oddly, the database distinguishes among novels, novels for young adults, novellas, and novelettes and among autobiographies, journals, and memoirs but does not distinguish among works of literary criticism, philosophy, sociology, history, social theory, feminist studies, and medical ruminations. These are listed indiscriminately in three categories: "treatise," "criticism," and "essay." Authors are listed alphabetically without the conventional breakdown by century, period, or genre. In another section, works are listed according to era; there are 11 works from the 16th century, 4 from the 17th century, 3 from the 18th century, and hundreds if not more than 1000 from the late 20th century. The list of works annotated by each member of the editorial board-the number ranges from 10 to more than 250 annotations per member- allows the user to review works read and summarized by one annotator. As a result of the collective and nonauthoritarian nature of the enterprise, the level of effort and expertise among annotators ranges widely. Some annotations resemble paragraph-length book reports; others offer sophisticated interpretations of works or reflections on form.

The "Keyword List" offers a key of sorts to the entire enterprise. Primarily content-based, the Keyword List allows a teacher to select works of literature about, for instance, abandonment, abortion, alcoholism, anatomy, or anesthesia. A merging of the index of Harrison's Principles of Internal Medicine with that of a book of contemporary human psychology, the Keyword List lets the user view works that are "about" the same subject-for example, African-American experiences or aging or AIDS or arthritis-in order, presumably, to fashion a course or seminar or lecture around such a topic as it relates to the practice of medicine.

Finally, the works chosen for comment are an eclectic collection. Included on the list of novels are works by Kobo Abe, Lionel Abrahams, and Julia Alvarez, but absent are works by James Agee, Sherwood Anderson, and Jane Austen. This fulfills medicine's commitments to multiculturalism but loses sight of important traditional works. Perhaps because of the nature of the collaborative enterprise (the annotators may submit comments on any work that they choose), the database does not reflect the universe of literary texts that might be considered for comment. Nor is there an attempt to make comparative comments, so the user does not have the benefit of even the most conventional critical readings that might differentiate a work by Jane Austen from one by Dorothy Allison.

How Can It Be Used?

Many kinds of help can be sought from the database. For example, imagine that a pediatrician is attending on the oncology service. She wants her residents and students to read some fiction and poetry about children and cancer because she knows that they will learn some things from literature that they will learn nowhere else. She runs a Boolean search using the keywords children and cancer and finds summaries and commentaries on a series of poems by Paula Krauser called "Tears"; an essay about the death of a child by cancer, written by a pediatric intern and published in The Journal of the American Medical Association; a novel called Operation Wandering Soul, by Richard Kraft, written from the point of view of a pediatric surgical resident (it was nominated for a National Book Award); an autobiography by Lucy Grealy called Autobiography of a Face, about the author's experience with a chronically ill child; a series of poems by physician Henry Schneiderman called "Breast Cancer in the Family"; and Anton Chekhov's short story masterpiece, "The Doctor." The pediatrician is elated: Not only has she been reminded of some works of literature that she had known and forgotten, she has been introduced to many unfamiliar works, some of them written by physicians, in a variety of genres. Moreover, her quest has been reconceptualized, for, by reviewing the results of her search, she realizes that her team ought to consider not only children who themselves get cancer but also children who live around the cancer of other people.

Some people use the database to orient themselves in conceptual space. Andrew Kim, a first-year medical student, wrote to one of us about the database, having found it on his own.

"I love the database. It's through a combination of literature and personal experience that I continue to find meaning in my chosen career path. So, I see the database as a pretty powerful self-guided learning tool. It gives me a vantage point from which I can quickly and efficiently survey the array of literature related to the experiences of patients and medical providers. The on-line texts and audio links make the search infinitely more informative and more enjoyable than a standard bibliography."

What a powerful endorsement of an electronic medium that it nurtures a preclinical medical student, through literary texts and the writings of physicians and patients, to sustain his own motivations and visions of medicine.

These two examples suggest the range of users of the Literature and Medicine Database: teachers designing curricula, scholars seeking relevant literary works, physicians looking for some spiritual or existential accompaniment to their daily work, patients seeking information about their illness that might alter their own experience, and students trying to remember why they took the Medical College Achievement Tests. Although we do not have access to information about the number or sources of "hits" on the Web site, we imagine that, like any electronic database, this one attracts many users with different goals, bending to the user's needs and wishes to search for a particular text or to move, in almost free association, among interrelated topics and texts.

Our overriding impulse is to celebrate the presence of such a generative and accessible scholarly tool for the physician interested in literature. That such a database exists at all speaks to a groundswell of sophisticated interest in what the humanities-and literature in particular-can contribute to medical practice [2]. That it has been shaped by collaborative and anti-elitist forces distinguishes it from literary studies scholarship in general, which is apt to be marred by scholarly prudery or correctness at such a pitch that nothing can be said about anything. Medicine, that is to say, brings literary studies around to their human goals, their powers to sustain and heal without getting mired in impenetrable jargon or sloped on a sliding scale of status among subspecialized scholars. Instead, what we see here is a circle of readers gathering for nourishment for themselves, their students, and their profession. Although available to anyone on the Web, the database retains some of the feeling of the underground, as if the pre-Revolutionary Russian manuscripts of Chekhov's days were now being circulated electronically.

The formal characteristics of the database provide evidence for the conceptual state of some parts of the field of literature and medicine. Although it is not representative of all scholarly work proceeding in this field, this database nevertheless reflects a highly visible strand of literature and medicine. Thematic and content-driven, this strand draws attention to the specific lessons that physician-readers can gain from texts explicitly about illness and doctoring. Most of the works cited are plotted around diseases, medically significant developmental stages, or such emotions as grief and depression commonly met in medical practice. The lack of such literary keywords as unreliable narrator or irony or free indirect discourse suggests that the database is not intended-yet, at least-to support research in the formal or generic characteristics of the texts themselves. That the commentary, even of the poems, is largely restricted to plot summaries further characterizes the effort as supportive of thematic rather than conceptual work in literature and medicine.

We think that some growth in the database would make it even more helpful to physicians and to scholars in literature and medicine. Because some of the most lasting rewards of teaching literature to physicians and medical students come not only from reading and discussing works about illness but also from rigorously training physicians in the complex acts of reading, the database might consider expanding its keywords and texts to include more theoretical aspects of literary studies [3]. To make sense of a hospital chart or a death summary or a consultation note, the physician must know a great deal about narrative frames, temporal dimensions of storytelling, metaphoric structures, authorial intention, and reader response; in short, physicians need to know how stories do their work [4].

For too long have physicians been naive and unskeptical readers, unable to decipher the deep structures of what patients tell them or of what they write for one another. The genres of medicine-the admission note, the emergency department face sheet, the referral letter, the history of present illness, the "complaint"-have complex formal structures, temporal scaffolds, and authorial voices. To "get" the meaning embedded in these written and oral forms of language, the physician-reader-listener needs to master fundamental literary skills that combine sophisticated semiotic abilities, complex capacities for affective accuracy, and singular knowledge about his or her own personal response to the stories of others [5, 6]. The same multilayered process obtains in listening to a patient tell of her congestive heart failure that obtains in reading Pride and Prejudice: The reader or listener identifies the story's teller, views it from as many perspectives as possible; situates it in the context of other stories told by the same teller; probes it for unspoken allusion; examines the memories and associations stirred up by the text; and runs through an orderly drill of attention to form, frame, point of view, diction, time, register, reliability, imagery, and the like. The more ably a physician has mastered these literary skills, the more effectively he or she will gather, comprehend, and respond to clinical stories told by patients or colleagues and the more grounded he or she will be in the full, rich, morally and diagnostically resonant life of the individual patient [7].

What Is Its Future?

As we look to the future of literature and medicine, we hope that, in addition to continuing to achieve its primary goal of increasing the accessibility of literary works relevant to medicine, the database can also give physicians what can be had in the lap of literature-not only the rewards of plot (these are not insignificant), but also the great and daring beauty of form, style, and meaning. Literary scholars should not be allowed to hoard what they know. This database can give physicians and medical students knowledge about individual texts that is sophisticated enough to allow the novice reader to situate a work, understand in rough terms how it is built and how it does what it does, learn what scholars consider its critical strengths, and be guided through an informed close reading to "get" its point. If each annotation included not only a plot summary but also an overview of critical appraisal of the work, a biographical or cultural or formal context within which the work can be understood, and several references for critical essays on the text, interested searchers could develop some depth of knowledge about particular works, authors, or genres, improving their teaching skills and deepening the effect of the works on both teachers and students. The database is at its best when it offers links to critical databases elsewhere, providing a clearing-house for complete scholarly critical analysis and opening a door for physicians and medical students into the riches available from literary studies. (Many such resources exist for works or authors already catalogued, such as John Keats, Flannery O'Connor, and Walker Percy, that are currently not indicated in the database.)

We are intrigued by the idea that this database could support conceptual research in literature and medicine as well as topical groupings of works. If such conceptual keywords as framed tale or implied reader or transference were to be included along with the concrete or topical ones, users might set out on paths of literary study that would help them discover, very basically, what happens during the healing transactions of medicine. And, finally, reviewing this database leads us to brood about the need for a centralized and updated annotated listing of critical and theoretical secondary works in the field of literature and medicine itself, sorted according to schools of criticism (perhaps using the Modern Language Association bibliography categories); we wonder whether this database could become a home for such an undertaking.

Taking full advantage of all that literary studies have to offer, the database can open even more doors than it has cracked to date, bringing to medical readers the richness of literary texts of all periods along with the guidance of literary scholars in identifying texts of lasting quality. With some revision, the database can attend more forcefully to the pedagogic needs of physicians and medical educators who will absorb whatever help it offers in teaching and reading literary texts, thereby improving the quality and power of their teaching and learning in literature. We trust that the database will, in the future, support the scholar, teacher, and student in both the conceptual and the instrumental undertakings in the growing field of literature and medicine. And the database will certainly continue its already effective ambassadorship, deepening the ongoing dialogue between healers and readers.

Dr. Montello: History and Philosophy of Medicine, Kansas University Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160.