Mudras in Medicine: A Role for Dance in Appreciating Non-Verbal Communication in the Clinical Encounter

Listen to ASCO's Journal of Clinical Oncology essay "Mudras in Medicine: A Role for Dance in Appreciating Non-Verbal Communication in the Clinical Encounter," by Drs. Maheetha Bharadwaj, Nagda Dipal, et al. Essay authors Dr. Bharadwaj, a urology resident at the University of Washington, and co-author Dr. Dipal, a medical student at Harvard Medical School, are interviewed by host Dr. Lidia Schapira. Drs. Bharadwai and Dipal provide insight on how they use non-verbal communication in the form of Bharatanatyam, an Indian narrative art form, as a way to reflect oncology patient care.

TRANSCRIPT

"Mudras in Medicine: A role for dance in appreciating non-verbal communication in the clinical encounter," by Maheetha Bharadwaj, MD, MS, Mphil; Dipal Nagda, MPH1; and Lipika Goyal, MD, MPhil (10.1200/JCO.22.00657)

Narrator: We present a classical Indian dance piece that depicts a patient and their partner receiving a cancer diagnosis from their oncologist. The primary purpose of this piece

was to provide a vehicle for patients, physicians, and caregivers to process a life-altering cancer diagnosis. The piece was choreographed and performed by two of the authors (M.B. and D..), who are medical students and classically trained Bharatanatyam dancers, and the project was guided under the mentorship of the senior author (L.G.) who is a medical oncologist. Through the process of designing this project during the COVID-19 pandemic, the authors also reflect on the role of visual arts in providing a space for contemplation and in promoting nonverbal communication in the era of virtual medicine.

Mudras, or hand gestures, embody one of ancient India's most visual forms of storytelling and are the threadwork of the Indian classical dance form of Bharatanatyam. Historically performed as a temple dance, Bharatanatyam serves as a vehicle for communicating and preserving narratives from Hinduism's greatest epics.1-3 Every mudra is intricately crafted and distinctly designed, with each bend of a finger and curve of the wrist representing an object, an emotion, or a state of being. Mudras are interlaced with rhythmic footwork and facial expressions in Bharatanatyam, producing a language that connects the performer to themselves, to the audience, and to the story being told. The style of Bharatanatyam specifically has been previously adapted for therapeutic relief and healing among survivors of natural disasters and victims of trauma. Although some artists have explored the use of Bharatanatyam to convey medical narratives, none to our knowledge have directly covered the nuances of clinical relationships in the context of a cancer diagnosis.

A few weeks after the onset of the COVID-19 pandemic, we found ourselves in an exchange of mudras over coffee on the patio. As both medical students and trained Bharatanatyam dancers, we were lamenting the difficulties of communicating to patients with masks. "He couldn't hearme," one of us expressed. After some pause, the other extended her right hand in

Katakamukham toward her chest, whereas her left hand also in katakamukham drifted toward her ear, together signifying a stethoscope. "Is this how you asked your patient if you could listen to their heart?" she asked. We both smiled. With her hands in place, she leaned her torso to the left and extended both hands in chaturam. She painted a rectangular frame in mid-air, signifying a chest x-ray. In silent melody, we played call and response, gliding our hands across the table and delicately placing our fingers into mudras.

As case counts ticked upward, distressing news filled our personal and professional lives and we both found ourselves turning to mudras to express our states of emotion and responses to the pandemic. It dawned on us that dance may play a critical role in reflecting on and processing difficult medical situations, especially in the isolating environment of the pandemic. We thus embarked on a project to explore the relationship between a patient and an oncologist through Bharatanatyam. Over the course of our clinical years in medical school, we collaborated with patients, clinicians, caregivers, and artists to choreograph this Bharatanatyam narrative medicine project. Mudras were combined with facial expressions, eye movements, and footwork to craft a narrative between a patient, a doctor, and a caregiver in the setting of a cancer diagnosis. In what follows, we describe our choreographic process, the resulting narrative, and

key takeaways from this artistic exploration. We propose a role for Bharatanatyam and other visual arts in enabling both the performer and the viewer to process narratives of cancer, suffering, healing, and hope. We further use this piece as a call to reclaim the

importance of nonverbal communication in the therapeutic relationship.

Developing and Choreographing the Narrative

We first reached out to several physicians to help develop a medically accurate narrative. Our clinician collaborators included an oncologist who specializes in cholangiocarcinoma, a hematology-oncology fellow, two head and neck surgeons, and a palliative care physician. Our patient and caregiver collaborators included three patients undergoing treatment for metastatic cancer and two parents. Through multiple conversations with these partners, we developed our narrative. For musical and artistic input, we partnered with Indian Raga, an organization dedicated to the celebration of South Asian art and music. Indian Raga developed a musical score for the piece, provided a dance collaborator, and offered creative feedback on our choreography.

Our choreographic process was iterative, as we moved from the dance studio to conversations and back again to the dance studio. We incorporated the feedback from our collaborators into our storyboard and our final choreography. We recorded the performance on March 1 31, 2021, at the Cambridge Community Center for the Arts, in Kendall Square.

The Dance Narrative

A video of the performance can be accessed at https://youtu.be/Nru_nWiiDXk.

Our narrative details the journey of receiving and processing a cancer diagnosis and features three members of the therapeutic triangle: the patient, the caregiver, and the physician.

Part 1: The diagnosis (0:00-2:05). The first part opens with a couple that, amid a jubilant celebration, receives an urgent phone call to present to their doctor's office. At their appointment, the physician performs a history and physical examination and subsequently prepares to disclose the patient's diagnosis of a worrisome mass visualized on a chest x-ray. We drew from mudras in the existing Bharatanatyam repertoire to depict clinical objects. For instance, a stethoscope was depicted using katakamukham as the earpiece and the bell, whereas an x-ray was depicted by drawing a square in the air using chaturam.

Part 2: The malignancy (2:05-3:20). The second section represents an interpretation of the physiologic growth and uncontrolled spread of malignancy. Our change into redcolored

garb signifies a switch in character from representing three individuals to three cells. At the beginning of this section, the three cells are depicted as physiologically

normal, dancing in unison with each other. Their uniform vitality is demonstrated with the suchi and alapadma mudras. One cell undergoes a somatic mutation and becomes malignant, gaining ruthless vigor in her dance form. We demonstrate rapid replication of the malignant cell with the mudra kartarimukham. As the malignant cells continue to replicate, they pull resources and grow in their harsh dynamism, portraying the unchecked growth potential of cancer cells.

Although the choreographic intention of this section was to represent a growing malignancy, many of our reviewers provided varying interpretations, including a depiction of the patient's inner anxieties, the therapeutic fight against the cancer, and the turmoil of treatment resistance.

Part 3: The emotion (3:20-5:05). The third and final section returns to the patient, doctor, and caregiver. Here, we explore the nuanced emotional journeys of the three characters as they come to terms with the gravity of a cancer diagnosis. Each has their own moments of grief, fear, recognition, and solidarity. The caregiver expresses concerns of the patient passing, and the doctor struggles with her ability to offer hope. The patient is overwhelmed with denial, anger, and grief. The piece ends in a message of unity, as the patient, doctor, and caregiver embrace their role in this shared journey.

Reflections

What began as an exchange of mudras over coffee blossomed into a reflective process to understand the role of Bharatanatyam within the therapeutic triangle of the patient, doctor, and caregiver. Witnessing how reviewers who were unfamiliar with Bharatanatyam responded to our narrative dance piece shed light on common themes that emerged from engaging with this piece. Here, we describe two key takeaways that surfaced through our own reflections and discussions with members of the medical community. First, we were reminded of the role that visual art

holds in promoting self-reflection and empathy for all members of the therapeutic relationship. Second, facial expressions and body language from the dance narrative resonated with the experience of oncologists and patients in the clinic. The repeating motif of body language served as a critical reminder of the role of nonverbal communication in the therapeutic relationship. In the era of virtual training and medicine, we use performative arts as a reminder to deliberately preserve nonverbal communication when interacting with patients.

Visual arts as a space to process, reflect, and empathize.

Our dance narrative received a range of interpretations, only some of which matched our original intention. These similarities and differences in choreographic intention and audience interpretation demonstrated the power of visual arts in both representing universal emotions and reflecting one's personal experiences. For us as choreographers, the dance studio became a space of contemplation and healing. We dissected the impact of illness on the human body, adjusting our limbs and contorting our faces to embody raw human emotions of pain, anguish, and resilience. As viewers, patients and physicians also expressed moments of reflection

while processing our piece. For example, many physicians discussed how the piece reminded them of the personal toll that repeated delivery of bad news can take on them as a clinician. Although one clinician thought that this difficulty in delivering bad news was best represented by the emotional end of the piece, another felt that this internal turmoil was better portrayed through the middle section that consisted of more intense footwork. Engaging with our dance piece encouraged viewers to recognize certain universal clinical themes while also providing room to reflect on nuanced personal experiences.

As a broader entity, visual arts have often been underrepresented within the field of medical humanities. Searching the literature for examples of visual arts curricula across medical schools across the United States yielded a plethora of prose and painting-based visual arts curricula yet very scarce incorporation of movement-based art.7-10 We propose that dance plays an important role within medical humanities curricula in understanding illness, emotions, and empathy. Movement-based arts promote a sensory experience of illness and an expression of physical and emotional states that cannot be conveyed through words alone.11 With more medical training programs embracing humanities in clinical training, we attest that the visual arts, particularly movement-based art, should also be considered.

Recognizing the value of nonverbal communication. As the COVID-19 pandemic progressed, virtual medicine replaced in-person encounters and masks grew to be a necessary

component of the hospital environment. Like many, we encountered muffled words and frozen facial expressions on Zoom. Faced with the dramatic change in verbal communication as medical trainees, our choreography unfolded into an exploration of the ways in which physical space, facial expression, and hand gestures enhance the clinical relationship.

Early in our choreography, we shared a rehearsal video with our collaborators. Although all immediately recognized the\ role of the patient and the doctor, several felt that something critical was missing. One patient felt that the physical distance between the doctor and the patient was too great, and one physician pointed out the lack of compassionate physical contact by the oncologist. Inspired by these conversations, we re-entered the dance studio and

experimented with the physical space our bodies occupied. We explored nonverbal ways to convey care and concern. In our choreographic revision, we had the doctor place a hand on the patient's shoulder when she was coughing, and we incorporated a stool to allow the provider to be eye level with the patient and increase the portrayal of open communication. Intentionally incorporating the empathetic touch into our choreography increased the perception of care between the doctor and the patient.

In a time where we are forced to embrace virtual care and communication, our choreographic process reminded us of the critical role of nonverbal communication in the therapeutic relationship. We found that physical space, facial expressions, and eye contact are just as integral to the clinical encounter as they are to Bharatanatyam. What we have lost through the screen is the unspoken care held in the extra moment of eye contact, the supportive forward lean

of the torso, and the comfort of a hand on the shoulder. These wordless extensions of care are a cornerstone of patient satisfaction and the therapeutic alliance. With masks and virtual visits becoming potentially permanent fixtures in medicine, we highlight the importance of trainees

and clinicians being deliberate in using nonverbal communicative techniques in caring for patients.

In our exploration of Bharatanatyam within Western medicine, we found that, ultimately, the qualities most coveted in a dancer and a physician are one and the same: a broad understanding of the human body, a deep sense of empathy and humility, and a profound commitment to using body language to support the journeys of themselves and those around them.

Dr. Lidia Schapira: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by ASCO podcasts, which cover a range of educational and scientific content, and offer enriching insight into the world of cancer care. You can find all ASCO shows, including this one at: podcasts.asco.org.

I'm your host, Dr. Lidia Schapira, Associate Editor for Art of Oncology and Professor of Medicine at Stanford University.

Today, we are joined by Dr. Dipal Nagda, medical student at Harvard Medical School, and Dr. Maheetha Bharadwaj, urology resident at the University of Washington. In this episode, we will be discussing their Art of Oncology article 'Mudras in Medicine: A Role for Dance in Appreciating Non-verbal Communication in the Clinical Encounter.'

At the time of this recording, our guests have no disclosures. Dipal, Maheetha, welcome to our podcast, and thank you for joining us.

Dr. Maheetha Bharadwaj: Thank you for having me, Dr. Schapira.

Dr. Dipal Nagda: Thank you for having me. It's a pleasure to be here.

Dr. Lidia Schapira: So, tell us a little bit about the origin for your narrative. You've told us about your collaboration in dance, and your appreciation for what movement and dance can bring to self-expression and to the clinical encounter. But let's start by hearing what brought the two of you also to collaborate on a narrative, a written piece.

Dr. Dipal Nagda: I'm happy to get started on this one. So, Maheetha and I met our first year of medical school and we hit it off right away for a variety of reasons, one of which was that we both shared a training in Bharatnatyam. And so, we had actually performed early in our first year of medical school, a piece for a local performance at Harvard, and then, around the start of the COVID pandemic, which was about two years into our second year of medical school, right in the middle of our clinical rotations, we both found ourselves pulled from the clinical environment, with a lot of time on our hands. And as dancers do, we both turned to dance in our own ways, and collaboratively, to try to find a way in which to channel some of the feelings and emotions that we were having into a creative performative piece. Maheetha, I don't know if you have anything else to add to that.

Dr. Maheetha Bharadwaj: Yeah. No, I think that sums it up pretty well. Just one thing to add is that both of us remember kind of talking to each other about how, when we came back from COVID, right around June of 2020, our clinical experience had changed dramatically, in that, masks were now mandatory. And I distinctly remember thinking about how it was hard for me to hear this one patient who was this 90-year-old woman, and she was a little bit hard of hearing. I just remember feeling that that encounter was just so much more difficult, and Dipal and I have been talking about encounters like these ever since we came back after the first surge of the COVID pandemic. And I think just all of that also kind of led to this idea for this project.

Dr. Lidia Schapira: And so, the project starts with the two of you who are dancers and very aware of the power of movement, again, just for yourselves, right? And you're now thinking about exploring that as a narrative, or as a story, and you chose cancer as your example. What path led you to cancer?

Dr. Maheetha Bharadwaj: I think cancer is a disease that can affect everyone. And I think, I, personally, have had family members affected by cancer. My mom is a palliative care physician. So, talking about cancer and cancer-related illnesses is not new for me and my family. And on top of that, I think the emotional impact of having such a life-altering illness is something that I think was deeply affected by COVID. We saw that patients weren't coming into the hospital, from a surgical perspective, patients weren't getting the treatment that they needed, and those treatments were being put off. And I think that adds a wealth of anxiety to an already very stressful situation. So, I think for both of us, I know that Dipal is really interested in Oncology at the moment, and me, as a Urologist interested in Urol Onc as well, I think that topic really hit home for both of us. And I think it was a great way to kind of also explore the different types of emotions that someone might feel with a life-altering illness.

Dr. Lidia Schapira: So, did you co-create the scenario, the narrative?

Dr. Maheetha Bharadwaj: Yes, we did.

Dr. Dipal Nagda: Yeah. So, I would agree with everything that Maheetha said. And in addition, I think when we were originally thinking about this, we were thinking about dance in the setting of a patient-doctor relationship. And so, when trying to map out the numerous patient-doctor relationships that exist within the field of Medicine, I think both of us felt that within Oncology, specifically, there is that longitudinal component, and there is that, as Maheetha mentioned, that deeply emotional piece, not only for the patient, but for the physician as well, and caregivers. And while that definitely exists in other fields, I think within Oncology was one that we felt would really come alive in a dance narrative, to both explore that collective journey of the patient, doctor, and caregiver and the individual journey of each of those three individuals.

Dr. Lidia Schapira: Well, I can speak for the readers of Art of Oncology and say that we don't disagree with you, we totally agree that there are very strong bonds and that there's an emotional resonance to being a professional caregiver, and of course, of the patient and family members and family caregivers. So, kudos to you for recognizing that.

How does movement affect communication? And how did the experience of that additional layer of isolation, and perhaps masking, and distancing during COVID affect your entry into this world of Medicine and Cancer Medicine?

Dr. Dipal Nagda: That's a great question. First, I think for my specific clinical rotations, I was in an ambulatory predominant clinical rotation site. And so, a lot of the interactions that I was having in my early clinical years were via virtual patient interviews. And I think that is a place where movement really came out, and I found turning to hand gestures. And I also found that there was a certain distance via zoom that the clinician and the patient were trying to overcome, that isn't totally, from what we found through this piece, able to be overcome through zoom. And I think that was really perspective-changing, in terms of realizing the value of movement, and the value of proximity and the distance, and the ways in which eye level, and body gestures, and physical contact really impact that relationship.

Dr. Lidia Schapira: I read in your narrative and in watching your video, sort of the lament for not having the ability to move and touch. And I'm very happy that you're able to express that, and I hope that now that things are more normal, that you have gone back to feeling that you are freer to connect with patients, and with your colleagues, even, through facial expressions and touch.

And so, tell me a little bit about how you view movement as a potential tool in your therapeutic connections with patients going forward at this early stage of your careers.

Dr. Maheetha Bharadwaj: I think that's a fantastic question, and a question that's really important because, in Medical Education, we often talk about the Art of Medicine, which I think, cannot be emphasized more in this time of wearing masks in hospitals. And just as Dipal had said, I also found myself with patients compensating for wearing masks. Patients often ask, "Are you smiling under that mask? Are you frowning under that mask? I can't tell." And the ways in which we compensate, which is, coming down to the level of the patient. So, sitting down in a chair, or sitting down at the edge of the bed with the patient's permission. You know, in pre-op sometimes, I actually remember distinctly doing this the other day, I was on the colorectal service, and oftentimes, colorectal cancer is diagnosed in one day, in one week, and then you have the surgery two weeks later. And patients are just kind of taken for this whirlwind of emotions while they're contemplating chemotherapy versus surgery, and before and after surgery. And so, almost everything happens so quickly, and in pre-op, during the pre-op time, before they go into the procedure, it's amazing how much as medical students having been working in these environments with masks, we have adapted to be able to recognize when someone is anxious, nervous, crying, not crying, sad, happy.

And I distinctly remember this one patient who was very clearly nervous, and I just took a little bit of time before signing her in, checking her consent forms, I just said, "Hey, how are you? Are you okay?" And the gesture was, going to her bedside, just laying an arm next to her hand, in between her hand and her blanket, and saying, "Are you okay?" And immediately, this patient burst into tears. And she said, "I'm not. I was just diagnosed last week, and next thing you know is, surgery is this week." And it's just because the masks are there, it kind of makes me be more aware of what the patient is feeling because I can't immediately tell. So now I'm thinking about it a lot more and I'm trying to understand it a lot more. I'm paying more attention to it. The ways that we compensate is, trying to bring our physical bodies a little bit closer to the patient in order to compensate for the distance brought into that rapport by the masks. And I think that's like really, really crucial.

Dr. Lidia Schapira: It warms my heart to hear you talk like that because instead of viewing this as an impediment, you work extra hard to try to understand the emotion that your patient is feeling, to connect with her or him in that circumstance, and to show some humanity. And it's amazing how much comfort that can bring to a person who is feeling extremely vulnerable and anxious.

Dr. Maheetha Bharadwaj: Yeah. And I just want to add that, I had been taking care of this patient after her surgery for the entire week. I was rounding on the weekend as well, and we discharged her on a weekend. And as I was giving her discharge papers, she burst into tears again. And she said, "It was lovely seeing your face every day. I look forward to seeing your face every morning. It's nice to have that continuity of care." And I did feel that that pre-op interaction made a difference. It 100% made a difference in how she viewed us, our care, and the hospital system itself.

Dr. Lidia Schapira: So, bottle that feeling, and on a bad day, bring it out, and it'll carry you through some of those more difficult moments in medicine.

So, tell our listeners a little bit how the two of you took your dance to a written narrative.

Dr. Dipal Nagda: Absolutely. So, actually originally, when we came up with this idea of a dance, we did not think about sort of the next steps from that original dance narrative. And when we started to show our piece and our choreography to different physicians, but more importantly, I think the patients and the caregivers who watched our piece, who had so, so much, not only input and feedback for us, but their own reflections, and their own takeaways. And what was incredible, was their own interpretations. That really took us for a surprise is, people find different pieces of the visual arc of our dance piece to relate to, to comment on, to help us improve. And I think Maheetha and I both realized that the benefit of visual arts, specifically, this dance piece, wasn't just from doing the dance itself, but from interacting with the wider community of people who are either watching our piece, or providing feedback. And that sort of bridged, for both of us, this idea of, "Let's try to put all of these things that we're feeling into words, into concrete ways in which we can use visual arts broadly in medical education."

Dr. Lidia Schapira: And what was your relationship to the third and senior author in your paper, Dr. Goyal?

Dr. Maheetha Bharadwaj: Dr. Goyal has been incredibly supportive throughout this entire process. I think early on that Dipal and I were looking for mentors who are familiar with Indian classical dance, familiar with Indian culture, but also had a strong passion for Narrative Medicine, for understanding and improving upon empathetic care for patients. We searched and emailed many, many mentors, all whom gave us valuable feedback, and we've acknowledged in our acknowledgement section, but Dr. Goyal for us, really took our vision under her wing and said, "You know, I think what would be great is, if you could show the beginnings of your narrative, whatever rough choreography you have, to patients." And she helped us connect with some of her own patients, and to be able to give feedback on the narrative, and improve the narrative to be perhaps more all-encapsulating, more relatable to a wider group of individuals, to tweak the narrative itself a little bit. I think she's been incredibly instrumental in helping with that, but also shaping our narrative as well, and kind of pinpointing, "What exactly do we want to convey? And what do we want to tell people? What do we want to tell the world?"

Dr. Lidia Schapira: So, what is the take-home message from your narrative?

Dr. Dipal Nagda: I think for me, beyond the scope of what we've written, this project for me, really served as a reminder of the things that matter to me outside of the clinic, and how all of those passions that we have for, Maheetha and I specifically, dance, really not only provide us a reflective outlet outside of the clinical environment, but I would argue it enhanced our performance as doctors, our relationships with our patients, and I think truly contribute to the clinical environment as well. So, I think that's a personal takeaway for me, and a really important reminder as I think about applying to residency in the next step of my life, but then I think broadly, as we are starting to recover from the COVID 19 pandemic, and we're thinking about how to deliver care in both measurable and non-measurable ways, I think there's parts of the clinical environment that matter so deeply that we don't always think about. And for us, it was really non-verbal communication, and body language, and how to keep that authenticity alive. And if we know, you know, as Medicine turns more and more to virtual care, how do we train the next generation of medical providers to really keep some of those aspects of body language, and eye contact, and non-verbal communication really alive in virtual delivery of care. And so, for me, that was sort of the broader call to action.

Dr. Lidia Schapira: Any plans to do more pieces?

Dr. Maheetha Bharadwaj: Absolutely. I think this is just the beginning, and Dipal and I have already talked about different topics that we could do, particularly because, Bharatanatyam, which is the style of Indian classical dance that we have used to choreograph this narrative, has always been heavily tied to religion. And now in the modern days, we're seeing the secularization of this art form, or in other words, the use of this art form and other Indian classical art forms to depict and portray more secular pieces. Pieces that convey aspects of human lives that aren't necessarily connected to religion. And I think that's incredibly important, and you know, Narrative Medicine is a field of its own that I think is very important in order to, as people said, kind of craft the Art of Medicine within you, and within each clinician. And so, we've definitely talked about, for example, having stories about COVID, potentially having stories about erectile dysfunction - topics that aren't necessarily talked about on a day-to-day basis, but are relatable to each of our fields in different ways. And I think the goal of that is to be able to reach people, to be able to talk about topics that are important to people, but people don't have awareness of. To increase awareness, education, and I think there's many avenues we can take. This is just the beginning.

Dr. Lidia Schapira: Well, it's been a pleasure to work with both of you. I'm very impressed by what you have already accomplished. I love hearing your humanistic visions for what good Medicine is, and your contributions to the Art of Medicine. So, thank you so much.

Until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review, wherever you listen. Be sure to subscribe, so you'll never miss an episode.

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Show Notes:

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Bios

Dr. Dipal Nagda is a medical student at Harvard Medical School

Dr Maheetha Bharadwaj is a urology resident at the University of Washington. In this episode we will be discussing their Art of Oncology article

Video Performance: https://youtu.be/Nru_nWiiDXk