Seeing Christina’s World

© MoMA, used with permission. Print in color from Editor’s allotment

A young woman lies in a field, her white dress in stark contrast against the dark house and gray horizon. Her arms are outstretched; her legs appear at an odd angle. Despite viewing from behind, I am nearly certain that her gaze remains fixated on the house, simultaneously appearing so close and yet so far.

When we began our first-year medical school Observation and Interpretation course, I wondered if I would encounter the painting Christina’s World by Andrew Wyeth which hangs at the top of my parents’ staircase. Seeing Christina each time I ascended or descended the stairs led to a profound and intimate familiarity with the piece. I suspected Christina would make an appearance in our course as academic scholarship has been fascinated with her for decades.

Including arts education in medical education as a methodology to enhance clinical observational skills is new, but rapidly growing with promising results. When we view art, the observer’s viewpoint predominates. The challenge with seeing the truth behind the image is to integrate our angle within the artist’s frame of reference. During our course, we asked questions like “What does the color palette suggest about the mood or tone? What aspects are prominent in the foreground and which aspects only come to light after prolonged observation?” When shown a new image, I systematically applied these questions and produced well-thought-out answers, toggling between what I saw and what I thought the artist wanted me to see.

During the final exam, I opened the test and saw the painting I had seen countless times. Considering how to approach the prompt staring at me, my mind started to race. It felt impossible to systematically apply the steps I had been taught and write a cohesive response. Further, doing so felt dehumanizing. Describing the contrast in colors, quality of lines, and shapes would accurately describe the apparent situation at hand, but would fail to describe Christina’s story.

I knew the answer the course directors were looking for. Academics’ allure to Christina’s World perpetuates an obsessive desire with determining her diagnosis. Over the years, historians and clinicians have debated if she had polio or, recently, Charcot-Marie-Tooth disease. However, in doing so, Andrew Wyeth’s and Christina’s vantage points become essentially obsolete. My eyes saw Christina, but they also saw my late Aunt Teenie, who, coincidentally, was also named Christina. An eerie feeling encompassed me while mentally crafting my thematic analysis—this painting fit Aunt Teenie’s narrative too well. Aunt Teenie was kidnapped, shot, and left in a field to die. The gunshot left her paralyzed from the waist down, and for hours, she lay in the field staring at the cross atop a church, hoping someone would find her. I could not see Christina without seeing Aunt Teenie too, enabling me to recognize that this painting was simply a singular representation of the individual. I wondered what Christina thought of this depiction of herself? Did she find it accurate? Comprehensive? And for how long? Who did Christina use to be and, more importantly, who did she want to become when she reached the house on the horizon?

Clinical practice is like a seesaw—a constant balancing act of our beliefs, knowledge, and the information provided to us by the patient. This toggle leads us to believe that only one perspective can predominate and rise to the top, as the other falls to the ground. I was hyperaware of the tension between analyzing the images through my own eyes and through Christina’s eyes. Answering the prompt was my agenda, but what was Christina’s agenda?

Without a doubt, my personal experience influenced the way I saw Christina’s World. Yet, this time, as I constructed my response, I saw the painting in a way I had never before. Previously, I saw Christina as Aunt Teenie. This time, I felt my focus morph and I leveraged seeing Aunt Teenie to help me center Christina and see her more fully. My mind produced new questions like “Did Christina even want to reach the house on the horizon?”

In addressing the prompt, I answered the main question about what I saw and my interpretation. My response keyed the reader into my analysis, like a differential diagnosis: describing Christina as the subject matter and noting salient details of the foreground: her body positioning, her shoes, her pink dress. I checked all the boxes and answered all the questions.

I narrowly avoided falling into a trap.

My response continued as it explored Christina as a person, a subject with a story, and followed Christina’s gaze to the horizon. Solely answering the question would have been satisfactory, and I would have passed. But limiting my response would have been a camouflaged version of objectification and dehumanization. I answered the question, but I challenged myself to ask a better question, allowing Christina to tell her whole story. I stepped away from a sole focus on her presumed diagnosis. Despite my knowledge of the scholarship written on the woman in the painting, I avoided projecting a diagnosis as I knew that the moment I labeled her, I would cease wondering who else she was, and strip her away of all that makes her Christina.

Perhaps the true toggle of humanistic medicine is not that of a seesaw. Centering the patient’s experience requires just that—putting the patient at the center and allowing our experience to serve as guiderails, like training wheels, when we falter.

When we arrive at a diagnosis, does the seesaw stop—leaving the patient up in the air, isolated with no way down? How can we shift our practice to that of a tricycle—allowing our patients to drive their definition of their illness or diagnosis in their own unique way and serve as training wheels, ready to help when they falter? We can start by asking more questions.

Did I need to ask who Christina was and who she would become in my response? No, but I did it anyway. And in doing so, I saw Christina.