Improving medical education: what is the potential role of the humanities?
Introduction
The concept of medical humanities emerged in the US in the 1970s as a result of a growing sense that something is lacking in the understanding of human nature, demonstrated by the approach to evidence and clinical practice1. Medicine has developed, but at the cost of arts and humanities. Many philosophers have critiqued medicine for its logical atomism and have explored the lost dimensions as a result of this approach. The study and incorporation of medical humanities in the curriculum therefore arose in response to a wave of moderate anti-intellectualism present in medicine. However the approach of humanities has been segmented in addressing particular issues within healthcare, like the patient narrative or specific ethical issues, thus failing to challenge the core assumption of biomedicine: viewing the human as a physically embodied collection of atoms in a social context.
Robertson Davies described the physician in ‘The cunning man’ (1994) as ‘men of substantial education, though not always men of wide culture’. This poses the questions of whether the reading of medical students should consist of scientific journals and medical textbooks only, or whether there is an advantage to be gained in comprehending the meaning behind ‘Madama Butterfly’, in being familiar with the overture of Mahler’s Second or having gained an understanding of the harsh realism in ‘Crime and Punishment’. Answering this question is not only an intellectual pursuit but becomes a practical concern in the face of both medical and non-medical publications abounding in stories of dehumanised doctors. One can argue that being humane is as essential to fulfilling the clinician’s responsibility, as are the basic sciences.
Defining the humanities, the humane and the relationship between them
In order to attempt a discussion on the potential role of the humanities in medical education, a clear definition of what medical humanities entail is in order. Gordon defines medical humanities as concerned with ‘the science of being human’, bringing the perspective of disciplines such as history, philosophy, literature, art and music to understand health and illness2. Thus, they aid in overcoming the separation of clinical care from ‘human sciences’, foster interdisciplinary teaching and research with the purpose of optimising patient care. Humanism in medicine is defined by Branch as a ‘physician’s attitudes and actions that demonstrate interest and respect for the patient and address the patient’s concerns and values’3.
The above definitions imply that the study of humanities is somehow linked to the formation of a more ‘humane doctor’. And indeed, Sir Geoffrey Keynes, breast surgeon, believed that humanities have ‘kept alive in my mind the value of imagination in a material world’ and liked to think that this has had an impact on his work on humanising the treatment of breast cancer.
One argument for the humanities producing humanity in their consumers is the mirror analogy4. By engaging with the medical humanities, people are subjected to a vicarious experience and project upon themselves the thoughts and feelings that emerge, similar to seeing one’s reflection in a mirror. This encourages empathy, promotes understanding and provides insight. Humphrey, a promoter of socio-biology, argues for example that the spectator to Anna Karenina’s death provides greater insight into both himself and others, and this heightened awareness increases fitness as an individual member of society. T. S. Elliot sees books as a means of extending our physical limitations: ‘ we read many books because we cannot know enough people’. Additionally, engaging with books and humanities on a whole is subject to the rapid evolution of technology in the 21st century. In a pressured and time-constrained society, there is little incentive to engage in reading a book, even less so with one that provides an acute intellectual stimulus.
It is, at any rate, difficult to argue against the doctor as a Renaissance person as few would object to the image of Leonardo in a white coat. If the assumption that liberal arts make people more liberal holds true, then this establishes humanism as an ideal referent for humane social conduct. The famous counter-argument by George Steiner is quoting the atrocities of the Third Reich: Hitler was a painter and artist, his passion for Wagner was well known, however this did not preclude evil. Nonetheless, this fails to take into account that the defining characteristic of a psychopath is lack of empathy, thus rendering the mere engagement in cultural activities meaningless without critical analysis and self-reflection5. Humanities can indeed develop humane attributes, but this is not accomplished with uncritical engagement alone.
Development of the mind
Zachary Cope classifies the cultural development of the mind as having a cognitive and affective division6.
The affective side refers to the emotional, the empathetic awareness of different experiences, culturing the individuals to see ‘outside the body and inside the mind’. Thereby, humanities further the understanding of human condition and should be seen as integrated, rather than additive to the medical curriculum. Outcomes of medical training have been increasingly summed up as becoming a ‘safe doctor’, but arguably being a safe doctor should include interacting with patients in a perceptive manner with failure of doing so potentially compromising patient care or adherence to treatment. Biomedicine can do harm when it overlooks or marginalizes particular individuals of groups2, who might then credulously turn to alternative medicine, challenging the privileged status of biomedicine and leading to suboptimal care. The reason for why a dramatically increasing number of people prefer consolation and kindness to the perceived physical and psychological harness of modern medicine must be sought.
The pragmatic need for emotional detachment in the practice of medicine should not and does not equate to the lack of feelings. Medical humanities can acknowledge the complex webs of emotion and furnish an outlet for their release. Imaginative works of art for example can be seen as gateways to compassion and empathy. The intellectual pursuit of humanities provides opportunities to experience emotion once removed from the clinical setting, in an environment free of permanent consequences, potentially preparing the doctor to better handle emotions when they appear in medical reality.
On the other hand, the cognitive side seeks to broaden perspectives, fight dogmatism and develop critical thought. Humanities motivate practitioners and students to confront fundamental questions about their chosen field. Answering questions on how art and science interact in medical care, on the role of language, on how cultural beliefs influence decision-making or on how different people experience the same disease allow for experiencing a wide range of imaginative possibilities of encounters that will inevitably occur in the professional life of a doctor. Furthermore, more personal questions of where one fits within the medical profession, how medical practice has historically changed and evolved or how to balance professional and personal demands carry a great value in the personal life of a doctor. Lastly, the cognitive domain of humanities aims to facilitate tolerance for ambiguity and uncertainty, important features in medical practice since its beginning. Eventually, the hope is to dispel the debilitating myth that anything non-scientific is a free-for-all where no man’s opinion prevails over the others.
The value behind humanities
Macnaughton suggests two further ways in which the humanities are relevant to medical education7, partly overlapping with the cognitive and affective components mentioned previously.
The most often quoted is the instrumental role, of introducing problematic life situations with which medical students might be unfamiliar. Thus through literature, once can engage in imaginative identification with the characters. A patient’s experience lies at the core of the poem ‘Ambulance’ by Philip Larkin, while depression is accurately captured in Sylvia Plath’s ‘The Bell Jar’. More modern, personal accounts of terminal illness resonate with physicians and patients alike, as in ‘When breath becomes air’ by Paul Kalanithi.
The humanities help with envisioning medicine as a story. One should recognise that the story of a patient’s illness should not be segregated from the story of their lives. Narrative medicine, or medicine practiced with narrative competence is the ability to acknowledge, interpret, absorb and act upon the stories of others. A patient’s story should be analysed not only at the level of content, but also the level of form, and this can be honed by the study of literature. This would enable the physician to produce more meaning from the same story, by picking up on the use of a certain word or metaphor, by detecting the change in the pace of speech or by noticing the bit of chronology that might be missing in a history. Arguably this can result in a more accurate and complete diagnosis, and eventually a more adequate and prompt treatment. Furthermore the way to engage with the patient narrative can also be shaped by the humanities: away from an attempt to master a fixed story and more geared toward a continuous involvement in a dynamic singular entity.
Drama can shed light on the nuances of communication, both verbal and non-verbal, and this has been partly harnessed within communication skills sessions. The non-verbal intricacies are also transposed through painting. Sir Luke Fides’ famous painting ‘The Doctor’ shows a physician leaning over a sick child with deep concentration on his face, brought forward by the use of light, while the parents are left behind in the dark background. Contemplating the more recent self-portraits of Bryan Charnley and their associated descriptions can provide a gateway into the troubled mind of a schizophrenic and enhance understanding a patient’s experience.
The study of philosophy teaches us how to order our thoughts and construct logical arguments, so that a logical conclusion can be reached at the end. Lastly, the study of history acknowledges change, and can make the student aware of how medical sciences are fundamentally social enterprises. It emphasizes the humane dimensions of the doctor-patient relationship and can construct a useful parallel with diagnosis: history attempts to construct an intelligible and importantly, provisional, narrative from a wide range of sources, process that is remarkably similar to that of arriving at a diagnosis8. Lederer provides a multitude of reasons for teaching medical history as part of the medical curriculum9. History shows that ethics, human research and race can be combined in forceful ways, as in the Tuskegee Syphilis Study, which nowadays forms a valuable lesson in research ethics. Looking in the past also shows how evidence can be manipulated in a fraudulent way, with ensuing profound and long-lasting damage, as in the case of Andrew Wakefield. History can also provide a dynamic perspective on the basic sciences, as part of an evolving historical process, rather than a constant and immobile one. This can highlight the transient nature of medical knowledge and the practicality of staying up-to-date.
While arguably of great use to medical practice, reducing them to mere means to an end would devalue the humanities, even in the context of professional education. The second role that Macnaughton mentions is the non-instrumental one, which can be argued is the humanities’ primary purpose and origin: to reflect human joy and sorrow, celebration and reflection. Intrinsically understanding art not only elevates humans but reminds the doctor of the purpose of his own art, that to enable people to participate fully in life, free from the burden of illness and disability.
When talking about medical education, the preferred term is ‘training as a doctor’ and not ‘being educated’ as one. Furthermore, questions such as ‘what are you training in?’ or ‘what are you training to do?’ are not appropriate for an educational process7. Educational theorist R. S. Peters explains that ‘to be educated is not to have arrived, it is to travel with a different view’. Thus, there is an element to medical education that entails something else, closer to personal development- it is not about what people can do at the end, but what they become as a result of their education. The humanities and what they stand for offer a fine awareness to medical professionals, more attuned to how Henry James saw doctors as being ‘finely aware and richly responsible’. Something that Macnaughton makes a note on is the impression, often encouraged by medical teachers and promoted by the tough entry requirements, that the study of medicine allows for an intellectual and moral superiority compared to the general population. The study of humanities might therefore provide a much-needed ‘counter-culture’ for fostering a better relationship with the outside world. Even more so, humanities actually expose students to the critical analysis of ideas and higher order cognitive challenges, very different from the menial task of committing anatomy, physiology or pathology to memory.
On the cognitive side of Cope’s division, the study of humanities makes more allowance for individual differences, and results in individuals that are better equipped to select a pathway consonant with their interest and long-term goals. Grant even claims that in the absence of humanities, graduates can be seen as educationally deprived, as they ‘don’t know what they don’t know’10. Introducing students to the humanities has the potential of creating pockets of expertise and lifelong interests, being able to provide an informed opinion for colleagues in the future on one hand, and offering a way of coping with the rigors of professional life on the other. However in this shape, the humanities can take the form of a supportive friend, which while definitely being positive, fails to provoke critical reflection and challenge thought.
Medicine being at its core a social enterprise, humanism can be deployed as a rhetorical device to advance almost any ideology. A vivid example is the frequent substitution of medical humanities for disciplines such as medical ethics, decision making and communication skills6. This is an error similar to that of philosophers who discard literature as a form of moral argumentation for being too soft, emotional or specific. Judith Shulevitz argues that this is a mistake as ‘literature reveals the significance of things irreducible to theorems, it protests the tyranny of the abstraction’. The analogy hold true as bioethics has evolved from a speculative discipline into one dominated by principles and rules, helpful for practicing physicians who need pragmatic guidelines to resolve daily ethical dilemmas. Such an evolution, reminiscent of the methods and scope of science is understandable and even necessary, argues Friedman, but tilts bioethics away from the humanities6. Bioethics and humanities should therefore be regarded as equally indispensable, but not duplicative as it is one thing to explore ethical dilemmas in a rather prescriptive and largely consensual fashion and another to focus on the creative work itself, with ethics being but one of a host of ingredients.
Why humanities find themselves at the periphery of medicine
Several arguments have been traditionally brought forth against the universal worth of the humanities4. One can argue that they are only effective when voluntary, that humanism cannot be taught or that knowledge does not entail virtue. Furthermore, there is the idea that real medical progress has been made by science and scalpel, not by cultured physicians pondering on philosophy. McManus can’t help wondering if these arguments don’t perhaps stem from a voluntary ignorance when realising that humanism is actually hard work and therefore represent attempts to dismiss it.
Debatably, the more relevant critiques to the role of anything in medical education are brought by those targeted by it: the students. Shapiro discusses the common reasons why medical students are reluctant to engage with the study of humanities11.
The first critique targets the content of medical humanities and their relevance to the curriculum. Students often perceive the material as being simplistic and common sense, and thus uninteresting and most importantly irrelevant to their medical education. A milder variant of the same relevance argument sees the humanities as enjoyable and even relaxing subjects, but not crucial. Whatever form it takes, the dissatisfaction of the students partly arises from a failure of the educators to convey the importance of the study of humanities. On the other hand, it might partly reflect what Shapiro classifies as ‘intellectual bait and switch’ as students often internalize the study of medicine as an exclusively objective and scientific pursuit, re-enforced by the emphasis on a scientific background as a requirement to entry and then by a hospital culture favouring technical expertise over patient-centred medicine. Thereby when confronted with the study of humanistic subjects, one can experience a sense of injustice in the face of a seemingly unfair course. Even within those who find the study of humanities to be stimulating and relevant, there is still a sense that such pursuits are better left as elective and peripheral components, rather than being integrated as part of a core curriculum.
The second set of critiques addresses the teachers and their methods. Indeed, the culture cultivated in medical education relies on insider (physician) knowledge, with a clear separation from the outsiders (non-physicians). The widespread perception that non-physicians cannot comprehend the realities of clinical practice results in the belief that it ‘seems like they are talking the talk without walking the walk’, as Shapiro puts it. During teaching, the lecturers often open the floor for discussion by saying ‘I don’t know, what do you think?’. This approach is antagonistic to the certainty and foundational expertise that students learn to expect from their medical teachers. Therefore the very ‘softness’ of the humanities poses a threat by forcing an introspective pursuit of vulnerability and uncertainty, possibly leading to anxiety, as there is no universal truth.
Lastly, Shapiro notes the structural critique to medical humanities: there seems to be no good place for them. If placed too early within the course, they are perceived as not relevant, whilst placing them towards the end adds pressure to a year already encumbered by numerous exams. And indeed this is no easy task, as Grant acknowledges the competitive pressure on the medical curriculum10. Not only is the placement in time critiqued, but also the nature of the content. If the content is dense, consisting of heavy lectures and long reading lists it is regarded as overwhelming, whereas lighter, process and discussion based content is seen as vague, open-ended and personal. This creates a ‘catch 22’ situation, hard to escape by its very definition.
Unfortunately, the sparse evidence for their long-term impact does little to help answer the critiques brought to medical humanities12. This may pose a threat to the further development of humanities in the face of pressure to demonstrate educational effectiveness. Clear, prospective longitudinal studies would help in shedding quantifiable, scientific light on a matter of subjectivity.
Conclusion
To recognise the role of humanities in medical education, one must move away from applying the atomist philosophy of Bertrand Russell1. Understanding humans by breaking them down to their ultimate constituent parts is simply not enough in medicine. As William James put it, the ‘first thing the intellect does to an object is to class it along with something else’. Whilst fitting for the physical world, is important to see the centrality on emotion in understanding humans. Psychologist Jordan Peterson builds upon this idea when claiming that in our evolution as humans, we have first and foremost experienced the world subjectively, in an experiential manner. In other words, rationality rests on feeling. Medical humanities can help recreate a compelling vision of human nature and enter our original world of subjectivity and feelings, informed by philosophy, and illustrated in literature and other creative arts. Thus not only do humanities have a role in improving medical education, but they allow for a connection with what makes us intrinsically human. Simply put, experiences speak to us as humans in a way science does not.
The ancient ideal of the humane physician, which I have shown to be linked to the study of humanities, is as important as ever. As long as medicine remains a profession that seeks an authentic social role, the words of Jonathan Miller hold true: ‘Medicine spans the two ends of the art-science spectrum, one foot planted in the physical world (…), the other in the subjective, experiential world of consciousness and conduct’.
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