Medical Humanities and Medical Education

How the medical humanities can shape better doctors

Alan Bleakley

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317676249
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Education

The field of the medical humanities is developing rapidly, however, there has also been parallel concern from sceptics that the value of medical humanities educational interventions should be open to scrutiny and evidence. Just what is the impact of medical humanities provision upon the education of medical students? In an era of limited resources, is such provision worth the investment? This innovative text addresses these pressing questions, describes the contemporary territory comprising the medical humanities in medical education, and explains how this field may be developed as a key medical education component for the future.

Bleakley, a driving force of the international movement to establish the medical humanities as a core and integrated provision in the medical curriculum, proposes a model that requires collaboration between patients, artists, humanities scholars, doctors and other health professionals, in developing medical students' sensibility (clinical acumen based on close noticing) and sensitivity (ethical, professional and humane practice). In particular, this text focuses upon how medical humanities input into the curriculum can help to shape the identities of medical students as future doctors who are humane, caring, expressive and creative – whose work will be technically sound but considerably enhanced by their abilities to communicate well with patients and colleagues, to empathise, to be adaptive and innovative, and to act as 'medical citizens' in shaping a future medical culture as a model democracy where social justice is a key aspect of medicine.

Making sense of the new wave of medical humanities in medical education scholarship that calls for a 'critical medical humanities', Medical Humanities and Medical Education incorporates a range of case studies and illustrative and practical examples to aid integrating medical humanities into the medical curriculum. It will be important reading for medical educators and others working with the medical education community, and all those interested in the medical humanities.

1 Where do the medical humanities come from and where are they going?

DOI: 10.4324/9781315771724-2

The medical humanities in North America

The medical humanities first developed an identity in the USA, where the term was coined in 1948. Barr (2011) argues that American doctors in the 1870s, who had visited Germany particularly to study laboratory sciences, started a long revolution in medical education that was brought to a head by the Flexner Report in 1910 (Flexner 1910; Cooke et al. 2010; Bleakley et al. 2011). Commissioned by the Carnegie Foundation, Flexner’s report exposed a lack of adequate scientific and clinical education across many American medical schools and recommended a root-and-branch overhaul, including the standardization of curricula. Unfortunately, and paradoxically, this led to closures of underfunded schools catering for minority students such that persons of colour and women would for many years find it difficult to gain entry to medical school (Hodges 2005). It is ironic that now women make up approximately 60 per cent of medical school entrants worldwide (Bleakley 2014).

Wujun Ke (2012) offers a standard critical reading of Flexner, suggesting that Flexner’s emphasis on the importance of the biological sciences in early medical education led to a bias towards curative rather than caring medicine, where basic science teachers rather than clinicians have a formative influence on students. Life sciences teachers are the first to shape the identities of students, particularly anatomists who traditionally educate through the ritual of dissection, where clinicians primarily shape students’ identities in the later clinical years. The voiced scepticism of many basic science teachers towards the humanities may contribute to the ‘empathy decline’ of students mentioned in the Introduction – a process by which medical students also develop cynicism (Neumann et al. 2011). New celebratory readings of Flexner, however, suggest that his interest towards ethical and humane practice has been overlooked. Flexner was an admirer of John Dewey, sharing the latter’s democratic and humanitarian values. Garrett Riggs (2010: 1669) suggests that ‘if history is a guide, medical education could be on the cusp of another set of great advances by renewing interest in medical humanities…The time is ripe to embrace the rest of the Flexner Report.’

In 1937, at Vanderbilt University School of Medicine in Nashville, Tennessee, E.E. Reinke (2003: 1058) called for ‘leavening technical [medical] training with a liberal education’. That such a call should be made at all was a reminder of how far medical education had strayed from the ideal of the liberally educated ‘gentleman-physician’ described in the Introduction. Reinke’s article was a call for the development of medical humanities in undergraduate medical education in order to stem the trend, described starkly by Reinke, even in an inflammatory way, of producing the doctor who is ‘a healer of organs’ treating patients as ‘experimental animals’, rather than ‘a doctor in the ancient meaning of the word’.

Reinke’s reminder that a more liberal medical education was sliding into tightly focused technical training is, in retrospect, even more alarming when placed against the background of North American medical schools offering graduate entry programmes. Most students entering medical schools at that time would have previously graduated with a science degree such as biology, chemistry, physics or engineering. However, most students, in the North American tradition of higher education, would also have studied a compulsory humanities introductory course in their early undergraduate career following a mini ‘great books’ curriculum, where critical and liberal thinking would be espoused. In other words, they would not be strangers to ‘thinking with the humanities’. Currently, 15 per cent of entrants to medical schools in North America have a first degree in either social sciences or the humanities (Wershof Schwartz et al. 2009).

Throughout the 1970s, a series of discussion papers developed a critical debate around ‘warm’ humanist medicine in a time of unprecedented explosion of ‘cold’ scientific understanding (Clouser 1971; Banks and Vastyan 1973; Leake 1973; Pellegrino 1974, 1979; Reynolds and Carson 1976), arguing that the traditional bedside art of medicine may be eclipsed as a need for greater knowledge of science crowded out the curriculum. A further group of papers in the 1980s and 1990s brought this debate to a head, already describing a lost era not only of the art of bedside medicine, as discussed in the Introduction, but of humane practice in general, noting the ‘inhumanity’ (Weatherall 1994: 1671) of scientific medicine, including serial objectification of patients.

Sceptics towards the value of humanities in medicine responded vigorously towards these criticisms of medicine’s perceived inhumanity. For example, Wassersug (1987: 317) cynically argued: ‘real medical progress has not been made by humanitarians but by doctors equipped with microscopes, scalpels, dyes, catheters, rays, test tubes, and culture plates’. Such sceptics gained a tactical high ground by demanding that proponents of medical humanities should offer solid (scientific) evidence of impact, placing the burden of proof on the shoulders of those who would characteristically question the meaning of such instrumental ‘evidence’. This challenge is discussed at length in Chapter 9.

Thus, McManus (1995: 1143) suggested that ‘Any serious evaluation of the humanities in medicine… must bite the bullet of definition and measurement, even if it seems to be “defining the indefinable”.’ At this point, the body of orthodox medicine could readily absorb the promised critical sting of the medical humanities. From the perspective of the medical humanities, the ‘bullet of definition and measurement’ to be bitten was also the bullet of sterile experimental science – by definition intolerant of ambiguity – that threatened to kill the fecund and ambiguous body of art.

In this emerging debate about responsibility for providing evidence of the worth of medical humanities interventions, the lesson of Crawshaw’s seminal paper ‘Humanism in Medicine’ was buried. Crawshaw (1975: 1320) had suggested that it was the responsibility of the medical profession to respond to the accusation that it is ‘more mechanical and less human’, where ‘Our ears are bent, our minds filled, perhaps even our hearts weighed with the burgeoning catalogue of iatrogenic problems.’ Such ‘iatrogenic problems’ were identified from cumulative evidence of an unacceptably high level of medical error, as indicated earlier.

Brian Hurwitz and Paul Dakin (2009: 84) note that the historian of science George Sarton ‘first used the term “medical humanities” in the 1940s in the pages of ISIS, a journal devoted to the history of science, medicine and civilization’. In 1951, in a Canadian context, Van Wyck (1951) wrote an article on the role of the humanities in medical education. And in 1952, the first major medical humanities curriculum innovation was established in a North American medical school in the wake of Reinke’s (1937) suggestion mentioned earlier. Case Western Reserve medical school in Cleveland, Ohio overhauled the medicine curriculum over a period of five years between 1952–57 and in this process introduced an optional element of study in the history of medicine (Cook 2010). Case Western Reserve had a history of innovation – in 1852 and 1854 it graduated two women, only the second and third to receive medical degrees in North America. Its curriculum overhaul between 1952 and 1957 was considered radical at the time, integrating basic and applied (clinical) sciences.

Over a decade passed before a North American medical school underwent a major curriculum development of the sort modelled by Case Western Reserve. In 1967, Pennsylvania State University’s College of Medicine developed a unique undergraduate medicine programme biased towards community medicine, ethics and spiritual aspects of chronic illness and care, providing a fertile ideological ground for the establishment of the medical humanities, where the reductive biomedical model was already enlarged to a more encompassing biopsychosocial model. A Department of Humanities, the first of its kind, was established within the medical school (Hawkins et al. 2003), where medical students learned about religion, history and philosophy as these applied to medicine, while literature was added in 1969.

In the same year (1969) The Society for Health and Human Values was officially launched as a membership organization, keeping records from 1970–97 now lodged at the University of Texas medical school at Galveston (Moody Medical Library undated). This was the first professional membership organization internationally for those committed to supporting and developing human values in medicine. In 1998, the Society was merged with the American Society for Bioethics and the Society for Bioethics Consultation to form the American Society for Bioethics and Humanities (www.asbh.org), now a vigorous and flourishing organization promoting scholarship, research and teaching in the twin fields of bioethics and the medical humanities but with a clear bias towards bioethics.

Whereas bioethics and the medical humanities have traditionally been closely aligned in North American medical education, this has not been the case in the United Kingdom for example, where the establishment of ethics and law as compulsory study in the undergraduate curriculum has been seen largely as a separate stream of interest from the establishment of the medical humanities. While establishing ethics in medical schools has often been seen as an instrumental precursor to the development of the medical humanities in the UK, a careful argument has yet to be made about the pedagogical structure of an ethics curriculum being used as a prototype for development of the medical humanities in medical education.

The marriage between ethics and the medical humanities in the medical education curriculum has been more successful in a North American context. In the early 1970s, around 4 per cent of American medical schools taught formal courses in bioethics where by 1994 such courses were compulsory in the medicine curriculum (Fox et al. 1995). Many overlaps were noted between bioethics and the medical humanities, especially in the use of narrative. For example, Tod Chambers (1999) analyses classic ethics ‘cases’ regularly used in teaching as literary, rather than functional, texts. Hilde Lindemann Nelson and colleagues (1997) also outline a narrative approach to bioethics. However, just as a subject such as the history of medicine has its own specialized journals, associations and meetings, so bioethics tends to run as a parallel stream to the medical humanities. In the UK, the British Medical Journal publishes sister journals dedicated to ethics (Journal of Medical Ethics) and medical humanities (Medical Humanities) with little overlap. This carries through to separate associations, conferences and academic communities.

That the landmark events briefly described above occurred is one thing, but why they occurred is of course much more important. Introducing medical ethics to the undergraduate medicine curriculum can be explained as a response to a variety of new ethical problems raised by technological advances throughout the 1960s and 1970s. Advances included a proliferation of new drugs, including those for mental health such as anxiolytics (antipanic and antianxiety) and antidepressants that were appropriated as lifestyle drugs as a replacement for, or in concert with, alcohol. Other advances included in vitro fertilization, organ transplants and readily available contraception.

Beyond medical ethics, why would the humanities be of interest to medical schools during this period? The introduction of medical history seems straightforward, where students should know about the history of diseases as a background to public health and even a smattering of knowledge about the history of their own discipline of medicine – but why humanities such as literature? Drawing on the work of Kathryn Montgomery (then Kathryn Montgomery Hunter), Tess Jones, Delese Wear and Lester Friedman (2014: 2) suggest that academic literary criticism was increasingly becoming interested in the inward-looking intricacies of the text isolated from its historical and cultural contexts. This resulted, in Kathryn Montgomery Hunter’s phrase, in a cadre of ‘intellectually underemployed’ scholars disinterested in the intricacies of intratextual analysis, so that, in the words of Jones, Wear and Friedman, ‘these disenchanted faculty members, along with a growing cadre of newer scholars interested in interdisciplinary education were drawn to medical education as a fertile ground for their ideas and passions’ (ibid.). Hunter (1991a) wrote a key article on this evolving condition (‘Toward the Cultural Interpretation of Medicine’) in the journal Literature and Medicine. But this journal was already nearly a decade old, having been launched in 1982, showing that the convergence between the two disciplines of literature and medicine was already under way. However, literary approaches had not yet gained a foothold in medical education, despite initiatives at Galveston, Texas described below.

Edmund Pellegrino (1972) saw the wave of interest in medical ethics and the first flush of interest in narrative medicine within medical education as a marriage made in heaven, where abstract issues of value (ethics) could now be given concrete focus in doctor–patient encounters and the structures of medical knowledge (diagnosis and treatment) through an ethics–humanities–medicine trialogue. An inaugural meeting of the Institute on Human Values in Medicine (ibid.) considered the value of humanities disciplines for medical education working in concert with medical approaches for mutual benefit. Jones, Wear and Friedman (2014) ask, in hindsight, just how this mutual benefit might work and point to two possibilities. First are the multiple nuts and bolts of narrative knowing, such as close noticing in medical diagnosis as an equivalent to close reading of texts in literature; second is the complex education of a moral practice promising the incorporation of cross-cultural perspectives and social justice into medical work – the first a perceptual sensibility, the second a moral sensibility (or, better, sensitivity). In total, the humanities can offer an education into seeing otherwise.

In 1973, the Institute of Medical Humanities was founded at the University of Texas, Galveston (Jones and Carson 2003) with a bias towards literature and medicine. Anne Hudson Jones joined this faculty in 1979 as one of the first literature professors to teach in a medical school. Where modern medical humanities reinvented the traditional art of medicine, it offered an extension to the study of scientific medicine, but not a critical rejoinder. The introduction of literature, however, potentially offered the medical humanities a clear critical stance, articulating a paradigm of care based on careful appreciation and use of patients’ stories. Narrative-based medicine (Chapter 7) challenged the dominant values of evidence-based medicine, turning attention away from generalized population statistics to the meaning of illness for the individual in context, encouraging a felt response to persons rather than simply a clinical problem-solving mentality.

The North American Journal of Medical Humanities (http://link.springer.com/journal/10912) was launched earlier, in 1979, inviting articles on humanities, social sciences with ‘strong humanistic traditions’, cultural studies and bioethics topics related to medicine and healthcare. The journal is edited by Tess Jones from the University of Colorado at Boulder, a humanities scholar with a PhD in English and a research interest in HIV/AIDS and the arts. Tess Jones is lead editor of the Health Humanities Reader (Jones et al. 2014) published by Rutgers University Press, a landmark publication in the field. The journal she edits now calls specifically for papers from the three areas of medical humanities, cultural studies ...

Table of contents

• Cover Page
• Half Title Page
• Other Title
• Title Page
• Copyright Page
• Table of Contents
• List of figures
• Acknowledgements
• Foreword by Arno K. Kumagai
• Introduction
• 1 Where do the medical humanities come from and where are they going?
• 2 What are the ‘medical humanities’? Definitions and controversies
• 3 The distribution of the sensible
• 4 Empathy and its discontents
• 5 Towards a medical aesthetics: creativity and imagination in medical education
• 6 Close noticing
• 7 Can narrative medicine take the strain?
• 8 Writing out prescriptions: hyper-realism and the chemical regulation of mood
• 9 Evaluating the impact of medical humanities provision
• Bibliography
• Index