Medical Humanities: Education or Entertainment?

November 8, 2007 at 4:46 pm

Medical Humanities: Education or Entertainment?

Commentary by Brian Dolan, Ph.D., Professor of Social Medicine and Medical Humanities at University of California at San Francisco

A few weeks ago, I hosted a workshop for faculty from a number of campuses who work within medical centers and are involved with medical humanities courses or programs. My opinion at that time was that scholarship and courses in the medical humanities needed to be academically rigorous to gain credibility amongst medical educators who are obsessed with defining skill sets, setting objectives, and measuring the "impact" of course content. I was (and am) not prejudging anyone's commitment to academic standards. But if anyone had experience anywhere close to my own, it probably involved meeting with skepticism from within medical centers about the uses, or "value added," of providing instruction in medical humanities in an already overcrowded curriculum. Fundamentally the challenge of maintaining a role for medical humanities seems to lie in balancing the students' desires for freedom of intellectual inquiry with an institutional pressure to herd.

I asked others what kinds of projects are supported under the name of medical humanities in their institutions. Does a jazz session count? Painting? Poetry writing is very popular amongst students, residents and faculty, but why, I wondered, can't that just be called a hobby? On the other hand, we have an "art for recovery" program, and it raises provocative questions and potential data about the importance of humanities-based therapeutic intervention for patient care. Thinking I was playing devil's advocate, I asked why all this had to be brought further into the classroom and formalized, naming specific skills and objectives to be met through such instruction? Might that raise further problems rather than provide increased opportunities for the students? What follows is a paraphrasing of my thoughts and discussions about this.

Would medical students want to pursue course work laden with the requirements that match the rigor and standards set for students geared for a different degree path? Why not, I thought. When I was in college I took electives to see what other fields were all about and I didn't expect to be given a watered-down version. It would be offensive to humanities scholars to ask them to present their subject in a different way to medical students. Esteemed colleagues of mine who hold MDs and teach courses in writing believe in the rigor of course workathey themselves have enrolled in humanities courses and on occasion received other degrees. On the other hand, I repeatedly hear that medical students don't read, so don't assign too much. And is going into Foucault's notion of the "clinical gaze" really necessary? Is there utility in making medical students genuflect to the humanist-theorists in the way that professional humanists need to do for career advancement?

But who said anything about professional humanists (i.e., people with PhDs in history, literature, philosophy, etc.)? I have also been told that medical students will not really pay attention unless the instructor has a MD. They need role models, leaders who will show them that it is OK for MDs to pursue such interests. Also, unless you have been in the clinic, it's hard to share the emotional reasons why humanities are useful. It sounds like it's therapy, I say, a different kind of utility than opening up new research methodologies for reflecting on the complexities of modern medicine. It then struck me that the distinction between "education" or "entertainment" is not absolute but relative to what one wants out of it. The humanities can represent deeply philosophical, pragmatic, emotionally driven and/or entertaining approaches to understanding the human condition and the social relations of physicians, scientists, patients and the rest of the world.

The dilemma of medical humanities is not that it is reduced to a formulaic set of educational goals or dismissed as a form of entertainment, but that it is a "field" with no boundaries, yet apparently centered on each individual. To think and act like a humanist-physician or humanist-scholar requires an understanding of one's relationship to the rest of the world. Whether one is analytical in approach or expressive, a chronicler of the times or a jazz musician, the humanities supports your form of engagement. It seems counterproductive to reduce this to skill sets and the mechanics of cognition. "The medical humanities" is a form of consciousness about all that is educational and entertaining about being human. It embraces what should be the overwhelming commitment of every medical school: to honor art and humanism in medicine, however that is expressed, and by whomever it is expressed. The lesson of medical humanities ultimately relates to respect for others' views, but formalizing that runs the risk of excluding people from that lesson-plan. My feeling now is that medical humanities should not be curricular-bound; it is too big for that. Rather, it should be articulated and supported as part of campus culture, contributed to by everyone who thinks of themselves as a humanist. This does not exclude instruction or "education," but neither does it dismiss "entertainment." In fact, make the elective or non-credit classes entertaining. After all, that might be more important than subjecting students to another test.

Establishing a Medical Humanities Program at George Washington University School of Medicine

September 23, 2007 at 3:17 pm

Portrait of Hippocrates sitting, reading.

Commentary by Linda Raphael, Ph.D., Director of Medical Humanities and Associate Clinical Professor of Psychiatry and Behavioral Sciences

My introduction to medicine and humanities occurred at a Narrative Medicine Seminar in New York in 2003. I was attracted to the seminar because my teaching and writing have focused on narrative theory and representations of the Holocaust in literature and film. Thus, how one tells stories, especially stories about pain and suffering, have long been an interest of mine. I was excited to find physicians, nurses, social workers, psychologists, historians, philosophers, and literature professors gathered to discuss the world of medicine and illness from a variety of perspectives. When I heard Shlomith Rimmon-Kenan's talk, "Whose Story Is it Anyway?" I was convinced by the close reading of a patient's story which had been determined and then narrated by family members and medical institutions that the relationship between the world of medicine and narrative theory was well worth pursuing. At the end of the seminar, I mentioned my interest in developing a course for GWU School of Medicine to Rita Charon, Director of the Program in Narrative Medicine at Columbia’s College of Physicians and Surgeons, whose encouragement was immediate. Both she and one of her colleagues know the Medical Director at GW Hospital and put me in touch with him because they knew he would be interested in humanities and medicine. I then started on an unanticipated and exciting path that led to developing a program rather than one course.

After meeting with the Medical Director I sought out medical faculty who were interested in medicine and humanities. I heard from a professor in the Physician Assistant program with whom I was acquainted about a few physicians on the faculty who would be interested in humanities. One of them discussed the idea with the Dean of the School of Medicine, which led to a meeting with me. Soon after that, I was asked to write a proposal for a program in medicine and humanities. I turned to Ann Hawkins of Penn State Hershey Medical Center, whom I had met briefly at the seminar at Columbia, and then to Kathryn Montgomery, of Feinberg School of Medicine at Northwestern University. Their generous sharing of materials and ideas enabled me to write the proposal that convinced the Dean that I would be able to initiate a small program in medicine and humanities.

My initial appointment was part-time (2005-06). I have worked under both the Dean and the Associate Dean for Academic Affairs. They have been extremely supportive (both have taught in the courses) and have carefully thought through how we can best introduce humanities into the medical school curriculum. They combine a visionary perspective and a cautious understanding of what will work and at what pace we should move. We introduced three electives in medicine and literature - greatly aided by the NYU Literature, Arts, and Medicine data base - for First Year students in their second term. Thirty-five students (approximately one fifth of the class) enrolled, which the deans and I regarded as a very positive sign. The courses were taught by me, the deans, and other physicians (a different doctor at each class session). It has been no problem finding doctors who are excellent and willing teachers. In the summer of 2006 I introduced a humanities session (reading distributed in advance followed by discussion and sometimes short writing exercises) to the clerkships; initially pediatrics, then primary care, and soon all. We have had book groups to which the entire medical school is invited, and I have also gathered faculty who express interest in small groups to discuss a book.

In the 2006-07, the university (Academic Affairs) gave me a grant for five Medical Humanities interdisciplinary seminars (art history, poetry, fiction, etc) and 30-35 townspeople, students, faculty and staff attended each session. The evaluations were positive, and Academic Affairs funded the seminars for a second year (2007-08). In this same year I added sessions with residents; these have included primary care medicine and psychiatry, and soon Ob/Gyn. We have had several book group sessions, some advertised to the entire medical community and others to individuals who have expressed interest in a reading group. The Dean was the first to suggest that we have an all medical school group, and he has continued to be a great enthusiast (and fine reader!). Finally, we now have, in addition to the two courses for First Year students, two courses for Second Year students.

My position is now full-time. Student evaluations for the electives have been extremely positive, and those who take the first-year electives tend to sign up for the second-year offerings. Some students have reported that they would like very much to take a humanities course, but they pass up the chance to take an elective because they worry that they won't have enough time to study their required medical school course material.

The most important factors in the development of this program have been the enthusiasm and generous support from others in the field, a dean who was an English major and who continues to love to read and discuss literature, a medical school that prides itself on training students in the art of medicine, and the national visibility of other programs.

The Craft of Writing: A Workshop for Doctors-in-training

September 9, 2007 at 5:55 pm

A pair of round glasses on a sheet of writing, Wellcome Library, London, Photograph 2004Commentary by Anna Reisman, M.D., Co-Director, Department of Internal Medicine Writers' Workshop, Yale University School of Medicine

In this blog, I'll tell you about a writing workshop for residents at Yale that centers on the craft of writing, and I'll argue that this focus has great value for doctors-in-training.

We created the Yale Internal Medicine Residency Writers' Workshop in 2003 to enhance residents' power of observation, provide a creative outlet, increase empathy, encourage reflection, and, through all of these, to combat burnout. The annual workshop runs for two full days each November and was led by Abraham Verghese in year 1 and Richard Selzer in years 2-4 (Selzer and I will co-run this year's workshop). The participants, mostly internal medicine residents with a smattering from psychiatry, pediatrics, and surgery, submit a piece of fiction or nonfiction prose. We spend a good portion of the time critiquing these manuscripts in detail. Unlike the writing that goes on in other residency programs and medical schools, where the idea is to set down one's thoughts and experiences in ordinary prose (i.e. journal entries, critical incident reports, parallel charts), our focus is on the writing itself: how to relate our experiences, and those of our patients (whether imagined or real), in clear, resonant, interesting, and lively prose. The Department sponsors a Grand Rounds on writing and medicine two months later, as well as a reading for faculty and residents and an annual publication called Capsules that is distributed widely. This year, we created sound files of some of the readings: (http://residency.med.yale.edu/writer.html )

In a study of the workshop, we found some of what we had expected: residents in focus groups reported a heightened awareness of patients' humanity and enhanced self-awareness. What we hadn't expected, and what we believe was one of the key ingredients to the workshop's success, was that the process of sharing writing created a unique camaraderie. The group bonded because everybody was similarly vulnerable.

Does a focus on the craft of writing make better doctors? Or does spontaneous, unpolished writing accomplish the same thing? I believe that there is a role for both in medical training. Informal writing - journal writing, for example - can be a very effective way to process our many often overwhelming experiences. Similarly, sessions devoted to writing critical incident reports can be a way to bring disturbing interactions (that might otherwise never see the light of day) to a discussion format with peers.

Taking the next step - finessing one of these unpolished pieces into a publishable piece of writing - is something else altogether. In the process of reworking the language, the rhythm, the images, the presentation of ideas, the writer must explore the experience more thoroughly in order to make the story logical and clear. For example, my own journal is a rich repository of experience but when I extract a section and prune and shape it into an essay or story, that is when I really start to understand its deeper meaning.

An emphasis on craft will, of course, appeal to a subset of residents who are interested in improving their creative writing skills. But shouldn't all physicians be able to write clearly? I believe that an opportunity to gain tools for expressing one's thoughts and beliefs in a variety of settings — whether writing a story, an opinion piece for a newspaper, or a research study — should not be missed. You can't go wrong with good writing skills.

 

 

The Patients as Teachers, Medical Students as Filmmakers VIdeo Project: The Video Slam

August 13, 2007 at 1:26 pm

Boy looking at camera is the teacher!Commentary by Dan Shapiro, Ph.D., Director, Medical Humanities Program, University of Arizona College of Medicine

Last year I asked 8 medical students to make films about patients. In pairs, they spent 8 months visiting and filming a patient and filming their real lives. They had to make at least three visits (most made 5-6), interview someone else in the patient’s life, go to a medical visit, and capture how the patient adhered, or failed to adhere, to the medical regimen. In fact, they went to home visits, birthday parties, festivals, sat in waiting rooms and met with a variety of health professionals. Then we edited their videos down to 7 minutes and showed them publicly and then in the curriculum.

Here’s the idea behind the project. Our medical school curricula have evolved, but were largely constructed between 1910 and 1950 when most patients presented with acute illnesses. Lengths of stay averaged more than three weeks in some hospitals and the medical trainee could watch, first hand, the entire illness experience from start to finish. Now, we spend 75% of our health care dollars on chronic illnesses and yet our trainees only see a smidgeon of the patient’s life.

In 1987 I was diagnosed with Hodgkin’s Disease and spent the next five years in and out of treatment. I had a few relapses, a bone marrow transplant, and more chemotherapy and radiation than one person should be allowed to enjoy. Along the way, I met a lot of physicians. While they were pleasant and competent, few had any idea of what it was like to live with the disease and its harsh treatments. And if they’d had a better idea of what it was really like to live with illness — they could have done a better job of preparing me for the predictable psychological and physical challenges I endured.

So, a few years ago I was editing a home vacation movie (new macintosh software gave all of us access to great editing software) when I noticed that there were things on the tape I hadn’t seen when I’d been taping the experience. I also observed that the act of editing is time consuming and requires careful thought — creating an organized narrative means understanding the important and less important parts of a person’s story. That’s where the idea came from.

We made four brief films including a woman with metastatic breast cancer, a young man with AIDS, a family coping with juvenile onset diabetes, and a woman living with a head injury, status post motor vehicle accident 25 years ago (in which her daughter was killed). While 8 data points are hardly convincing, to a person the medical students described this is as highly impacting experience and as of this writing I have 19 students signed up for this year’s project. They’ll likely work in groups of two or three.

Consider some of the issues portrayed on the films: Some are practical, such as, How do you get a six year old child to take a needle regularly? Which approaches to adhering to complex mediclal regimen work the best? And some are psychological, such as, How do you cope with the question of why me? How do you keep going when you’re convinced you’re about to die?

Here’s the bottom line:
Until our medical training systems realign to focus more energy on prevention and care of the patient with chronic illness, it behooves us to invite articulate patients to teach our students — our physician teachers have part of the story AND our patient experts have part of the story.

I’ll step off this little soap box now. Thanks for reading my diatribe.

Video excerpt at public TV station, KUAT website

Please send comments and questions to this blog, and feel free to e-mail Dan Shapiro at shapiro@u.arizona.edu