Medical Humanities - Initiating the Journey at Xavier University School of Medicine

August 26, 2014 at 11:30 am

Dr P. Ravi Shankar has been facilitating medical humanities sessions for over eight years, first in Nepal and currently in Aruba in the Dutch Caribbean. He has a keen interest in and has written extensively on the subject. He has previously written several pieces for the Literature, Arts, and Medicine blog.

I have always enjoyed facilitating medical humanities sessions right from the time I facilitated my first voluntary module for interested students at the Manipal College of Medical Sciences, Pokhara, Nepal in 2007. The energy level during the inaugural module was incredible. The participants, both students and faculty, and I really enjoyed the evening sessions and the feeling of freedom and discovery as we did various activities and discussed different issues. We had a lot of fun.

When I joined Xavier University School of Medicine (XUSOM), on the beautiful island of Aruba in January 2013, the Dean, Dr Dubey was keen that I facilitate a medical humanities module for the undergraduate medical (MD) students. The school had just shifted to an integrated, organ system-based curriculum from the traditional discipline based model common in offshore Caribbean medical schools. Didactic lectures were the main teaching-learning methodology but the school was working towards introducing small group activities and problem based learning sessions. I decided to facilitate a short medical humanities (MH) module for the incoming first semester students.

At that time the school had only lecture rooms and a traditional desk and chair seating arrangement. Luckily the desks could be rearranged, and I conducted my first session in the lecture hall with the students arranged in four small groups. Some of the students had completed a premedical course of study in the institution and were only familiar with lecture based-teaching. Small group activity was something new for them. Medical humanities do not occupy an important position in the United States Medical Licensing Exam (USMLE) Step 1, and students in Caribbean medical schools focus on step 1 preparations. Subjects which are not tested or tested less in step 1 are not considered important. MH is thus not commonly offered in offshore schools.

The first group of students: I concentrated on six topics for the inaugural and subsequent medical humanities modules. These were empathy, the patient, the family, the doctor, the patient-doctor relationship, and the medical student. The modules were activity based and I used case scenarios, role-plays, debates and paintings to explore different subjects. The learning objectives of each session were listed in the study outline posted on the class server and also highlighted at the beginning of the sessions. For example, for the session 'The doctor' had these objectives:

At the end of this session students will be able to:
•Obtain a perspective on what it means to be a doctor
•Explore balancing a meaningful personal life with a busy and rewarding professional career
•Understand 'certain' influences and pressures on a doctor today
•Interpret the changing role of doctors through paintings and stories

Certain students enjoyed the freedom and flexibility offered by the module while others tended to 'misuse' the freedom. I had a few disciplinary issues which I had to deal with carefully as I did not want students to feel intimidated. I did not confront the students with disciplinary problems during the class but had a quiet word with some of them after the session. The formative assessment rubric addressed issues like attendance, punctuality, discipline and commitment and students who worked harder and showed greater commitment performed better in the assessment. Also for each session each small group had a group leader who was responsible for keeping the group active and focused on various tasks. The role was rotated during different sessions. I wanted them active, focused and interested in the activities and the subject. Among the various activities employed, students eventually did well in interpreting paintings and in the debates. The role-plays however needed more work. They often did not explore the issues in sufficient depth and students felt inhibited to act out certain scenarios in front of their classmates. This was in contrast to the students in Nepal who had enjoyed the role-plays with their skits and acting became richer and more complex as the module progressed.

Two of the role-plays I introduced were:
1. Ms. Mohini is a 28 year old lady from South Asia who was trafficked and was compelled to become a commercial sex worker. After ten years of service she was sent back to her country and village as she became HIV positive. The disease is at an advanced stage and she has no money for treatment. Her family has reluctantly allowed her to stay with them but is not happy that a retired prostitute is living with them. Explore what it means to be sick using a role-play. (Used during the session 'What it means to be sick')
2. Dr. Richard is an Internal medicine specialist in Toronto. He has been treating a twenty-two year old college student named Rachel for the last five years. The lady suffers from severe attacks of migraine and is on drug prophylaxis. Richard has realized that he is in love with Rachel. He wants to live happily ever after with her. However, he is not sure about whether it would be correct for a doctor to marry his young female patient. Analyze the issues involved using a role-play. (Used during the session 'The patient-doctor relationship')

Among the different cohorts of first semester students I found the fall 2013 and the spring 2014 cohorts to be the most interested and active (XUSOM, like most offshore Caribbean medical schools, admits students three times a year in January, May and September). These students created interesting role-plays to explore various issues based on the scenarios provided. The debates and the interpretation of paintings were also rich and varied. I enjoyed facilitating these groups. These two cohorts had a few students who were active, dynamic and committed and with good leadership skills. They were able to motivate and stimulate their colleagues to give their best. They also had good acting skills, which was useful during the role-plays. With greater exposure to small group learning these cohorts were more comfortable with group work and the academically stronger students were more willing to support students who were less strong academically. Class sizes at XUSOM are small and till date around 90 students have completed the program.

Co-facilitators:

At XUSOM many students, though American or Canadian citizens, are of South Asian or Middle Eastern descent. There were no major cultural and other problems involved for me in facilitating this group of students. Many students were interested in this new perspective and in understanding the art of medicine. XUSOM also offers courses in English and scientific communication to premedical students and the faculty members teaching this subject eventually joined me as co facilitators during the module. They were from a liberal arts background and were able to offer a 'different' (often a layperson) perspective during the various activities and the discussion. A challenge I faced similar to Nepal was that not many 'medical school faculty' were interested in MH and in co-facilitating the module, though two or three did attend certain sessions.

Small group learning room and other developments:

Over the preceding twenty-month period MH has become an accepted part of the school curriculum. The school created a separate room dedicated to small group learning with comfortable seating, white boards, flip charts and projection facilities. The room is now being used for various small group activities including problem based-learning. Slowly there is a greater number of small group learning and self-directed learning activities at the school. MH is now an established discipline at the school and the module is a part of the patient, doctor and society module for first semester students. Students' ability to show empathy, make their patient feel comfortable and obtain a proper history is assessed at the end of the first semester using standardized patients. Students also visit a local general practitioner every fortnight to learn history taking skills and interact with patients. I am sure MH will progress and grow in the sunny, hospitable climate of the one happy island of Aruba in the Southern Caribbean.

You can learn more about the MH modules in a forthcoming article in the Asian Journal of Medical Sciences titled 'Four semesters of medical humanities at the Xavier University School of Medicine, Aruba.' (in press)
Photos courtesy of Dr. P. Ravi Shankar

Four Years of Medical Humanities in Nepal: What Worked and What Did Not

September 12, 2010 at 2:56 pm

Everest region: Living in harmony with nature. Photograph

Commentary by P. Ravi Shankar, M.D. and Rano Mal Piryani, M.D., Department of Medical Education, KIST Medical College, Lalitpur, Nepal

In previous articles in the Literature, Arts, and Medicine blog we discussed sowing the seeds of Medical Humanities in the Himalayan country of Nepal; teaching Medical Humanities (MH) in English which, though the language of instruction, is not the native language of the participants; and also the challenge of creating and maintaining participant interest in MH.

MH was started as a voluntary module at Manipal College of Medical Sciences (MCOMS), Pokhara (1) and then we (PRS and RMP) conducted modules for faculty members at KIST Medical College (KISTMC), Lalitpur. In 2009 and 2010 we conducted modules for first year students at KISTMC. In this blog article we describe what in our opinion worked in the four modules and what did not and reflect on possible reasons for the same. Our experiences may be of interest to other MH educators, especially in developing countries.

What Worked

Small groups:

Small groups worked well in all four modules we organized and are an excellent way to learn MH. Small groups work together at a given activity and share ideas. In MH, unlike other more formal medical subjects, there may be no particular well defined solution of a problem. Participants mainly reflect on a painting, a case scenario, or a problem and share their views. In social sciences as opposed to the biological and physical sciences there may not always be a 'particular' way to solve a problem. One problem we faced was that not all members of small groups were active. We could only gently nudge the reluctant individuals into more active participation. We tried giving participants greater responsibility for self-managing small groups. We asked the groups to select from among themselves a group leader, a time keeper, a recorder and a presenter and rotate these roles during different sessions.

Paintings:

Paintings were a great success. We incorporated them more and more in successive modules. We have described our experience of using paintings in MH in a recent article. (2) Our major source of paintings was the Literature, Arts, and Medicine Database maintained by New York University. The database arranges literature excerpts, paintings, and videos according to different subject categories. Online access to photos of paintings and their annotations were useful. Participants were able to relate to the paintings, which were mainly from a western context. In Nepal only students from a science background take up medicine and most were not previously exposed to art appreciation and critical analysis of paintings. Most participants enjoyed the paintings but also recommended more use of art from Nepal.

Case scenarios and role-plays:

These were extensively used throughout. The case scenario usually had an ethical or a social issue which had to be explored wit role-plays by participants. A variety of issues such as diseases with social stigma, abortion, euthanasia, mental illness, patient confidentiality-among others-were explored. Student participants enjoyed role-play and interpreting different scenarios. Students brought out many issues and sometimes interpreted the scenario in a novel manner. Role-plays in KISTMC also served to bridge to a certain extent the language barrier as they were conducted in Nepali, the national language. We also introduced an exercise of interpreting scenarios depicted in paintings using role-plays, which was extremely popular with students. Interestingly, participants of the faculty module had problems with certain role-plays dealing with sexual and reproductive issues.

Debates:

Debates were used to explore certain issues in MH, for example, euthanasia, whether students from non-science backgrounds should be allowed to take up medicine, the nature of the doctor-patient relationship. Participants enjoyed debates but due to time constraints, full fledged debates-which require more thought and deliberation-could not easily be organized. Debates were more effective in the recently concluded MH module (2010). Students showed greater interest in the module as evidenced by their greater participation in group activities and high attendance (above 80%) even before assessments. In light of our previous experience, we modified the format so that the group/s speaking for the proposition would first put forward their points and then the group/s speaking against would counter those points. In addition to arguments prepared during the ten minutes allotted to the activity, students also had to oppose arguments put forward by the opposing group/s on the spot. We concluded that debates can be a good way to explore controversial issues.

Flip charts and flip boards:

These have the advantages of flexibility and ease of use. Flip charts are an excellent way for noting down the results of small group work and for small groups to present their findings to the whole house. We have been using flip charts effectively during Pharmacology practical sessions. During MH sessions flip charts were used to note main points and by presenters to guide their presentations. Flip charts are an excellent way for noting down the results of small group work and for small groups to present their finding to the whole house. On reflecting after the sessions it was our opinion that participants used flip charts in the same manner during both MH and Pharmacology practical sessions. Flip charts could have been used in a more creative manner during MH sessions. Certain groups did so but we could have developed and given guidelines to the groups. Creativity also may require a certain amount of artistic talent and ability among group members.

Venue of the sessions:

All student sessions were conducted in the college auditorium. The auditorium offers an empty space about 30 m x 30 m which can be arranged and organized to meet specific requirements. Students could be arranged in small groups with a separate area for role-plays and a main projection area. The only problem was the auditorium was being used for a variety of activities and we had to rearrange it before each session. A free area that can be reconfigured and rearranged to meet specific requirements is ideal for small group sessions that require creativity and flexibility, unless you can get a dedicated area for sessions, which can be difficult in developing nations.

What Did Not Work

Literature excerpts:

Literature excerpts have been widely used in MH sessions in the west. In the module at MCOMS, Pokhara, and in the faculty module at KISTMC we used literature excerpts. The excerpts were in English and participants often felt they were difficult to understand and the language was difficult. In MCOMS the participants were multinational. In KISTMC the major problem was getting literature excerpts in Nepali relevant to MH and the particular topic being covered. For English excerpts the Literature, Arts, and Medicine Database made the task easier as excerpts were arranged according to subject matter. We did not use literature during the two student modules; however, considering the complexity of issues which can be provoked and addressed by good literature we are thinking about how to incorporate it in future modules.

Reflective writing assignments:

MH is basically a process of reflection about various events in medicine. Reflective writing can be a good method to get participants to reflect. We tried giving reflective writing assignments to participants, but only participants in the MCOMS module, which was voluntary, were regular in submitting their assignments. Assignments were not used in the faculty module. In the 2009 student module submission was irregular. In the 2010 module students submitted more regularly. In South Asia compared to the west students are younger and less mature when they enter medical school. There is a dichotomy between arts and science in the education system. Creative writing and keeping a personal diary are not very common. These could be reasons why students were not very comfortable with reflective writing. However the interest and participation of the 2010 batch gives us hope that this could be a modality to be considered in future.

Medical Humanities online:

We created a medical Humanities group on the web (a private Google group). Slides of various topics, other material and selected publications related to MH were uploaded. There is also a discussion forum where individuals can discuss and comment on various topics. Participation in the group is voluntary. We invited selected faculty and other experts and sent an invitation to all students who participated in the module. Problems of net access, lack of time, and a hectic academic schedule were cited as possible reasons for not joining and not being active in the group.

Creating interest among other faculties:

Over the four years of MH only few faculty members were interested in being module facilitators. During the 2009 student MH module six faculty members from various departments joined as co-facilitators. Many of them were not entirely comfortable with small group learning and with using art and role-plays in medical education. Many were clinicians and their tight clinical schedule could have been a hindering factor. During informal discussion with western MH educators a factor which emerged was only faculty with a personal interest in the arts or with a hobby related to the arts like photography, painting, sculpture and creative writing may be interested in MH. Lack of success in creating new facilitators may be a limiting factor for the module in future.

Creating linkages with persons outside the traditional world of medicine:

In the west MH programs use resources and facilities from many sources. Artists, writers, philosophers and others have made a significant contribution to MH. In the west most medical schools are in a University sharing a campus with other disciplines while in Nepal medical schools usually exist in isolation. We were successful to a certain extent in that we wrote about using art in the education of doctors for a Nepalese magazine and created a certain amount of interest among people outside traditional medicine. The challenge will now be to transform interest into action.

The situation in South Asia is in many ways different from the west. Also batches of students and individuals vary in their interests and aptitude. Tailoring a module to meet the aspirations of groups and individuals is a challenge. Flexibility and an open mind could be important in meeting the challenge!

References

1.Shankar, P. R. A voluntary Medical Humanities module at the Manipal College of Medical Sciences, Pokhara, Nepal. Family Medicine 2008; 40: 468-70.

2.Shankar, P. R. and Piryani R. M. Using paintings to explore the Medical Humanities in a Nepalese medical school. BMJ Medical Humanities 2009; 35:121-122.

Creating And Maintaining Participant Interest In The Medical Humanities

October 28, 2009 at 3:39 pm

Everest region: Living in harmony with nature. Photograph

Commentary by P. Ravi Shankar, M.D., Department of Medical Education, KIST Medical College, Imadol, Lalitpur, Nepal

In previous blog articles I looked at medical humanities teaching in Nepal, explored the link between trekking and the medical humanities in a Nepalese context, and discussed the benefits and disadvantages of English as the language of medical humanities teaching. In this article I will share my experiences of creating and maintaining interest in the medical humanities (MH) among student and faculty participants in two Nepalese medical schools.

The voluntary module at Pokhara

At the Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal a voluntary module was conducted for interested students and faculty members. (1, 2) Students from the third semester (basic sciences) and the fifth and sixth semester (clinical sciences) participated. Interested faculty members also joined the module.

Interest about the module was created through interactions at individual and group level with students and through posters and notices put up on the notice boards and prominent places on campus. (3) Students were invited to 'try out' the module for one or two sessions. If they found the module interesting they could continue- otherwise they could opt out.

Sessions for basic science students at Pokhara

The sessions for the third semester students were conducted during the afternoon lunch break. Each session was of 30 minutes duration. The number of students was small, not more than eight and they were highly motivated. Due to various problems sometimes students could not attend the sessions. I decided to be flexible over attendance. The module used small group, activity based learning strategies. Literature and art excerpts, case scenarios and role plays were used to explore the subject. The students were particularly interested in using role plays to explore various scenarios.

Creating a sense of belonging among the group of students was important. On occasions I distributed 'Thank You' notes to the students which had a photograph of a particular location in Nepal, very scenic country. Periodic assessments of the participants were carried out by the facilitator and constructive suggestions for improvement provided where required. We had a get together over tea and snacks at the end of the module. Group photographs were taken and the students were given a letter signed by the Dean of the institution and myself stating the various skills they had acquired during the module, as well as a certificate of module completion. The specific skills acquired were an appreciation of the patient perspective on sickness and health, awareness of the effect of sickness of a loved one on the caregiver, ability to break bad news gently and humanely, understanding of the patient-doctor relationship and recent developments on this topic, knowledge of the process of obtaining informed consent from the patient/patient's legal representative, and knowledge of the complex issues underlying abortion among others. Students were informed that they and their seniors on the clinical side were the first MH students in Nepal and their inputs and feedback would be useful for conducting future modules.

Sessions for clinical students at Pokhara

The sessions for the fifth and sixth semester students were held two days a week after 7.30 pm. Extra sessions were conducted when required. My colleague, Mr. P. Subish was kind enough to offer the meeting hall of the Drug Information Center (DIC) for holding the sessions. The place was comfortable and quiet and offered a relaxed and protected environment for the participants. The participants were interested in using role plays to explore issues in MH. They were also interested in using debates to explore controversial topics. The inputs and knowledge of the faculty participants was useful. Tea was served during the sessions. The discussions were free and frank and the teacher-student relationship was friendly. With the passage of time, the sessions became an intellectually stimulating get together of friends and colleagues. We had fun while learning!

'Thank you' notes and regular constructive feedback were provided to the participants. The participants also assessed the facilitator periodically. The sessions were conducted using a small group format. All the participants were staying on campus or nearby and the sessions could go on till late at night (around 10 pm). Pokhara is a small city and shuts down early except at the tourist hub of Lakeside. Though the module was not included in the formal curriculum and had no marks allotted to it in the examinations, the participants were beginning to understand the importance of the subject for their future practice.

Students who participated had an understanding of what sickness meant to the sick person and his/her family. They were able to consider sickness in the context of social, economic, cultural and family background of the sick person. In the hospital they witnessed the process of obtaining consent for various procedures and as they had already designed an informed consent form and discussed various aspects of the process of obtaining informed consent they were better able to understand and appreciate the importance of the procedure. During their Psychiatry posting they were more comfortable dealing with mentally ill persons and obtaining a psychiatric history. They had developed a historical background regarding improvements in the management of the mentally ill in Western countries and strongly felt the management of the mentally ill in health institutions and in Nepalese society as a whole should improve.

In Nepal for a long time abortion was illegal except in certain circumstances. Recently abortion has been legalized and women occasionally visit the Gynecology OPD at Manipal Teaching Hospital seeking abortion. Students who had taken the module were better able to understand various issues underlying abortion and the far reaching psychological effects it can have on the women and their families. Following the module students were more comfortable discussing issues of human sexuality. Nepal is a conservative society and these issues are not generally discussed; there is a great deal of secrecy and embarrassment associated with sexuality. Students who completed the module were able to discuss these aspects during history taking with patients and were able to put the patient at ease about these 'sensitive' topics.

Module for faculty members at KISTMC

KIST Medical College (KISTMC) is a new medical school in Lalitpur district of Kathmandu valley, Nepal. The management was interested in further developing humanistic qualities among doctors and faculty members of the institution. An Internal Medicine specialist, Dr. Piryani, was interested in MH and joined me as a co-facilitator. . The experience of the MCOMS module was useful in developing a module. The module was conducted during Sunday afternoons. (Sunday is a working day in Nepal where Saturday is the weekly day off.) The sessions were held in the 'Doctor's room'. We used PowerPoint slides to link together various activities and different aspects of the presentation.

I was apprehensive about dealing with faculty participants. The group was very diverse with basic science faculty, physicians, surgeons, dentists and medical and dental officers. Initially the module was conducted in a similar fashion to the pioneering one at MCOMS. However, the faculty members were not comfortable with role plays and felt it was childish. They were uncomfortable openly discussing issues of human sexuality. (4) They wanted the sessions to more closely reflect various issues and problems they encounter in practice. Regular participant feedback was obtained at the end of each session and informal feedback through interaction with participants.

Based on their feedback we decided to change the nature of the sessions. The number of role plays was reduced and group work and presentations were used to explore MH. During the session on 'Dealing with the HIV-positive patient' an example of group work given was 'Should HIV-testing be made mandatory before surgery in KIST Medical College? Should other patients in the ward be told that a particular patient is HIV-positive? Should commercial sex workers be registered and HIV testing be made mandatory for Commercial Sex Workers?'

KIST Medical College at the time had just started hospital operations and we wanted to obtain guidelines and standard operating procedures for the hospital also. Certain protocols linked to topics covered during the module were developed for further discussion. The group work and the activities were designed keeping in mind that participants were clinicians and faculty members. Another activity was as follows: 'An HIV-positive patient has been admitted in KIST Medical College. A batch of first year students has come to your unit for their weekly clinical posting. Chalk out a plan of action regarding how you will use the patient to teach students about dealing with the HIV-positive'. The presentations were about various procedures and mnemonics developed for 'Breaking bad news' and their applicability in Nepal, the effect of modern psychiatric medicines on the management of the mentally ill, and the effect of the prolonged conflict in Nepal on access to health facilities among others. Presentations were on medical humanities topics of importance in daily practice.

The literature excerpts were felt to be difficult by the participants and were discontinued. Each session concluded with a summing up by the facilitators regarding why the particular topic was important to practicing clinicians and medical educators.

Module for students at KISTMC

The author gave a presentation about MH to various faculty members (especially new members) and the college management. A case was made for teaching MH to medical students. The management was supportive and a MH module was started for the undergraduate MBBS students of the institution in February 2009. The module was planned using the experience gained at MCOMS and at KISTMC. Valuable inputs were offered by international experts like Dr. Johanna Shapiro and Dr. Huw Morgan. Dr. Morgan was a cofacilitator for certain sessions.

The module is held every Wednesday from 8 am to 9.30 am. A big room at the top floor of the hospital is used for the sessions. The room gives us the flexibility to arrange seating according to our requirements. Mikes and speakers and a central area for conducting role plays are present. Flip charts and the LCD projector are used. The students are divided into various groups. Considering previous feedback literature excerpts are not used. To explore MH, paintings-which do not have the cultural and linguistic barriers associated with literature-are used, as well as group work, case scenarios, and debates.

The module is activity-based and all 75 first year students attend. Considering the large student number and the need to develop new facilitators for this and future modules, six clinical and basic science faculty members were selected as cofacilitators. Various innovations have been carried out during the module to maintain participant interest. Music I feel is a powerful means for exploring MH so songs and music are part of the session these days. We have devised an activity where the student group sign a song or recite a poem about a scene depicted in a painting. The facilitators often join in! Most sessions have an 'Open Space' (Khula Manch in Nepali) were the participants recite poems and sing songs on various topics.

Thus I have used a variety of approaches to maintain interest in Medical Humanities among both student and faculty participants. It has been a challenge to maintain interest in a subject which is not a formal part of the curriculum and which is not assessed. However, I have relished taking up the challenge!

References:
1. Shankar PR. A voluntary Medical Humanities module at the Manipal College of Medical Sciences, Pokhara, Nepal. Family Medicine 2008; 40:468-70.

2. Shankar PR. A Voluntary Medical Humanities Module in a Medical College in Western Nepal: Participant feedback. Teaching and Learning in Medicine. 2009;21:248-53.

3. Shankar PR. Running a voluntary module - Personal experiences. Journal of Medical Sciences Research. 2007;2:55-58.

4. Shankar PR. Design the shoe according to the foot! The Clinical Teacher 2009; 6:67-8.

English As The Language Of Medical Humanities Learning In Nepal: Our Experiences

April 22, 2009 at 9:17 am


Commentary by P. Ravi Shankar, M.D. and Rano Mal Piryani, M.D., Department of Medical Education, KIST Medical College, Lalitpur, Nepal

A previous blog (Shankar R., Medical Humanities: Sowing the Seeds in the Himalayan Country of Nepal). and journal articles (1, 2) described medical humanities modules at two Nepalese medical schools. Here we discuss some aspects of language choice when teaching medical humanities to participants.

Language is a touchy issue among students. Many Nepalese medical schools admit students from Nepal, India, Sri Lanka and few students from other countries. Most Nepalese students have Nepali or Nepal Bhasa (Newari) as their mother tongue. The Indian students speak a variety of languages; however, Hindi is the national language of India. Neither group is favorably disposed towards the other's language. English is the medium of instruction and is accepted by all (students and teachers).

Multiplicity of languages

The multiplicity of languages spoken in South Asia creates its own set of problems. Often the language of the dominant ethnic or religious group or of the majority of people is selected as the national language. However, the minority groups are often decidedly lukewarm towards this 'national language' and feel they may be at a disadvantage compared to 'native speakers' with regard to the national language. English often steps in as a compromise language. Due to the British legacy English is a familiar tongue and is also not the 'mother tongue' of South Asia's various ethnic groups. Only a very small minority have English as their native language. So all groups have an equal status as regards English and the issue of language can be resolved amicably at least for a certain period.

Language of higher education

English is the language of higher education in Nepal. Classes are conducted in English in universities and colleges. The language of interaction in the classroom may be Nepali or other languages. Also often the slides and other audiovisual materials are written in English while the subject matter is explained and discussed in a mixture of English and Nepali. Certain posh English medium schools in South Asia insist that students use only English within the campus to ensure that they become more familiar with English, especially the spoken language.

Language of teaching the Medical Humanities

A voluntary Medical Humanities module was conducted at the Manipal College of Medical Sciences, Pokhara, Nepal (1, 2). The majority of student participants were from two countries, Nepal and India. Literature and art, case scenarios, group work, debates and role plays were used to explore various aspects of the humanities. The debates and role-plays were conducted in English and language did not seem to act as a barrier to communication. The only problem noted was with literature excerpts. The English was felt to be tough on occasions by the participants and they had difficulty identifying with the situation depicted in certain excerpts.

The authors had conducted a module for faculty members and medical/dental officers at KIST Medical College, Imadol, Lalitpur, Nepal which also used English as the language of learning. The difference from MCOMS was that most of the participants were Nepalese. The authors used 'different' literature excerpts keeping in mind feedback from the participants of the Pokhara module. The excerpts were simplified. However, again the participants had problems with certain of the literature excerpts. Language difficulty and inability to identify with the situation depicted were again cited. The role-plays were conducted in Nepali and the group work was presented using a mixture of Nepali and English. As is common, the writing was in English but the presentation often in Nepali!

Art as a substitute for literature

At present, the authors are conducting a module for medical students at KIST Medical College. Six of the faculty participants of the previous module have joined as facilitators for the student module. The module again uses English as the language of learning. Keeping in mind previous experiences, the authors are not using literature excerpts in the module. It has been our consistent observation that painting and art has the ability to overcome linguistic, cultural, social and other barriers. We are using paintings for various sessions and the feedback has been positive. The role-plays are usually conducted in Nepali and the group work presentations are carried out in English and Nepali.

Jekyll & Hyde

We feel that being exposed to English right from childhood, students in South Asia accept it as a working language. Most however, speak a different language at home and this causes a dichotomy. May be we develop a split personality, a kind of Jekyll and Hyde phenomenon. English describing common place events and household and social activities may be especially difficult as these events are often described using local languages in our setting. Fruits, vegetables, flowers, common implements and religious and other customs and ceremonies common in the west are often difficult for South Asians to understand and comprehend.

Disadvantages and Advantages of English

Using English has the disadvantage of excluding patients from deliberations and decisions about their condition in many cases and may preserve and perpetuate an elite, snobbish image of the medical profession. Does thinking in the western language westernize our thoughts and our outlook? Do we loose the ability to think and understand the native perspective? Do we become 'brown sahibs'? Could this be one of the reasons behind the massive brain drain and migration to the English speaking west? Are we becoming strangers in our own countries?

English also has many advantages. South Asians have easy access to the vast amount of medical and non-medical literature written in English. In the case of the Medical Humanities we were and are fortunate to be able to access and use material in English. Also we can more easily communicate our findings and observations to other workers in the field. Western teachers also find it easier to help and contribute to a course using English as the language of learning.

Language and literature

We wonder, sometimes whether language is the only factor behind this lack of identification with and difficulty in understanding literature. In South Asia, after completing ten years of schooling students diverge into three streams, arts (humanities), commerce, and science. The top ranking students usually go for science. For getting admission to medical school it is mandatory that the student takes the science stream and studies Physics, Chemistry and Biology during the last two years of schooling. A study conducted at MCOMS had shown that preclinical students read widely beyond their course and were interested in literature. (3) However, information on reading habits of doctors is lacking. Could it be possible that doctors have not developed the ability and the aptitude to understand and appreciate literature? A demanding professional career may have prevented them from developing interests beyond medicine. Could the teaching of arts in schools, or the lack of it, have been partly responsible for this lack of interest? Certain aspects of arts and crafts teaching in South Asian schools and the language of instruction at school have been covered in a recent blog article (Shankar R.A Arts and humanities: a neglected aspect of education in South Asia, British Medical Journal: Medical Humanities blog).

Our experience with using English for humanities modules has been largely positive. But as English is the medium of instruction in medical school we are conditioned to the language and the viewpoint and thinking framework it imposes. Most of us are comfortable with English and will have difficulty dealing with technical medical terms in native languages. I think we will continue to use English as the language for Medical Humanities modules as long as it remains the medium of instruction. We have accepted its advantages and disadvantages and at present are unable to look beyond English. Eventually English may become more localized and accepted as a South Asian language or the region will develop another link language and medium of instruction. Which one of these two scenarios will come to pass only time will tell but considering past and present experience we think the former may be more likely!

References:
1. Shankar PR. A Voluntary Medical Humanities Module in a Medical College in Western Nepal: Participant feedback. Teaching and Learning in Medicine (in press)
2. Shankar PR. A Voluntary Medical Humanities Module at the Manipal College of Medical Sciences, Pokhara, Nepal. Family Medicine 2008; 40:468-470.
3. Shankar PR; Dubey AK; Mishra P; Upadhyay DK. Reading Habits and Attitude Toward Medical Humanities of Basic Science Students in a Medical College in Western Nepal. Teaching and Learning in Medicine 2008; 20:308-13.

Trekking And The Medical Humanities

September 13, 2008 at 10:35 am

Trekking through the Himalayas

Commentary by P. Ravi Shankar, M.D., Department of Medical Education, KIST Medical College, Imadol, Lalitpur, Nepal

 

Nepal, trekking, and new perspectives

In a previous commentary for this blog I wrote about the development of medical humanities modules in two Nepalese medical schools. In this article I aim to pen my thoughts about trekking in Nepal and the Medical Humanities (MH). Nepal is a small country in South Asia surrounded by two of the most populous countries in the world - China and India. Nepal has among the greatest altitude variations of any country on Earth. The land rises from the flat plains of the 'terai' to Mt. Everest, the highest point on the planet within a distance of 150 km. The hills and the mountains of Nepal are a trekker's paradise and attract people from a number of countries. The unspoiled villages, green hills, verdant valleys and soaring Himalayas are the major attractions. The present population may be somewhere between 27 to 30 million. A number of ethnic groups inhabit the land and more than 500 different languages and dialects are spoken.

How can trekking be related to the humanities? On first glance these two appear very different. MH is an intellectual activity and is pursued by medical students, medical teachers and others to obtain a perspective on the human and humane side of medicine. Trekking is a tiring physical activity where you tramp up and down hills, cross streams and endure cold, heat, sweat and grime. Trekking basically is about freedom and following a simpler and gentler way of life at least when you are on the trek. Karl Benz's motor car is absent and the gently rising middle hills with their river valleys have to be traversed on foot. The air is pure, the light magical, the people friendly and you have stepped back a few decades in time! You follow the rhythms of nature. You go to sleep soon after sunset and wake up with the first light of dawn or even before. Many of the illnesses of civilization are the result of leading a lifestyle not in tune with nature's clock. MH in my opinion searches for the simple in disease and health. This is becoming a difficult task in an increasing complex world and trekking may be of some help!

The landscape can stimulate creativity among the students and inspire them to reflect on life, relationships and death from a 'different' perspective. Also exposure to the legends, voices and rich oral traditions of the mountain villages can enrich the writing and other creative skills of students and faculty. These stories, paintings and other art objects can serve to explore a number of issues in the humanities.

Medical humanities retreats

Trekking regions could be a location for weekend MH retreats. In the Dalhousie University, Canada, weekend retreats in the beautiful Canadian countryside are common during the MH module. In Nepal, the trekking areas can serve a similar function. Cities like Kathmandu and Pokhara have the Langtang/Helambu and the Annapurna trekking regions at their door step and students and faculty can easily trek to some of the nearby villages. Many other cities in the plains also have hill towns nearby. The trekking regions have over the years built up good infrastructure and facilities. Sitting in the dining room of a lodge by a roaring fire as the mist settles in for the evening can be a delightful experience for students and faculty and can lead to a closer and more informal relationship between them. The student-teacher relationship is relatively hierarchical and authoritarian in Nepal and trekking can lead to a more egalitarian and friendly relationship that may be more conducive to learning the humanities.

A cultural and social journey

Most treks in Nepal start in the middle hills though these days roads are making greater inroads. The road head is usually a congested and noisy small town and you can study a village slowly urbanizing. An interesting phenomenon with MH implications! People may either trek alone, with a porter or with a group. The porter is usually a farmer from the hills and it is an interesting experience to walk along this person for days on end. You are offered a different perspective on life and the country! Trekking in a group can also introduce you to other members from a different region or even from a different country.

The middle hills are welcoming with bright sunshine and villages mainly inhabited by the Brahmins and Chettris, the dominant castes in Nepal. Education is becoming more widespread and you can watch children race along the trail to their schools, the same steep trail where you rest and catch your breath after every two steps. As you go on the valley gradually becomes narrower and the river flows through a deep gorge and the terrain becomes increasingly rocky. Magnificent waterfalls and dense forests create an enchanted atmosphere. The going is tough but the reward is great! After a few days travel you reach the dry Tibet-like valleys behind the Himalayas. These are mainly inhabited by Bhotia communities of Tibetan extraction. This is a classic description of the Around Annapurna, Around Manasulu or even the Everest trek from Jiri. However, you can also fly in to a remote airfield and then start your trek. There are also shorter treks for those short on time.

Difficulties in accessing health care, and the modalities followed by the inhabitants to cure disease and protect health are important issues for the Medical Humanities. Because of the mountainous terrain, the volatile and unstable political situation with its prolonged conflict and poor socioeconomic development, modern health care may sometimes be many days walk away. Complementary Medical practitioners and faith healers often fill in the yawning gap for health care. Thus complementary medicine, rising standard of living, increasing number of trekkers and access to medical care are closely interlinked.

Access to health care, standard of living, and complementary medical systems

Many of the villages are situated one or two days walk from the nearest road head and to reach them you have to walk up and down winding trails through the hills. You can see first hand the important role complementary practitioners play in providing health care. Sick persons are also often carried in baskets on the back of sturdy village porters to the nearest health centre or hospital. The basket is often called the 'hill ambulance'.

The main trekking areas have seen a rise in the standard of living along with westernization and a change in the outlook. The approach to illness and its treatment is also changing. Western medicine is being more widely accepted and westerners (even trekkers) are regarded as doctors and experts in modern medical care. The farmers are able to supplement their income through the cash earned from trekkers and the traditional subsistence village economy has been replaced by a cash one. The overall health status has improved but the diseases of civilization are slowly beginning to make an appearance.

In the middle hills, Hinduism is the main religion and ayurveda and herbalism are the main medical systems. Faith healing is also common. In the gorges, the Buddhist influence becomes stronger and shamans become the main faith healers. In the trans-Himalayan valleys, Tibetan medicine dominates and the practitioners called 'amchis' cater to the healthcare needs. Modern allopathic health centers and hospitals are also present in a few areas mainly manned by paramedics. The process of creation of an indigenous medical system, its interaction with other medical systems and with western allopathic medicine (which came from the cities) can be a fascinating subject of study. The complementary systems offer a different perspective and while not always scientifically rigorous like the allopathic system may be more holistic considering man in the perspective of the cosmos.

Progress made

In the recent decades tremendous progress in healthcare indicators and access to health care has taken place. Education is becoming widespread among the younger generation. The importance of clean drinking water, sanitation, proper sewage disposal is becoming evident to the rural and the underprivileged urban populace. A number of health centers, health posts and subhealth posts (institutions delivering primary health care) are being set up and both doctors and paramedical workers are looking after the health of the population. Community hospitals and dispensaries have been set up in many areas and good quality medicines are being manufactured in the country. Nepalese manufacturers now meet more than 40% of the country's requirements and this proportion will increase in the future. Students can see first hand these changes in the rural areas of Nepal. These changes are also present in urban areas but are more dramatic and easier to study in the rural areas.

Humanities issues of particular concern to Nepal

The major humanities issues of particular concern to Nepal in my opinion are to encourage a caring attitude towards patients, taking into consideration the patients’ weak socioeconomic conditions in treatment decisions; help patients make proper decisions about treatment and health care; promote service in rural and underprivileged areas; play a role as a motivator and an agent of change in rural communities; develop good working relationships with complementary medicine practitioners and involve them in making healthcare accessible to the underprivileged; and adapt western allopathic medicine to a traditional setting. Many of these issues may also be applicable to other countries in South Asia.

Thus trekking can serve to introduce, highlight and underline a number of MH issues in the Nepalese context. The exposure to fresh air, fresh food and an unhurried pace of life can do wonders for the mental and physical health of the students and faculty. The unhurried environment allows for deep reflection and in depth study of a number of issues. Thus trekking and the humanities may be closely related in the Nepalese context. The challenge is to explore and utilize the connection to the full!

Medical Humanities: Sowing the Seeds in the Himalayan Country of Nepal

April 14, 2008 at 4:43 pm

Composite Nepal Photgraphs by P. Ravi Shankar
Commentary by P. Ravi Shankar, M.D., Department of Medical Education, KIST Medical College, Imadol, Lalitpur, Nepal

Nepal, a country in the lap of the Himalayas is still predominantly agricultural. The majority of the festivals and cultural events have a strong correlation with the planting and harvesting of rice, the principal crop. With the hard rocky soil and the lack of suitable flat land it is difficult to cultivate crops in Nepal. Agriculture like in most of South Asia is a gamble dependent on the vagaries of that great seasonal phenomenon, the monsoon. Adequate rainfall at the right time is the major determiner of whether the sown crops will yield a good harvest and can mean the difference between eating well and going hungry. I was taking a similar kind of risk with an initial voluntary Medical Humanities module in the Himalayan country. Whether I would be successful at the end of the day depended on a variety of factors, the chief one being the enthusiasm and interest of the participants.

The PSG-FAIMER Institute

It was early January 2007 when I came to know about the PSG-FAIMER regional institute in Coimbatore, India through one of my good friends. PSG is a charitable group who run a number of educational institutions in Coimbatore, India and FAIMER is the US-based Foundation for the Advancement of International Medical Education and Research. The institute was inviting applications for a part-time fellowship in Medical Education and was inviting an outline of curriculum innovation projects from potential fellows. I have always been interested in medicine from a ‘different’ perspective. I have a keen interest in the history of medicine and am also interested in literature and creative writing. I am a keen trekker and photographer and have spent many weekends and vacations in the delightful trekking areas of Nepal. Most of my contemporary fellows (mainly from India) had chosen projects well within the confines of the curriculum. However, I wanted to do something that pulled together my interest in history, literature, and art within the framework of medicine, something along the lines of what is called Medical Humanities in the west." I discussed my proposed curricular innovation with Dr. SK Dham, dean of the Manipal College of Medical Sciences in Pokhara, Nepal, and he was very supportive. I decided to submit my project and hope for the best.

The first on-site session

It was a delightful experience to receive the e-mail from the institute confirming my selection. The first on-site session was to be held in mid-April at Coimbatore and I set about working on the project. At Coimbatore we were taught about project planning, force-field analysis, concept maps and looking at the project in a structured fashion under various headings. The overall attitude towards my slightly novel project was positive though there were occasional suggestions to choose a more conventional subject. The food at Coimbatore was a delight and I could not have enough of idlis, dosas, upma and other South Indian delicacies.

Initial days of the project

On coming back to Pokhara I started work on my project in earnest. The first task was to obtain feedback from the stakeholders and design a curriculum. One of our faculty members at PSGFAIMER was Dr. Janet Grant of the Open University, United Kingdom and she was kind enough to send me material on curriculum design. For a long time I had been intrigued by a feature in the journal Academic Medicine titled ‘Medicine and the Arts’ (MATA). I wanted to contribute and wrote to Ms. Anne Farmakidis who was in charge of MATA at that time about how I should go about writing a MATA article. She gave me a few hints and was kind enough to send me a copy of the book titled Ten Years of Medicine and the Arts. The book’s a compilation of MATA articles published over the years from 1991 to 2001. The book was a delight to read and I was hooked! This book was also a key factor in strengthening my interest in the medical humanities.

Preparing for the module

The module I was planning was voluntary so maintaining participant interest was the key! I had noted that in many courses of study in South Asia the objectives are not clear. I resolved to put down the objectives of each session on paper in black and white. Ironically I ended up with clearer objectives for a ‘soft’ course like Medical Humanities than for courses like Anatomy or Pharmacology! I also set about constructing a student guide, a facilitators’ guide, a guide to further reading, and session descriptions. A major question in my mind was how many sessions should be conducted. I wanted the module to serve as an introduction to the fascinating topic of medical humanities. As part of the course I was in touch with my friends and faculty at the PSGFAIMER Institute through a listserv and we started discussing how to go about our respective projects. We also cover various topics related to health sciences education every month. As medical humanities is not well developed in South Asia I got in touch with various medical humanities educators from other regions through e-mail. All were gracious enough to respond and offer their suggestions. All wanted to help kick start medical humanities in a developing Asian country. I owe a special debt of gratitude to Dr. Johanna Shapiro of the University of California at Irvine, Dr. T. Jock Murray of the Dalhousie University Faculty of Medicine, Canada and Dr. Tom Tomlinson of the Michigan State University in US. My friend, Dr. Rakesh Biswas was also very helpful.

Learning modalities

I finally decided to conduct fifteen sessions divided into three units titled Medicine and the Arts, Ethics and Medicine, and Contemporary Issues in Medicine. There were also home assignments. A major goal of the module was to make learning fun and avoid the heavy, boring didactic teaching which is in vogue in most of South Asia. Learning sessions were to be conducted in small groups and were to be activity based and interactive. Literature and art excerpts, role plays, case scenarios were among the different modalities used to explore various aspects of the humanities. Medical humanities was not widely known and it was up to me to popularize the term and what it meant. MCOMS has two campuses with the basic science campus being located at the scenic and wooded Deep Heights in Pokhara. The students run a wall magazine called Vibes and I often contribute to this delightful magazine. (A wall magazine is like a notice board and various articles and features are put up on the board. The contents are changed regularly and a particular collection of articles and features constitutes an issue.) I wrote an article about medical humanities for Vibes.

Sources of literature & art

For the module I mainly used literature and art excerpts from a western context. I was able to use a couple of excerpts from South Asian authors in the module. Photos of the violent conflict in Nepal were used and the majority of the participants could easily relate to this. A major difference between America and Nepal is that in Nepal, like in most of South Asia the student-teacher relationship is authoritarian and hierarchical. I had to make sustained efforts to get the students to open up. The case scenarios and role-plays were designed by me to reflect various aspects of the practice of medicine in Nepal and south Asia and were well received by the participants.

Canvassing for volunteers

I started canvassing support among the students of the clinical semesters. In Nepal the undergraduate medical course is of four and half year duration and is divided into nine semesters. The first four semesters are devoted to the basic science subjects and the last five to the clinical ones. Initially I concentrated on the fifth semester as the students had just entered the clinical phase and were the most ‘free’ batch of learners. However, the fifth semester also runs a program to help the poor patients of the hospital — the socially aware and active students were active in the poor patients’ fund and had no time for medical humanities. I then turned my attention towards the sixth semester. I started canvassing among faculty members to join. My colleague, Subish is keenly interested in the more rational use of medicines and other issues as well; he enthusiastically participated in the module. He was instrumental in providing the excellent facilities of the Drug Information Center Conference room for the sessions. The room helped to create a relaxed, protected and comfortable atmosphere.

Initial days of the module

The initial sessions were a touch and go affair. People kept coming to the sessions and dropping out. Some of them were irregular in attendance, attending scattered sessions. Gradually word spread about the unique module. Participants started coming and staying! A sixth semester student came to test the waters; she found it was to her liking and more of her friends joined. One of my colleagues, a physiologist, trekker, artist, photographer and many other things besides was an enthusiastic participant. My clinician friends were generous in sharing their rich clinical experience as co-facilitators. Another colleague had done his doctorate in Denmark, where, as in most of Europe, it is expected that medical and other health science students know some philosophy. With his help I started a ten minute discussion on philosophy during the module. One of my students then in the final year of medical school asked me to contribute an article about medical humanities for the college magazine, Reflections which they bring out.

Sessions for the Basic Sciences

The students in the Basic Science campus requested me to conduct a module for them. It was difficult to find a time period convenient to both the parties and finally we settled on the lunch break. It was indeed gratifying to note the enthusiasm of the participants. This module was conducted along the same lines but each session was divided into ‘bytes’ spread over three working days.

Novelties of the module

The module introduced a few new concepts and also further developed certain others which I had been using in my small group sessions for students. Constructive formative assessment, reflective writing assignments, assessment of the facilitator and faculty and students learning together were a few of them.

Module at KIST Medical College

At present I am conducting a module for faculty members at the KIST Medical College and these members could be used as co-facilitators for future sessions. I really enjoyed being a part of Humanities 101 and I am sure my student and faculty participants did too. I sincerely hope the seed of medical humanities will take root in the fertile soil of Nepal (among the highest countries on Earth) and bloom among young, energetic and impressionable minds!