Medical humanities: to cure sometimes, to relieve often, to comfort always

The American Society for Bioethics and Humanities was established in 1998 to “promote the exchange of ideas and foster multidisciplinary, interdisciplinary, and interprofessional scholarship, research, teaching, policy development, professional development, and collegiality among people engaged in all of the endeavors related to clinical and academic bioethics and the health-related humanities.”1 The UK Association for Medical Humanities has defined the field as representing “a sustained interdisciplinary enquiry into aspects of medical practice, education and research expressly concerned with the human side of medicine”.2

In discussing medical humanities, it can be difficult to avoid emphasising, as the latter definition does, the idea of two opposed sides — the biomedical and the human. It is an opposition that translates too easily into stereotypes: science as cold, unfeeling, and sometimes dangerous, and the humanities as warm-hearted and well-intentioned, but possibly less “scientific”.

Both sides can be united if a shared approach is used to deepen our understanding of human health and wellbeing by calling on multiple perspectives — biomedical, philosophical, historical, artistic, literary, anthropological and sociological. The result of this approach should be a more insightful view of the patient, the doctor and the healthcare system, and an enhanced capacity to cure, relieve and comfort.

James Edelman, Medical Student (Year 1), University of Sydney

James enrolled in the postgraduate subject Medicine and war as an option in the medical program. ”I was interested in military history in general, but I found the focus on paradigm shifts brought about by war particularly interesting. I kept thinking about myself as a 22-year-old if I were to be caught up in war, and my faith in authority was challenged. I enjoy opportunities to relate to and imagine ‘the other’ and I think that’s an important clinical skill.”

Medical humanities are “good” not only for their own sake, but also because they are instrumental in:

• reducing the gap between biomedicine and the human sciences, such as philosophy, history, sociology and anthropology;3

• facilitating interdisciplinary teaching and research;4

• promoting a patient-centred approach to medical care;5

• counteracting professional burnout;6

• reducing biomedical hubris;7and

• equipping doctors to meet moral challenges not “covered” by biomedicine.8

The arts, humanities and social sciences act as a counterbalance to the relentless reductionism of the biomedical sciences, which rely on knowledge that enhances the order and predictability of diagnosis, investigation and treatment. History, philosophy and sociology warn that the person with the disease is all too easily reduced to the non-hygienic, non-rational, disordered “other”. These are not abstract or outdated notions; we all see doctors who make it quite clear that patients are an irritating obstruction between themselves and the disease.

Biomedicine can do harm when it overlooks or marginalises particular individuals and groups. Once seen as a potential cure-all, biomedicine has limits and dangers that are now more clearly understood.9 The public reaction to this perceived danger is particularly well illustrated by the acceptance of non-evidence-based alternative medicine. This challenges the privileged status of biomedical science. It leads some doctors to despair in the face of public credulity and tempts others to abandon science and jump onto what may be a lucrative bandwagon. Paradoxically, it multiplies the potential for harm to patients,10,11 while illustrating that the real conceptual divide is not between medicine and the humanities but between science and non-science. The biomedical and social sciences are united in their commitment to scepticism and scholarship.

It is natural that medicine will attract students who are interested in the biomedical sciences, many of whom are particularly good at processing and memorising information. Unless they have adequate time for reflection, such students may ultimately adopt a dogmatic or overly technical approach to clinical practice, where every question has just one correct answer. They may fail to reflect on broader questions about the healthcare system or their place in it. Recent research into the psychological wellbeing of recent medical graduates found that rates of emotional exhaustion and depersonalisation rose significantly during the intern year, and that more than a third met criteria for psychiatric disturbance towards the end of internship.6

Jenny Donovan, Radiation Oncologist, Royal North Shore Hospital

Jenny flies to Coffs Harbour for regular clinics, often involving long days, but refuses to miss the evening seminars in the medical humanities program. “This degree has been a catalyst for me to explore new concepts and ideas. I love where it takes me. I had no idea studying could be so enjoyable. I work in a field which requires compassion, and studying medical humanities has helped me to tap into this more deeply. It has been my best investment ever.”

Examinations can reinforce a narrowed focus if they reward rote learning. While assessment can be used to encourage a deeper approach and promote reflective thinking,12 appropriate tools are difficult to develop and apply with a high level of reliability.13 However, if deep learning and reflection are not included in assessment, students will soon infer that these approaches are not really valued and will continue to focus on the examinations that “count”. Recognising critical reflection as a basis for self-directed lifelong learning has led some continuing professional development programs to incorporate requirements for reflection as part of learning.14 Linked to reflective practice are notions of self-awareness, “mindful practice”15 and greater insight into one’s own personal values and assumptions.

One approach to teaching medical humanities is via “narrative medicine”,16 with programs to promote “narrative competence”, a term that includes the capacity for empathic understanding, perceiving the significance of the patient’s and doctor’s metaphors, and being able to adopt multiple perspectives. Central to the approach is the belief that this shared understanding of the patient’s story is an intrinsic part of the therapy. Whether what it offers is actually new or even generally applicable remains to be demonstrated.17

Terms such as “reflective practice” and “narrative competence” can sound vague and irrelevant to the busy clinician, but they are brought into sharp focus by the recent implication of doctors in abuse of prisoners at Abu Ghraib in Iraq, through their alleged falsification of medical records to conceal torture and human rights violations.8

Medical education is only one of the many forces that shape doctors’ values. Nevertheless, one might ask: what kind of curriculum could offer the best preparation for times of psychological and moral duress? Biomedicine falls silent. What might the humanities offer?

History, sociology, literature and philosophy all have roles to play. The Stanford Prison experiment showed how easily research participants could be persuaded to mistreat simulated prisoners.18 Milgram’s famous study of obedience to authority showed that most participants obeyed orders to apply what they thought were dangerous electric shocks to innocent people.19 These examples demonstrate the ease with which unbridled power takes hold. The influence of time and context is demonstrated by histories of crime and punishment20 and by studies that delve into the nature of torture.21 If these seem too remote from medicine, a reminder on changing norms in medical research may drive the message home.22 Between 1932 and 1972, in Tuskegee, Alabama, doctors deliberately did not treat African American subjects with tertiary syphilis, purportedly to observe the natural history of the disease.22

Margaret Morgan, Medical Educator and General Practitioner

”I have always had a love of learning as a lifelong process and, now that my children are grown, I have more time to indulge myself. The wonderful aspect of this [medical humanities] degree is its flexibility; one can choose from a wide selection of course units and also complete a unit by pursuing a specific area of interest under the supervision of a senior academic. I have had great enjoyment from the course so far and look forward to much more.”

Literary heroes can inspire, and philosophical concepts help to define, the nature of our shared humanity.23

Drawing back from the darkness at Abu Ghraib and Alabama to everyday medical practice, medical humanities remain an important subject. As a recent issue of the Journal made clear, doctors are generally experts in the art of delayed gratification and self-neglect,24 and bad at avoiding burnout.25 A broad range of interests and an encompassing world-view make for emotional and physical wellbeing.15

Medical humanities have become part of the mainstream in medical education in North America and in the United Kingdom. In 2003, the journal Academic Medicine reported on 41 programs in medical humanities in North America and internationally.26 The extent to which the humanities are integrated into each medical curriculum is highly variable, with some schools offering electives or options to a limited number of students. In the UK, following recommendations from the General Medical Council,27 “special studies modules” in medical humanities have become increasingly common, but not compulsory. Where the medical humanities are compulsory, they are sometimes delivered in discrete courses and at other times incorporated into strands in ethics and professionalism (some of which merge into areas as diverse as health policy and instruction in clinical skills). The explicit intention of many such programs is to promote a humane approach to patient care.28

In Australia, a number of broad changes in medical education have supported the incorporation of the humanities into medical curricula. New selection methods have increased student diversity,29 bringing more varied perspectives, while early clinical experience now brings students into contact with patients while they learn about disease mechanisms. Problem-based learning uses patient histories that encourage students to take a biopsychosocial rather than “disembodied” approach, even while studying the basic biomedical sciences. Curriculum strands or themes such as “The Doctor in Society” and “Personal and Professional Development” significantly broaden and deepen the curriculum.30 For example, following this approach, the graduate-entry program at the University of Sydney has produced graduates who feel well prepared for internship and who are rated highly by their supervisors, especially in clinical competence, confidence, communication and professional skills.31

At the University of Melbourne, study in the Medical Humanities Unit at the Centre for the Study of Health and Society is an option for the research year undertaken by all students who enter the medical course as school-leavers. The program includes undertaking four subjects in the Faculty of Arts, as well as submitting a research report. Other medical schools in Australia and New Zealand offer a variety of short courses in the medical humanities as options and electives, as well as core programs.32

John Hickie, retired Professor of Medicine, University of New South Wales

John is the oldest student in the Masters in Medical Humanities program and author of The thinkers, a history of the physicians at Sydney’s St Vincent’s Hospital. For John, the most enjoyable parts of the medical humanities program are those most remote from medicine. “I would never have read so widely without the stimulation of this course. One thing just leads on and on to others — it’s hard to know where to stop.”

This year, the subject Medicine and war examined the ways in which human conflict has driven change in medical research and practice. In 2005, a unit on Medicine and music will explore music and wellbeing, the psychological and physiological basis of music appreciation, and the place of music therapy in, for example, psychiatric disorders such as autistic spectrum disorders in childhood. For 2006, plans are under way for a new unit of study, Medicine in antiquity, which will include a trip to the great medical centres of the ancient world, such as Epidaurus, Pergamum and Kos, and to monuments, including the medieval Islamic hospitals in Istanbul and Cairo.

Students who come to the study of, for example, history with the idea that it is all about events, dates and places are bound to be disappointed. The real challenge of history lies in finding and using information as a means of imagining the world of the 17th century before William Harvey wrote De motu cordis, or the 19th century before Charles Darwin wrote The origin of species — a much more demanding enterprise than memorising Davidson’s principles and practice of medicine.

Imagination is the key. Students who, in the hours outside the classroom, manage disease, pain, suffering and loss move into a classroom where they may feel overwhelmed or deficient. An excess of imagination is sometimes too painful in clinical practice, but the arts, humanities and social sciences thrive on imagination and on new interpretations of old ideas. Students rehearse and test the principles that underpin our moral and ethical positions. The humanities recognise, cultivate and applaud uncertainty. For the students, adapting from the certainties of medicine takes time.

Although the disciplines of medicine and the humanities sometimes demonstrate diametrically opposed modes of thinking, they share a focus on the human. The separation of clinical care from the “human sciences” is a professional and social mistake, and the growth of medicine as an economic and rational profession has paradoxically contributed to the social diminution of the body, the very object of its focus.

A postgraduate student who is a specialist physician noted: “Medicine has degrees of evidence. We work on the idea that if a happens then b follows; we find out what works and what does not. We seek and desire a concrete outcome, because medicine fixes things.” By contrast “. . . it took a while to realise that this course is not about the acquisition of facts, but the ability to explore, evaluate and criticise”.

Another student described the anxiety created by the ambiguity of literary and historical ways of knowing. How can we know anything, be sure and assert a viewpoint when the humanities multiply the number of answers to any single problem? Reading and thinking in such an environment can provoke anxiety, but this is not “medical school” anxiety. Rather than identifying the single best answer on a multiple-choice examination, the medical humanities rely on the power of the imagination to open up ever more complex issues. Rather than using medical specialisation to draw boundaries around what we need to know, boundaries are removed.

Collaborators in Durham include philosopher Martyn Evans, Professor of Humanities in Medicine,33 and Dr Jane Macnaughton, a general practitioner and Director of CAHHM. Professor Evans was instrumental in setting up the only Master of Arts in Medical Humanities degree in the UK. Mature students in that program report similar challenges and benefits to the students in the Sydney program.34