DISCUSSION MEDICAL HUMANITIES
Medical humanities … almost
Brought up in the traditional education system in a large teaching hospital in Mumbai, India, I moved on to do specialisation in neurology in the United States of America. The Indian system of pre-medical education mandates early choices between the humanities and the sciences and thus precludes a more well-rounded development of a student. Though medical humanities is not taught as a subject as part of the medical curriculum in India, listening to inspiring and learned teachers and the daily interaction with scores of patients who are willing to submit themselves to examination “in the cause of medical education” is a humbling experience to a sensitive student. I see similar willingness in patients in the United States. However, a formal course in the medical humanities, including arts, literature, and philosophy will surely enrich the experience of a larger number of undergraduates and postgraduates learning the core subjects and help in moulding a more rounded physician.
As a beaming 18-year-old I embarked on my medical journey, not knowing why I wanted to become a doctor; but I knew this was the only thing I had ever wanted to do. The Indian education system is extremely focused and warrants that we choose our paths very early on. At times, I felt that focus took away from a more well-rounded educational experience with exposure to various arts and sciences which would have helped broaden our perspectives. In my experience as a neurology resident, the medical students in the United States, when compared to Indian medical students, have had the chance to pursue a pre-medical course, whether it was learning a new language or anthropology, music or the fine arts, which perhaps, enabled them to make a better informed choice, by way of trial and error, as a result of the options they were able to explore.
This article is by no means a comprehensive comparison of the different medical education systems in India and the United States. It is a narrative of what I have learned about the medical humanities and the teaching of medical humanities in India and the United States.
There are certain personality traits which help us become good physicians; physicians who transcend the boundaries of age, religion, culture, and languages and heal, if not cure, to the best of our abilities. Medical humanities is that interdisciplinary union which seeks to identify all the qualities which make a good physician and helps young doctors in training to identify some of those traits in themselves and work towards becoming better human beings and better doctors in that process. The New York University website (1) defines “medical humanities” broadly to include an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), the social sciences (anthropology, cultural studies, psychology, sociology), and the arts (literature, theatre, film, and the visual arts) and their application to medical education and practice.
The continuum of medical humanities starts as we step into medical school in India. Although, we do not have any repository of literature, arts, sociology, medical anthropology or philosophy; somewhere all these sciences and arts manage to seep through the voluminous accounts of the medical curriculum. Each aspect of medical humanities is touched upon, perhaps, not always by way of formal teaching but by means of examples sometimes knowingly and sometimes unknowingly. One of the best things I learned in medical school was “Non sibi sed omnibus” (Not for self but for all) and slowly but surely, all of us were being moulded into conscientious young physicians in medical school.
Medicine has come a long way. We are diving deep into nuclei to unearth the secrets of life and death. We have learned a lot along the way, but human suffering has found new ways to challenge medicine every step of the way. Our standard textbooks tend to allude to history very briefly, and whether that manages to inspire awe or wonderment is a little unclear. Then, how do I remember the story of Insulin, Best and Banting? How did Pavlov’s dog become pop culture? That is because these stories were related to us by much admired teachers. As first year medical students, we had group discussions or dissections in rooms named after great Indian practitioners like Susruta, or Greek gods like Janus. The writing on the walls left an indelible mark on my memory, and on those of many of my classmates, and somewhere a small hope to make a bigger contribution to the field and take it forward was taking root.
As I began my residency in neurology in the United States, and began teaching medical students on my service and then as part of my work of being an IQ group (a small case discussion group at the School of Medicine at Case Western Reserve University) facilitator, it only became more evident to me how different these systems of education were. Of course, grades or marks mattered in both systems but the approaches to medical education differed so much that I wondered how such disparate systems managed to produce equally good doctors. The emphasis on medical humanities in undergraduate and graduate medical education has managed to take the form of various creative curricula across the United States. The New York University website is a good resource, providing links to other medical curricula as well as a searchable database for various literary, movie and pop-culture references to the medical humanities. However, there are very few instances of a formal medical humanities curriculum in India. Medical college curricula in India are based on factual learning. However, when we start our clinical rotations we learn a lot by observation. Humility, philosophies regarding healthcare, end-of-life care, discussions about death and dying, prognosis, and so on are all learned at the bedside by observing several members of the medical team lead by example. This learning by observation is very much a part of the teaching of medical humanities in the United States as well.
Morality and religion in India are sometimes indistinguishable. Religious tolerance is an innate aspect of taking care of patients in India, which is usually not very difficult, as most of us have been exposed to various religious and cultural beliefs in our schools and colleges as much as in our homes. Praying with patients at the bedside was a direct extension of religious sensitivity as a physician and it helped foster greater faith and trust. In the United States, I have seen great pastoral care for patients at the bedside, and solitude in the places of worship at various hospitals. One can even choose to do a Masters program in theology to better understand religion and its role in healthcare but the basic tenet of being tolerant and respectful of all faiths, in health and more so in disease, is something we learned throughout our training in medical schools. As second year medical students, we get formal teaching in medical ethics as part of forensic medicine and also receive an introduction to the direct legal implications of our actions. What I learned about medical ethics was learned more because of the examples set by my peers, junior and senior house staff, and faculty members and patients alike. The onus of teaching the new breed of doctors how to be compassionate and ethical seemed to rest squarely on the shoulders of everyone who was involved in our learning of medicine.
In a setting like the King Edward VII Memorial (KEM) Hospital, Mumbai, which is teeming with patients, patient privacy was not always easy to maintain; but most of our patients were also equally eager to share their stories of triumphs and tribulations with eager groups of medical students and letting us examine them over and over again to learn clinical exam skills; it was a universal phenomenon to hear that they were just happy that they were helping future doctors learn. This was the best example of selfless charity which was enriching my young mind each day on the wards. Here at Case Western, when I take one or two medical students with me to patients’ private rooms and ask for patients’ permission to allow my medical students to interview them or examine them, I come across the same eagerness, the same generosity. I find my task of preserving someone’s dignity as we learn or teach how to do a clinical exam much easier here than doing the same with a group of onlookers in a large ward full of patients. The patients however, seemed to be at equal ease in both environments.
On the wards and in our clinics each day in KEM, we helped out in procedures or assisted in surgeries and watched various physicians take consent, discuss prognoses or answer questions posed by families to the attending physicians in front of the whole medical team and we learned each day how to communicate with patients; how to comfort their worried family members, how to inspire confidence in them; how to be gentle and how to be firm with patients who continually posed a challenge by being non-compliant or defiant. Now when I look back at those times I can clearly remember the god-like worship in the eyes of patients and their family members; and my memory doesn’t fail to echo the words: “We’ll do whatever you say, doctor saheb.” Was it a simplistic belief that the physician is always right? I wonder now: where did all that faith come from? How did physicians get elevated to god-like status? Does dealing with matters of life and death make us even half as omnipotent as the Creator? Was it the lack of awareness or lack of education or a matter of faith which defied reason? The adoration which patients and families had for their physicians was not something we were taught to expect as part of any formal curricula, but we just saw it each day, and that faith inspired us to strive to do our best, as someone was always counting on us to come through.
Do I feel that I missed out on something by not having a formal curriculum to help me learn about medical humanities? To a certain extent I do. I wish I had taken the time to read and admire poetry and literature dealing with medicine; or learn about Leonardo da Vinci’s artistic renderings of scientific concepts. I felt that the emphasis on mastering concepts on which questions would be set deprived us of the time to stop and think about how we got here. Did that make me less compassionate or less appreciative of the wonders of modern medicine? It did not. Somehow, I managed to learn a little of everything and my thirst for knowledge and search for the art in medicine and the medicine in art continues to become keener. A formal curriculum in medical humanities surely provides a wide array of choices, and increases awareness; but compassion, sincerity and humility we all learn by example, whether by setting our own or from our peers and teachers alike.
We are fortunate to be living in a world where knowledge is freely available just like the air we breathe; it is only a matter of seeking it out. This availability of knowledge has also inundated us with surplus knowledge which we will find difficult to navigate and make the best of without the help of proper guidance. A well-structured curriculum in medical humanities will help decrease the reliance on experience alone; for instance, I was fortunate enough to train at the Seth GS Medical College, Mumbai, with some great teachers, but would I be as conscientious a physician if I hadn’t seen good medicine being practised as much? We need to increase standardisation among medical schools across India, so no matter where you train, you can avail of at least a good standard well-rounded medical education. Of course, the curricula should have enough scope for each institution to incorporate its own philosophy. There is no substitute for exemplary teaching but a formal curriculum dealing with medical humanities will enrich the time spent in medical schools in learning core concepts. I believe this kind of teaching, coupled with the current system of education, will enable us to produce more well-rounded physicians in India.
- Medical Humanities [Internet]. New York: New York University; c 1993-2012. Medical Humanities Mission Statement;1994 [cited 2012 Jul 3]; [about 1 screen]. Available from: http://medhum.med.nyu.edu/