Putting the humanities back into medicine: some suggestions
Meenu Singh, KK Talwar
The practice of medicine is an art as well as a science. As doctors diagnose illness and treat patients day after day, they constantly interweave the social, psychological, ethical and scientific aspects of clinical practice. However, the humanistic values necessary for this approach are generally perceived to be lacking in today’s medical practice. The Medical Council of India (MCI) believes that a course in medical humanities can help students cultivate a humane attitude towards their patients, as well as give them the knowledge and skills to deal with the complex challenges they will face as they practise medicine. The new Graduate Medical Regulations being formulated by the MCI provide time for teaching this aspect of medical practice. This paper contains some suggestions for the implementation of a medical humanities course in medical colleges.
Is medicine an art or a science?
“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Sir William Osler (1).
Medicine is an art based on science. In the practice of medicine basic human values must be amalgamated with sound scientific practice. In the course of a doctor’s medical practice, hardly a day passes when s/he does not touch the basic human aspects of the lives of patients and their families. As one becomes more mature in dealing with patients, the social, psychological and ethical angles of clinical practice become interwoven with the scientific approach usually adopted while diagnosing and treating patients.
The World Health Organization defines health as “the complete physical, mental and social well-being” of an individual “and not merely the absence of disease or infirmity” (2). This concept of health requires us to bring in several inputs from non-medical domains such as socio-cultural disciplines. For example, how many of us think about the financial status of the family while prescribing medicines to a patient? The need is increasingly being felt for a systematic curriculum to sensitise budding doctors to such considerations, as also teach them to deal with the complex negotiations involved with patients, their families and the community.
The practice of medicine: a complex and complicated art
There are many areas of medical practice where decisions cannot be easily made. Let us take the example of an 84-year-old individual suffering from advanced cancer. A beginner may see this as an opportunity to investigate and treat a complicated problem. However, an experienced doctor may think otherwise. He may give preference to the individual’s quality of life which could become worse during the process of clinical management. He may give the family and the patient the option of making life comfortable for the patient rather than treating the condition aggressively. We often face the dilemma of making end-of-life decisions for severely ill and neurologically damaged patients. These are examples of situations illustrating how empathy and sympathy for the patient are core values in the practice of medicine and need to be developed in young medical professionals.
Training courses are designed to suit the expected qualities of the end product — in the present case, a doctor. What are the inherent qualities of a good doctor which need to be developed in the instruction years?
Some of the qualities that immediately come to mind are: the ability to maintain confidentiality, being a good listener, respecting privacy, acting always in the best interests of the patient, respecting the patient’s right to know and being truthful about the outcome, trying to be free of biases and prejudices, and being honest and trustworthy.
The making of a “good doctor”
A question that is always raised is: “Is it possible by training to make a person truthful, just and honest?” Given the current trend of medical practice in a corporate healthcare sector becoming a business, many feel that these core values must be taught in medical school. The medical student should be able to imbibe, as a part of his training, this concern for the patient as his prime consideration. The biblical saying “Do unto others as you would have them do to you” should be the motto in professional practice.
Introducing medical humanities
Medical humanities encompass an interdisciplinary field of subjects such as literature, philosophy, ethics, history and religion, social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theatre, film, and other visual arts) and their application to medical education and practice (3). Literature, arts, economics, sociology, and history can be used to broaden the vision and understanding of the medical student. Literature, more so literature that relates to medicine, can widen the perspectives of a doctor by kindling the imagination and applying innovative ideas to the patient interface. In today’s world, the cost-effectiveness of therapies as well as healthcare approaches finds a mention in all fields of medicine, and the discipline of health economics must be taught to practising physicians.
A doctor needs to be socially sensitive and ethically correct. Individual and contemporary Indian history can help students understand our socioeconomic realities and better relate to patients and their problems. It has been shown that the teaching of humanities has a positive effect on medical professionals (4). In the western world, numerous departments of medical humanities (MH) have been established since the late 1960s (5). However, in India, there are no established departments of MH, though many institutions have introduced infomal modules to teach medical humanities (6,7).
The general experience of teaching MH has been that it tends to inculcate more “humane” qualities in the medical student. In view of the this experience, regulatory bodies in India, especially the Medical Council of India (MCI), have recently started deliberating on this aspect of medical practice. Although it is felt that the teaching of humanities should be incorporated into regular bedside teaching, some structured programmed teaching can also be introduced.
The MCI plans to introduce the teaching of humanities in the foundation course prepared by its academic committee (8). However, the course can be developed more fully over a period of time to teach these aspects of medicine.
The MCI’s suggested curriculum for medical humanities
- Patients’ perception of illness;
- History of medicine;
- Influence of culture, faith and spirituality on well-being and illness;
- The end of life and the experience of death;
- The doctor-patient relationship;
- Life as a doctor;
- Medicine in literature;
- Social and economic issues in healthcare and medicine;
- Influence of media and communication on healthcare;
- The evolving role of the physician with changing social values, and
- The art of doctoring.
Salient issues in implementing these elements in the proposed foundation course
- The courses should be introduced in the foundation years, as well as in the clinical years which give hands-on practical experience.
- Some parts of the course will be mandatory; advanced training in chosen areas or electives will also be offered. Departments of “medical perspectives” are envisaged for this purpose.
- Teachers’ training courses for medical teachers contain many exercises on how to increase sensitivity and awareness of the feelings of others.
- Non-medical faculty are an important resource. People from humanities and social science departments will be co-opted to help design and implement these courses.
- Courses should be student-friendly, relevant, and interesting. For example, components such as bedside manners, talking to patients, breaking bad news, end-of-life care or end-of-life decisions must be incorporated in regular clinical teaching.
- Medical ethics can be taught as a full course.
- Lectures can be given by prominent role models
- Demonstrative workshops should be directed at honing some of the important skills referred to earlier.
These aspects will be covered at different professional levels during graduate medical training. Similar courses can be made subject specific and taught to PG students.
The experience of several decades worldwide shows that introducing the humanities into medical education helps to produce more “humane” doctors. In view of this, medical regulatory bodies in India propose to introduce a foundation course based on the humanities and the social sciences in medical colleges. This is will done in a phased manner, allowing for flexibility not only to accommodate special local needs but also make use of available teaching talent and other resources.
As the skills required in imparting this knowledge are different from those of regular medical subjects, it is important to involve faculty and experts from the humanities and social sciences to work alongside medical teachers, so that this education and training are done in an effective manner. It is important to make the course interesting and relevant to students.
- Osler W. Aequanimitas: with other addresses to medical students, nurses, and practitioners of medicine. 2nd ed. Philadelphia: Blakiston’s Son, 1920; p 386.
- Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
- Macnaughton J. The humanities in medical education: context, outcomes and structures. Med Humanit. 2000 Jun;26(1):23-30.
- Ousager J, Johannessen H. Humanities in undergraduate medical education: a literature review. Acad Med. 2010 Jun;85(6):988-98
- Shapiro J. A sampling of the medical humanities. J Learning Arts [Internet], 2006[cited 2012 Nov 30]; 2(1). Available from: http://escholarship.org/uc/item/58b5h3h9#page-10
- Shankar PR, Piryani RM, Thapa TP, Karki BM. Our experiences with ‘Sparshanam’, a medical humanities module for medical students at KIST Medical College, Nepal. J Clin Diag Res. 2010 Feb;4(1):2158-62.
- Gupta R, Singh S, Kotru M. Reaching people through medical humanities-an initiative. J Educ Eval Health Prof. 2011May;8:5.
- Medical Council of India. Regulations on graduate medical education 2012 [Internet]. New Delhi: Medical Council of India, 2012 [cited on 2012 Nov 30]. Available from: http://www.mciindia.org/tools/announcement/Revised_GME_2012.pdf