What are the medical humanities?

The medical humanities (MH) have been defined as ‘an interdisciplinary, and increasingly international endeavor that draws on the creative and intellectual strengths of diverse disciplines, including literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology and history in pursuit of medical educational goals’ (1). In MH, subjects traditionally known as the humanities are used for medical educational purposes. Many reviews have highlighted the importance and usefulness of MH in medical education (2, 3).

A voluntary MH module at Pokhara

In early January 2007, I was selected for a two-year, part-time fellowship in health professions education and educational leadership at the PSG-FAIMER (PSG Foundation for Advancement of International Medical Education and Research) Regional Institute in Coimbatore, India, while working as a faculty member at Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal. As part of the application process, candidates have to submit the outline of a curriculum innovation project (CIP) to be carried out at their home institution. I have a keen interest in creative writing and photography and thought of using these interests to develop an MH module as my CIP. The module was further refined during the first on-site session at PSG-FAIMER in April 2007 (4) and was offered to interested students and faculty members at MCOMS during May-June 2007. Participant feedback about the module was positive (5).

Module for faculty members at KISTMC:

I joined KIST Medical College (KISTMC), a new medical school in November 2007 and explored the possibility of conducting an MH module at the institution. Dr Piryani, a faculty member in the department of Medicine, was interested in being a co-facilitator and we conducted a module for faculty members during March-August 2008 (6). Literature excerpts, paintings, case scenarios, small group work and role-plays were used. The sessions covered were Empathy, The patient, The family, The caregiver, The doctor-patient relationship, Breaking bad news and euthanasia, Obtaining informed consent, Abortion, Patient participation in clinical research, Dealing with the HIV-positive patient, Dealing with the mentally ill, and Women and medicine. Participant feedback about the module was positive but certain problems were noted (6).

Challenges faced during the first two modules

The major challenge faced during the inaugural module at MCOMS was creating and sustaining participant interest and involvement (7). Students sometimes found it difficult to participate due to the pressure of other subjects and assessments. The module was held in the evening and social and other activities occasionally prevented participation. A group of 10 sixth semester students started participating regularly in the module and their interest and enthusiasm played an important role in driving the module forward. There were students of different nationalities and the language of the module was English. The literature excerpts used were in English and participants felt certain excerpts were difficult to understand (8).

The participants in the faculty module at KISTMC had problems with discussing sexual and reproductive issues openly. They had problems with the level of English used in certain literature excerpts and were reluctant to enact particular role-plays.

Module for first-year medical students at KISTMC:

KISTMC emphasises excellence in education, healthcare and research and the principal and the Director (Academics) were keen to have an MH module for all first year students (9).Students are posted in the hospital for early clinical exposure once a week and we (Dr Piryani and I) decided to conduct the module during this period. Six teachers who had attended the faculty module were selected as co-facilitators for the student module. Participants had problems with literature excerpts during the first two modules (at MCOMS and the faculty module) and we decided not to use these during the student module (10). Small group activities, case scenarios and role-plays, and the flexibility afforded by the use of flip charts and flip boards were the strengths of the sessions and we continued these during the student module.

The first task was preparing an outline of topics to be covered in the module. Among the topics stressed was empathy, the doctor, the patient, the doctor-patient relationship, the caregiver, the family, dealing with HIV-positive patients, the medical student and what it means to be sick in Nepal. The module was held in the college auditorium, a room which could be arranged according to session requirements. The students were divided into six small groups and an LCD projector, flip charts, flip boards and microphones were made available. A place for conducting role-plays was also created. The scenarios were created by the author in consultation with other facilitators after a lot of thought and debate and reflected the socio-cultural milieu of Nepal. Some of these scenarios have been described elsewhere (11).

In the next academic year (2009-2010), we had 100 students. This created a different set of challenges. The major problem was how to divide 100 students into six small groups. Students were divided into two batches of 50 students each. Each batch was then subdivided into six small groups. Sessions were conducted on alternate Thursdays for a particular batch. Each topic was subdivided into two sections and the number of topics was reduced. The author’s experiences with three years of MH has been discussed in a recent article where the topics covered during the modules conducted in 2008, 2009 and 2010 are listed (12).

The module uses facilitator presentations, facilitator inputs, audience elicitation sessions, interpretation of paintings, case scenarios, group work and other activities to explore different aspects of MH. The paintings used during the module and their annotations are mainly obtained from the literature, arts and medicine database (13). Recently we have also used some paintings and sketches by our students. Detailed participant feedback about the paintings used in the module has been recently obtained (14). Paintings were better able to bridge the cultural and social divide compared to literature.

How students perceive the module

Informal feedback about the module is obtained during discussion with students. Detailed written feedback is also obtained at the end of each session. Feedback is again obtained at the conclusion of the module. Students’ perception about the module is positive. The module is not assessed and is not a ‘formal’ part of the curriculum. Student attendance is good and is about 75 % to 80% even on days preceding internal examinations. Students feel the module offers a different perspective, is entertaining and ‘fun’, and will be useful in their future practice. They also feel proud that KISTMC is one of the few institutions conducting an MH module in Nepal and South Asia.

Table 1: Examples of case scenarios used during the medical humanities session

My own evaluation of the modules

I have now been conducting MH modules for over six years. When I first started the voluntary module at MCOMS I did not think I would be able to sustain MH for long, and contribute to the development of the discipline in Nepal and even other countries. At KISTMC I feel the module has progressed well. The basic framework of the module is now well defined. Its strength is its activity-based nature conducted in small groups. Students enjoy participating in the module and learn while enjoying themselves. The sessions are lively and a variety of issues are explored.

Possible future directions of the module

Recently three “young” faculty members joined the module as co-facilitators and now actively contribute to its design and implementation. The basic framework of the module should, I feel remain the same in the future. The module may change depending on consensus among the young facilitators and their vision of MH and may become more “localised” in the sense that more art and paintings and literature excerpts from Nepal may be included. The module will remain activity-based and be conducted in small groups using team-based learning principles.

Advice for other medical schools considering an MH programme

In the present scenario MH remains largely confined to medical schools in the West. In Asia, the discipline is only now beginning to generate interest. In South Asia isolated programmes have been conducted in medical schools. In New Delhi, India, regular lectures on topics related to MH are conducted (15). The major challenge according to me is that MH is regarded as yet another “subject” in an already overloaded medical curriculum. Finding time for MH in the busy teaching schedule is another problem. In KISTMC, the MH module is conducted from 8 am onwards and the early hour creates difficulties for faculty members.

My advice is: before starting MH training, each medical school should chalk out the learning objectives of the module. I am not in favor of a uniform, didactic module imposed by an external authority. I feel MH should spring from the creativity of the faculty in each institution. Faculty interested in the humanities could play a key role in driving MH forward. The sessions should be activity-based and conducted in small groups. A voluntary module can be initially offered and later schools may explore a module for all students. I feel it is extremely important to preserve the “fun” nature of the module and create a protected and friendly environment. Faculty involved should be familiar with small group dynamics and facilitating activity-based learning. Sharing of experiences between medical educators involved in MH in the region is important and a mechanism for this should be worked out.

Statement of similar work: The author has written extensively on the subject and has cited previous publications as references when appropriate.