Background: the problem

The unending corridors and wards of a government hospital can confuse any first-time visitor. I remember on my first day at my department, I could not find the Doppler room though it was just around the corner from where I stood. So surely it is too much to expect an illiterate old man with his frail wife to find their way from casualty to x-ray to the ward on their first visit. Yet many of us would not bother to stop and help such a person in distress.

As medical students, and then as doctors, we fail to read the anxiety and apprehension on our patients’ faces as they approach us. We are ruthless in the way we rush to finish with the long queue of patients. We are mechanical in inserting catheters, lines and tubes. We do not consider it necessary to explain procedures in detail, to calm the patient on the table. It is true that we are overworked and sleep-deprived, live in inhuman conditions, and must survive the taunts and tantrums of seniors. We have struggled through arduous entrance exams, toiled day and night for years to reach where we are. But as a result, by the time we realise our dreams of working as post-graduates, we have lost all our ideals. All the compassion, empathy and sensitivity we had when we entered this field have faded away.

Medical practice without the patient

The divorce between medicine and the arts begins early in a student’s life, right from school. The studious, ‘brainy’ bookworms are segregated from their more creative, intuitive and imaginative classmates. The rigorous, rote-memory-based examination system throughout their medical education erases any creativity that they have, as they concentrate on memorising endless facts and answering non-analytical questions. When they graduate and enter the real world of clinical medicine, they are uncomfortable before the real people who come to seek their help. They forget that medicine is not just mastering facts and figures; it is an art in itself – the art of observing, recording, reflecting, and integrating the events around us.

William Osler, described as the father of modern medicine, once said: “Care more for the individual patient than for the special features of the disease… Put yourself in his place… The kindly word, the cheerful greeting, the sympathetic look – these the patient understands.” (1)

However, for some residents and doctors constantly in search of what is ‘publishable’, patients are mere cases. I have heard a radiologist looking at an MRI of a brain say, “What an amazing mass, just look how beautiful it is!” Just listening to him sent chills down my spine. I fail to fathom how a malignant mass in the centre of somebody’s brain constitutes beauty. We exclaim in awe at a unique presentation of a disease process, but we forget the suffering endured by that person.

The situation is worse when one has paid an enormous amount just to enter the medical field or get a postgraduate degree. Add to that the ridiculous annual fees one is charged and you have doctors who graduate with only one thing in mind: to recover their investment. This attitude drains the disheartened student of any remaining trace of empathy. A patient is viewed merely as a source of income – and this the greatest injustice one can do to a suffering human being.

In India, doctors can talk about a patient’s prognosis and chances of death while standing at his bedside. An invisible wall is created by doctors using the English language in the presence of their patients. Patients wait fearfully, while doctors discuss their fate in medical jargon, and that too, in an alien language. They wait for their turn to come, thinking that most, if not all of it, will be explained, only to be turned away with unsatisfactory replies.

Sound clinical skills and a vast knowledge base form just one aspect of what comprises a good doctor. If the doctor is unable to communicate effectively with the patient in an easy and understandable manner, the purpose of medicine is not served.

What is needed: medical humanities

Sensitising young minds using the arts, literature and documentaries can gradually bring a paradigm shift in their outlook towards the patient.

Through literature and the arts, medical students will be exposed to a variety of cultures, living conditions and places of which they can have no personal experience. This will bring a broader perspective to their interaction with patients. The scope of the humanities is not limited to the undergraduate or postgraduate level. It will have a far reaching impact on how these future doctors will interact with, and be perceived by, the general public.

Have we ever given a thought to what it is like to care for the terminally ill? To making life comfortable for a disabled child? Or even to what it is like to be bed-ridden with no feeling below the waist? There are innumerable sensitive pieces written by people in such situations. Making some of these works compulsory or suggested reading could transform a medical student’s attitude towards people in distress, and life in general.

Humanities and the medical curriculum

For the humanities to be effectively incorporated into our medical curriculum the latter must be transformed. There are serious flaws both in the current medical school curriculum and in the method of teaching, acting as fire-extinguishers towards the scientific temper as well as creativity. The syllabus is not well defined. The learning objectives are unclear. Exam questions promote rote learning, instead of testing clinical and analytical skills. Even before they discover the magic of clinical medicine, these enthusiastic young doctors-to-be fall prey to the system of assessment based on memorising facts. Preparation for postgraduate entrance exams is not addressed in college, so students attend coaching classes at the cost of precious days of undergraduate training. Constant stress, competition and deadlines lead to tunnel vision, focusing on medicine alone, and extra-curricular hobbies take a back seat.

The way ahead

Any change will require multiple revamps – in the curriculum, in teaching methods, as well as in the overall focus of medical practice.

The medical curriculum must become more relevant, with basic sciences taught in the context of clinical practice. The curriculum must also be trimmed to cover the basics required at each stage. For example, ophthalmology and ENT should be made part of general surgery; they do not need to be taught in detail for an entire year. Community medicine must be taught in a more practical and interesting manner. The focus should be on India-specific problems rather than rare syndromes or uncommon presentations. Medical students in India should be aware of the bigger picture, the important health challenges that the country faces.

Teaching and evaluation methods must change. For example, lectures should be made more interactive, with case discussions and seminars. Questions based on clinical skills should be given greater weightage in the postgraduate entrance tests.

An increase in the number of postgraduate seats will reduce the cutthroat competition that permeates the educational system and diverts students’ attention from their primary concern – the patient’s welfare. Most important, the obsession with specialisation should be removed by promoting the concept of a good, competent general practitioner or family physician (as in the UK), giving GPs special benefits.

How not to kill the baby at birth

Before introducing humanities as a separate discipline, it needs to be integrated into daily classroom and bedside teaching. For this the first step is sensitisation and training of medical college teachers. Teachers are role models, setting standards for their students, for example, on how to talk to patients. However, not all teachers can teach the humanities. The degree of interest in humanities which can be generated amongst medical students will depend largely on the teacher. These teachers should be well trained and knowledgeable.

It is important to use various teaching methods. Teachers can strengthen their arguments by referring to relevant medical history and contemporary events. Interaction with people working in other fields like performing arts, photography and literature can help broaden students’ horizons. Role play and poster making can be organised on social and health issues. Films and other media coverage of the topics being taught can be followed by informal open discussions.

The teaching should highlight socio-cultural differences and epidemiological variations in the disease under study. Public health education is critical – encouraging medical students to participate in rallies, camps and drives and organising street plays for the general public. Students should learn about the socioeconomic basis of illness, possibly by following poor families over the period of their medical education, in order to understand demographics, economics, sanitation, and health status. This will give them a sense of purpose and help them understand the larger context of health and disease in India.

To achieve a balance between the head and the heart in the medical profession we need to infuse a sense of empathy from the very start of medical education, introducing medical students to the humanities at the time in their lives when there will be the maximum impact.