Introduction

The dictionary defines the word “humanities” as “learning or literature concerned with human culture, especially literature, history, art, music, and philosophy” The humanities should not be confused with “humanism,” a specific philosophical belief, or with “humanitarianism,” the concern for charitable works and social reforms. Medical humanities (MH) can be defined as the application of the techniques of the traditional humanities fields to medical practice. Over the past 30 years, there has been a trend towards the development of a humanities curriculum in medical education, both in the United States and Europe (1). There are variable reports regarding the usefulness and the effectiveness of such curricula all over the world (2, 3).

The purpose of a medical humanities curriculum

Modern allopathic medicine is considered scientific, objective and evidence-based. Due to an overemphasis on objectivity, it sometimes lacks a holistic approach, as the patient is treated as a case, and not as a whole person. The growth and development of current medical practice is deeply rooted in science but there is definitely too little emphasis on the “art of medicine”. Over the years, due to an evidence-based approach and objective assessment of students (especially in CET-based career choice examinations) there has been a loss of comprehensiveness and of a holistic approach to medicine. However, one must understand that medicine is as much an art as it is a science. There is not always one right answer. Not every patient is cast in the same mould and the broad brushstrokes of a one-size-fits-all treatment model are not always appropriate. In addition to economic factors, there are tremendous cultural differences in the community that determine treatment choices. Innovation and creative thinking are necessary to develop new methods of healthcare delivery, discover new medicines or treatment options, and prevent the emergence of new diseases. By educating healthcare practitioners to be more receptive to creative input and encourage innovative thinking, those entrusted with delivering healthcare will not be stifled by the repetition and lack of originality that is today’s healthcare system.

The medical humanities were introduced into various university curricula with the intention of enhancing this aspect of the “art of medicine”. The medical humanities can have both instrumental and non-instrumental functions in a medical school curriculum. The term ‘instrumental’ function implies that learning can be directly applied to the daily work of the clinician. The clinician has to develop the ability to observe and recognise visual clinical signs of disease in the patient. This ability can be directly enhanced by the study of the visual arts (4, 5). The study of literature can help develop another important skill of handling ambiguity and empathy (6). Likewise, the evaluation of case study narratives has been used to improve clinical skills (7).

The humanities exert a non-instrumental function when they help to develop the concept of medicine as art, general education, personal development, or instil new ways of thinking beyond the biomedical perspective (4, 6, 8). Study of the medical humanities has been used to understand the role of the professional in a society and develop self-reflexivity (9). A health professional has the capability and opportunity to influence society beyond biomedical decisions. With the current pattern of professional practice, we are losing this perspective in clinical practice that was an integral part of the “family physician” concept two decades ago.

When one considers the various attributes of a good doctor – they can be broadly divided into the scientific and the artistic. To develop good clinical judgment he/she needs technical expertise and scientific decision-making that is based on objective evidence and knowledge. On the other hand, to develop a humane approach (which is also an integral part of clinical judgment) he/she has to gain interpretative insight and an understanding of ethics and education, and a broad perceptiveness (6). In summary, I feel that a physician needs to have both aspects – the scientific and the artistic. Currently, we are not bothering to develop the second aspect in medical education. An MH curriculum will be able to fill this gap in our orientation.

Methods for implementing an MH curriculum

Subjects traditionally grouped under the humanities, such as painting, music, literature, sculpture, philosophy, sociology, anthropology and others are widely used in educating doctors in the developed nations. MH programmes are well established in many universities of the United States (US), the United Kingdom and some other countries in Western Europe, Canada, New Zealand, and Israel. In many medical schools, MH was attempted as a voluntary module and gradually a case was made for introducing the discipline formally into the curriculum. Literature, painting, fine arts, drama, photography have been used to teach MH. Many medical schools offer a number of elective courses in MH and students can select one according to their interests and aptitude. Other schools have a core subject area in the humanities, but students can choose electives according to their interests. In certain schools, MH is restricted to particular years of study while in others this is spread throughout the course. Small-group, activity-based learning is used in the majority of medical schools.

In Canadian universities, students can choose particular courses and do summer research projects in the humanities. The School of Medicine, University of California, Irvine, in the US, informally started a literature and medicine elective in 1997, emphasising small-group interdisciplinary learning and the use of creative projects. The programme aimed to enhance some aspects of professionalism including empathy, altruism, compassion, and caring for patients, as well as to improve clinical communication and observational skills. At the University of Tel Aviv, Israel, a course on the Philosophy of Medicine was introduced in the year 2002-3 comprising formal lectures, question-and-answer sessions and exercises.

Ravi Shankar (10) introduced a medical humanities module for the faculty members and the medical/dental officers in Nepal. He organised small group activity-based sessions, using literature excerpts, paintings, case scenarios, small group work and role-plays. At the end of the module, feedback was obtained from selected participants through focus group discussions. These discussions revealed that MH was a very important topic, often found to be missing in medical education. Shankar concluded that the module with small group activities was appreciated by the participants as well as the faculty, and recommended that similar sessions be conducted in other medical schools of South Asia.

Impact of a curriculum on students learning

The MH curriculum is considered useful in improving a physician’s communication skills (8). Debate still continues on the definition and exact role of MH in medical curricula. Wershof Schwartz et al (11) reviewed the literature on the impact of a humanities education on the performance of medical students and residents. They also discussed the challenges posed by the evaluation of the impact of humanities in medical education. Students who are exposed to the MH curriculum perform academically on par with their peers with science backgrounds in medical school. Courses in MH are diverse and varied in content and goals and hence measuring and quantifying their impact has been challenging. Many of the published studies involve self-selected groups of students and seek to measure subjective outcomes, which are difficult to measure, such as increases in empathy, professionalism, and self-care. The review recommended defining the optimal role of a humanities education in medical training, and carrying out more quantitative studies to examine the impact that MH may have on physician performance beyond medical school and residency.

In another systematic review in Academic Medicine (2010) by Ousagar and Johannessen (12), 245 publications were reviewed. These articles were categorised into four groups. Sixty eight strongly recommended inclusion of MH into the curriculum and were described by the authors as “pleading the case” while 156 described courses and positive short term evaluations. Overall, 224 (68+156) publications described the positive effects of the humanities on medical education or described existing courses, but provided little substantial evidence. Only nine articles studied the evidence of long-term impacts using diverse test tools and stated that though graduates were similar in overall evaluation, they were “more confident in managing patients’ with psychosocial problems when compared with graduates from the traditional curriculum. The remaining 12 articles expressed criticism and were skeptical about recommending an MH curriculum in medicine. The authors concluded that “evidence on the positive long-term impacts of integrating humanities into undergraduate medical education is sparse” and suggested further studies.

The Indian perspective

Richa Gupta et al at the University College of Medical Sciences (13), Delhi, formed an MH group in 2010, and have shared their experiences. They arranged for lectures on subjects such as rationalism, the Tibetan art struggle, faith healing, and communication with a grassroots and holistic approach. This was very well received by the faculty and students and had increasingly positive responses at subsequent sessions.

In medicine, there have been tremendous advances in technology for use in diagnostics and imaging as well as therapy. There has been growth in newer sub specialties for specialised care in specific areas that has created physicians who treat only a limited spectrum of diseases. This underscores the need for a more holistic approach towards healing and cure. Besides, it has been increasingly felt that doctors today lack empathy and compassion for their patients. This may be attributed to many reasons such as the lack of a formal curriculum, overload of knowledge, excessive dependence on technology and compassion fatigue. Experiences with MH programmes offer many benefits, including improving clinicians’ abilities to communicate with patients, developing more confidence while treating patients with psycho social problems and improving empathetic behaviour. (12) There is need for setting up of fellowships, degree and diploma courses in MH like those available in the West (12).

The website of the Medical Humanities Foundation of India is available for all Indians with an interest in making medical care more humane (14). It has many subsections that provide suggested reading, event announcements and patient narratives. Though an isolated example, this is a good movement towards introducing pooled resources for interested faculty and colleges to introduce MH curricula. Reddy (15) has also emphasised the need for MH in the Indian medical curriculum for more empathetic clinical care, and improved communication skills in graduates.

The way ahead

Currently the Indian MBBS curriculum is overloaded with knowledge and dominated by objective entrance examinations. The Medical Council of India in 2010-2011 introduced Vision 2015 – a curricular revision plan. Graduate Medical Regulations proposed in 2012 include the introduction of a foundation course in the undergraduate curriculum. They also propose a humanities curriculum to nurture in students a broader understanding of the socioeconomic framework and cultural context within which healthcare is delivered, through the study of humanities and the social sciences. This is a welcome move by the Medical Council of India.

Every medical college should have an MH cell with a few designated members from the faculty, students, as well as external experts. The concept of MH should be introduced to all faculty and students through various programmes throughout the year. Sessions may be conducted preferably every month, or once in two months. Involving teachers who are already well versed in the humanities and who use every opportunity to introduce art, history and literature to the students will be more successful than having structured curricula. There should be open discussion after each session, with active participation from students and debriefing by experts. There is a faculty shortage in many medical schools in India and hence, initially external experts may be enlisted for initiating these programmes till internal expertise is available.

As suggested by Pandya (16), such a curriculum can be started at two levels by:

• introducing the humanities into the school curriculum “in such a manner that students do not fear examinations and assessments in the subject, but find their study a joyful and rewarding experience”; and by
• orienting teachers at all levels of education “into studying, enjoying and communicating to their students the rich treasures available in poetry, philosophy, fiction, history, songs, music, paintings, sculpture and other forms of culture” (16).

In summary, MH curricula are being introduced in various medical schools with the purpose of improving the quality and attitudes of medical graduates. There is a strongly felt need for such curricula in India, and some institutes have already initiated them with positive feedback from students and faculty. There is also a need for further studies to develop substantial evidence on the impact of the MH curriculum on the attitudes of students and residents.