BY: MARK CRAWFORD
Quality medical care is more than just good science. It assesses the ways in which illness impacts patients or families on emotional, spiritual and cultural levels so that physicians can design the most effective, caring and meaningful patient management plan possible.
Such a broad view of illness and healing is the basis of "person-centered care," yet it can be, as many a medical professional knows, an elusive goal in the rushed environment of medical care today.
So over the years, medical schools have broadened their scientifically rooted curricula, adding programs in what is broadly termed "medical humanities."
The term is often applied to courses "exploring the ethical, legal, social and interpersonal aspects of medicine," and may come under such headers as "medical ethics and bioethics," according to Mark G. Kuczewski, Ph.D., professor of medical ethics and director of the Neiswanger Institute for Bioethics and Health Policy at the Stritch School of Medicine, Loyola University Chicago. Kuczewski also serves as assistant vice president for mission and identity in Loyola's Health Sciences Division.
More recently, the medical humanities curriculum has expanded at some schools to include programs that offer content traditionally associated with the liberal arts. While curriculum content varies, the goal is to target the emotional, spiritual and cultural elements of illness, root them in a deeper understanding of what it is to be human and relate them to the practice of medicine. This emerging field can include such studies as history, philosophy, religious studies, art, literature and music.
Although the best physicians always have known that a deep appreciation for the "human condition" is an important part of being a good doctor, a sense that this appreciation must be fostered and nurtured has grown in medical education as technology becomes ever more sophisticated, setting off alarms in some quarters about the dangers of depersonalization.
At Catholic medical schools, programs vary from such traditional humanities content as art, literature and music to others that focus on what it means to be a suffering human, to a theological approach that focuses on the inherent dignity of the human person and the moral requirements of Catholic social teaching.
"Since the late 1980s, medical schools have been consciously concerned with making sure medical students leave medical school with an appreciation of the human dimension of practicing medicine," said Kuczewski. The subject matter has evolved over the years, but, in general, he said, "It is a hallmark of our curriculum as a Catholic and Jesuit school to bring together the head and heart. We think of our task as medical educators as offering the student a formation opportunity."
At Georgetown University's medical school in Washington, D.C., Caroline Wellbery, MD, has developed a program based largely on content traditionally associated with the liberal arts. "Art and literature are deeply concerned with the human experience, of which illness is an important part," said Wellbery, who is associate professor in the Department of Family Medicine and creator of the university's "Interacting with the Medical Humanities" website. "There are deep emotional and spiritual components to a patient's illness experience. The arts and narrative can communicate the emotional tenor of these experiences." For instance, literature "helps readers understand human dilemmas well beyond his or her own limited experience," she said.
"I use poetry and stories in the classroom and have students develop creative projects to synthesize their knowledge, rather than write papers," she said. "I also run a monthly arts and music program where students perform and read poetry and prose during noon hour, based on Dr. Jon Halberg's Hippocrates Café at the University of Minnesota." The café showcases professional actors and musicians using music, theater and humor to explore health care topics.
"Much of literature is concerned with ethical questions," Wellbery said. "Visual art, dance and theater often parse ethical dilemmas." Other aspects of the humanities, such as history or ethics, address patients' subjective experiences by providing a context for the biological processes going on in our bodies." As an example of how she weaves the humanities into clinical training, she recently used a poem about diabetes in a seminar she led to communicate a patient's frustration with managing his disease.
At Creighton University's medical school in Omaha, Neb., a recently introduced, four-year medical humanities program focuses on various dimensions of Jesuit values and spirituality. "These values are consistent with those of other major religions to which our students belong, while being rooted firmly within the Catholic tradition," noted Thomas J. Hansen, MD, an associate professor. "The challenge," he said, "is how to assist a religiously diverse student body studying medicine to reflect on the transcendent values that are part of their tradition as well as the transcendent values of their future patients."
The first year of the Creighton program, completed in 2011, was based on what it means to be a contemplative in action. In the 32nd General Congregation of the Society of Jesus, the Jesuits wrote, "If we wish to continue to be faithful to this special character of our vocation ... we must 'contemplate' our world as Ignatius did his, that we might hear anew the anguish and aspirations of men and women." Students were asked to articulate and reflect on a personal mission statement and related core values in the context of the mission of Catholic health care founders, including the Jesuits and Sisters of Mercy, Hansen said.
In the second year, the program focuses on the spirit of cura personalis, Latin for care of the whole person. The phrase is used in Jesuit documents to describe the responsibility of the Jesuit superior to care for each man in the community with his unique gifts challenges, needs and possibilities, Hansen said. In the third year, the focus is magis,"the more," a Jesuit phrase linked to the Latin ad majorem Dei gloriam, for the greater glory of God.
In Chicago, all students at Stritch School of Medicine take "doctoring," a three-year, patient-centered care curriculum that explores bioethics, cultural awareness, cultural sensitivity, social justice and underserved medicine. It also offers courses in business, professionalism and justice.
"If future doctors are to be effective advocates for their patients and leaders for social justice, they must also understand the business and economics of medicine so they can understand the justice implications of our system," said Kuczewski. "These courses provide the understanding they need to be medical professionals who advocate for change on behalf of the marginalized."
"From the dying grandparent to the undocumented patient with a new cancer diagnosis, only a physician well-versed in the complex web of psychology, culture and ethics will be able to respond intelligently and appropriately," commented Mark Stoltenberg, a fourth-year student at Stritch.
REFLECTIVE DIMENSION
Humanities study can make physicians more aware of the all-important cultural, religious and spiritual traditions and beliefs and traditions that factor into medical decision-making. Knowing how other people approach life and death is a critical part of using mind-body-spirit principles to make the best decisions in these extremely stressful situations. And it can foster deeper relationships between physicians and their patients.
"Ethical considerations, moral values, religious beliefs and legal issues all must be factors" in medical decisions, said Paul Evans, DO, dean of Marian University College of Osteopathic Medicine, a new Catholic medical school in Indianapolis that will open its doors to 150 students in 2013. "Physicians must be comfortable knowing that patients may have different thoughts about their situations than the physician does."
Daniel F. Dilling, MD, associate professor of medicine at Stritch School of Medicine's Loyola University Medical Center in Maywood, Ill., a Chicago suburb, often faces decisions about withholding life-sustaining therapies and pursuing a palliative-measures-only approach to care. He specializes in pulmonary and critical care and frequently works with a fragile-lung transplant population.
"I pride myself in my ability to sit and face a patient or a family in such a situation and explain things in detail, with language that makes sense to them, and with honest projections of outcome, using verbal and nonverbal language that helps them come to terms with decisions to remove a loved one from life support," he said. "I even give a monthly lecture to our ICU team about the importance of communication with families and how to approach such a family meeting. Medical humanities training in school prepared me for the basic approach to ethical dilemmas and also cemented my resolve to make my patient relationships as rich as possible by fostering solid communication with my patients and their families."
WHERE THE HEALING BEGINS
It is that richness of relationships the humanities can foster, according to its proponents. However, some warn that it's misguided, reductionist, to think of humanities education as a tool to some clinical end. Jeffrey Bishop, MD, director of the Albert Gnaegi Center for Health Care Ethics at Saint Louis University, said, "Some claim that since there is a narrative competency to medicine, doctors will be better at that by reading literature. Others think that if doctors take art history, they will learn to look at the patient in a more comprehensive way, in much the way an art critic looks at a painting. I think, however, that trying to justify the humanities by claiming it makes doctors technically better undermines the very purpose of humanities education, which is to place that technical expertise into a humanitarian framework."
Third-year Stritch School of Medicine student Nathan Kittle just finished his clinical rotations at a community hospital that primarily serves a disadvantaged population on Chicago's West Side. He was working with a newly diagnosed patient who was dying of idiopathic pulmonary fibrosis. The team he was on had tried to talk to her about hospice care, but she didn't understand and wanted to stay in the hospital.
"Later I returned to her room and started from the beginning, asking about her life, her family and her thoughts on her health situation," said Kittle. "It became obvious that she did not understand she was dying and that she didn't really want to understand either. She kept saying she didn't want to make these decisions because they were frightening. She mentioned she had a daughter she trusted and would do whatever she suggested."
Kittle asked the other residents on the medical team if they wanted to call the daughter; they were uncomfortable with this idea and were relieved when Kittle volunteered. He called the daughter and spoke with her for about half an hour; at the end she understood the situation and wanted to speak to a hospice representative about taking care of her mother.
"I'm not exactly sure what led me to feel comfortable having this conversation, but I am certain my medical humanities training helped prepare me," said Kittle. "None of the residents I was working with were Catholic-trained physicians, which I think was obvious in their reluctance to have these complicated, personal conversations. My humanities training helped me immensely because it allowed me to focus on the patient, when most of our education tells us to focus on the disease and the disease process."
For Nichole Boisvert, a second-year student at Georgetown, the medical humanities help her listen. "We are human beings together in the world," she said. "The humanity in the patient speaks to the humanity in us as physicians or medical students. This is where healing begins. It teaches us to listen and notice things in a different way, to pay attention to gestures, tone of voice and metaphor — to understand the people we are caring for at a deeper level."
Carlos Antonio Rivas, one of Wellbery's students, believes study of the humanities can be a leveling experience for physicians, keeping them grounded in "the real world." "Embracing the humanities allows us to embrace our emotions and our diversity of perspective — the full range of human experience that happens inside and outside of the hospital," he said. "This allows us to be more than medical scientists and approach the ideal of being compassionate, thoughtful and richly knowledgeable physicians who can adapt to our patients' needs and our workplace's limitations."
MAKING A DIFFERENCE
Christy Tharenos, MD, with the Georgetown University Department of Family and Community Medicine, has a passion for using photography and videography for developing greater cultural awareness. She has used her visual arts skills to help her better understand and communicate with underserved people in different cultural settings, transcending barriers of economics and culture to explore medical issues that are often difficult for these populations to understand and communicate.
"I am able to better understand the different perspectives of my patients and learn from them via the humanities," she said. "I have worked in Uganda with youth and explored their concepts of physical activity and health via the visual arts and photography. This enriches my understanding of their perspectives and gives participants a way to voice their experiences. It is also a unique way to share this information with others in both Ugandan and American communities outside of medicine."
Wellbery believes medical humanities can help overcome religious barriers as well, by bringing out the common dimensions of religion that transcend specific doctrines. "I like to think that the humanities, when taught in a medical context, even when they deal with ugliness, fear and suffering, emanate from a deep ethical space that has to do with commitment to learning and healing," she said. "We have a responsibility to broaden the boundaries of our hearts and souls. The world has become so complex. Humanities keep us engaged with what is happening in the world. Through humanities we seek to understand the influence of history, politics and even human nature on our everyday lives, social groups, values and future."
MEASUREMENTS ELUSIVE
In theory, every medical school thinks humanities are important. However, when it comes to supporting humanities with funding, time and resources, they often fall short compared to other items on the wish list. Part of the reason is that medical humanities do not show measurable outcomes easily.
"Humanities do shape the character of students, but we don't have a good way to measure that," said Georgetown's Tharenos. "Measurement is often what's required to justify financial support or add more courses in the classroom. These are tough balancing acts. I would encourage medical programs to consider longer-term investments in the humanities for students, which I think is just as important as longer-term investment in medical education itself."
Kuczewski indicates it's hard to determine how Catholic medical schools compare to the average medical school in terms of volume and resources devoted to medical humanities. "We would all certainly be above the median," he said. "I think the thing we can clearly say is that the curricula of Catholic medical schools tend to be unapologetically in the service of our values to the dignity of all persons, including the marginalized, as well as a commitment to social justice. I believe most other humanities programs might have an element of this, but are more likely to phrase it in terms of understanding the patient's perspective."
MARK CRAWFORD is a freelance writer based in Madison, Wis.
THE 'SOFT STUFF': MEDICINE AS ART
Medical humanities are at a turning point, according to Howard Brody, MD, Ph.D., a noted bioethicist and longtime national leader in the field. At a May, 2012, conference at the University of Louisville, Ky., participants are expected to learn that medical humanities, long on the fringes of medical education, are on their way to becoming an essential component.
Recent revisions to the MCAT, the Medical College Admissions Test, scheduled to roll out in 2015, are a harbinger of what's to come. Other likely changes on the horizon, Brody said, include greater focus on humanities in accreditation standards for medical schools and heightened emphasis in residency programs. The trend, he said, is "to emphasize the importance of the humanities as more central." The revised MCAT favors "the better-rounded students," those who can demonstrate thinking and problem-solving skills and creativity over memorization of facts, he said.
In a Feb. 16, 2012, news release, posted on the website of the Association of American Medical Colleges (www.aamc.org), the organization's president and CEO, Darrell G. Kirch, MD, said, "Being a good doctor requires more than scientific knowledge. It also requires an understanding of people." Accordingly, the new MCAT2015 will test applicants' knowledge of behavioral and socio-cultural determinants of health. Additionally, a new section testing analytical and reasoning skills will ask students to evaluate and apply information from a wide range of social sciences and humanities disciplines.
Brody said greater emphasis on the humanities has long been recommended in reports about medical education. The reports go back to the 1930s, he said, but they've been largely kept on the shelf. "Now, it seems, it may actually happen."
Brody directs the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston, where he also holds the John P. McGovern Centennial Chair in Family Medicine. He is a member of the planning committee for the May 9-11, 2012 conference, where, he said, the new direction will be highlighted. The conference is sponsored by PRIME, The Project to Rebalance and Integrate Medical Education, and organized by co-conveners David Doukas, MD, University of Louisville, Ky.; Laurence McCullough, Ph.D., Baylor College of Medicine, Houston; and Stephen Wear, Ph.D., of State University of New York at Buffalo.
The institute Brody directs was established in 1973, nearly 40 years ago. The oldest such program is the Medical Humanities Department at Pennsylvania State University's College of Medicine in Hershey, Pa., which has been part of the medical school core studies since 1967.
The simplest way to understand medical humanities, Brody said, is to think of a liberal arts college with a traditional focus — philosophy, religious studies, history, literature, art — that aims to not just prepare students for careers, but to prepare them for a richer understanding of human life. Medical humanities aim to shape "broadly educated physicians and other health professionals, not just well-trained physicians, to understand the deeper meanings of what is going on with our patients who are facing dramatic changes in their lives," he said. Such physicians will go well beyond "What pill do I prescribe?" to think about "the meaning and impact of this event on the lives of our patients, and in our own lives," and on "what kind of people are we becoming as we continue our careers in medicine?"
Part of the reason for the trend, Brody said, is a deeper understanding of what's important in education: "The old adage about medical education was, there's the hard stuff and the soft stuff, and the students need the hard stuff. The soft stuff we can dismiss."
However, today, he said, there's growing evidence that it's the "soft stuff" that really shapes us as persons and professionals, while the "hard stuff" soon leaves the brain. "The brain can't keep all those facts and, anyway, today who needs to?" he asked. "You can Google facts. But the soft stuff is what stays with you: the skills of good interviewing, what illness may be like from the patient's point of view. One meaningful experience in the soft realm and, 10 years later, you're a changed person because of that experience."
Brody acknowledged some tension among advocates, some of whom favor an applied, others a pure approach to medical humanities. Those stressing applied suggest humanities study improves communication skills, patient relations and the like.
But if you focus on that, Brody said, "you miss the glory and beauty of these disciplines." For example, art and literature "are wonderful in their own right, not just because they make you a better doctor. "So we're trying to find the right balance between encouraging our student to grow intellectually"— study of the humanities for its own sake — "versus the more focused, applied use of humanities to improve the quality of medical care. I think everybody who teaches it struggles with that tension. I suspect it won't go away any time soon. I hope it won't. I think it gives liveliness to what we do."
At the Galveston program, Brody explained, medical students can choose one of four options for incorporating medical humanities. At a minimum, they can take the required courses, which include a six-week block in the second year, and "bits and piece" in other courses. Students who are "more excited," he said, can opt for a medical humanities track as part of a four-year medical school program, or add on a fifth year, which provides them with a master's degree in medical humanities in addition to an MD degree. The truly devoted can choose a Ph.D. in medical humanities, either in addition to an MD or on its own.
The trend to include more humanities parallels the trend some 40 years ago to incorporate medical ethics into medical education, Brody said. Back in 1972, only 10 to 15 percent of medical schools included ethics in the curriculum — and those were largely the Catholic medical schools, he said. Today, nearly all medical schools have ethics as part of the curriculum.
"Now the question is how many are doing humanities beyond ethics. It's an increasing number, but it's nowhere near the 100 percent mark. It's still a work in progress," he said.
— Pamela Schaeffer