What are the Humanities Doing in Healthcare Education?

David Hatem, MD

We are forever envisioning and re-envisioning healthcare education. Each time we do this, there seems to be a new emphasis. The original Flexner Report emphasized standards for medical school, the scientific basis of medicine, and the evolving body of knowledge in medicine (1). More recently, healthcare education has sought to integrate foundational and applied science, reinforcing that there is a scientific underpinning to this endeavor, and that clinical care is ultimately the end goal, even from the most dedicated and focused research.

Recent additions to the healthcare education mandate include an emphasis on health systems science(2), a foundational framework for the study and understanding of how care is delivered, how health professionals work together to deliver that care, and how health systems can improve patient care and healthcare delivery. A second recent emphasis is professional identity formation—the process by which our education takes developing humans and layers onto their existing identity new knowledge, skills, and values that help them “think, act, and feel like healthcare workers.” (3)

These overarching concepts reinforce that healthcare work has scientific underpinnings, but it is also delivered by people to people in a specific context. While the scientific foundation is crucial and a source of impressive advancement, the need to apply our knowledge each day when caring for patients entails significant uncertainty. This is exactly where the healthcare humanities can integrate with evidence-informed care to help us to personalize our approach while developing as caregivers.

The Aeneid is not only a story about war, it is a story about a man and his unique experience with hardship and trauma. In healthcare, at the juncture of science and care for people, is a place for stories about those people, with distinct hopes and specific disappointments in their role as parents and children. Healthcare humanities can expand and add depth to the personal. In The Death of Ivan Ilych, Ivan grapples with his impending death, evaluates the worth of his life, and ultimately reconciles with his family while he is dismissed by physicians who remain above the fray and of little help. Only Ivan’s servant, who stays with and comforts him, is truly moved at the end and at a loss for his passing. It is he who knows the man (4). Kayla Thomas, RN reminds of this in “Humanities as a Tool» on page 6, where she invites us to elicit our patients’ perspectives, and step into their experiences to understand them.

“We read many books, because we cannot know enough people” – t.s. eliot Eliot encourages our reading about people as much as about medicine. Medicine provides countless stories about illness that personalize this, with particularity, and uniqueness. The novel, The Curious Incident of the Dog in the Night Time by Mark Haddon, in which a boy with autism investigates the murder of his neighbor’s dog, provides great insight into the character’s way of experiencing the world. Entering into the world of another requires embracing uncertainty and engaging openly with others. In her article, “Embracing the Good, the Bad, and the Weird» on page 8, medical student Megan Hansen encourages us to embrace patient stories and create the possibility that these stories will embrace and change us. On page 19, Wendy Arena writes about eliciting stories from our patients, helping them make meaning of their experience, and helping medical professionals make meaning of our work. She also reminds us of the power of listening-- allowing our patients to be heard, and to be seen.

As we broadly consider health, medicine is asking us to engage our imagination and embrace social science research that suggests that factors beyond the personal inform health outcomes. These social determinants of health include economic stability, educational access and quality, healthcare access and quality, neighborhood and built environment, and social and community context (5). Conversations about these topics bridge healthcare humanities, medical ethics, history, and public health in works like The Immortal Life of Henrietta Lacks by Rebecca Skloot (unconsented medical research), Bad Blood by James H. Jones (observational syphilis study despite developed treatment), and Life on the Line by Emma

Goldberg (COVID-19), to name a few. Community factors and what is truly going on in our patient’s lives sometimes require us to re-story what we are told, like in Roddy Doyle’s The Woman Who Walked into Doors, where stories of personal injury beyond what the history suggests are envisioned for what they are: acts of intimate partner violence. These accounts encourage us to enter into our patient stories, into their communities, and into their lives.

Our task as clinicians is to remain curious -inquiring about the next detail and coaxing the story out. I recall seeing a patient whose lung disease rendered him short of breath, most easily measured by how winded he was when he walked his dog around the local golf course. After several years, I recall him telling me that he was no longer having trouble keeping up with his dog. I was ready to conclude that his lungs were getting better until the next question occurred to me, “so how old is the dog?” What followed was the story of an aging dog increasingly hobbled by arthritis, cutting across the golf course instead of walking around it, shortening the walk, and slowing its owner. In this case, curiosity allowed me to personalize the story and seek another way to measure his day-to-day lung function. Rebecca Kowaloff’s article on page 9 provides context about curiosity in patient care as she talks about the skills and the function of narrative medicine.

Sometimes physicians write stories. While practice is full of engaging stories, healthcare is also delivered by people, who happen to be healthcare workers. In this issue, we see Gold Humanism Honor Society’s award winner Golda Grinberg’s piece about the challenge of her busy life as a healthcare worker when it is interrupted by the illness of her child as an example of balancing life and learning as a medical student with life and learning as a mother. Telling these stories can enhance self-awareness, lead to personal growth and development, promote personal reflection, and build an integrated personal and professional identity (6, 7). This process of growth and identity formation continues, as does the story (8, 9).

Healthcare is delivered by people, to people in a specific context. Currently, that context is changing. We are coming to appreciate the health system as a player, sometimes welcoming, sometimes a barrier to the delivery of caring. On page 11, Hugh Silk and Anindita Deb consider how to integrate the health humanities into the medical curriculum, and call for true integration, bringing literature or works of art related to the healthcare topic being discussed so that the scientific and the humanities perspective on disease is discussed together.

While much of this issue is focused on reading and writing, art, music, and history are also part of the health humanities. In a provocative piece on page 14, Joel Popkin explores music as therapy, cleverly demonstrating how thinking about music engages the mind, while listening to music engages the heart. This issue also includes pieces by Parul Sarwal and Sara Shields that consider incorporating works of art into healthcare education to reinforce the powers of observation, dealing with ambiguity, and the need for skillful interpretation.

As you read this issue, I hope that it activates not only your cerebral cortex, but that it activates emotional engagement. Healthcare that includes humanities aims for whole people taking care of whole people in a humanistic context. I hope you read, listen, then engage your whole selves in the practice of health care. It is likely to be moving. +

David Hatem MD, Professor of Medicine at UMass Chan Medical School, teaches reflective writing to medical students to help them learn from their experiences.

References

1. Ludmerer KM. Abraham Flexner and medical education. Perspect Biol Med. 2011 Winter;54(1):8-16. doi: 10.1353/ pbm.2011.0009. PMID: 21399378.

2. Gonzalo, Jed D. MD, MSc; Ogrinc, Greg MD, MS. Health Systems Science: The “Broccoli” of Undergraduate Medical Education. Academic Medicine 94(10):p 1425-1432, October 2019. | DOI: 10.1097/ACM.0000000000002815

3. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med. 2015. 90:718-25. doi: 10.1097/ ACM.0000000000000700. PMID: 25785682.

4. Tolstoy, Leo. The Death of Ivan Ilych. Translated by Ian Deiblatt, Melville House, 2009.

5. https://health.gov/healthypeople/priority-areas/socialdeterminants-health, accessed 3/31/23

6. Binyamin G. Growing from dilemmas: developing a professional identity through collaborativereflections on relational dilemmas. Adv Health Sci Educ Theory Pract. 2018 Mar;23(1):43–60. https://doi.org/10.1007/s10459-017-9773-2.

7. Levine RB, Kern DE, Wright SM. The impact of prompted narrative writing during internship on reflective practice: a qualitative study. Adv Health Sci Educ Theory Pract. 2008;13(5):723–33. https://doi.org/10.1007/s10459-007-9079-x.

8. Grinberg GR. When Practice Questions Become Real Life. JAMA 2022;328(8):711. doi:10.1001/jama.2022.13837.

9. Grinberg GR. Staying Home. JAMA. 2023;329(8):633–634. doi:10.1001/jama.2023.0040