MEDICAL EDUCATION AND THE HUMANITIES
B.A., University of Colorado at Denver, 1990
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Humanities
This thesis for the Master of Humanities
has been approved for the
Weimer, Ed (M.H., Humanities)
Medical Education and the Humanities
Thesis directed by Professor Mark Yarborough
The role of the humanities in medical school education is
discussed, focusing on history, existing programs, current issues,
recommendations for change, and barriers to change. This essay traces
the long association of the humanities with medicine and medical
education. It opens with the argument that the role of the humanities is
to provide broadly educated physicians who, because of their
background, can be expected to be more humane physicians. It closes
by illustrating the potential which exists for the participation of the
humanities in medical school education.
The practice of medicine needs new tools and skills, as well as
clear educational goals, if it is to function adequately in today's fast
paced environment. Curricula which are narrowly focused on the basic
sciences do not equip physicians to solve the myriad problems they will
confront in medical practice. Medical education must integrate the
various humanities departments into their curricula in order to produce
effective physicians. Further, traditional methods of medical education
and educational goals must be reevaluated to facilitate instructional
excellence in medical education. Also, effective doctor/patient
communication must be taught in order to reap the benefits the
This abstract accurately represents the content of the
candidate's thesis. I recommend its publication.
1. INTRODUCTION 1
Flexner Report 5
2. MEDICINE AND HUMANITIES IN THE PAST 8
3. CURRENT PROGRAMS AND ISSUES 13
Updating and Reforming Curriculum 16
Curriculum Content Changes 16
Educating the Medical Student 19
Learning Styles 20
Problem Based Learning 21
4. TREATING PEOPLE, NOT DISEASES 23
5. PHILOSOPHIES BEHIND THE MEDICAL HUMANITIES 28
6. HUMANITIES IN LITERATURE 37
7. MEDICAL HISTORY 40
8. LANGUAGE AND COMMUNICATION 43
Gender Expectations 44
Modern Problems in Communication 45
Suggestions for Effective Communication 46
THE MEDICAL SCHOOL LEARNING ENVIRONMENT
Agents for Change 51
10. CHANGE AND IMPLEMENTATION 57
Constraints on Recommendation Implementation 60
Recommendations for Implementation of Issues in
11. CONCLUSION 67
This thesis will deal with the past, present, and future role of the
humanities in medical school education. Medical humanities, as herein
discussed, has two aspects: cognitive and affective. Cognitive
disciplines most pertinent to medical humanities are the classical liberal
arts, history, literature, language, and philosophy. The affective aspect
emphasizes humanitarianism, humaneness and sensitivity to the patient's
needs as a person. It centers on empathy, caring, receptivity, and
openness to the human and personal dimensions of illness.
The role of the humanities in medicine is considered, with attention
to the classic disciplines, existing programs in medical school, and
obstacles to continuing or increased participation by the humanities.
Specific values of teaching literature, historical referents, philosophy, the
tools of teaching, communication skills, and reasoning will be identified
and considered. Literature offers the opportunity to see the interplay of
illness and persons, including the role of physicians in the lives of others
and the perception of physicians by laypersons. In addition to providing
an historical context for viewing medicine and science, history provides a
methodology for understanding time and process. Teaching doctors how
to think about the body and about persons (ie., the objective and
subjective, data and values) in formulating patient care goals allows
them to integrate knowledge of medical science, the body, everyday life,
and the overall functioning of individual sick persons. It is argued that
medicine has demands to make of the humanities that may exceed what
humanitarian disciplines are willing to or able to offer. In the process of
meeting medicine's changing needs, the humanities' view of their own
nature and function may also change. Currently, medical investigation is
focused narrowly on disease by the constraints imposed by scientific
methodology and technology, but there is an ever-increasing push by
both practitioner and patient alike to broaden this focus to include a
closer and more understanding relationship between the ill-patient and
physician. Support for this argument will be drawn from a review of the
role of the humanities in medicine, looking specifically to the role of the
humanities in medical school education, the benefits which the
humanities have to offer present and future medical practices, and some
of the obstacles which stand in the way of the increasing role of the
humanities in medicine. The basic argument of this thesis is that
humanistic concerns, as expressed in the notion of total patient care
instead of disease treatment, has always had a significant role in
One of the points of-discussion will concern the change in attitude
by both the patient and the physician towards a view of the patient who
is experiencing an illness, as opposed to the view of a disease with a
patient attached inconveniently to it. The General Professional Education
of the Physician Report (GPEP), Association of American Medical Colleges
1984, for example, in its introduction (p. 1) affirmed the belief that "every
physician should be caring, compassionate and dedicated to patients to
keep them well and to help them when they are ill." The report further
stated that "ethical sensitivity and moral integrity, combined with
equanimity, humility, and self knowledge are quintessential qualities of all
physicians." Another step forward in the reiteration of the tradition of
the humanely based medical practice occurred when the American Board
of Internal Medicine accepted a position paper of its Subcommittee on the
Evaluation of Humanistic Qualities in the Internist (1983). In this position
paper, the American Board of Internal Medicine in essence proposed that
the public has a right to expect humanistic behavior in its physicians, and
it further defined this as practicing medicine with integrity, respect, and
compassion. An increasing role of the humanities in medicine should
change the way patients and physicians define their role within the
doctor/patient relationship. The change must come from both sides, but
the side of the physician must be the site of initial change for two
important reasons; first, the role of the physician in the doctor/patient
relationship is that of a recognized authority and as such any meaningful
changes must be acceptable and permissible by that authority. Second,
although the electronic media as an educational medium has a strong
influence on public awareness, the sheer numbers and diversity of the
health care seeking public make any type of rapid change an
impossibility. In essence, doctors need to be taught, and to understand
that, as doctors, they are distinct from their tools and their science, they
are first and foremost, members of a community of individuals who need
each other at varying degrees and levels. As physicians they are uniquely
positioned and qualified to meet many of those needs, hopefully with as
much compassion as possible.
A quote by Francis Weld Peabody sums up well the role of the
humanities in medicine. "One of the essential qualities of the clinician is
interest in humanity, the secret of the care of the patient is in caring for
the patient" (Reynolds and Stone 1992, 17). This is one part of the
essential nature of medicine, caring for the sick patient. The other
essential aspect to medicine, especially Western medicine, is the use of
scientific skills and reasoning which provide and maintain an authoritative
knowledge structure and exclusivity for the physician/scientist
practitioner. The main thrust of this paper is that there must be a
synthesis of both parts to form a new role for the practitioner to follow.
In order for this synthesis to take place it must be believed and taught in
medical schools, and integrated into all levels of clinical training.
Within the last decade there seems to have been a much stronger
push towards this type of synthesis. The me generation of the 70s
combined with the consumer generation of the 80s began a push for a
more meaningful doctor/patient relationship. Now in the 90s, the
informed consent generation is demanding that humanitarian changes
become a matter of public policy. Demands for alternative forms of
health care such as acupuncture have become the norm instead of the
exception. A significant portion of the general public appears to be
turning away from the staunch and restrictive scientific focus fostered
by the Flexner Report of 1910.
What Abraham Flexner essentially saw at the turn of the century
was a large discrepancy between medical science and medical
education. "Society reaps at this moment but a small fraction of the
advantage which current knowledge has the to power to confer" (Flexner
1910, 20). America, at that time, had some of the best and worst
medical schools in the world (Starr 1982). Flexner recommended that
medical schools focus primarily on the study and practice of scientific
medical investigation, with a heavy emphasis on lab and
clinical/diagnostic skills. His recommendations, though harsh, were
simple. The program in medical education for doctors at Johns Hopkins
University was his model and with this in mind he sought to strengthen
even further the level of good schools. He sought to raise the levels of
mediocre schools to that of a high standard by demanding comprehensive
scientifically grounded coursework and assessment standards, and
eliminate those which could not compete. Flexner believed that America
was oversupplied with poorly trained practitioners and that it could use
fewer but better physicians.
Flexner's recommendations were broadly adopted, but at a price.
Flexner himself realized several years after the presentation of his historic
report that his recommendations were being misinterpreted and tried to
reiterate the importance of the role of the humanities in medicine.
"Assuredly, humanity and empiricism are not indentical; with equal
assurance, one may assert that humanity and science are not
contradictory....It is equally important and equally possible for physicians
of all types to be humane, and at the same time to employ the severest
intellectual effort that they are severally capable of putting forth" (Flexner
1925, 11-12). Flexner seemed displeased with the way in which his
recommendations were used to bolster a purely scientific approach, and
commented on the state of the changes which he saw taking place,
"Scientific medicine in America young, vigorous, and positivistic, is
today sadly deficient in cultural and philosophic background" (Flexner
1925, 18). His comment is still applicable today.
Medicine appears to be searching for a new role, and is,
consequently, frantically trying to redefine itself. Medical schools are,
however, in the same dilemma and are faced with stiff political and
faculty resistance to significant changes in physician training; in fact,
faculty and dean resistance is cited most often when medical school
reluctance to integrating humanities into their programs is explored or
questioned (ACME-TRI Report 1992). Despite this resistance, the
humanities have had an increasing input on medicine paradoxically
because of the scientific technology so heavily relied upon in healthcare
settings today. Bioethics, and the concern for the ethical dimensions of
such technology, is forcing medicine to change its singleminded focus
and search for new solutions which encompass not only science and
technology but the soft sciences of the humanities as well.
MEDICINE AND HUMANITIES IN THE PAST
In his key work, The Social Transformation of American Medicine,
Paul Starr (1982) gives a wonderfully detailed account of what medicine
was like prior to the Flexner report and what it has become since. Too
familiar is the traditional notion of the medical practitioner, a kindly
member of the wealthier class whose status in American society was
unquestionable. This portrait was quite wrong. Early American medical
practitioners were not a large part of the upper class, nor was medicine
seen as an aristocratic profession. Being a lawyer or statesman was
much higher on the social registers list than being a doctor. Within the
medical tradition, there was a caste-like distinction between the
relatively lowly family practitioner and esteemed surgeon. The one thing
which was common, however, was the notion of caring for the patient.
At this point in medical history scientific technology and its benefits were
only a dream. The doctors of the past seemed to be heavily grounded in
a desire to help relieve the suffering of their fellow man. In Sharon
Kaufman's book The Healer's Tale (1993), four of the seven doctors
whose lives she chronicled had doctors for fathers during the turn of the
century, and each one expressed the feeling that their fathers didn't really
want them to go into that profession, because of the harsh demands
medicine placed on the lives of physicians. Their main reason for
becoming doctors stemmed from their desire to relieve the suffering of
the people with whom they had contact. The one exception was Saul
Jarcho's father who, "didn't know any other way in which a young
Jewish man could earn a living" (Kaufman 1993, 62).
Because being a physician didn't have the same status it holds
today, and was not a popular career, qualifications for being a physician
were accordingly less stringent. In his report, Flexner notes that medical
schools were more interested in turning a profit than in turning out quality
doctors (Flexner 1910, 126). At that time teaching medicine was mainly
a didactic process of lecturing with little or insufficient attention paid to
laboratory or clinical skills. The focus in treatment was one mainly of
pain management, as there was very little clinical benefit to their
treatments when measured as to how we view effective treatment today.
The role of the health care practitioner was to ease patients' paths to
the grave. The very reason for the Flexner Report was rising conflicts
about the effectiveness of many who called themselves physicians.
There were many types of schools of medical thought; homeopathy,
allopathy, osteopathy, all claiming to provide beneficial medical care but
having no set requirements for educational background or knowledge
The Flexner Report, in setting forth recommendations for
educational standards, established guidelines which remain today.
Despite Flexner's largely positive role in wedding medicine more firmly to
science, and establishing educational and licensing standards, many
argue that his report contributed to the demise of patient caring and
initiated the impersonal scientific treatment of disease. A fixed
curriculum, based on courses in biology, anatomy and pharmacology
became standard. Laboratory courses and clinicals were made
mandatory. This weeded out those schools which didn't have sufficient
funding to support such courses. In such a context the Flexner Report
was repeatedly and rigorously used to defend the push towards a strictly
scientific focus of education in medicine. A close reading of the report
does give the strong impression of the need to teach science exclusively,
yet, the fact is, that Flexner championed the ideal of the physician as an
educated person, one in whom science and humanity were necessarily
united. "Such enlargement of the physician's horizon is otherwise
important, for scientific progress has greatly modified his ethical
responsibility. It goes without saying, that this type of doctor is first of
all an educated man" (Flexner 1910, 26). Only half of his report was
utilized effectively. That half has become the part which is most
criticized and many feel most misunderstood. The Flexner Report has
grounded medicine in science, when Flexner's intention was for medicine
to be grounded in medically humane competence. The diverse state of
medical education that existed during the turn of the century produced
physicians of varying levels of competency and empathy. Flexner's
recommendations were an attempt to standardize medical competency
and encourage the growth of a well rounded physician through the
pursuit of excellence.
If, in the current zeal to reconsider the role of medicine in our
society, there were to be an attempt to write a Second Flexner Report it
should not be an attempt to exclude the scientific bias in the initial
report. Rather, it should be an attempt to reconcile science and humanity
so as to increase competence and caring in the practice of medicine.
Given the climate of the times, and the state of medical education as it
existed then, the Flexner report served a valuable purpose and its impact
should not be overly criticized because of its being too narrowly utilized.
To off-set the strong tendency towards being strictly scientific
there were physicians such as William Osier who strongly encouraged a
grounding in the classics of literature and philosophy in order to balance
the didactic and scientific method of teaching medicine. Osier believed
that to be a good physician one must be broadly read and educated
(Osier 1919). Robert Petersdorf, commenting on medical education after
the Flexner report, says that "The competition that characterizes pre-
medical education is an abomination that brings out the worst in people
and that it is antithetical to promoting humanism in medicine" (Petersdorf
1987,19). Petersdorf believes that medical schools want only
applicants who have majored in science, students who avoided the
humanities courses and took only courses which would enable them to
get good grades in medical school with less effort or just to get into
medical school. In addition to the effects of a scientific bias on the part
of a large number of medical school applicants, the difficulties for the
humanities have been compounded by the national shift towards
education in the sciences following the first Russian space flight, and the
current shortage of funds for education in general.
CURRENT PROGRAMS AND ISSUES
Throughout the history of western medicine the goal of medical
education has been to select and train humane physicians. For twenty-
five centuries the Hippocratic oath has served as the standard of those
humane qualities to which the physician should aspire. Indeed, the
ancient Hippocratic manuscripts clearly indicate that the medical
profession exists to benefit human life (Osier 1919). The past several
decades, however, have witnessed a growing debate as to whether
medicine is a profession more of the sciences or of the healing arts.
Spectacular technological progress has occurred, perhaps obscuring
medicine as art. Some charge that medical educators have abandoned
teaching communication and interpersonal skills in favor of teaching more
technical skills, such as the interpretation of nuclear magnetic resonance
imaging. In addition, given how medical education is funded, the fact is
that research, not teaching, is the main priority of medical school faculty
has led some to argue that medical education must refocus educational
goals (ACME-TRI 1992). This funding is based almost exclusively on
research in the biomedical sciences. Thus funding issues drive the focus
on the biomedical sciences as much as, or in concert with, cultural biases
in medical training.
Since the time of the Flexner Report gargantuan leaps forward
have taken place in the size and scope of medical institutions, yet
surprisingly little has changed regarding the structure and implementation
of the medical school curriculum. The first two years of medical school
studies emphasize a firm grounding in the biomedical sciences of
anatomy, physiology, biochemistry, and microanatomy, in addition to
preclinical courses such as pharmacology, and various courses in
preclinical medicine such as interview and observation techniques.
Courses in behavioral sciences such as psychology are also standard. In
addition, there is an Integration of clinical science topics, including
genetics, cell biology, molecular biology, immunology and neurology, as
well as courses concerning issues in public health, health policy,
epidemiology, and bioethics.
Next, third and fourth year programs consist of supervised clinical
experience. Included in these are relevant electives, clerkships,
internships and externships in subjects ranging from emergency room
proceedures to pediatric oncology. The clinicals and internships have
traditionally used inpatient units of affiliated teaching hospitals. All
schools require clerkships in internal medicine, surgery,
obstetrics/gynecology, pediatrics and psychiatry, and more than half
require a clerkship in family practice or some other primary care setting.
Driven by economic necessity, and given the recent push and eventual
implementation of health care reform by the present administration on the
increasing numbers of general practitioners and family health care
providers, general and family care clerkship requirements are certain to
increase in the near future. In addition, students generally have the
option to elect additional training opportunities. Upon satisfactory
completion of this four year curriculum, the student is awarded an M.D.
degree. Graduating students are not considered to have the skills
necessary for independent practice, however. A period of graduate
training follows, which leads to certification in their chosen speciality.
Since Flexner, there have been periodic national reviews of the
medical school curriculum, beginning with the 1932 report of the
Rappeleye Commission and including the widely publicized Physicians for
the Twenty-First Century, an Association of American Medical Colleges
sponsored 1984 Report of the Panel on the General Professional
Education of the Physician (GPEP) and College Preparation for Medicine.
More recent national studies and reports have been sponsored by the
Macy, Pew and Robert Wood Johnson Foundations, and the American
Medical Association (AMA).
These reports reflect a remarkably broad consensus on desired
changes in medical education. First is the need to improve institutional
focus on medical student education. Second are the required changes to
prepare students to meet the demands of future medical practice. A
recent AAMC study, Assessing Change in Medical Education: The Road
to Implementation (ACME-TRI), has concluded that most medical schools
have only been modestly successful in implementing these reforms. A
report of that study suggests strategies to assist medical schools in
overcoming or at least minimizing the barriers to change that have been
Updating and Reforming Curriculum
The challenges medical schools face as they seek to reform
medical education appear in four general areas: updating the content of
curricula in response to new scientific understanding and technology,
changing populations, and changing health care needs; improving
teaching and learning; integrating advances in information technology and
medical information systems into medical education programs; and
changing the sites for clinical education and the nature of the clinical
training experience (ACME-TRI 1992).
Curriculum Content Changes
Patterns of mortality and morbidity have shifted dramatically in the
latter part of the twentieth century. Vaccines, antibiotics, and
improvements in public health and sanitation have largely eradicated the
infectious diseases that earlier accounted for most premature deaths,
with the exception of the recent epidemic outbreaks of AIDS and
Tuberculosis. Much of the focus of medical care has taken a decided
turn from the young to the old and from acute to chronic conditions.
Physicians in the future will increasingly treat problems of aging,
Alzheimer's disease, chronic neurologic disorders, heart and circulatory
failure, and bone and joint disorders as the Baby Boomer generation
moves into the next century. Curriculum design for medical education
programs must take into account these changes. Serious afflictions of
the young and middle-aged remain infant mortality, drug abuse, cancer,
and AIDS, to name a few. Many of these health problems are embedded
in culture and lifestyle and need to be understood in context, taking into
consideration the social, psychological, and biomedical factors of our
diverse society. Issues of health promotion, community based health
care and promotion, and disease prevention have recently become a
popular focus for areas where curricula could be updated.
Regardless, the importance of basic science and technology in
medical school curricula is still unquestioned. Indeed, advances in
molecular biology in the last 25 years have caused a quantum leap in our
knowledge of the human organism. This dramatic increase forces
medical schools to modify the basic science requirements in order to
include these relatively new fields of endeavor in the basic sciences.
Technologies developed from these and other basic science investigations
continue to expand the medical capabilities of physicians and challenge
schools to improve the integration of basic and clinical science
For physicians and the public, improved medical technology and
capability are dual-edged, improving and extending life but usually adding
to health care costs and posing moral dilemmas. Physicians can no
longer afford to ignore the financial consequences of diagnostic tests and
treatment decisions. Medical educators are now teaching medical
decision-making, that is, evaluating the costs and benefits of various
treatment options on the basis of controlled studies of patient outcomes.
Medical ethics continues to be a prominent part of physician training as
new technology introduces further moral quandaries for physicians,
patients, and the families of patients.
Finally, whether caring for chronic diseases of the elderly,
educating in prevention, counseling about new medical technologies, or
dealing with the ravages of the AIDS epidemic, physicians must be adept
at communicating with patients. Patient dissatisfaction with physicians is
in large measure related to inefficiencies in communication. The skills
required are effective listening and understanding of the patient
complaints, sequenced and logical interviewing about the nature of the
symptoms, fostering patient understanding and informed and participative
medical decision making, and counseling and educating patients and
families. A comforting word and healing touch were once all that
medicine could offer. The revolutionary advancements since that time
have not diminished the importance of communication in the physician-
Educating the Medical Student
The research discoveries of the post-war era gave rise to increased
specialization in clinical medicine and the sciences basic to medicine. In
the ACME-TRI Report, put out by the American Association of Medical
Colleges, it was reported that responsibility for both planning and
implementing a program of education for medical students has
traditionally been widely dispersed among medical school departments
and faculty members. Medical student education competes for faculty
time with the training of graduate students and residents within fields of
faculty specialization and research. The result has been a dilution of the
effort focused on general professional education.
Some schools have countered these influences by designating
authority and responsibility for medical school education to specially
created organizational units, directed by an interdisciplinary group of
faculty, with resources budgeted for this purpose. These units are
charged with developing and securing faculty approval for a
comprehensive set of educational objectives, drawing on departmental
and faculty expertise to implement the various parts of the program, and
selecting methods for the evaluation of students against the objectives
and for the evaluation of the curriculum itself. By designating authority
and responsibility this way, medical schools avoid the problem of medical
student education being merely a by-product of other faculty projects.
This strategy also helps to ensure that students will complete a coherent
program of general professional education, better preparing them for the
next phase of the medical education. Schools have also redirected
faculty energies more toward medical student education by changing the
academic reward system to give greater attention to teaching.
Traditionally, achievements in research have been the key to academic
advancement. While that is still largely the case, medical schools now
more frequently demand evidence of the quantity and quality of teaching
in promotion and tenure reviews (ACMI-TRI 1992).
Eric Cassell discusses the notion that learning must be an active
process, that problem solving and reasoning skills must be fostered, that
biomedical sciences must be taught not as disembodied facts but as the
conceptual basis for understanding clinical phenomena, and, most
importantly, that habits of self-directed, independent learning that prepare
students for a lifetime of continuing medical education should be
developed. The struggle has been how to best achieve these goals
Lectures continue to serve as the mainstay of instruction in the
first two years, but medical schools have decreased the time students
spend in lectures and have attempted to introduce more opportunities for
small-group learning. Computer-assisted instruction (CAI) programs are
used to supplement teaching of basic and clinical science topics.
Interactive programs that take advantage of advances in graphic imaging
are now readily available for teaching the basic sciences, including
anatomy, physiology, pharmacology, and pathology. Other programs
simulate clinical encounters with patients and teach diagnostic skills and
medical decision making with a focus on treatment costs and outcomes.
Problem Based Learning
A promising new approach to medical student learning is the
problem based curriculum. This refers to a student-centered, small group
approach in which basic and clinical science topics are introduced in the
context of patient problems. Discussion of these cases is supplemented
by independent research, reading materials, and occasional lectures and
demonstrations. Problem based learning is valuable for enhancing skills in
hypothesis development and deductive reasoning and for fostering group
communication skills that are required of health care professionals
working within teams. Problem based learning requires a radical shift in
education paradigm from a disciplinary to interdisciplinary context. Only
about 10 percent of medical schools currently use problem-based learning
as an organizing principle for their medical education programs (AAMC
TREATING PEOPLE, NOT DISEASES
It is expected that physicians should define their diagnostic and
therapeutic goals in terms of the everyday life and functioning of
individual patients. Unfortunately that expectation is seldom met because
of the difficulty of holding impersonal technical imperatives in check, and
because doctors seem to be trained to focus on diseases rather than on
how sick persons actually live their lives in families and communities. In
part, the problem arises because physicians are trained from the first days
of medical school to disregard the knowledge they bring with them of
everyday human life and function as if this knowledge were irrelevant to
medicine. Another obstacle is that doctors are not trained to include in
their decision making the kind of soft and often subjective information
that is relevant to the everyday life and function of sick persons.
Correcting these educational errors would do much to help change
physicians' priorities in patient care.
To that end, Eric Cassell discusses how teaching students to apply
knowledge of disease and the body to persons in their everyday life takes
advantage of student's preexisting knowledge of the world, as well as
what they have learned from medical school. Teaching physicians how
to acquire information about persons expands the students' knowledge
and broadens the basis for the application of basic science and
pathophysiology. Teaching physicians how to acquire, evaluate,
measure, synthesize, and analyze information about sick persons and
their bodies provides them with the tools to gain the information about
individual patients necessary to meet an ideal of care. Teaching doctors
how to think about both the body and the person, about objectivity and
subjectivity, data and values, analysis and synthesis allows them, in
formulating the goals of patient care, to integrate their knowledge of
medical science, the body, and the everyday life and function of
individual sick persons (Cassell 1984). In recent years, the AAMC has
endorsed the use of the teaching of humanities to broaden students'
perspectives with an eye to these ideals.
While meeting these goals is desirable, it should be noted that the
distance that physicians' training places between them and sick persons
is a necessary component of medical education. Another word for
distancing the patient is depersonalization. In order to teach medical
students the sciences of medicine, it is necessary to depersonalize the
human body for them. Their cadavers, experimental physiology,
pathology, and all the preclinical studies provide a dehumanizing arena in
which to learn human biology. This aspect of medical education Cassell
believes is an essential part of the socialization of physicians. Students
must learn to conceive of the body as a thing apart from and different
from their own bodies. John Cody, who took the course in gross
anatomy twice, first as a medical artist, and then as a medical student,
provides an interesting description of how the student dehumanizes the
cadaver in the beginning of gross anatomy (Cody 1978). In this regard
the students' experience recapitulates the history of medicine. The
anatomical drawings of the seventeenth century, no matter what they are
meant to demonstrate, show the dissected body in a personalized
position, reclining comfortably, an arm uplifted as if pointing, or in some
similar pose. This is in sharp contrast to anatomical demonstrations of
the last hundred years, in which no trace of personalization is to be
found. For example, the anatomical drawings of Leonardo da Vinci show
the stripped away cross sections of various parts of the human anatomy
in poses of movement both with and without those props necessary to
the movement being performed. Understanding came from association
with an understood movement or function, trying to understand the
mechanics of movement and function through lifelike display. With the
changes brought about by the Flexner Report, the depersonalization of
the body was a natural outgrowth of a strict focus on the sciences.
Changes in technology allow for photographs, both of actual cadavers
and of microscope images, to be used as teaching materials, forcing out
the tendency towards personalization. The body has yielded its secrets
in a consistent manner only since experimental and statistical methods
were developed that totally divorced scientific generalizations from the
individuality of persons. A Flexnerian view would be that well-trained
physicians are able to think of both the body and the patient, logically
Excellent training in the sciences of medicine is the hallmark of
modern medical education. Unfortunately, neither the need for
repersonalizing the physicians' knowledge nor methods for teaching the
ability to apply the generalities of science to individual patients have
made much headway in medical schools. There is reason to believe that
training in the humanities might help schools approach these goals.
What must be taught? Unfortunately, there seems to be a great
deal of talk about physicians needing to take care of the sick patient, not
just treating the disease, but talking about it and making it happen are
always two very different things. The problem to overcome is not just
simply that the education of medical students has dehumanized their
knowledge, but that in every encounter with a patient, the knowledge of
the body that guides the examination, whether it be history taking or
physical examination, and the categories used by the physician to
process the incoming information, push the person of the patient into the
background. Medical education in America is extremely adept at
educating medical students in the physical sciences but needs help
training those same students to somehow bridge the gap which exists
between physical medicine and humane patient-doctor interaction.
Medicine and medical education have produced machines, both
technologically and metaphorically, which can treat most of our physical
illnesses. What is lacking is the philosophical background which enabled
their creation and retards progress towards more humane competence.
PHILOSOPHIES BEHIND THE MEDICAL HUMANITIES
In a recent article by D.J. Self, a study was undertaken to review
and define the theoretical and philosophical structure underlying medical
humanities and bioethics courses in those few institutions with such
programs (Self 1993). Sought out was the direction and goals of medical
humanities programs with regard to their philosophical assumptions,
methods of implementation, and evaluation techniques. A questionnaire
was sent out to teachers in the medical humanities asking their
perceptions of the amount of time and effort devoted by their programs
to several philosophical approaches.
Inherent in medical humanities programs is an assumption that
such programs are designed to increase the effectiveness and quality of
the patient-physician relationship, that is, to produce better clinicians. To
this end, the various schools of thought and approaches to medical
humanities education which Self identifies will be outlined.
The first approach is the Cultural Transmission Approach,
sometimes called the Classical Humanities Approach. This approach
looks at the methods and patterns of the transfer of facts and values
from one generation to the next. The Classical Humanities Approach is
concerned with the anthropological evaluation of the transfer of culture
or, enculturation. It looks at the passing on of the wisdom and skills,
social and moral norms, those knowledge skills which are not based on
experience or emotion. It is centered on the object of education itself,
not on the transmitter or receiver of the information. It teaches
professionalism, oaths, codes and so forth. The Cultural Transmission
Approach stresses the internalization of basic values and knowledge of
the culture of medicine and includes various basic rites of passage. It
stresses competency of knowledge foremost.
The second approach is the Affective Development Approach,
sometimes referred to as the Humanistic Psychology Approach. It
emphasizes the development of compassion, sensitivity, empathy, and so
forth towards patients, colleagues, generally anyone and everyone.
Feelings, attitudes and values are dealt with, seen as an important part of
medical education. The main point of emphasis for the Affective
Development Approach is the growth of the individual student, where the
students self-concept, self-esteem, and ability to focus introspectively are
cultivated and encouraged. This approach advances the belief that a
well-educated, and self-actualized physician will be a competent, caring
clinician. It is concerned with teaching competent communication skills.
The last approach is the Cognitive Development Approach. This
approach emphasizes the development of logical and critical thinking
based on a core set of knowledge and principles. Competency in the
Cognitive Development Approach is not just the transfer of facts and
values, but the integration of those facts and values with personal
experience. Independent thought is stressed, to the extent that individual
circumstances dictate courses of action over conformity to traditional
professional practices. Central to this approach is the development of
maturity in thinking and reasoning, both scientifically and ethically.
Effective medical education would provide conditions which would allow
for progressive maturity. Education is active and interactive rather than
passive and didactic, it attempts to increase the epistemological
complexity and sophistication of thinking in medical education. The
Cognitive Development Approach often uses problem-based case studies
and encourages positional conflict and defense. It is student-centered,
and not culture or profession centered.
One of the interesting results of this study done by Self was that
of the respondents, 15% said that the goals of the Affective
Development Approach were admirable but seen as "soft science" or
"extras" and "icing on the cake" to be dealt with only if there was time
left over. Yet a significant number of respondents indicated that
education in the medical humanities was important enough to devote a
majority of their time to it, although it must be noted that this particular
group of respondents were themselves teachers of the medical
humanities (Self 1993, 223).
While ethical issues have received the greatest attention,
philosophical problems related to the nature of disease and health, the
fundamental bases of medical action, the relationship between doctor and
patient, the nature of medical information and the problems of decision
making and problem solving, the place of medicine in society, and many
others have come under consideration recently. As Stephen Toulmin has
made clear, philosophy not only has been important to medicine, but
medicine has been a boost to philosophy in providing problems central to
the human condition whose solution has been made urgent by the
forward progress of medical technology and the changing demands of
society (Toulmin 1982).
The current revival of interest in medical ethics was not stimulated
by a plague of immorality among physicians. Rather, it has been fostered
by a growing awareness on the part of physicians and the public that
these general principles often seem inadequate to new situations and
rapid changes. Issues discussed in bioethics are necessarily general and
abstract. The physician, however, must make decisions about the care of
patients, often, those decisions will have ethical implications. The
general and abstract must become particular and concrete. It is not
enough to have a sincere attitude about discontinuing life-support
systems. It is not sufficient to read a moving essay on allowing the dying
to die in dignity. Attitudes and information must be transformed into
choices and practice. When the occasion arises, the ethical problems in
the care of a patient must be assessed as skillfully as the patient's
Patients approach physicians with the hope of receiving the benefit
of improved health or care in illness. The habitual activity of the
physician is to gather information from and about the patient and to
evaluate it with a view to determining whether or not medical intervention
can benefit the patient. Clinical judgement, in which informed and careful
estimates are made of the probable benefits and risks of each step in
diagnosis and therapy, reflects the primary ethical responsibility of the
One of the most referred to works in bioethics is Beauchamp and
Childress's (1989) Principles of Biomedical Ethics. Daniel Wikler calls the
set of principles found in the book by Beauchamp and Childress the
"Georgetown Mantra", owing to the authors' association with
Georgetown University's Kennedy Institute of Ethics (Wikler 1991, 239).
Some of the principles covered in their work concern the following: the
Principle of Beneficence (help people), Nonmaleficence (don't hurt
people), the Principle of Justice (be fair with people), and the Principle of
Autonomy (giving people the right to choose). What is brought out is
that the principles themselves offer only a rough framework for an
understanding of the issues which face a doctor in the course of practice.
Many times these theories come into conflict with each other such as in a
situation in which bringing a certain level of harm, in the form of certain
therapies to the patient, could ultimately provide beneficial outcomes
The phrase quality of life is used when people make judgements
about the goodness or satisfaction of the life they are living, or about
some part of it. It is an extremely sensitive and subjective judgement.
Doctors and patients alike are interested in maintaining as high a level of
quality as possible. In their dealings with each other, that interest
dictates efforts to alleviate pain and symptoms, to stop the ravages of
disease, and to allay fear and anxiety. Individuals are the best judges of
the quality of their own lives. In recent years, however, the phrase has
taken on a rather special meaning in medical discussions.
Those discussions often take place about a patient who is severely
ill and whose only prospects are a life of pain or extreme limitation.
Regardless of the cause, when acute medical intervention is needed, the
question may be asked, "Is a life of such quality worth saving?" The
problems raised by this question are extremely complex. In general,
several points should be made about using quality of life as a factor in
clinical decisions. First, reports by the person who is living the life should
be distinguished from the observations of others. Second, all quality of
life judgements are value judgements. Some of these judgements can be
supported by observational facts, such as the perception that someone is
suffering great pain or is depressed. Other value judgements are less
dependent on facts and more on personal or social prejudices, such as
disdain for people of low intelligence, the unproductive, and the
In clinical decisions, the former sort of value judgements
legitimately carry considerable weight, the latter should be given careful
scrutiny because of a tendency to be moralistic in nature. Reliance on
moralistic criteria starts one down a slippery slope: the terminally ill are
judged worthless, as are the mentally ill, the chronically ill, and so forth.
The tragic consequences for patients of certain economically and socially
unacceptable lifestyles are currently all too prevalent. Quality of life is,
then, an extraordinarily subtle notion. Its meaning in clinical decisions
must be carefully scrutinized and cautiously applied.
In addition, it is sometimes necessary to consider conditions
external to the patient. These are the effects created by others' lives or
in society by decisions made about the patient. Some of these are
burdens: costs incurred by families, coverage limitations by insurance
companies, and dangers posed to other parties. Some are benefits: relief
from hardships, and teaching and research potentials associated with
The influence of cost of care in clinical decisions is currently being
debated. The importance of this external factor on clinical decisions must
be viewed even more cautiously than quality of life considerations. In
principle, it is safe to say that only when patient preferences are unclear
or unknown, when likelihood of benefit is low, and when the quality of
the expected outcome is poor, the costs of continued care, for the family
and for society, may become a legitimate consideration in deciding to
forego life-sustaining treatment.
The hazard of following any set of philosophical principles without
adequate cognizance of the conflicts which can be created has been
cause for much of the criticism surrounding bioethical programs. Some
of the criticisms of bioethics have been in the area of practitioner bias.
Peter Toon talks about the tendency towards bias as it relates to a
philosophical axe to grind. He describes the threat of the popular Kantian
axe labelled autonomy. Toon says that while axe grinding is a normal
occupation, neutrality of the opposing forces should never be assumed.
Impartial analysis must be applied, and dissention expressed, allowing for
open and honest discussion (Toon 1993).
Bioethics, as the purveyor of truth, causes disenchantment
because too much is expected and claimed. Clouser and Gert describe
what they call Principlism; the notion that beneficence, autonomy,
justice, and non-maleficence could solve medical problems rather than be
a useful framework for clarifying them (Clouser and Gert 1990).
Philosophical analysis is central to producing a physician who is
capable of exercising bioethical analysis, but this will not make an ideally
humanitarian physician. Bioethics gives medicine a framework for ethical
analysis, and an understanding of the issues which surround patient care
and treatment, yet, intellectual knowledge without emotional integration
still renders the practitioner an automaton; competent but unfeeling.
Necessary in countering principlism is philosophical reflection and
introspection, or perspectivism. Understanding of those impulses which
drive our philosophical pursuits, and cultural mores, can be seen in no
better place than in the outward expression of those feelings, namely
literature and art.
HUMANITIES IN LITERATURE
Literature offers the opportunity to see the interplay of illness and
persons, the role of physicians in the lives of others, the impact of their
own medical knowledge on the doctors' personal lives, and the
perception of physicians by laypersons. Because literature is free of the
constraints of the day-to-day world, it is able to offer a fuller picture of
individuals, their relation to objects, events, and other persons, of the
world of the sick and the meaning of illness to individuals, of how
compassion, empathy, mercy, and other moral qualities are expressed
and how they affect others.
The bibliography prepared by Joanne Trautman and Carol Pollard
(1975), Literature and Medicine, as well as, On Doctoring Stories,
Poems and Essays, by Richard Reynolds and John Stone (1992), offer
rich resources for those who wish to use literature in the teaching of
medical students and want to emphasize certain themes, or particular
materials for discussion.
Kathryn Hunter demonstrates how the humanities (particularly
literature) can reinforce the commitment of medical students to the goals
of primary care by pointing to the relative helplessness of the patient who
looks to the physician for relief (Hunter 1982). Sandra Bertman
identifies an additional use for literature, to affirm the legitimacy of
students' own feelings in the painful interactions of medicine with human
reality, such as death and loss. What concerns the physician has been
important to humankind throughout the ages and has thus been captured
in literature. She also uses literature and the visual arts to explore the
experience of dissection (Bertman 1979;1982).
In an interesting collection of essays, Medicine and Literature
(1980), editor Enid Rhodes Peschel illustrates the widely different ways
in which literature can be used to illuminate the medical experience, and
conversely, the manner in which medical experience has been used by
writers. In one essay in The Missing Medical Text (1978), Anthony R.
Moore demonstrates specifically how literature can be used to address
aspects of a doctor's duties not covered in the curriculum, to draw on the
medical heritage that is recorded in literature, to increase awareness of
effective patient care and professional self-assessment, and to explore
nonscientific ways of thinking and their importance in considering human
issues. The book consists of short literary passages that illustrate
specific topics the patient's or relatives' experiences, portraits of
doctors, ethical issues, and others and a transcription of students'
discussions following a reading of the materials. Not only are the
discussions interesting in themselves, but they give someone who is
unfamiliar with teaching in a medical arena an idea of medical students'
interests and concerns.
Another useful thing which literature does well is to put the body
back into medical considerations, with all of its connotations as an
integral part of the human experience. With relatively few exceptions,
modern society has denied the importance of the body and medical
notions seem to view it primarily as a vehicle for carrying around the
head. It might seem unnecessary to teach medical students about the
body; after all what is medicine all about? In fact, however, while
doctors know an enormous amount about how individual organs or body
parts function and malfunction, they receive little training in how the
body functions in everyday life. It is difficult to conceive of a medicine
primarily concerned with the care of the sick person in which the body,
as a whole functioning entity, does not come to occupy a more central
position. Here again, literature, and also including the graphic arts,
seems to make the point best.
One problem which arises because of depersonalization, which has
been noted as an important part of medical education, is the exaggerated
notion of medicine as a timeless and objective endeavor, wherein what
can be tested and proved is of singular importance. If the history of
medicine were properly understood, such misinterpretations of medicine
would not be so prevalent, thus pointing out the peril of teaching
medicine in an ahistorical context.
Chester Burns has pointed out that during the forties and fifties, in
contrast to previous and subsequent times, many medical schools offered
courses in the history of medicine. He suggests a relationship between
the popularity of the history of medicine and the pride of self and
profession to be found during that era (Burns 1978). The studies by
Genevieve Miller on programs in the history of medicine in medical
schools of the United States would seem to bear him out, although more
complex forces should undeniably be included (Miller 1969).
Another difficulty that stems from teaching medicine without
historical referents is a kind of egocentrism, a belief that what we do
today is the best that has ever been done, that we have the most
complete understanding of the human condition that has ever existed.
When historical events are considered, they are judged by their
contribution to the present. As Risse notes, this approach, presentism,
effectively denies any consideration of medicine before the mid-
nineteenth century (Risse 1975). Another problem caused by presentism
is that physicians fail to understand that in every era the profession and
the work of individual physicians has been subject to forces generated by
the interaction between medicine and society.
Additionally, history can provide an appreciation for how cultural
focus and the consensual process come to be seen as scientific when in
fact they are just traditions. Examples of this would be tonsillectomies,
radical hysterectomies, and even frontal lobotomies. If you had more
than one cold a tonsillectomy was recommended, not that it was really
medically necessary, but that it could not hurt to have the procedure
done anyway. All of these procedures are no longer considered a catch-
all remedy for various illnesses, but at one time they were very much a
tradition disguised as medically necessary scientific treatments. History
allows us to gain an understanding of the processes involved in change.
Today, economic pressures and changing societal norms exert
great pressure on medicine, and it would be helpful for physicians and
educators alike to realize that this has always been the case. In addition,
Shortt suggests that when the profession is fragmented, such as is the
case now, medical history provides a means of uniting it by emphasizing
a common heritage (Shortt 1982).
LANGUAGE AND COMMUNICATION
In the teaching and practice of medicine, communication skills are
essential to the diagnostic and therapeutic process. This is true in the
social sense, that is, doctors should be able to establish their interest in
and concern for their patients and be attentive to patients' problems and
anxieties. The most common complaint that patients have about doctors
is that they do not listen (ACME-TRI 1992).
Developing good communication skills is unquestionably basic to
the general scientific education and clinical training of competent and
humane physicians. Unfortunately, this subject is often delayed or
overlooked by medical educators searching for ways to decrease already
excessive curricular hours as they simultaneously include in a variety of
didactic forms what they perceive as the most current and vital medical
knowledge. Furthermore, medical students, eager to learn technical skills
enabling them to diagnose diseases and institute effective state-of-the-art
treatment, assume they possess these acquired communication skills or
ignore and are, in fact, unaware of the inadequate quality of their skills.
In addition, they do not recognize the distinction and common conflicts
between verbal and nonverbal communication. Leah Dickstein notes that
even more unsettling is the continued unspoken lesson, more by example
than by lecture, of a minority of faculty and resident teachers for whom
communication with patients and with students is a way to abuse power
and authority (Dickstein 1986).
Before proposing curricular modifications and other options that
can enhance medical students' communication skills with patients, not
simply for clerkship grades but for their entire professional careers, it is
important that discussions focus on medical students themselves as
people in context, over time and in familiar as well as unfamiliar
Studies of sex-role socialization along gender lines demonstrate
rather clearly that, even before the time of their conception, boys and
girls are communicated about differently (Rosenthal et al. 1979). Parents
bring gender-specific sociocultural expectations to their imminent
offspring. These gender-specific, stereotypical communication patterns
based on sex role socialization continue as young women and men
mature. Women make close friends on a verbal basis and enjoy time to
gossip and also make time to just talk throughout their formative school
years. Men are encouraged to play on competitive teams to win, boast,
and achieve through power moves and the games' rules, but they rarely
share personal feelings, particularly of vulnerability, though comparing a
continuum of successes is legitimate and expected. In adolescence,
women experience conflict over developing and achieving personal goals
versus pleasing men so the men will ask them out on a date. For the
men, raised to accept that actions speak louder than words, unspoken
rules are: win letters in sports, earn academic awards, obtain jobs and
cars, and give flowers to girls to show love rather than just to talk more.
No wonder, when given the opportunity to hide behind medicine's
increasing technology, lab data, and diseased organs, many men easily
and unthinkingly fit comfortably into this new yet old mold and reinforce
scientism in medicine.
Modern Problems in communication
Today's medical students might easily be alluded to as the
microwave generation. They live in an environment in which time is
measured in instants. This revised definition of time must be
acknowledged and incorporated into lessons about communication. For
example, students not only feed themselves hot dinners cooked in
seconds, but they learn about seconds of laser surgery and about
epidermal growth factor speeding up healing. When seconds are applied
to communication with patients born in different decades, students'
awareness must be raised. To understand their patients, they must learn
about what time and communication means to others of a different era.
Along with instant technology, students need to learn about patience.
Suggestions for Effective Communication
Students must become aware that people in their care their
patients, are dependent upon them because of their professional role.
That dependency creates a vulnerability to losing human dignity and
integrity simply because of illness. Therefore, it really is a necessity, and
not a choice, that physicians become aware of their own values and
attitudes, and at the same time understand their patients attitudes,
values, and culture. With such an understanding a bridge can be
constructed over the anxieties and fears brought on by
miscommunication and misinterpretation.
Weihs and Chapados (1986) found that a structured ten-week
course on the development of specific interviewing skills for first year
medical students proved to be beneficial. The patient-centered medical
interview is effective with careful analysis of signs and symptoms, an
understanding of patients' feelings about their condition, and the
implications of their illness for daily life (Weihs and Capados 1986).
The Developmental Helping Model, as discussed by Carkhuff
(1983), based on the client-centered theories of Carl Rogers, teaches
skills which include attending and responding. Patients perceive students
as possessing the core conditions of empathy, nonpossessive warmth,
In discussing the contributions of ethics and psychology to
medicine, Bergsma and Thomasma (1985) outline what they describe as
first level important relevant factors, that is, the most concrete,
consisting of measured numbers of verbal and nonverbal interactions.
They designate the second level as that of therapeutic success. They
describe their research which showed that "the greater the degree of
information and possibly personal engagement between professionals,
patients and their families prior to surgical operations, the fewer the
subsequent side effects experienced by the patients" (Skipper and
Leonard 1965, 62). They define third level as that of attitudes and
values which center around the way people compare their own illness
with others' to make themselves more exceptional and unique, and in the
comparison, finding a frame of reference for their level of suffering.
Another important consideration related to physician-patient
communication is that physicians should teach patients how to
communicate with them. If medical students learn how to teach patients
how to communicate well and completely, students will learn more and
be able to help patients more. The logical extension to this notion is to
teach students how to teach their patients how to ask questions, how to
describe symptoms, how to feel comfortable sharing feelings, how to
ask for help, solace and advice, not just for pain pills. Students need to
be taught that for them and for their patients all questions are
appropriate, and that asking questions improves students' learning and
The way in which the humanities can help in this training is by
providing examples, through history, literature and art, of the various
ways communication has provided benefit or miscommunication has
caused harm throughout history.
THE MEDICAL SCHOOL LEARNING ENVIRONMENT
With the knowledge that medical education is not only content
oriented but also a process for socialization into the profession of
medicine, concern about the effects that the educational experience has
had on student attitudes toward medicine has been a topic of
investigation. Two studies conducted in the 1950s reflected an approach
emphasizing that the value of the educational process lay in preparation
for or socialization into the profession of medicine. Research conducted
at Cornell Medical School by a group of sociologists from Columbia
University (Fox 1989), found that the educational process contained
sequential and often stressful events, such as life or death decisions
affecting the care of a patient in their clinical rounds, that were essential
in helping students frame their perspectives as future physicians.
The tacit knowledge accumulated as a result of these stressful
experiences was critical in helping the student handle future professional
concerns, such as uncertainty in clinical decision making (Fox 1989).
The experience of working on the cadaver in anatomy helped prepare
students to deal with their fear of death. The discomfort which they felt
when examining their peers in a physical diagnosis course helped
desensitize them to the issues surrounding the human body (Merton et al.
1957). Sociologists from the University of Chicago conducted a study
of student attitudes at the University of Kansas Medical School. In sharp
contrast to the Cornell study, their results suggested that the educational
environment negatively affects student attitudes toward patients (Becker
et al. 1961). Becker, examining the impact of stress arising from
student expectations and existing realities, reported that students
respond to conflicting demands of a separate and distant faculty by
secretly scapegoating them. In a study of interns in internal medicine,
Mizrahi found similar circumstances (Mizrahi 1986). Interns, responding
to meet the conflicting demands of coursework and patient load, while
providing thorough and complete patient care, developed a system called
Getting Rid of Patients (GROP), or turfing them out. The behavior served
to maintain the service load at a reasonable level while keeping only
those patients who would provide interesting teaching material for faculty
From the two studies of Merton and Becker and their colleagues it
is clear that students undergo a great deal of stress in their medical
training. The profession of medicine, with its consistent confrontation
with life-and-death situations and its emotional demand on the physician,
is a highly stressful occupation. Whether medical schools as they are
presently established provide a process whereby students are
systematically confronted with stressors that set them in opposition to
faculty and patients remains to be studied. What is clear is that stressors
in medical education are not there by perfect design, established to
provide hurdles for the student. Instead, these stressors appear to be
accidents of history which have, over time, become a tradition of
occasionally profound professional importance.
Agents for Change
Traditionally, medical education has been structured in a manner
which in some ways defies innovative moves. Such traditions as the step
lock approach to medical education (two years of basic sciences and two
years of clinical sciences), reliance on the lecture method during the first
two years, overutilization of house staff as teachers, and reliance on
clinical teaching in the tertiary care centers continue to dominate medical
education, making major reforms problematic.
Because the structural problems are not only historically based but
also heavily burdened with economic constraints of private medicine
(Starr 1982), most institutions set on medical reform have had to
consider the financial implications of change. Indeed, the economics of
health care in the United States has a decided impact on the types of
innovations chosen, as evidenced by the extreme industry-wide
uncertainty created by the current proposals for health care reform, and
the method by which a medical school goes about reforming itself
(Funkenstein 1968). For instance, with the current push for more primary
care practioners, medical institutions are responding by selecting for
students who show a greater interest in general and family medicine as
well as pediatrics and internal medicine.
The role of private funding in medical education innovations is also
critical. The Josiah Macy Foundation, the Robert Wood Johnson
Foundation, the Commonwealth Fund, the W.K. Kellogg Foundation, and
other groups can take credit for the majority of innovations by funding
what they consider effective and implementable changes. The driving
commitment of private foundations to medical education is symbolically
represented by the Flexner Report of 1910. Funded by the Carnegie
Corporation, Abraham Flexner examined the status of medical education
at United States institutions. His report signaled the rise of medical
education as one of the most serious educational endeavors in the United
States. Although funding is clearly central to educational reform, it is
equally clear that most extensive innovations must find favor in the court
of some benefactor.
Although innovations have been occurring over the past decades,
most are limited by certain structural parameters within medical schools
and institutions. These parameters have dominated the manner in which
medical education is organized and may be the major stumbling block to
any substantial reform. As discussed earlier, this structure has its roots
in an academic tradition which has successfully distinguished itself as a
profession. However, like many other professions, its emphasis on
standardization of academic preparation has resulted in few major
educational innovations. The manner in which medical education is
organized is highly functional, yet within such a structure may lie the
barriers to a more humanistic education. The major components of
medical education are (AAMC 1992): (1) The Departmental structure of
medical education where the objectives and required knowledge base is
determined within each department or discipline. This results in large
amounts of data to be memorized with few attempts to relate the
relevance of the material to the future role of the physician. (2) The lock
step approach where students are taught the basic sciences within the
first two years and the clinical sciences in the second two years with
little connection between the two, either in content taught or in the style
of teaching. (3) The reliance on the lecture method as the dominant
mode of teaching, and content examination for assessing information
retention during the first two years of medical school with a group of
adult learners who have a variety of learning styles. (4) A faculty
promotion policy which is based on research endeavors rather than
teaching expertise, leaving faculty with little interest in providing new and
stimulating ways to communicate their wealth of knowledge. (5) The
reliance on house staff, with no formal preparation for teaching, to
provide the majority of teaching during the second two years of medical
training. (6) The reliance on the tertiary care or university hospital-based
setting to teach clinical medicine. Such a reliance assures consistency of
information and up-to-date medical procedures and technology and
reduces the lack of controlled standard which had previously existed in
the pre-Flexnerian ambulatory care setting, but also limits that care
because of the economic constraints of providing such care to patients
with fewer payment resources.
This rigid manner of education and training continues into
residency training. Students move through each rotation, picking out the
specialist's attitudes toward the patient. What they learn to value in one
specialty may not be highly valued in another. As a result, students
seem to operate in a very case specific manner, quickly learning that
what they take from one area cannot be easily used in another.
This lack of integration starts early in the medical student's
careers. What students have picked up in their first two years cannot be
easily translated into their second two years. Often, what they learn
about patients in one rotation cannot be used in another rotation. If
students learn the value of bioethics and psychosocial factors in
psychiatry, will they readily transfer this information to a pediatrics
clerkship where such attitudes may not be so strongly supported? In a
special issue of the Yale Journal of Biology and Medicine, two letters
were written asking whether the humanities can and should be taught in
medical school. To answer the question of whether the humanities
should be taught, Spiro (1992, 158), points to the astounding climb in
the numbers of people who actively seek out alternative forms of illness
therapy, forms that deal more with people and illnesses as an integrated
whole. Stating that "the humanities,... are the record of how men and
women have looked at quandaries in the past...," Spiro believes that the
humanities can help deal with modern quandaries integrating the added
benefits of our burgeoning technologies.
The implications for humanism in medical education are important.
It may not be enough to teach a course in bioethics; students will learn
the information but may not apply it in a clinical setting. It may not be
enough to teach ambulatory care issues in a primary care clerkship, for
students probably will not transfer such values as patient negotiation
onto the wards. It is not enough to provide a humanistic environment for
students in the first two years if in their clerkship years and residency
training they suffer under unrealistic expectations and performance
demands. Harvey Mandell, in "A Slightly Dissident View", writes that the
humanities have no measurable or quantifiable effect on the doctor-
patient relationship, but at best they provide an amusement. If
something humane rubs off, then so much the better (Mandell 1992). His
argument stems from the fact that being well-read in the classics won't
help a surgeon control the bleeding from an accidental nick in the liver.
While this is probably true, his focus seems to be primarily on whether an
education in the humanities will have any effect on those skills which a
doctor needs to be competent, from a scientifically beneficial point of
view. Mandell argues that those attributes which are considered to be
humanistic should have been learned at home, in childhood, and little
emphasis need be given them in medical school.
In response to Mandell, physicians make decisions about patients
which often times have ethical considerations. Simple childhood
etiquette is certainly far from adequate to deal with the multiplicity of
ethical issues which face the modern physician. Numerous studies point
to the need for effective and empathetic communication (Skipper and
Leonard 1965), which is seldom fostered in childhood.
CHANGE AND IMPLEMENTATION
The first part of this chapter will deal with the recommendations
made by the AAMC in their ACME-TRl report of 1992. The
recommendations of the report are of a general nature and refer to those
changes which the AAMC feels are necessary to the profession of
medicine as a whole. Putting these recommendations first is intended to
provide a contextual understanding of the changes necessary as those
changes pertain to the humanities and medicine. Next, specific
recommendations concerning medical education and the humanities will
The recommendations of the 1992 ACME-TRl report stem from the
resultant lack of implementation of earlier reports by the AAMC during
the 1980s, such reports as the 1983 GPEP (General Professional
Education of the Physician) and various other surveys which tried to do
more than just point to areas which are in obvious distress, and the
ACME-TRl survey of 1990. As the AAMC is the self appointed watchdog
of the medical school profession, it is important to recognize that firstly,
its recommendations are seen as representing the main stream of
innovation and implementation, and second, medical schools are a force
unto themselves when they can placate the AAMC into relative
The first recommendation by the AAMC concerns the organization
of the financial and institutional structure of medical schools themselves.
It calls for the formation of a specific budget for a program which will set
out recommendations for an integrated and coherent system of medical
school education, involving the formation of a central curriculum and a
program of implementation and accountability for maintaining its
standards. Central to this recommendation is the formation of the office
of chief academic officer, as recommended by the 1991 Liaison
Committee for Medical Education. This position would have the
resources and authority not only to organize a coordinated curriculum,
but to maintain and enforce its necessary standards of cooperation. In
keeping with the idea of coordinated cooperation it was further
recommended that a peer and student review committee be formed to
evaluate the curriculum and its instruction.
The second recommendation is for medical schools to establish a
career pathway for those pursuing excellence in [teaching]" (ACME-TRI
1992, 53). In essence the recommendation is to establish a new forum
for tenure and peer recognition. As was mentioned earlier, current
standards of recognition and grant funding come from those endeavors
which provide benefit to either the private sector, such as the
pharmaceutical field, and to those who further the recognition of their
respective institutions through excellence in clinical and/or technological
care. Recognition of excellence on the behalf of those who, at the very
core, provide for the previously mentioned benefits through excellence in
teaching is an exciting notion which can provide for it's own funding and
position in medical education once its benefits are more thoroughly
understood and appreciated. To that end the AAMC recommends that
principal teaching faculty not be expected to provide their own support
from income derived solely from their clinical endeavors, but that their
support should be indicative of the importance of their teaching.
The third recommendation focuses on the need for newer
standards of academic evaluation. Currently, students are required to
memorize and recall vast amounts of information with standards of
evaluation which mimic the didactic way in which the information was
given. The Objective Structured Clinical Examination (OSCE) is a newer
method of evaluation which assesses information integration and
retention from a problem based perspective, focusing more on students'
problem solving and patient skills.
Area four concerns efforts to foster cross-disciplinary dialogue and
educational cooperation. The aim is to integrate knowledge skills from
many or all medical disciplines, and to support the standards and goals of
the other disciplines. Currently, lack of interdisciplinary communication,
much less cooperation, slows the transmission of potentially beneficial
information from one field to another. Development of a faculty
consensus concerning educational goals and knowledge requirements for
graduation is recommended to foster cooperation not only among faculty
but students as well. The focus of this recommendation is to encourage
faculty members to accept responsibility for educating medical students,
and not to further their own research to the exclusion of all else.
The fifth, and final recommendation of the 1992 ACME-TRI report
is for the integration of computer information systems in faculty and
student education programs. The hope is that new educational programs
can be written to increase the cooperative capabilities of current
programs in medical education across disciplinary and institutional
Constraints on Recommendation Implementation
The largest areas of resistance to the changes recommended are
not new or specific to the field of medical education. The major
constraints, to be defined below, are economics or the sources and lack
of funding, and arrogance or the perception that each individual
department has an absolutely indispensable curricula and should be the
sole determiner of its content, and time or priorities. There is also the
persistent view that there is never enough time to accomplish what needs
to be done and that the never-ending work has nothing whatsoever to do
with the reorganization of their priorities.
The major point of resistance to a central consensus group or
individual was reported to be faculty resistance to relinquish any authority
or funding over their department and their educational program. Further
entrenchment of this resistance comes from the open acknowledgement
by department chairs that the education of medical students is not their
principal priority (ACME-TRI 1992).
As pertains to the clarification of institutional goals, the 1990
survey shows that the principal constraint was the perception by the
faculty that no change was needed or warranted. "If it isn't broken, why
fix it?"(ACME-TRI 1992,8) Further inquiry into this issue reveals that
there are a great many things which are indeed broken and in need of
fixing which fight for the attention of the faculty. The increasing demand
on faculty members to do more with less, and to continue to make
improvements in patient care seem to take precedence over the
restructuring of institutional goals. In addition, it was noted that many
institutional goals were so broad as to be all inclusive and not conducive
Another area which does not lend well to innovation is the lack of
grants or funding to those who strive for excellence in teaching. The
psychological notion of reinforcement conditioning has universal
implications, and currently there is little recognition outside of traditional
fields of research which would promote a renewed interest in the
endeavor of teaching. Here again clarification of institutional goals might
Lastly, an unusual conundrum seems to exist concerning
technology and its usage. The field of medicine and the endeavors of
medical researchers have produced such wonderfully useful technological
advances that it would seem that any advances in the field would be
actively sought and utilized, yet the 1990 ACME-TRI survey reported that
faculty members are reluctant to move from the tried-and-true."(ACME-
TRI 1992, 38) Further, the survey also said that faculty members are
reluctant to relinquish any of their job security as information providers to
the computer information programs currently in development, the lab coat
equivalent to losing your job to a robot in a manufacturing plant.
The conclusion asserted by the ACME-TRI report is that the
priorities of academic medicine are misplaced. Education of the students
must be central if any meaningful changes are to take place in the near
future. It is their contention that the lecture load of medical educators is
light and the resources are abundant, quite the opposite of what is
normally expressed, based on their belief that the educational priorities
could be rearranged, finding both the necessary funding and time for
making the necessary and appropriate changes they recommend.
Recommendations for Implementation of Issues in Humanities
With the rise of medical and ethical problematics such as informed
consent, quality of life, rights of the patient (autonomy), not to mention
the issues surrounding the advances in technology and experimentation
such as genetic and fetal tissue research, scientific analysis alone is
insufficient. Humanities, in the guise of knight in shining armor, with its
subjective approach and shining sword of advocatus individuus, often
falling prey to perspectivism, is also inadequate in-and-of-itself. The
central question is not whether basic science is necessary for medical
research, since few would deny its importance there, but whether it is
relevant in the education of every physician to the degree to which it is
currently emphasized. In the real world of patient care, public health, and
medical economics, should the student have to struggle with the
intricacies of post-transcriptional modifications of messenger RNA, or is
this merely a rite of passage prescribed by science-obsessed faculty?
This is a reasonable question and calls for a response other than a simple
reference to Flexnerian orthodoxy. Consequently, programs in the
humanities must also come under the recommendations outlined by the
ACME-TRI report, namely that of cooperation in reprioritizing the goals
and expectations of medical schools and their students. In essence,
instead of finding its own niche in medical school programs,
recommendations for programs in the humanities must seek to integrate
its own unique perspectives with those of the sciences to produce
physicians who are able to provide relief to their patients' illnesses in
whatever form those illnesses are manifest. As Clouser wrote, I want
to help students (become philosophical doctors)...Using the skills and
insights of these extra disciplines (humanities) to enhance medicine and
be integrated with medicine is the point" (Clouser 1978, 29).
The humanities have something special to offer medicine, if sick
persons, rather than their diseases, are to be the new focus of medicine.
Fresh concepts, skills, and guidelines for behavior are necessary to
supplement the strictly technical. In medicine, the procedures for an
appendectomy are not merely described and then students are left to
their own devices. Precise definitions are outlined from the fields of
anatomy and pathology, illness manifestations and diagnoses' are
discussed, as well as treatment choices and alternatives.
Correspondingly, it is not sufficient to tell a student or physician to treat
sick persons, not just their diseases. Without the necessary definitions,
tools, and skills, all that has been created is a moral injunction to do all
the right things, for all the right reasons. When the occasional failure
occurs, guilt and self-blame are logical results. So, despite good
intentions, patients are not better, and doctors are confused and feel like
failures. Given that they have no special training in the aspect of
empathetic patient care, that they are usually overwhelmed by work, and
that they are usually rewarded for technological competence rather than
interpersonal skills, their sense of inadequacy may defeat their good
There have always been physicians who were naturally adept at
working with patients, who showed empathy and were good at effective
communication, who generally had wonderful success with their doctor-
patient relationships, the type of physicians who are jokingly told that
they do not have to practice medicine anymore since they are already
good at it. Because of this it has been said that the art of medicine is
intuitional, and hence, unteachable, if you've got it, you've got it.
Those skills which culminate in humane physicians must be seen
as a discipline, and taught as such for those in whom a natural ability is
not found. Critics, from within medicine, like Mandell, seem to say that
the only true discipline is that of scientific investigation which provides
measurable results in patient care, and that programs in the humanities
provide benefits to the doctor-patient relationship through some sort of
osmosis. Humanists would be quick to dispute the issue by pointing out
the incredibly disciplined and systematic complexity of humanistic
endeavors such as art, literature and especially music. Regarding the
possibility of teaching an art, while it may be the case that talent or
intuition may be a feature, even child prodigies have teachers and work
constantly to refine their skills. In the absence of disciplined effort, they
would surely not realize their full potential.
This chapter has illustrated how the art of medicine is composed of
abilities in four different but interrelated areas. The first is the ability to
acquire and integrate subjective and objective information to make
decisions in the best interests of the patient. The second is the ability to
strengthen and utilize the relationship between the physician and patient
for therapeutic ends. The third is knowing how sick persons (and
doctors) behave. Finally, the central skill upon which all the others
depend is effective communication.
This essay has traced the long association of the humanities with
medicine and medical school education. It opened with the argument
that the role of the humanities is to provide broadly educated physicians
who, because of their background, can be expected to be more humane
physicians. It closed by presenting a view of the potential which exists
for the participation of the humanities and medical school education. It
has been suggested that the potential benefit provided by an education in
the humanities is overexaggerated because measuring the effects of
outcomes of an effective doctor-patient relationship is difficult at best.
The safe and insulated environment of medical school departments has
expressed only token approval for full range programs in the humanities.
Yet, medical education programs in general and the humanities
specifically have been entreated to increase their efforts to provide
physicians who are more than the sum of their technological backgrounds
and overly scientific educations.
Whether the humanities or medical schools are ready or not,
medicine needs new tools and skills, goals and insights for understanding,
which are falling behind in the wake of medical technological advances.
Science cannot solve many of the problems that loom on medicine's
horizon. Thus, like it or not, interested or not, in the years ahead
medicine and the humanities will need to grow together to produce what
medicine needs. Change is slow, but the demand for change is great.
With the increasing pace of today's society, and the complex and
exciting benefits which can come from further technological innovation,
medical education systems must allow for the cooperation and integration
of their various departments in order to not be trampled under in the
wake of society's demands on the health care system.
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