The Program in Medical Humanities & Arts at the University of California, Irvine, (UCI) College of Medicine started informally in 1997, with a literature and medicine elective in which three second-year students were enrolled. The program received recognition from the Department of Family Medicine in 1998, and from the UCI College of Medicine in 2000. The program is now housed jointly in the Office of Medical Education and the Department of Family Medicine. The program’s director is responsible to the chair of Family Medicine, the associate dean of Curriculum, and the senior associate dean of Medical Education, and receives staff support from both Medical Education and Family Medicine.
In the program, we define medical humanities and arts as the incorporation of humanities- and arts-based teaching materials into medical school and residency curricula. To date, this has included the use of poetry and prose, especially about and often written by doctors and patients; narrative ethics, in the form of elicited patients’ and preceptors’ value histories; and visual and performing arts, including art and photographic exhibits, readers’ theater, plays, musical performance, dance, and independent humanities research projects. Our program is distinctive in its emphasis on faculty development and its use of learner creative projects (see below).
The Program in Medical Humanities & Arts was initiated to fulfill several interlocking needs. These needs were related to the Medical School Objectives Project criteria of professionalism, specifically criteria emphasizing humanism, empathy, altruism, and self-reflection.1 Although the standard curriculum has always emphasized development of ethical standards and professional behavior, and for the past seven years has specifically targeted training in communication skills as an important educational goal, concern remained that didactic and behavioral approaches to conveying these qualities, attributes, and skills did not always produce the desired effect in learners. In fact, research conducted at our institution suggested that communication skills of our medical students decreased as they proceeded through training,2 and observers at other institutions have noted the disillusionment and cynicism that results from discordance between the formal and informal curricula.3,4
Humanities and arts were identified as a potentially rich method for addressing these concerns. The craft and artistry of literature and painting can help learners see clinical situations and patients not only from different perspectives, but also with greater clarity, identifying insights and feelings in ways learners might not be able to fully articulate. Further, humanities and arts have different interests and emphases than medicine. Therefore they challenge the priorities, understandings, and presumptions that are conveyed to students and residents through formal training.5 Finally, because the study of literature and art does not burden the learner with direct clinical responsibility,6 and in fact is generally pleasurable,7 it creates a welcome zone of safety and relaxation in which learners can be imaginative, creative, self-aware, and playful, without fear of medicolegal consequences, and consequently learn to see their patients from a calmer, more compassionate vantage point.
The Program in Medical Humanities & Arts was established to achieve the following objectives embodied in the concept of narrative competence:8,9
* Stimulate skills of close observation and careful interpretation of patients’ language and behavior;10
* Develop imagination and curiosity about patients’ experiences;11,12
* Enhance empathy for patients’ and family members’ perspectives;13
* Encourage relationship and emotional connection with patients;14
* Emphasize a whole-person understanding of patients;15 and
* Promote reflection on experience and its meaning.16
Faculty and Learners
The program director is a clinical psychologist by training who is an experienced teacher of medical students and residents. Other than having an interdisciplinary undergraduate major in English and cultural history and an inveterate love of literature, she has no formal training in the humanities beyond faculty development sessions attended at professional conferences. Approximately seven physician faculty and three nonphysician faculty are involved with the program on a regular basis. Approximately 15 physician faculty and two nonphysician faculty participate in the program in a more limited way. The disciplines represented by the core faculty include family medicine (FM), internal medicine, physical medicine and rehabilitation, pediatrics, anatomy, psychology, and philosophy. The core faculty has participated in several faculty development sessions for teaching medical humanities offered on our campus, but none holds an advanced degree in either literature or art. This lack of specialized training is consistent with our philosophy that literature and art can speak directly and meaningfully to laypersons. As a group, these individuals are committed to medical education, particularly the importance of training compassionate and caring physicians, and tend to be interested in teaching methods that cross disciplinary boundaries.
In terms of targeted learners, the primary focus of the program has been medical students. However, required humanities-based curricular components have been introduced to both the Family Medicine and Physical Medicine & Rehabilitation (PM&R) residencies. Further, special events and projects sponsored by the Program in Humanities & Arts, such as an AIDS musical, a theatrical performance about ovarian cancer, creative writing for patients with cancer, and an anatomy photography exhibit have involved community physicians, patients, nurses and other hospital staff, and members of the general public.
We have also invested considerable resources in faculty development, in the belief that if we can train faculty to appreciate the relevance of the humanities and arts to medical education, the program can, at least in part, become self-generating. Faculty who are comfortable with literature and art as pedagogical resources will then invent their own ways of integrating these into their teaching. To this end, we have presented two day-long conferences on uses of humanities and visual and performing arts in medical education that were each attended by approximately 50 faculty. On a smaller scale, we have also offered a mini-faculty development session for physicians involved in the second-year Patient-Doctor course, which has a required humanities component. Additional faculty development has occurred informally because of the program’s emphasis on co-teaching.
Structure and Teaching Methods
The program is guided by three structural principles. Horizontal coherence refers to the linking of medical humanities material by theme and content to existing courses within a given year. For example, an optional creative project in Year 1 is linked to the students’ subjective experience of the gross anatomy course. The literature and medicine selective in Year 1 uses prose and poetry to study in greater depth patient care issues and topics covered in the five modules of the Patient-Doctor course that integrates physical examination with communication skills and a range of psycho-sociocultural patient-related issues. The humanities sessions in Year 2 are integrated into small group discussions of students’ early clinical experiences, whereas the humanities sessions in Year 3 are part of various primary care clerkships. The creative projects in the Year 3 Medicine clerkship are also coordinated with ethics and values history instruction.
The second structural principle we endorse is vertical complexity, or the organization of medical humanities curricular material over the course of training from Year 1 to residency so that the program progressively introduces concepts and methods of greater depth and intricacy. For example, medical humanities in Year I focus on topics such as anatomy, interviewing, and the physical examination, all content covered in this year. In Year 3, humanities coursework examines topics such as socialization into clinical medicine, breaking bad news, and death and dying, all relevant to the third-year experience.
The final principle we use is application to clinical care. The medical humanities program over time increasingly emphasizes the specific relevance and application of teaching to patient care, paralleling increased learner contact with patients. This principle is particularly important at the residency level, where residents frequently express skepticism that humanities and arts can teach them anything that would be useful in the day-to-day management of their patients.
With the exception of one didactic presentation to the entire first-year class, “Introduction to Medical Humanities,” all of the teaching in the program is based on small-group discussion, almost always facilitated by an interdisciplinary team of physician and nonphysician. Much of the content of these discussions is triggered by the students’ creative projects. At the residency level, the triggers are usually readings, videotapes, or artwork, as well as point-of-view writing exercises. Discussions start with learners sharing their own emotional reactions or thoughts evoked by a shared project or reading, as well as reflecting on incidents in their own clinical experience that come to mind. Learners also discuss what they learned about patient care or doctoring by working with a creative medium, as well as what they learned by listening to the creative efforts of their peers.
Our program emphasizes direct student and resident expression. For the first three years, medical students have approximately three hours per year devoted to either point-of-view writing or other creative literary, artistic, dramatic, or musical forms of self-expression. We believe that this direct engagement with literary and artistic forms provides an emotional immediacy and connection that does not occur as readily through the more passive exposure involved in reading the works of others. The focus of these projects is on exploring some aspect of becoming a doctor, of the patient’s illness experience, or of the interaction between doctor and patient.
Description by Year
The Program in Medical Humanities & Arts contains required and elective components. In Year 1, we present a required three-hour humanities session, consisting of a mini-lecture on the relation of humanities to medical practice; a panel of physicians and patients discussing the therapeutic value of creative writing and painting; and a small-group, point-of-view writing exercise based on a literary selection that explores what it means to be a patient. We also offer a literature and medicine selective (an elective 12-week course chosen from a list of ten options), in which approximately one fifth to one quarter of the class enrolls each year. In Year 2, as part of a problem-based learning curriculum examining aspects of students’ first clinical exposures, one small-group discussion is devoted to sharing student creative projects about a patient’s experience, the student-physician/patient relationship, or the student’s own training. This discussion is co-facilitated by the student group’s faculty physician mentor and the humanities program director.
These required creative projects and group discussions are repeated on the Internal Medicine and Pediatric clerkships during third year. We have found that reiterating this activity in Year 3 is useful as students transition from the preclinical to the clinical years and their sense of responsibility for patients increases. The Family Medicine clerkship also requires all students to read literary selections linked to clinical case vignettes, and to write two subjective, objective, assessment, and plan (SOAP) notes that show how these readings influenced the formulation of their treatment plans. All clerkship humanities course components are co-taught by the humanities program director and experienced clinicians, usually including the clerkship director, and on Medicine, a hospitalist, and a bioethicist. In Year 4, students have the option to enroll in a four-week humanities research elective. Two students have selected this elective and completed projects on the role of the physician in colonial America and children’s narratives of illness.
Thus far, two residencies, Family Medicine and PM&R, have become involved with the humanities program. Both of these residencies have instituted ten required humanities sessions per year. In FM, these sessions are linked to behavioral science training and target “hard-to-teach” clinical competencies17 such as “difficult” patients, geriatric patients, cross-cultural medicine, poverty medicine, and death and dying. Sessions in PM&R focus on caring for patients with chronic medical conditions or disabilities such as stroke, Parkinson’s disease, or paraplegia, from the patient’s, caregiver’s, and physician’s perspectives. We have been able to integrate two video presentations on disability and dance into these sessions that were choreographed for a differently abled dance troupe. We also incorporate two expressive writing sessions per year, which in FM are linked to sessions on difficult patients and cross-cultural medicine; and in PM&R, to sessions on stroke and caregivers.
Finally, the humanities program sponsors the development of special projects involving students, residents, faculty, staff, and patients. So far these have included a student-initiated journal of arts and humanities, and various dramatic, musical, and photographic programs that have explored patients’ experiences of illness, the doctor-patient relationship, and students’ experience of their own socialization into medicine.
Changes over Time
Because this is a relatively new program, we have experimented with several different approaches in its design and implementation. In the past five years, we have expanded the program in several ways. Initially, it was comprised of essentially one individual. Now, several members of the faculty are involved in the program on a regular basis, and all humanities required course components are co-taught by an interdisciplinary team of an experienced clinician and the humanities program director. In its inception, the program was conceptualized as a literature-based program that relied exclusively on learner exposure to illness-related poetry and prose to satisfy our objectives. We have since extended the program to include special educational events for learners using visual and performing arts. Historically, the program was more passive and didactic, in that it relied exclusively on reading and studying texts. Now, as previously discussed, it emphasizes learners’ active use of creative media as a way of processing their own and patients’ experiences.
Outcomes and Successes
Because required humanities curricular encounters are part of larger courses, students do not receive separate grades for their participation in the Program in Medical Humanities & Arts. Indeed, the idea of grading learners’ creative projects and comments during discussion seems problematic and unproductive. Instead, students are required to complete the projects, and are strongly encouraged, although not required, to share them with classmates during the group discussions.
Lack of time and resources has made it impossible to formally assess all components of the humanities program. Standard anonymous evaluations used with medical students, residents, and faculty indicate a moderate to high level of satisfaction with the program. Systematic research conducted on specific aspects of the humanities medical student curriculum shows significant improvements in self-reported empathy and attitudes regarding the usefulness of humanities to ongoing professional development.
Several factors contributed to our ability to put a successful humanities program into practice. First is the support from institutional leadership, including the dean, the senior associate dean of medical education, the associate dean of curricular affairs, and the chair of FM. Of equal importance is the existence of supportive faculty colleagues and faculty in positions of influence, including the course directors of the Patient-Doctor course in the first two years, and the clerkship directors in medicine, pediatrics, and FM. Although it only takes a single faculty member to teach an elective, to have an integrated program it is necessary to have a dedicated core of faculty. In addition, student involvement in the development of the program has been critical. We have had the benefit of student advice and participation for many aspects of the program, as well as student-initiated projects such as Plexus, our journal of arts and humanities; a student interest group; and the planning of two humanities/arts-related electives. Finally, the ability of the program to attract funding from the U.S. Health Resources and Services Administration and from various private foundations has provided essential resources and legitimization. Similarly, the recognition that accrues to the program through presentations at professional conferences, publications, and the humanities Web site has contributed to the program’s success.
Starting in 2003, we intend to introduce a “Graduation with Distinction” designation for students in research, service, and the humanities. In the humanities, students may suggest themselves for consideration or be nominated by peers or faculty. They will be required to submit a body of work completed over their four years of medical school, demonstrating systematic and creative efforts to explore the interface of medicine and the humanities and/or arts. Work will be juried by College of Medicine faculty active in the humanities program and scholars from the Schools of the Arts and Humanities. We are also considering expansion of the humanities program to other primary care residencies including pediatrics and general internal medicine.
We also intend making our teaching more truly interdisciplinary. Up to this point, the program has relied exclusively on College of Medicine faculty. We are in the process of developing links to the UCI School of the Arts, the UCI School of Humanities, and the University of California Humanities Research Institute to explore collaborative opportunities for teaching and research. For example, we are currently discussing a joint project focusing on mapping the overlap of observational skills used in dance and medicine. A similar project in development involves a randomized trial to study the effects of exposure to representational art as a means of enhancing the observational and interpretative skills implicated in clinical decision making. We also are attempting to involve members of the local artistic and literary communities in the program. We piloted a creative writing course for medical students co-taught with a professional writer, and are developing a “drawing-with-the-right-side-of-the-brain” workshop to supplement the gross anatomy course, to be taught by a local artist.
Finally, we recognize that the next step for our program must be a systematic evaluation to document that exposure to the humanities and arts can in fact improve learner empathy toward and insight into patients, to identify the specific mechanisms by which such exposure uniquely affects these attitudes and skills, and to demonstrate that learner exposure to the humanities is related to increased patient satisfaction and improved patient care. These efforts should ensure that programs like our will continue to thrive and flourish.
The authors would like to thank John Boker, PhD, director of research in Medical Education, University of California, Irvine (UCI), College of Medicine, for his unstinting contributions and ongoing evaluation of the Program in Medical Humanities and Arts. This project was supported by funds from U.S. Health Resources and Services Administration (HRSA) Predoctoral Training in Primary Care Grant HP 000224-02 (Elizabeth Morrison, MD, MSEd, principal investigator); HRSA Establishment of Departments of Family Medicine Grant CDFA 93.984 (Joseph Scherger, MD, MPH, principal investigator); the Arnold P. Gold Foundation; the California Council for the Humanities; the UCI Office of Medical Education; and the UCI Department of Family Medicine.