Montgomery, Kathryn PhD; Chambers, Tod PhD; Reifler, Douglas R. MD
The Medical Humanities and Bioethics Program at Northwestern University’s Feinberg School of Medicine began in 1978 with an ethics elective for second-year students.1 Today it is a university program that provides medical humanities and bioethics education in all four years of medical school, including five units of the required Patient, Physician, and Society course, 37 to 40 medical humanities seminars in years one and two, more than 125 ethics case conferences in third-year clerkships, and electives for fourth-year students. In addition, the program faculty participate in ethics and humanities education for residents in internal medicine, obstetrics and gynecology, and surgery, and the program offers an annual one-year fellowship in the medical humanities and bioethics. It introduced the small-group teaching by volunteer clinicians that now characterizes much of the school’s curriculum2 and has served as a resource for both faculty development and curricular innovation.
Goals and History
From its beginning, the Medical Humanities and Bioethics Program has had as its mission the encouragement of a community of discourse on social and moral issues in medicine. Its courses draw on literature, religion, ethics, philosophy of medicine, film, history, social and cultural anthropology, and jurisprudence, all of which serve a common goal of considering medicine as an inherently moral enterprise.
In 1977, a priest who is also an ethicist and a lawyer was invited by a group of medical faculty and students to discuss the need for curricular attention to the ethical and values issues in health care. The elective for second-year students that began the following year soon grew from a one-quarter course focused on the patient-physician relationship to a two-quarter course that also took up social, legal, and policy questions. A first-year elective was added in the mid-1980s. From the start, the program used the now common pattern: a plenary hour followed by small discussion groups led by volunteer clinicians. Although the courses remained electives until 1989, they were given regular, protected times in the curriculum. They attracted one third to one half of each class, with some students signing up in both years. In the late 1980s, when students requested the opportunity to discuss troublesome social and ethical issues during their clerkships, clinicians who were tutors in the elective courses set aside conference times on their clinical services that were at first informal but became enduring parts of the clinical curriculum. One of the great pleasures these days is the participation of many of those early students as volunteer teachers throughout the humanities curriculum.
Inspired by the Association of American Medical College’s Extensive Report, Physicians for the Twenty-First Century (the GPEP Report),3 the full-time faculty of our program was doubled in 1988; that second faculty member had the task of negotiating the inclusion of the electives in the required curriculum. The Profession of Medicine, the 12-week first-year course, was poorly located in the late spring of the first year. Medicine and Society, the eight-week second-year course, was squeezed into the fall. When a student review committee complained that some students came to class ill prepared to discuss the designated topic, weekly response essays were added. Volunteer clinician-tutors may have been daunted at first by the prospect of reading and responding to 11 one-page essays each week, but most found they gained rewarding insights into the thoughtfulness and maturity of students they had been tempted to call “kids.” In 1989-90, with the help of graduate students in religion, anthropology, and history, a full roster of six-week-long medical humanities seminars was added to both the first and second years, and the clinical ethics conferences were expanded to every rotation of every clerkship at all but one very distant site.
With the curriculum reform of 1994, the program’s courses and seminars became part of the two-year-long preclinical “afternoon curriculum.” Called Patient, Physician, and Society (PPS)--a course title becoming standard in the medical curriculum--this sequence meets for two hours twice weekly and includes not only the medical humanities and bioethics, but economics, community health, communication skills, and the physical diagnosis sequence. In the last two years, PPS has been extended to the third and fourth years with monthly Friday-afternoon meetings, and Ethical, Legal, and Social Implications of Medicine (ELSI) has been introduced as a part of the third-year interdisciplinary clinical skills curriculum.
Teaching the Medical Humanities
The two major preclinical units for which the Medical Humanities and Bioethics Program is responsible employ a variety of disciplines to address important topics in medicine. With readings that include short stories, poetry, ethics essays, and ethnographic studies, the 12-week Ethics and Values unit consists of two parts The first introduces key ethical concepts in the patient-physician relationship: confidentiality; truth telling, informed consent, and surrogate decision making. The second part explores some of the ways people experience illness: disability, suffering, stigma, and isolation. Now well placed at the beginning of the first year, it asks students to consider moral issues intrinsic to the patient-physician relationship. The second-year Profession of Medicine unit, by contrast, addresses social issues, including the meaning of the physician’s patient advocacy in light of the many problems facing 21st-century medicine: the care of the poor, mistakes, malpractice, abortion, physician impairment, physician-assisted suicide, participation in torture and capital punishment, and discrimination within and by the profession. The Profession of Medicine is taught to half the students in the fall, half in the spring. The medical humanities seminars are offered separately each winter to first- and second-year students, and meet for two hours each week for five weeks. Chosen from a list of 18 to 20 possibilities, they have no more than 12 students who have ranked first or second (or, very rarely, third). Many of the seminars are explicitly related to medicine: Women and Medicine; Subjectivity, Objectivity, and the Clinical Attitude; Ethical Issues in ER; Ethical, Legal and Religious Issues in the Care of the Dying; Performing Health: the Drama of Disease in Five Cultures; Osler’s Profession; Difficult Choices (legal and ethics issues); Spirituality in Medicine; Medicine and Macbeth4; Sherlock Holmes and Clinical Judgment5; and Ethical Issues in Clinical Research, which presented historical cases to students acting as a review board.6
Others offer valuable insight into medicine, such as Alternative Medicine in Chicago; Arts Connect (arts activities with children); Dr. Flash Gordon: Science Fiction and the Future of Medicine; The Doctor as Author; Assuming Authority (an art seminar); Here’s Looking at You, Doc: Physicians in Film; Playing Doctor (improvisation skills in the clinical encounter); and Writing the Other.8
A few are valuable in the ways humanities education traditionally is valuable. A sculpture class, Literature of New Americans, The Art of Observation (history and theory of art with weekly visits to Chicago museums), King Lear or As You Like It (or another of the annual offerings at the nearby Chicago Shakespeare Theater) all cultivate observational skills and a knowledge of human nature and its predicaments.
In the 15 years since the medical humanities seminars began, they have become incubators for curricular innovation. Creative faculty who are inspired to try out new educational ideas have piloted activities and formats that have made their way into the required curriculum. In the early 1990s a clinical psychologist offered Tuberculosis and American Culture, a seminar that delved into the history, culture, and psychosocial aspects of a single disease. In addition to reading from literature, history, and public policy, students visited observed-therapy clinics, had a chance to test homeless people on Chicago’s cavernous Lower Wacker Drive, and were met with La Boheme pouring out of a boom box as they walked into class. This multidimensional format was generalized in the College Curriculum Focus, a PPS unit that now engages each of the four first-year colleges in a similar project guided by its college mentor. Their work is presented to classmates and faculty at an annual symposium.
Two early creative writing seminars that focused on important transitions in medical education have been extended to every student. A first-year seminar in which students read and wrote about gross anatomy has been integrated into the gross anatomy course.9 Every student now writes an essay or story meant to aid them in processing their gross anatomy experiences. An annual student-run gross anatomy closing ceremony includes readings by several students of the pieces they have written for class. Similarly, the heart of a second-year seminar, in which students wrote about learning to interview and examine patients,10 has been adopted as a general assignment in the Clinical Encounter unit. Students write about a patient or their own experience as they interview and examine patients for the first time; in class they contrast the narratives they produce with the standard medical language they are otherwise learning for write-ups of the history and physical. A story written for this assignment is read by its author at the annual white coat ceremony that inaugurates the third year, and several students have published their work in clinical journals. 11,12
Not all curricular generalizations have been successful. A seminar on medicolegal topics that had been frustratingly oversubscribed year after year formed the pattern for an early version of The Profession of Medicine. Although the law had been a vital, perhaps anxious interest for many students, the legal emphasis of a required course was not well received by the majority. After two years, the unit was redesigned, and health law seminars have returned to their former popularity among those who choose them.
In 2001 the medical humanities expanded into the clinical years when Patient, Physician, and Society III was offered monthly in four college-based sections. Third-year students read a combination of fiction and nonfiction on topics that pertain to clinical medical education: adapting to ward teams; virtue in medicine (or inspiring and regrettable behavior); the medical hierarchy and student abuse; the care of very ill or dying patients; stress, anxiety, and depression in medical training; aging and geriatric care; palliative care; tribalism and teamwork in medicine; and boundary issues in medicine. Students then write and then read to one another brief stories based on their own clinical experiences, accounts that provide the basis for discussion with classmates, college mentors, and small-group tutors.
In 2002, ELSI was added to PPS III as one part of the third-year interdisciplinary curriculum. Students now leave their clerkship assignments one afternoon a month to gather at the main medical school campus. ELSI presentations focus on the videotaped presentation of a troublesome patient or a problem in one of four specialties and require students to analyze its clinical, ethical, personal, and cultural aspects. A four-times-yearly session for each student, ELSI is repeated (with different cases) for each third of the class. These sessions add a broader emphasis on humanities and expand on the scope of the more immediate student-generated problems addressed in the ethics case conferences.
New in 2002 for senior students is the required monthly Patient, Physician, and Society interactive video (IV), which meets in four college-based groups. Blocks of the course are devoted to health care economics and their ethical implications, students’ teaching skills, a disability-rights view of impairment, cultural difference in medicine, the problem of maintaining personal and professional balance, and empathy. As with PPS III, the unit uses short stories, essays, and films, and students are asked to write brief, topic-related accounts of their clinical experiences. Students’ class time is devoted to reading their stories to one another and to discussing the issues they raise. Inspired by the anthology created this year by one college mentor, the Medical Humanities and Bioethics Program has offered to collect a book of the best of students’ writing for each college. An anthology, the creative compendium of the anxieties and pleasures of becoming a physician, will be given to each student at graduation.
Small-group and interactive teaching are the central pedagogical methods in the Medical Humanities and Bioethics Program. Essential to the success of those methods in a school that admits 165 to 175 students each year are the clinicians who volunteer as tutors and the college system that began with the 1994 curriculum reform. Upon entrance, every student is assigned to one of four “colleges,” each headed by a college mentor who follows the educational careers of 40 to 45 students until graduation; college mentors receive a stipend, most of which is paid in the first two, labor-intensive years. The college system provides the organizational structure for the now four-year Patient, Physician, and Society sequence. The pattern of the two-hour medical humanities units is, first, a one-hour plenary meeting and then four small discussion groups led by clinicians. Because the curriculum reform limited morning science lectures and banned lectures in the afternoon, the plenary sessions require interactive formats. The Ethics and Values unit schedules informal interactions with patients, role-playing with professional actors, and discussions based on trigger films. For The Profession of Medicine, visiting experts are asked to leave their slides and PowerPoint materials behind and, after a short presentation, entertain students’ questions instead. ELSI uses a panel of experts and discussion based on videotaped case presentations by faculty members. During the long reform process, faculty members joked self-consciously about “the small group of 44” that each full college constituted. But, in fact, the stable groups of students meeting weekly soon develop the habit of asking patients, panel members, and other visitors respectful yet penetrating questions.
Small-group discussions are vital to medical humanities teaching. Students are encouraged to test their ideas and to challenge as well as tolerate the ideas of others. Yet this pedagogical method must work against the traditional passivity of medical education that has been the norm for most of faculty.13 Tutors at Northwestern include both veteran teachers, who move among the PPS units as schedules and interests change, and newcomers, who have been more numerous since the recent expansion of PPS into years three and four. All are offered advice about small-group discussion strategies and some peer supervision during the units. Because these faculty members are expected to strive to make their presence ultimately superfluous, one colleague has suggested that our pedagogical motto has become Shut Up and Teach. Serving as a PPS tutor is a prerequisite for becoming a college mentor, and the positions are sought after and highly esteemed.
All preclinical courses are graded pass/fail, although there is also a cumulated but off-record warning grade of “marginal pass.” Students in both the first- and second-year medical humanities units are evaluated on the basis of preparation, participation in discussion, and weekly response essays. In addition, tutors supply narrative commentary for each student and occasional recommendations for Alpha Omega Alpha. At the conclusion of the Ethics and Values unit, first-year students’ intellectual independence from their instructor is tested through a group examination that requires them to analyze an ethics case and reach a consensus without a word of assistance from their instructor. The medical humanities seminars variously require from each student a report or class presentation or weekly essays along with preparation and regular class participation. Student participation in ethics case conferences is not evaluated but almost always lively; PPS III and IV are graded pass/fail based on monthly student essays and class participation; ELSI requires students to fill out a case assessment for each session, a chart that also serves as an attendance record.
Course units and seminars are evaluated at their conclusion by both students and faculty in questionnaires; some questionnaires are now online. The relevant student and faculty course-review committee discusses these evaluations with the unit directors, and an annual PPS retreat that includes student representatives as well as all unit directors reviews the entire afternoon curriculum. A committee made up of directors of the various units in the interdisciplinary clinical curriculum responds evaluations for PPS III, PPS IV, and ELSI. The medical humanities courses are among the most highly rated parts of a generally well-regarded curriculum. Tweaks and revisions and experiments are frequent; loquacious tutors are still a frequent weakness.
Problems and Prospects
Despite the many excellent faculty members who return each year, finding enough volunteer clinicians for the recently expanded tutors’ positions is never easy. With the exception of the college mentors’ stipend, teaching in the Northwestern curriculum has had to be its own reward. Absent an endowed and dedicated teaching program, we are dependent on the good will of our colleagues and the persuasion of their chairs and the dean. We are still looking for the right combination of persuasion and preparation that will enable beginning tutors to lead adult learners in informed discussions of the patient-physician relationships and medicine’s social role. The use of quizzes to guarantee student preparation is currently being debated; some simultaneous solution to the problems of student preparation and tutor dominance is being sought in prescribed discussion activities. For the future, the Medical Humanities and Bioethics Program plans one or two additional fourth-year electives, and participation in residency education is likely to increase as a consequence of the Accreditation Committee on Graduate Medical Education’s new General Competencies. Now that it is a university program, faculty in the program look forward to expanded contacts with colleagues on the Evanston campus, where a group of faculty interested in premedical education has recently organized a discussion group called Metamedicine.
We are seeking funding for additional medical humanities fellowships. Recent fellows have pursued projects in philosophy of medicine, writing and professional development, cultural studies, and bioethics. A similar diversity is planned for the masters-level program that will be offered to Feinberg medical students in the near future. As with the Medical Humanities and Bioethics Program as a whole, the emphasis of that graduate program will be on scholarly and pedagogical activities that draw widely on the humanities to inform an interdisciplinary consideration of medicine as a moral enterprise.