Dr. Charon is professor of clinical medicine and director, Program in Narrative Medicine, Columbia University, New York, New York.
Editor's Note: This is a commentary on Ousager J, Johannessen H. Humanities in undergraduate medical education: A literature review. Acad Med. 2010;85:988–998.
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Washington Square Park in New York City is undergoing a major renovation. Although the noble Arch, built in 1889 to commemorate the centennial of the first president's inauguration, still presides over the space, the park's varied vitality exceeds its historical frame. Today, toddlers in bubble-gum-pink snowsuits gleefully swing under their parents' pushful hands. Holly leaves so green they seem black hide their rare red berries. Fuzzy pussy willows are already, in February, budding. Bounding pets and the owners they haul choose between the “Dog Run” and the “Small Dog Run” for muddy exuberance. Amid all this activity, over half the park has been dug up. Gullies gape six feet deep where I sat reading novels last spring; sewer-pipe innards splay into view; foundational granite is exposed. It is a mess, surrounded by chain-link fence that reveals it all to passersby. But all of us—from the South Korean tourist snapping photos to those of us New Yorkers who still find the sky empty where the twin towers should be—comprehend that this parcel of land stands for something grand. It is permeated by all that New York and America mean and do, on display to all who meet it and influenced by all who enter it.
When two public health researchers from Denmark report on humanities teaching in undergraduate medical education,1 we all recognize the major renovation under way in clinical training thereby represented. Ousager and Johannessen's1 catalog of essays stands as a tribute to the vitality of this new arrival to medical school curricula. The publications included in this literature review emit from many continents, examine 31 disciplines of humanities studies, and represent the extremes and the subtleties of judgments on the worth and accomplishments of the new pedagogy. The report reviews selected papers published since 2000 in the journals indexed in Medline that describe or evaluate medical school courses providing education in the humanities.
As a result of the methodology, the review necessarily underreports both the content and the impact of the teaching it reviews because many salient humanities publications are not indexed in Medline and so are excluded. The choice to study the category “humanities” exposes complex interdisciplinary developments within medical pedagogy that combine traditional humanities study with qualitative social sciences and fine arts. The conceptual organization of the review (categorizing papers not by type but by opinion), their effort to read only the abstracts thoroughly in some cases (as pointed out by the authors), and the idiosyncratic system of cataloguing the humanities disciplines themselves limit the utility of the paper's manifest findings. The authors' choice of words to label the categories reflects problematic assumptions about the humanities in medical training; essays articulating the goals of humanities teaching are labeled “pleading the case,” suggesting an air of desperation in the field, while essays raising cautions are labeled “holding the horses,” as if the role of the humanities in medical education were not serious but almost extracurricular, as a sport. Since the population of learners is restricted to undergraduate medical students—in the case of non–North Americans, students just out of high school—these curricula cannot be assessed on their ability to demonstrate change in the eventual clinical practice of the learner. Hence, reporting outcomes in the sense of the empirical evidence called for by the authors is nearly impossible with respect to humanities in medical curricula. Nonetheless, the ground exposed by virtue of the effort is tremendously important and worthy of our attention here.
Measuring Humanities' Outcomes in an Outcomes-Based Environment
Most teachers of humanities in medicine have trouble containing their teaching within the restrictive frameworks of an outcomes-based medical education model that demands proof of efficacy of any newly introduced curricular material. Nonetheless, those of us who do such teaching insist on knowing the outcomes of our work, as would any serious practitioner toiling at something difficult want to know whether the outcome is worth the effort. Several proxy outcomes are typically measured in examining such teaching—trainees' attitudes toward patients and their work, early clinical habits or aspirations, disciplinary knowledge retention, capacity to represent and reflect on what they witness and experience, and sense of “at-homeness” in medicine. The ultimate metric to apply to this work is whether or not the teaching makes the health care provided by our learners more effective. Eventually, and I think soon, we can seek outcomes of humanities or narrative teaching not at the level of career choice or perceived “wellness” of young students, but in the HbA1c of learners' diabetic patients, the success of their patients to achieve the health goals (be it weight, smoking status, or LDL) they set for themselves, the power experienced by their patients with advanced disease to participate in health care decisions, or the ability of their patients to choose the forms of their own deaths. Unless the care gets better—as measured rigorously in such clinical outcomes—the curricular content is irrelevant. These considerations have swayed some of us toward teaching physicians already in practice instead of focusing narrowly on the seemingly more accessible quarry of medical students. Fortunately, more and more robust metrics are available to humanities teachers as social scientists and educational researchers now working in medical education develop stronger and more discriminating methods of evaluating our teaching.
Do We Want to Measure the Outcomes of Humanities Teaching?
Including humanities teaching in a clinical training program adds even more knowledge and skills to the requirements for already-swamped students. More important, it pries open for renegotiation the fundamental ways of knowing proposed to be required for clinical competence. More so than, say, adding viruses to the bacteria in the microbiology course, including humanities curricula makes the case that purely scientific forms of knowing are no longer deemed adequate to practice medicine. Students are made uneasy by such proposals for good reason: Humanities' ways of knowing operate out of very, very different parts of one's human equipment than do those of the sciences. In addition to reliance on one's cognitive, computational, and logical powers, inclusion of humanities proposes the need for imaginative, affective, relational, and symbolic powers as well. (This is not to suggest that the scientist is not a creative and highly imaginative professional but, rather, that the conventional medical school curriculum is not rich in the imaginative and creative aspects of science.) We need not fall into the outmoded C.P. Snow “Two Cultures” dichotomy to recognize the distinctions between these two aspects of human cognition, perception, and experience. Not altogether unlike the case made by proposing the inclusion of social and behavioral sciences in medical education, the inclusion of humanities in the curriculum occasions deep rethinking of what it means to be sick and what it means to take care of the sick.
One can and ought to wonder whether it is beside the point to try to measure, through reductive processes of evaluation, that aspect of learning which is meant as an antidote to the reductiveness of the curriculum itself. One can, cynically, predict that the demand for “evidence” creates an ever-receding unattainable goal (offering up a study with an n value of 100 will lead to demands for n values of 1,000; providing cross-sectional studies will trigger demands for randomized trials) or that such demands are the truculence of the powerful. Nonetheless, new practices have to be inspected, if only to assure their proponents that their benefits outweigh their risks.
Who Are the Students?
One salient question not posed by Ousager and Johannessen is, “Who are the students?” The short answer to that question has already been suggested here—lumping European, UK, and Asian students in with North American students gives a misleading pool of mismatched learners to assess and complicates the effort to make sense of the findings.
A more challenging but even more productive answer to “Who are the students?” is “All clinicians.” The Washington Square renovation is not just working on the pipes installed in the past four years. Even the old-timers are being dug up and restored. More and more humanities sections, including mine at Columbia, target faculty and staff as their learners. Not only does a teach-the-teachers economy take place with this strategy, but the bottom-up effects of introducing young students to new approaches and skills are complemented by the top-down modeling by senior clinicians, who themselves have been exposed to and altered as clinicians by deep learning in humanities and narrative studies. As these senior influential clinicians—course directors, clerkship directors, residency program directors, associate deans—grow in their competence as readers, writers, listeners, and bearers of witness to the sick, the medicine practiced at our institutions changes, and the clinical training offered to our students widens. More and more such efforts include not only doctors but nurses, dentists, social workers, chaplains, public health professionals, administrators, and patients. Such efforts, we believe, have the capacity to fundamentally change the face of health care in our institutions.
What Medicine Is Practiced Here?
By next summer, not only will the Washington Square holly trees be bushy and the pussy willows green but the whole of the park will have attained an integrity and coherent beauty it currently lacks. The hermeneutics of the park—the iterative relations between the parts and the whole—will have been transformed. When medicine undergoes as dramatic a change as to incorporate the ways of knowing of humanities, it undergoes a transformation. The enterprise itself changes from trying to fix that which is broken to trying to recognize that which one beholds. However hard, it is not sufficient to measure our new teaching against the goals of the old teaching. Rather, the goals have changed by virtue of what our excavating new learning has exposed. Yes, we are still trying for glycosylated hemoglobins under 6 or BMIs under 25. We are also trying for patients who feel at home in their bodies, who can take charge of their health decisions, who may need help simply remembering the traumas that have been visited on them in the past.2 We are trying for a medical practice that does not divide us from our colleague nurses and social workers and chaplains, a medical practice that takes account of the neighborhoods in which our patients live, the beliefs about the afterlife they hold, the cultural significance of bodily phenomena within their circles, the languages they speak.3 We yearn for a medical practice that does not belittle our own experiences of sorrow and defeat but that gives us the permission and the skills to reflect on these complex human experiences.4 At the risk of sounding like a pleader for the case, I suggest that we are midwifing a medicine that makes contact with the mysteries of human experience along with its certainties—a medicine that appreciates the deep beauty of health, the silence of health, the wisdom of the body, and the grace of its genius. It is an arch to far times and places, a site for all the living and the dying that go on; it is a link to what it means to be human.
The author acknowledges her colleagues in the K07 Faculty Seminar at Columbia and the Macy Project on Training for Health Care Team Effectiveness.
The author is supported by NIH NHLBI K07 Enhancing Social Science and Behavioral Science Teaching in Medical Schools, Training for Health Care Team Effectiveness, Josiah Macy, Jr. Foundation.