Objective knowledge is considered scientific and valuable, whereas subjective information is thought to be “soft” and second-rate. For the relief of suffering, that conflict is not only false but an impediment. - —Eric J. Cassell. Diagnosing suffering: A perspective. Annals of Internal Medicine. 1999;131:531–534
The article by Ousager and Johannessen1 makes me uncomfortable, even defensive. I want to resist their warning that, in a medical education culture seeking certainty and security based on empirical evidence, the burden of proof lies on those who seek to integrate humanities into the undergraduate medical curriculum, rather than on those who want to exclude such work. I can't tell whether Ousager and Johannessen approve of this instrumentalism or not; they just provide data, appearing to assume that the methodology they use, like the methodology they recommend, is the only way for the humanities to avoid marginalization. “But wait,” I want to say. “Will outcomes measurement efforts really make the place of the humanities in undergraduate medical education (UME) more secure?” (And who, I think, should do this measuring? It's not what humanities scholars are trained to do.)
But this discomfort with the assumptions of other disciplines can be a catalyst for creative negotiation. Ousager and Johannessen are right to warn us not to assume that the value of the humanities is self-evident. They remind us that despite the substantial humanities teaching presently being carried out in most medical schools—work documented in the long list of publications that form their database—the value of this work is not proven within the parameters of the dominant paradigm.
The value of humanities work may lie in revealing some of the limitations of that paradigm and offering alternative frameworks for thinking about medical education. Ousager and Johannessen's data are valuable, and their warning is well taken, but I will resist (as they predict a humanities scholar would) the reductionism that underlies both their study and the kind of research they seem to believe is the only way to bolster the integration of humanities. Resistance need not mean rejection. Discomfort can produce constructive engagement, and their article underlines tensions that need to be addressed.
The pedagogical value of discomfort is central to one of the articles classified by Ousager and Johannessen as “holding the horses,” or indicative of reservations about the humanities in UME: Delese Wear and Julie Aultman's2 analysis of student resistance in a medical humanities course that they taught. Because of the blunt instrument Ousager and Johannessen seem obliged to use in their categorization, Wear and Aultman's work is, I think, misread.
My professional training is in the reading of cultural texts, so the first thing I did after reading Ousager and Johannessen's article was to look at their data: I read a few of the articles they refer to. Feeling defensive, I went right to their fourth category, research purportedly showing that those who promote integration of the humanities should “hold our horses.” I expected to find arguments here for keeping the humanities on the optional and decorative edges of the curriculum. Instead, I found something reassuring: evidence that Ousager and Johannessen's method unwittingly demonstrates a need not for more quantification of value but for the kind of attention to specificity that the humanities provide.
I will show what I mean by referring to textual evidence from two of the articles in this group. While the title of Wear and Aultman's article describes “the limits of narrative,” and mentions “medical student resistance,” it in fact constitutes a powerful demonstration of the need for humanities in the UME curriculum. The article warns of the danger of taking the salutary effects of narrative for granted, proposing instead a sturdier pedagogy that acknowledges the discomfort—and resistance, and defensiveness—that humanities material can provoke in students, building on that disruption to expand students' thinking about the implications of cultural and sociopolitical contexts in which narratives and patients (and medical students) are embedded. Far from expressing reservations about the value of medical humanities in UME, Wear and Aultman articulate the limitations of treating humanities merely as a palatable reprieve from “hard” work. They argue instead that we must attend to resistance, even provoke it, if humanities teaching is to promote critical inquiry as well as neutral reflection. Wear and Aultman make a powerful argument that rigorous humanities teaching can develop an orientation toward uncertainty, knowledge, and action that characterizes the best physicians. But within the limitations of Ousager and Johannessen's study, the only good argument relies on empirical evidence of long-term, concrete outcomes.
Juxtaposed with Wear and Aultman's article in the category said to express reservations about the effects of the medical humanities, Ousager and Johannessen include a piece from “Jabs and Jibes,” the humor section at the back of the Lancet, which includes the following passage:
Enjoyment of literature is a leisure pursuit, like trainspotting or collecting stamps, and [just] as irrelevant to medical practice. Some of our physicians' professional time should be spent learning what the people they are called on to treat, read; what they see in the cinema and on television—matters that might really concern them, whether or not the physician can understand why on earth that should be. Education in the human condition of everyday is quite as important as mastering anatomy.3
I object to the inclusion of Bignall's3 piece less because it is not a serious or informed study than because its language will not submit to Ousager and Johannessen's reading method, for it is ironic.
Irony poses a lethal challenge to the literalism of reductionist taxonomies. If an author means something other than what the words mean, key propositions cannot be extracted and taken at face value. Ousager and Johannessen are right to ascertain that the piece rejects literature as a worthwhile component of the curriculum—to the extent that “enjoying” it sums up literary studies. But Bignall goes on to say that the study of popular culture might enhance physicians' understanding of their patients. He proposes a medical humanities course in “illiterature” (punningly and patronizingly, the culture of an “illiterate” class: patients). The joke, I gather, lies in his assumption that no one could possibly take seriously so absurd a proposition. But many medical humanities classes do include popular culture texts. In taking Bignall's piece seriously, did Ousager and Johannessen read between the lines and find a persuasive, albeit satirical, argument against the medical humanities? Or did they reduce it to its overt thesis and miss the irony altogether?
I focus on this text because it demonstrates the need for a different way of knowing in medical education: Without the distinctions made by reading for meaning rather than for data, the results of efforts to classify and measure human endeavors—like research or texts, or like treating disease or experiencing illness—may at best be trivializing tokens of cooperation and at worst egregious distortions of their material.
Because of its focus on quantification, this article fails to illustrate the importance of attention to linguistic irreducibility in the multiple texts of medicine. The authors' taxonomy excludes precisely what they purport to seek: the contribution of humanities-based epistemology to medicine and medical education. For me, reading Ousager and Johannessen's article generated three challenges to those who teach medical humanities and who try to evaluate its contributions: We should work together to define our terms and develop a coherent description of our heterogenous field, we should teach reading skills (promote, that is, a nonreductive approach to the interpretation of all human objects), and we should establish effective and persuasive alternatives to outcomes measurement.
A greater barrier to the integration of humanities in UME than a shortage of outcomes studies is the lack of a clear account of the field and precise definitions of its key terms. The selections made by Ousager and Johannessen make it clear that there is no reliably accepted definition of humanities in UME. Their work shows care, but without more precise parameters and a taxonomy internal to the field, their sample is flawed. This is clearest in the small group of exemplary articles seeking evidence of long-term benefit. In fact, not one of these is about the medical humanities. Some measure the effectiveness of communication skills training; three promote a survey instrument for tracking students' responses to ethical dilemmas; one compares problem-based learning with traditional teaching of medical ethics. As they are normally taught, though, neither communication skills nor clinical ethics are strictly considered part of the medical humanities.
The inclusion of a randomized controlled trial of Harvard's New Pathway program indicates a more pervasive terminological problem, the use by proponents of the medical humanities of cognate terms like “humane” and “humanistic” as if they followed automatically from humanities work (which is itself often used synonymously with “arts”). While one of the outcomes the Harvard study seeks to measure is the promotion of “humanistic” attitudes, the study examines a complete curricular innovation introducing problem-based and small-group learning. The inclusion of humanities disciplines is not mentioned and, even if it were, would be just one among many variables. The assumption that a study of humane attitudes implies the inclusion of humanities teaching confuses outcomes with interventions.
At present, most cases made in support of medical humanities rely on the authors' chosen definition of the field and tend to apply narrowly to the authors' own work. This explains the large second category, “Course descriptions and evaluations”; in most cases, the n value for these defenses is 1. It may well be a generalizable “1,” though, if we used the right tools, for there are alternatives to blunt reductionism other than fuzzy holistics. Wear's4 precise application of the concept of interdisciplinarity to her recent survey of medical humanities practice is one good starting point.
A second challenge, both to those who teach medical humanities and to those who study medical education, is not to take reading for granted. As Ousager and Johannessen's use of Bignall's comic piece demonstrates, human texts cannot be treated like natural objects. The humanities resist the homogenization of social science metrics, for our focus is on the specific and particular, exactly those aspects of human texts that resist reduction. We value fine distinctions, even at the risk of defaulting to an n value of 1. This is precisely why the humanities are so valuable to medicine, for we offer a counterpart to the necessary reductions of the natural sciences. The unit of medicine is the particular patient, always irreducible. We know that medicine runs into trouble when individual persons are examined only with instruments that reduce specific meanings to simplistic data. The humanities must complement necessary generalizations, focusing attention on all the confounding variables that every effective clinician, bravely tolerant of uncertainty, has to hold in balance with the reassuring generalities that science provides.
Finally, the medical education establishment should be challenged to continue investing in immeasurable outcomes. The large number of publications listed by Ousager and Johannessen attests to the fact that this work is happening despite the difficulty of measuring its long-term product. This surely suggests that there is a vision in medical education that extends beyond the obviously instrumental. The humanities are not the only aspect of medical education to resist clear evidence of long-term outcomes. The methodological minefield that stretches between any curricular intervention and the improvement of patient health is immense, and it explains the powerful trust that medical education places in tradition.5 There is just one Flexner, and the dispensation he introduced a century ago is largely still in place.
Metrics like the one used by Ousager and Johannessen may produce easily digestible (and, in their turn, quantifiable) conclusions, but other kinds of reading may well translate more directly, if not necessarily more measurably, to the human context of the clinic than the dehumanizing extraction of manipulable data from resistant texts.
I suspect many in the medical humanities will respond to this study with defensiveness and resistance. Their discomfort might be productively channeled. We should use the reference list provided by Ousager and Johannessen to work out a different kind of taxonomy, focusing not on how each intervention justifies its own existence (or fails to do so) but on something far simpler and more valuable: How do these interventions constitute a field, and how should that field convey its value?
Ousager and Johannessen remind me that I should not be complacent about the value of what I teach, but they also remind me that there is a great deal more that the humanities have yet to contribute both to the training of medical students and, more apropos here, to how medical education thinks about its goals. The humanities offer precisely what is missing in both blunt reductionism and fuzzy holism: incisive attention to specificity. Those of us trained as humanities scholars must contribute better ways to assess medical education's objectives and methods and outcomes. This would be uncomfortable—and valuable—work for all involved.