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Medical Humanities at New York University School of Medicine: An Array of Rich Programs in Diverse Settings

Krackov, Sharon K. EdD; Levin, Richard I. MD; Catanese, Veronica MD; Rey, Mariano MD; Aull, Felice PhD, MA; Blagev, Denitza MD; Dreyer, Benard MD; Grieco, Anthony J. MD; Hebert, Cristy MA; Kalet, Adina MD, MPH; Lipkin, Mack Jr. MD; Lowenstein, Jerome MD; Ofri, Danielle MD, PhD; Stevens, David MD

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The New York University School of Medicine has a rich tradition of cultivating programs in medical humanities and professionalism. They are drawn from the departments, centers, students, and faculty in the School of Medicine, have linkages throughout the university, and are interwoven into the fabric and culture of the institution. Some are centrally based in the School of Medicine’s deans’ office, and others are located in individual departments and receive support from the dean’s office. This article describes representative programs for medical students and faculty. Curricular initiatives, the fundamental components of medical students’ learning, include a course entitled “The Physician, Patient, and Society,” a clerkship essay in the Medicine Clerkship, an opportunity for reflection during the medicine clerkship, and a medical humanities elective. In 2002, the Professionalism Initiative was launched to enhance and reflect the values of the medical profession. Its curriculum consists of a series of events that coordinate, particularly, with existing elements of the first-year curriculum (e.g., orientation week, a session during anatomy, a self-assessment workshop, and a peer-assessment workshop). The Master Scholars Program is a group of five, theme-based master societies consisting of faculty and students who share common interests around the society’s themes. Programs developed for the societies include colloquia, faculty-led seminars, a mandatory student-mentoring program, and visiting scholars. Finally, the authors describe three high-quality literary publications created at New York University School of Medicine. Each of the initiatives undergoes regular critical examination and reflection that drive future planning.

Dr. Krackov is associate professor of psychiatry and director, Advanced Educational Programs; Dr. Levin is professor of medicine and vice dean for faculty and academic affairs; Dr. Catanese is associate professor of medicine and cell biology and senior associate dean for education; Dr. Rey is assistant professor of medicine and senior associate dean for student affairs; Dr. Aull is associate professor of physiology and neuroscience and director, Medical Humanities Electives, and editor-in-chief, Literature, Arts, and Medicine Database (see page 1054 for a piece by Dr. Aull on the Literature, Arts, and Medicine Database); Dr. Blagev is a member of the NYU Class of 2003 and founder/editor of Agora; now a first-year resident in internal medicine at Beth Israel Deaconess Medical Center, Boston, Massachusetts; Dr. Dreyer is associate professor of pediatrics, associate chair, Department of Pediatrics, and director, Physician, Patient, and Society; Dr. Grieco is professor of medicine, associate dean for alumni relations, and associate chair for education, Department of Medicine; Ms. Hebert is director, Master Scholars Program; Dr. Kalet is assistant professor of medicine, and faculty advisor of the professionalism program; Dr. Lipkin is professor of medicine and director, Division of Primary Care; Dr. Lowenstein is professor of medicine, unit leader for the patient narrative unit of Patient, Physician, and Society, and director, Humanistic Aspects of Medicine; Dr. Ofri is assistant professor of medicine, and editor-in-chief of Bellevue Literary Review; Dr. Stevens is clinical assistant professor of medicine and director of Physician, Patient, and Society; all at the New York University School of Medicine, New York, New York.

Correspondence and requests for reprints should be addressed to Dr. Krackov, Director, Advanced Educational Programs, New York University School of Medicine, 550 First Avenue, New York, NY 10016; telephone: (212) 263-2196; fax: (212) 725-2140; e-mail: 〈Sharon.krackov@med.nyu.edu〉. Information about the authors is at the end of the article.

For more information, visit the program’s Web site at 〈http://endeavor.med.nyu.edu/lit-med/〉.

The author acknowledges the assistance and editorial support of Stephanie Pieczenik, Master Scholars Program.

New York University School of Medicine (NYU) has a rich tradition of cultivating programs in medical humanities and professionalism. They are drawn from the departments, centers, students, and faculty in the school of medicine; have linkages throughout the university; and have become interwoven into the fabric and culture of the institution. In this article, we illustrate several representative programs for NYU’s medical students and faculty. First, we describe curricular initiatives, the fundamental components of medical students’ learning to be physicians. Next, we describe an important, student-driven professionalism initiative that includes both curriculum and assessment. The Master Scholars Program develops activities related to curricular and extracurricular life. Finally, we describe three high-quality literary publications created at NYU.

All of these programs are rooted in the rich traditions of the school of medicine--a history of service and dedication to an underserved multicultural community and strong linkages with our university. The programs, developed from the 1970s to 2002, have addressed important needs identified by faculty and students. Some are centrally based, in the School of Medicine’s deans’ office, and others are located in individual departments and receive support from the deans’ office. For each program, where appropriate, we describe the background and purpose, structure, format, and student assessment mechanisms. Each of the initiatives undergoes regular critical examination and reflection that drive future planning.

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Curricular Initiatives

Physician, Patient, and Society

In The Physician, Patient, and Society (PPS) course, first- and second-year students develop skills in relating to patients and creating a doctor-patient relationship that is in itself healing. Throughout the course, students examine physicians’ professional responsibilities and a humanistic approach to patient care. PPS is directed and precepted by faculty in the Department of Medicine’s Primary Care Division and the Department of Pediatrics with support from the deans’ office.

The PPS curriculum includes substantial content on ethics, communication skills, behavioral medicine, prevention, cultural diversity, health care policy, management of chronic disease and pain, and issues of family violence. It is delivered primarily through small-group seminars and clinical preceptorships, and includes standardized patient interactions.

In the first year of medical school, students interview patients to appreciate their experience of illness. Under the guidance of experienced clinical faculty, they address topics ranging from coping with chronic disease to end-of-life care. Small-group discussions and selected literary and scholarly readings supplement these experiences. Students study and practice the elements of doctor-patient communication, including the patient’s unique perspective on illness and the development of a therapeutic relationship. They apply these empathic skills to specific challenging situations with actual patients coping with problems like drug abuse or metastatic cancer.

In the first unit of PPS, The Patient Narrative, medical students interview patients and use literature in preceptor-led small groups to expand their understanding of the patients’ experience of illness. They explore the doctor-patient relationship and issues raised in the interviews using assigned readings and group discussions. Topics involve patient narratives, effects of chronic illness, dealing with loss and disability, empathy, pain, and impacts of reimbursement systems on medical care. Readings include “The Loneliness of the Long-term Caregiver” by Carol Levine, “The Last Deal” by Jerome Groopman, “What Is Empathy and Can It Be Taught?” by Howard Spiro, and “The Vital Signs” by Jerome Lowenstein, in The Midnight Meal and Other Essays about Doctors, Patients, and Medicine.1-4

In the Culture and Diversity in Medicine unit, each student analyzes his or her cultural background and traditions to understand their effects on health care practices. In addition, students read and discuss Anne Fadiman’s The Spirit Catches You and You Fall Down,5 analyzing the importance and core components of cultural competency. Students collaboratively design appropriate care plans for standardized patients whose customs differ from their own.

During the second year, students build on the professional values and clinical skills they acquired in the first year. They work through challenging clinical problems that require an understanding of the patient’s perspective including, pain, chronic disease for poorly controlled asthmatics, and domestic violence.

Student assessment is based on class preparation and participation, written essays, projects and presentations, quizzes, and an objective structured clinical examination. Attendance at small-group activities is required.

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Medicine Clerkship

NYU’s Department of Medicine incorporated a formal writing exercise, the clerkship essay, into the core medicine clerkship in June 2000 to help students develop cognitive skills and the ability to synthesize information into a logical and comprehensible story. Each third-year medical student is responsible for writing one original essay during the medicine clerkship. They are told the essay should be based on a brief case report, which can include the chief complaint, pertinent history, physical findings and laboratory results, formulation leading to diagnosis, and outcome.

Students are encouraged to think in broad terms and to view medicine in its fullest context. The essay or poem can be a maximum of 1,000 words and the focus can be artistic, biological, chemical, economic, geographic, historical, literary, mathematical, mechanistic, metaphysical, ethical, humanistic, or any other area of interest to the student. The students’ essays touch upon a wide spectrum of topics, including experiences with death and dying; the insecurities of fledgling students; inspirational patients; and turning points in understanding scientific, clinical, and personal situations. Some of these essays have been published, including, “It’s Only Fifty Cents” by Daniel Chen, class of 2002.6

Submission of an acceptable essay is a requirement for satisfactory completion of the medicine clerkship. Departmental leaders evaluate the essays anonymously and determine the students’ identities after the ratings are completed. The evaluation involves assessment of logic, narrative flow, style, insight, and clarity. The department presents up to five clerkship awards for outstanding essay in medical humanism, medical science, philosophy of medicine, pathophysiology of disease, or creative arts.

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Humanistic Aspects of Medical Education

The Humanistic Aspects of Medical Education program originated in 1978 at NYU. Its goal is to help participants in the clinical rotation in medicine develop the ability to sustain themselves as humane practitioners by providing an opportunity to identify and explore issues and reactions that arise during this phase in their career. During the program, medical students, residents, and faculty meet in a seminar for one hour every week during the third-year medicine clerkship. The group usually involves up to ten people. There is no set agenda, no assigned reading, and no student or resident assessment. Participants can raise and reflect on any experience, concern, or mood--including excitement, satisfaction, and confusion. Confidentiality is strictly observed: nobody can divulge another participant’s statements or attitudes to anyone. The faculty, seven physicians and five social workers, meet every few months to share experiences and redefine goals.

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Medical Humanities Elective

“Betwixt and Between: Borderlands and Medicine,” a medical humanities elective for fourth-year medical students initiated in 2002, explores boundaries in medical training and practices utilizing fiction, patients’ and physicians’ memoirs, poetry, criticism, film, and visual arts. Students think in new ways about doctor-patient relationships, the experience of illness and disability, and the social and medical constructions of disability and disease.

In facilitated seminars, students examine the sometimes-ambiguous boundaries between being a student and a professional, health and illness, and personal and professional life. They consider clinical detachment versus engagement, the physician as patient, medical uncertainty, illness as a state of exile, and marginalization and illness. Course materials include essays by Perri Klass, Atul Gawande, and Edward Said; Kate Scannell’s memoir, Death of the Good Doctor; stories by Mikhail Bulgakov, William Carlos Williams, and John Updike; art by Thomas Eakins and Frida Kahlo; and poetry by Linda Pastan, Lisel Mueller, and physician-poets Rafael Campo and Jack Coulehan.7-20 In two, short, out-of-class writing assignments, participants respond to the material being discussed and relate it to their own experience. Students receive a pass or fail grade based on their class participation and quality of written work.

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Professionalism Initiative

The NYU School of Medicine Professionalism Committee was formed in 2002 with the overall goal of enhancing the already robust culture of NYU to better reflect the values of the medical profession by ensuring that students and faculty understand and embrace those values. The professionalism curriculum consists of a series of events that coordinate with existing elements in the curriculum.

During orientation week, a lecture introduces the program and defines conceptual frameworks for understanding medical professionalism. Students participate in a White Coat Ceremony and complete a survey to assess their understanding of professionalism.

During their anatomy class, in a session entitled “The Experience of Human Dissection,” the course director shares with students his interactions with donors and their families. Students meet to discuss their personal reactions to these first patients--their cadavers. Trained facilitators help them address the expression of professionalism during human dissection.

All first-year students participate in a professionalism self-assessment workshop in early fall. A brief talk, followed by a trigger video clip, initiates discussion of how professional behaviors are actually transmitted. Emphasis is placed on understanding that they are best taught in context, often after hours, and generally through conflicts between competing values. Next, in small groups facilitated by trained students and house officers, participants discuss student-developed case studies of unprofessional behavior in the preclerkship years including, for example, a disinterested student whose humorous comments and lack of participation undermine learning in a small-group conference. The students reach consensus on explicit criteria by which to evaluate their own professionalism, and they complete a written professionalism self-assessment.

In February of the first year, a peer assessment workshop prepares students to assess professionalism (and contribute to the portfolio described below). Students explore ways professional behaviors affect peers, particularly in small learning groups. Participants practice identifying professional and unprofessional behavior and giving feedback to peers in small groups with trained student facilitators

Faculty development efforts involve both faculty and residents to ensure they can reliably and accurately assess students’ professionalism and give effective feedback.21,22

With student involvement and leadership, we are creating an assessment of professional behavior to support students’ professional development and reinforce values and beliefs. The online portfolio will include course materials (essays; standardized patient interaction checklists; self, peer, and faculty assessments) and individualized materials (evidence of community service and club activities). Students will write a brief reflective statement about their activities and review their portfolios annually with a faculty member or trained peer. This review will lead to feedback and a learning plan for the coming year. We will pilot a version of the portfolio with all first-year students in the 2003-04 academic year. The experience will form the basis for collaboration with other institutions to develop a pilot project that is national in scope.

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Master Scholars Program

The School of Medicine’s Master Scholars Program aims to ensure that humanism remains an essential component of care in today’s challenging environment, equal in emphasis to the rigorous acquisition of scientific knowledge and diagnostic skills. The program, inaugurated in 2000, is centered in five master societies, each focused on a specific theme and named for a renowned individual associated with the school of medicine. Each society consists of faculty and students who share common interests clustered around these themes: Jonas Salk Society for Biomedical and Health Sciences, Severo Ochoa Society for Medical Informatics and Biotechnology, Walter Reed Society for Health Policy and Public Health, May Chinn Society for Bioethics and Human Rights, and Lewis Thomas Society for Arts and Humanities in Medicine.

Through the master societies, the program develops a range of activities:

Colloquia feature invited guest speakers for discussions around areas of interest (e.g., Oliver Sacks, Victor McKusick, Stephen Jay Gould, Alan Fleischman, Jack Geiger, and Christopher Reeve). Colloquia topics include the technology behind the human genome, the doctor-patient relationship as seen in literature, drug discovery for the third world, and humanism in medicine.

Faculty-led seminars on topics such as “law and medicine” and “art therapy” create an opportunity for students to participate in discussions and explore areas not necessarily covered in the core curriculum. Future plans for the series include evolving the seminars into “selectives” for first- and second-year students.

A mandatory student-mentoring program is implemented through the structure of the five master societies. In September, students select a master society for membership based on their interests. They meet on a regular basis in society-based small groups facilitated by faculty mentors. The faculty mentors represent different fields within the clinical and basic sciences but have a particular interest in the theme of the master society to which they belong. The discussions involve issues like professionalism, students’ ideas and passions, and the challenges they face in becoming physicians. The mentoring component is comparable within all societies and works collaboratively with the deans’ office, which continues to carry out the function of advising students about academic, curricular, and career issues.21

The Masters Scholars Program sponsors visiting scholars in an effort to introduce students to recognized faculty outside of NYU whose expertise can further develop the program’s mission. Each year, the program also welcomes an artist-in-residence who may lead a seminar or sponsor an exhibit with a text-based component that informs the visual display. The Gift, by artist-in-residence Phil Borges, displayed images and stories profiling the work of Interplast, a nonprofit organization that provides free reconstructive surgery for needy children throughout the world. The exhibit was followed by a colloquium featuring Dr. Shankar Man Rai, a member of the Interplast team who is based in Kathmandu.

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Literary Publications

The Bellevue Literary Review

If great literature arises from the unflinching examination of the tender underbelly of human existence, then a literary journal is a natural development for an institution like Bellevue Hospital, whose halls are witnesses to over 200 years of human drama. The Bellevue Literary Review was initiated in the fall of 2001 as a forum for examining the human condition through the prism of health and healing, illness and disease, and relationships to the body and mind.

Initial calls for submissions yielded over 1,000 manuscripts, confirming the notion of widespread interest in the human body and the ways it falls ill and heals itself. A broad range of writers, from students to Pulitzer Prize-winning authors, submitted fiction, nonfiction, and poetry. People wrote that they were patients once--some at Bellevue--or that they were physicians or nurses, or had cared for an ill relative, or had thought deeply about these issues and were compelled to illuminate them on paper.

In conjunction with the Bellevue Literary Review, published twice a year, poetry and prose readings at Bellevue Hospital attract community members, staff, students, and patients. This flagship municipal hospital is now also a center for literature, fortifying the mission to minister to the mind and spirit, as well as the body.

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Dialogues

In the fall of 2002, the Master Scholars Program began publishing Dialogues: Reflections on Medicine, Humanism and Professionalism. This journal is a collection of student-generated essays, poetry, photography, and artwork on the doctor-patient experience, with commentary from NYU faculty and alumni. The inaugural edition, “A Tribute to September 11, 2001,” was dedicated to the NYU response to the terrorist attacks on September 11 and was inspired by the groundswell of student participation and reflection that emerged over the months that followed. This publication has inspired additional “dialogues,” broadening the lines of traditional teacher-student communication within our own institution as well as beyond. Subsequent annual editions of Dialogues will be themed-based; the next edition will address balancing professional with personal life and values.

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Agora

Agora is the ancient Greek marketplace, a space where people gathered to buy food, exchange ideas, debate, and even vote. NYU’s magazine, Agora, is also a place for the exchange of lively ideas. The magazine was initiated in the spring of 2001 to highlight the diverse interests and talents of NYU medical students and to shine a light on the artistic pursuits that are as integral a part of a medical student’s life as is anatomy or pathology.

The submissions include short fiction, poems, creative nonfiction, drawings, and photographs, which display students’ love and appreciation for literature and art, along with their passion for medicine. Although medicine is not the theme of the magazine, much in Agora has come from students’ experiences and reflections while in medical school. These pieces address the questions that medical students are forced to ask, even from the first day of anatomy lab--confronting mortality, making sense of life and death, defining these enormous issues, and searching for the meaning in them. Through medicine, medical students learn how to prolong life, but it is through art that they learn why life is important, why it is worth prolonging, and why becoming a doctor has value.

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Reflection

The medical humanities involve the humanities, social sciences, and creative arts, and have professionalism as an integral component. At NYU, application of this interdisciplinary area of inquiry and creative endeavor enables students and faculty to explore the human and social significance associated with medical facts, develop insights into the meaning of illness in a person’s life, and gain tools to reflect on the impact of working with the sick and dying.

NYU’s strength lies in its rich array of program offerings in diverse settings. Throughout the institution, there are countless opportunities both within and outside the regular curriculum to engage with ideas, to learn and model professional behaviors, and to value the patient as a person. The medical humanities form an important part of the medical school curriculum, where students learn the science and the art of medicine. Through discussion, reflection, reading, and writing, NYU students and their teachers learn to understand their patients’ responses and express their own feelings as they confront difficult decisions, death, suffering and grief.

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References

1.Levine C. The loneliness of the long-term care giver. N Engl J Med. 1999;340:1587-90.
2.Groopman J. The last deal. The New Yorker. 8 September 1997, 53-64.
3.Spiro H. What is empathy and can it be taught? Ann Intern Med. 1992;116:843-6.
4.Lowenstein J, The vital signs. In: The Midnight Meal and other Essays About Doctors, Patients, and Medicine. New Haven: Yale University Press, 1997.
5.Fadiman A. The Spirit Catches You and You Fall Down. New York: Farrar, Straus, and Giroux, 1997.
6.Chen D. It’s only fifty cents. Ann Intern Med. 2001;135:1087-8.
7.Klass P. First night on call; flip-flops. In: Baby Doctor. New York: Random House, 1992.
8.Gawande A. The case of the red leg. In: Complications: A Surgeon’s Notes on an Imperfect Science. New York: Metropolitan/Henry Holt, 2002:228-52.
9.Said EW. Reflections on exile. In: Ferguson R, Gever M, Minh-ha TT, West C (eds). Out There: Marginalization and Contemporary Cultures. New York: The New Museum of Contemporary Art, 1990:357-66.
10.Scannell K. Death of the Good Doctor: Lessons from the Heart of the AIDS Epidemic. San Francisco: Cleis Press, 1999.
11.Bulgakov M. The steel wind pipe. In: Glenny M (trans). A Country Doctor’s Notebook. London: Collins and Harville Press, 1975:27-37.
12.Updike J. From the journal of a leper. In: Buckley S, Donley C (eds). The Tyranny of the Normal. Kent: Kent State University Press, 1996:286-96.
13.Williams WC. The girl with the pimply face. In: Coles R (ed). The Doctor Stories. New York: New Directions, 1984:42-55.
14.Eakins T. The gross clinic. Thomas Jefferson University Web site. Available at: http://www.tju.edu/eakins/grossclinic.cfm. Accessed June 30, 2003.
15.Kahlo F. Henry Ford Hospital and The Broken Column. In: Herrera H (ed). Frida Kahlo: The Paintings. New York: HarperCollins, 1991:71, 181.
16.Campo R. What the body told. In: What the Body Told. Durham: Duke University Press, 1996:122.
17.Campo R. The distant moon, I, II, III, IV. In: The Other Man Was Me. Houston: Arte Publico Press, 1994:113-5.
18.Coulehan J. I’m gonna slap those doctors. In: Belli A, Coulehan J (eds). Blood and Bone. Iowa City: University of Iowa Press, 1998:21.
19.Mueller L. Monet refuses the operation. In: Alive Together: New and Selected Poems. Baton Rouge: Louisiana State University Press, 1996:186.
20.Pastan L. Routine mammogram. In: Been Carnival Evening: New and Selected Poems. New York: W. W. Norton, 1968:134.
21.Kalet AL, Krackov S, Rey M. Mentoring for a new era. Acad Med. 2002;77:1171-2.
22.Rockfeld J, Horlick M, Kalet A. Setting our own standards: a student-led professionalism curriculum for preclerkship students. Med Educ. 2003;37:483.
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Cover Note

New York University School of Medicine

New York University (NYU) School of Medicine traces its roots to 1841. As the Medical College of the University of New York, it admitted its first class of 239 students to a four-month course of lectures conducted by the six professors on the faculty.

Over the years, the medical enterprise evolved. The old Bellevue Hospital Medical College, established in 1861, was merged in 1898 with New York University to form the University and Bellevue Hospital Medical College. The combined institutions became New York University College of Medicine in 1935. In 1960, the name was changed to NYU School of Medicine.

From the start, the School and its graduates have been at the forefront of medical education, scientific research, and patient care. Two alumni, Drs. Jonas Salk and Albert Sabin, developed vaccines for polio, and one of our faculty members, Dr. Saul Krugman, helped to develop a vaccine for hepatitis B. While affiliated with NYU, Dr. Howard Rusk, for whom our world-renowned Rusk Institute is named, pioneered the field of rehabilitation medicine following World War II.

The School counts among its faculty and alumni three Nobel laureates: Dr. Severo Ochoa, who conducted landmark studies in biochemical genetics and nucleic acids; Dr. Baruj Benacerraf, who performed groundbreaking research on genetic regulation of the immune system; and Dr. Eric Kandel, who made outstanding contributions to understanding basic mechanisms in the nervous system.

At Bellevue Hospital, where our medical students receive most of their clinical training, NYU physicians helped to establish the nation’s first outpatient department, as well as departments of rehabilitation medicine and forensic pathology. NYU physicians at Bellevue were the first to identify Kaposi’s sarcoma as an early symptom of AIDS.

Today, the School enrolls 703 students seeking the MD degree and 255 PhD students, including 80 MD-PhD candidates. The School also boasts 1,388 full-time faculty and 3,477 part-time faculty, with 61 endowed professorships. There are 1,060 residents/fellows and 4,979 postgraduate registrants.

The School of Medicine lies at the heart of NYU Medical Center, which embraces NYU Hospitals Center (Tisch Hospital and the Rusk Institute of Rehabilitation Medicine), Hospital for Joint Diseases Orthopaedic Institute, and NYU Downtown Hospital, as well as major affiliates Bellevue Hospital Center, and the Department of Veterans Affairs New York Harbor Health Care System.

For more information about NYU School of Medicine, please go to 〈www.med.nyu.edu〉.

NYU School of Medicine

© 2003 Association of American Medical Colleges