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The Centre for Medical Humanities, Royal Free and University College Medical School, London, England

Kirklin, Deborah BM, BCh, MA, MRCGP

Special Theme Article: International

The Centre for Medical Humanities is based within the Royal Free and University College Medical School. With a student body of more than 2,000, this large United Kingdom medical school benefits from being a fully integrated component of University College London. With its strong humanities and science faculties, University College London was founded more than 175 years ago to make education available to wider social and religious groups. With this background, it is logistically and ideologically well suited to sustaining a medical humanities program. The Centre’s aims are to raise awareness of the field of medical humanities, to develop resources for the academic and teaching communities, and to build a broad and well-grounded educational program supported by sound educational principles and innovative research. Since 1998, the Centre and its predecessor, the Medical Humanities Unit, which was established by a group of medical educators with a diverse range of interests in the arts and humanities, has built interdisciplinary links and collaborative relationships with individuals and institutions within the university and beyond, nationally and internationally. These links and relationships have provided invaluable contributions and stimulus to the Centre’s activities. The undergraduate educational program described in this article includes core and optional teaching throughout the curriculum, and a 1-year intercalated Bachelor of Science in Medical Humanities degree. For postgraduates, the Centre offers the United Kingdom’s first continuing professional development accredited 2-day course in medical humanities, and an annual residential retreat open only to graduates of the course.

Dr. Kirklin is Pfizer Senior Lecturer in Medical Humanities, and director, Centre for Medical Humanities, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, England.

Correspondence and requests for reprints should be addressed to Dr. Kirklin, Director, Centre for Medical Humanities, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, Archway Campus, Highgate Hill, London N19 3UA. Phone: 020-7288-3467; fax: 020-7288-3306; e-mail: 〈d.kirklin@pcps.ucl.ac.uk〉.

More information on this program may be found at 〈http://www.pcps.ucl.ac.uk/cmh/〉.

The Centre for Medical Humanities is based within the Royal Free and University College Medical School. With a student body of more than 2,000, this large United Kingdom medical school benefits from being a fully integrated component of University College London (UCL). With its strong humanities and science faculties, UCL was founded more than 175 years ago to make education available to wider social and religious groups. With this background, it is logistically and ideologically well suited to sustaining a medical humanities program. The Centre’s aims are to raise awareness of the field of medical humanities, to develop resources for the academic and teaching communities, and to build a broad and well-grounded educational program supported by sound educational principles and innovative research. Ultimately, the educational program of the Centre for Medical Humanities aims to help caring and competent physicians to do a better job for the patients entrusted to their care. Courses include optional and compulsory contributions to the undergraduate medical curriculum and a 2-day accredited program for established health care practitioners. This course is now followed by an annual residential retreat open only to previous graduates of the short course. In this article, I will detail the guiding principles and the interdisciplinary partnerships that shape and focus the Centre’s educational activities.

For many physicians not directly involved in the humanities field, it may not be clear what medical humanities has to do with them, and whether it is anything more than a nice way to spend the afternoon.1 So in addition to developing, delivering, and evaluating arts and humanities-based medical education, the Centre’s aims include working with a wide range of partners, from medicine and science, the arts and humanities, the charitable and public sectors, to raise awareness of medical humanities as an academic discipline. Some of the ways in which we have tried to do this are detailed below and represent the Centre’s contribution to the development of community resources for medical humanities educators throughout the United Kingdom and Europe.

Compared with many of the programs described in this issue of Academic Medicine, the Centre’s work, which began in 1998 with the establishment of the Medical Humanities Unit at our medical school, is in its infancy. Nevertheless, these early days have been very productive. To place the Centre’s program of activities in context, I offer some brief background information about how medical humanities in the United Kingdom has come into its own in the last few years.

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Medical Humanities in the United Kingdom

The publication in 1993 of Tomorrow’s Doctors: Recommendations on Undergraduate Medical Education 2 by the education committee of the General Medical Council (GMC) marked a turning point for those who, like Professor Robin Downie, a leading moral philosopher, and Professor Sir Kenneth Calman, the former chief medical officer for England and a leading palliative care physician, had been championing the developing discipline of medical humanities for many years.3,4 Tomorrow’s Doctors called on, and indeed required, all medical schools in the United Kingdom to implement radical changes to the undergraduate medical curriculum. Most importantly, the document proposed the introduction of a core medical school syllabus and suggested the allocation of as much as 30% of the timetable to optional “special study modules.” Until this time, elective, or optional, elements within the curriculum had been confined to a 3-month trip, often overseas, usually to a developing country.

The possibility of arts-based courses within these modules was highlighted by the General Medical Council, which cited the appropriateness of courses such as literature and medicine. Several medical schools in the United Kingdom have taken this opportunity to develop courses,5 and in 2002 the Association of Medical Humanities was established with a mandate to provide a national forum for all academics working in this field.6

Another influential voice in this move to incorporate the arts and humanities into medical education is the Nuffield Trust7 and its chairman, John Wyn Owen. The Nuffield Trust, a charitable foundation, organized two invited conferences, in 1999 and 2001, designed to bring together representatives of all of those working, across the United Kingdom, with the arts and humanities in relation to health.

In addition to medical educators, this gathering included representatives from arts therapy, arts in health, and community arts. The results of these important meetings, including a declaration of future aims, can be found in publications by the Trust.8,9 Importantly, these meetings, and the publications that followed, attracted the interest and attention of the wider medical establishment, the lay public, and policy makers.

In 1999, with support from the Nuffield Trust, the Centre for Arts and Humanities in Health and Medicine was launched in Durham University.10 In the same year, the National Network for the Arts in Health was launched with support from a wide range of arts bodies.11 In 2000, the first of a now-annual series of national medical humanities conferences was organized by the Centre for Medical Humanities’ predecessor, the Medical Humanities Unit, and 2001 saw the publication of the United Kingdom’s first two textbooks in medical humanities.12,13 Medical humanities in the United Kingdom had come of age.

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Medical Humanities at Our Medical School

The idea of introducing medical humanities at UCL’s medical school grew from a visit by Dr. Richard Meakin, a senior lecturer in primary care and now one of the Centre’s directors, to Michigan State University, where he saw, first-hand, the impressive program offered by that school. The first medical humanities course was offered at UCL in 1998, and it was funded by an educational prize from a UK charity, the Cancer Research Campaign. An optional, 2-week, full-time undergraduate course called Living with and Dying from Cancer used literature, practical art, drama, film, and creative writing to help third-year medical students think about the effect of cancer on patients, families, and professionals.14

This course, and a subsequent course about the human effect of the genetics revolution,15 was well received by students and instructors alike and provoked several articles in both national and local newspapers and a feature on BBC Radio 4. The use of the arts and humanities in the education and training of physicians was welcomed by the media, who talked of humanizing medicine.

Later that year, the Medical Humanities Unit was established within the Department of Primary Care and Population Sciences, where the winners of the Cancer Research Campaign educational prize, Drs. Richard Meakin, Surinder Singh, and Margaret Lloyd, and I all work. Dr. Singh is a lecturer in primary care, and Professor Lloyd is subdean for the curriculum at the medical school. In 2001, with a rapidly expanding program at both the local and national level, and with a 3-year core funding grant from the Pfizer Foundation and Pfizer UK, the Centre for Medical Humanities was launched. Since then, the Centre’s team has continued to work both within UCL and beyond to develop a dynamic and innovative educational and research program.

Although still housed within the Department of Primary Care and Population Sciences, and pursuing educational and research work specifically relevant to primary care, the Centre’s work is recognized within UCL as addressing educational needs across the medical school.

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What Is Medical Humanities?

It is worth explicitly stating that there is, to date, no agreed definition of what medical humanities is, nor for that matter what constitutes the humanities and the arts. In the United Kingdom, this is an evolving discussion in which a range of different views can be found and no one can be considered definitive. Important differences exist in what is understood by “medical humanities” from institution to institution, and from country to country. The fact that we can talk of the medical humanities or, as is most often the case in the United Kingdom, simply of medical humanities, is in itself interesting.

Although it is beyond the scope of this article to explore these different conceptions of medical humanities, the excellent overview of this by Evans is recommended to readers interested in a UK perspective.16 In recognition and acknowledgment of the various and often complementary understandings of the term, and to ground the content of this article, the Centre’s own working definition of medical humanities is given below.

Another important point that needs clarification is the distinction between medical humanities and the therapeutic use of the arts with patients, care givers, and professionals (known as art therapy), the use of art in health care settings where therapy, although often welcome, is the incidental rather than the primary objective (known as arts in health), and the use of arts in community settings (community arts). Again it is necessary to make clear that these distinctions and definitions are far from universally accepted.

The Centre has developed the following definition of “medical humanities”: Medical humanities is an interdisciplinary, and increasingly international endeavor that draws on the creative and intellectual strengths of diverse disciplines, including literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology, and history, in pursuit of medical educational goals.

Like all medical educators, those working in the field of medical humanities share the common objective of helping learners to be good physicians. This fundamental objective has been central to the development, delivery, and evaluation of the medical humanities program described in this article.

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The Centre’s Work

Educational Objectives

From the patient perspective, a good physician is someone who is not only competent but who also actively seeks to identify and address the needs and agenda of the patient. Doing this requires an ability to appreciate the effect of illness on the person entrusted to their care, on those who love that person, and on the health care professionals involved in caregiving.

Unfortunately even the most caring and competent physician sometimes fails to appreciate what the patient needs, feels, and wants; that is, what their priorities are. Conversely, they may appreciate the patient’s needs very well but do not know how to handle the combined burden of the patient’s pain and their own17,18 They may also lack cultural and historical sensitivities and insights relevant to the patient’s experiences of illness and expectations of health care. The Centre’s courses are therefore designed to help learners address these important issues.

In broad terms, the Centre’s educational objectives are

  • to help learners to connect with, or appreciate, the perspective of all those affected by illness: the person who is ill, the persons who love them, and the professionals involved in their care;
  • to facilitate reflection on the physician’s own practice, on its strengths and weaknesses, so that he or she can build on the former and address the latter;
  • to provide both cultural and historical perspectives on illness and health care; and
  • to act as a source of personal and professional support for the learner.
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An Interdisciplinary Approach

The Royal Free and University College Medical School is one of the largest medical schools in the United Kingdom, with an incoming class of approximately 400 medical students each year. As stated before, the medical school is part of UCL, which is a large university with strong humanities and science faculties.

The teaching for the medical humanities program therefore can draw on faculty from the Centre, the medical school, and the arts and humanities faculty of UCL. In addition, we have an experienced team of peripatetic tutors that includes writers, artists, and film and drama specialists. Some of them also have had personal experiences of serious illness, which deepens their understanding of the importance of medical humanities training. All Centre clinical staff have additional humanities training in medical ethics, anthropology, or the history of medicine.

From our earliest work, these interdisciplinary collaborations have been invaluable, and facilitating the development of interdisciplinary educational initiatives remains a key aim for the Centre. The richness of these interactions has encouraged us to develop an interdisciplinary research program. Current research includes the use of art in primary care to improve the observational skills of physicians and nurses.

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The Medical School Education Program

From 1998, many optional medical humanities courses have been available to medical students at UCL. While the Centre offers courses such as Poetry and Prose in Medicine, and Doctors in the Dock: What We Can Learn from Alder Hey and Bristol, students can also choose from courses offered by faculty across UCL in medical history, medical ethics, medicine in art, and many foreign languages. These courses are popular and well evaluated.

Despite the success of these elective courses, our long-term goal remains for all medical students to receive core medical humanities instruction, and so in 2001 we were delighted to be invited to develop core teaching material in literature and medicine for first- and second-year medical students. The teaching forms part of a course called the Professional Development Spine (PDS). This teaching occurs weekly throughout the 5-year course and includes topics in communication skills, ethics and law, health promotion, community-based learning, evaluation of evidence, and clinical skills.

The PDS instructors come from a range of backgrounds and include clinicians, nurses, and psychologists. The positive response of these nonspecialist teachers to the use of poetry and prose has been particularly encouraging. As a result the amount of literature and medicine teaching, input into PDS is steadily increasing, with four dedicated sessions now scheduled for the first 2 years and plans for more.

In 2001, the Centre was approached by clinical faculty from Obstetrics and Gynaecology (Women’s Health) and Psychiatry, who had heard of our work and invited us to develop core materials for these clinical areas. During the Women’s Health course, students now take part in a 3-hour, small group interactive session. Facilitated by the Centre’s teaching fellow, Dr. Claire Elliott, a general practitioner with additional expertise in medical history and in literature and medicine, the seminar involves literature, art, film, and medical history. Another session, facilitated by physicians and midwives, explores the different types of loss and bereavement women may experience and uses a film made by bereaved parents and a poem about abortion.

As part of the psychiatry rotation, students, facilitated by psychiatrists and general practitioners, use film, literature and art to think about representations of mental illness, and their own and society’s preconceptions about those who are mentally unwell. Enthusiasm among the facilitators for these sessions is high, and the plan is to develop teaching in these two clinical areas as a model for teaching in others.

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An Intercalated Bachelor of Science

Most students enter medical school in the United Kingdom directly from high school. All medical students at UCL are now required to take 1 year in addition to their 5-year medical training to complete what is known as an intercalated bachelor of science degree.

Traditionally, these degree programs have been in biomedical subjects such as physiology, pharmacology, or human genetics. The most recent addition to the Centre’s undergraduate instruction is an intercalated bachelor of science degree in medical humanities, which includes units such as literature and medicine, history of medicine, film and medicine, philosophy of health care, social anthropology, and a research unit.

This is the first intercalated bachelor of science degree in medical humanities in the United Kingdom. Teaching is provided by clinicians and by faculty from the Arts and Humanities faculty, often teaching together. In addition, sources of teaching expertise from outside of UCL include the British Film Institute and the Wellcome Trust Video and Film Library.

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Continuing Professional Development

In the late 1990s, as established practitioners began to hear about the courses available to medical students, the Centre began to receive increasingly frequent requests from physicians, nurses, and other health care professionals for a course designed specifically for them. In November 2001, the Centre launched the first UK medical humanities short course specifically designed for established health care practitioners.

This educationally accredited, 2-day course, which is offered twice a year, is facilitated by a team of six experienced instructors and involves experiential workshops using literature, practical art, film, and creative writing. Nearly 100 physicians, nurses, physiotherapists, theologians, artists, writers, managers, and patient advocates have participated in the course to date. Twenty of them chose to attend a residential retreat in June 2003 open only to past graduates of the short course. Annual residential retreats are now planned.

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Raising Awareness of Medical Humanities

A very important aim of the Centre is to raise awareness of, and interest in, the emerging field of medical humanities. With this aim in mind, the Centre’s predecessor, the Medical Humanities Unit, offered the first of an annual series of medical humanities conferences in March 2000. Themes so far have included “The Healing Arts: the Role of the Arts in Medical Education,” “The Healing Environment: Without and Within,” and “Healing Partners: Learning from Each Other.”

The third and fourth annual conferences have been organized in collaboration with New York University School of Medicine, with the fourth conference taking place this year in Manhattan. Other venues have included the Royal Society of Arts and the National Gallery, in London. These annual conferences provide an opportunity for members of the growing medical humanities community to meet each other and learn about national and international developments.

The annual Arts and Health Forum Seminar Series, begun in 2000, brings together experts from the arts, humanities, science, and medicine to address central questions about the possibilities of working at the arts-science interface. Last year’s series, “The Genetics Revolution: Unwinding the Double Helix,” asked speakers what they thought the effect of the genetics revolution would be. This year’s series challenges speakers to argue the case for the inclusion of teaching of their respective arts and humanities subjects into the undergraduate medical curriculum.

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Developing Community Resources

Early on in the Centre’s work it became clear that determining what other educators were doing in the United Kingdom, and accessing useful resources, was not always easy. With boundless enthusiasm but limited resources, everyone was keen to share what we were all so rapidly learning. After a few years of exploratory and preparatory work, in March 2002, the Centre, working in partnership with the Centre for Health Informatics and Multiprofessional Education at UCL, launched the Medical Humanities Resource Database, the first such online database in Europe.5 Besides listing details of courses offered throughout the United Kingdom, and soon we hope throughout Europe, the database also offers reviews of teaching resources by experts in the field. The idea for the database was inspired by the Literature, Arts and Medicine Database.19

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The Future

The years since the Centre’s founding have been exciting and stimulating ones for those working with the Centre. The steepness of the learning curve has been less intimidating because of the generosity of our colleagues, both in the United Kingdom and elsewhere, in sharing their ideas. We have been encouraged and energized by the enthusiasm of colleagues from medicine and also from the arts and humanities, whose creativity and openness have played a key role in any success we have had.

The aim is now to consolidate the initial work we have done and to ensure that we are achieving the high standards that society rightly demands of medical educators. Our long-term goal remains to integrate medical humanities throughout the entire undergraduate curriculum and to provide a range of high-quality courses for established practitioners, including eventually a Master of Arts in Medical Humanities.

Finally, we are continuing to develop a research program that aims to answer questions about the effectiveness of the arts and humanities in educating and training better physicians.

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References

1.Meakin R, Kirklin D. Humanities special study modules: making better doctors or just happier ones? J Med Ethics. 2000;26:49-50.
2.General Medical Council. Tomorrow’s Doctors: Recommendations on Undergraduate Medical Education. London: General Medical Council, 1993.
3.Calman KC. Literature in the education of the doctor. Lancet. 1997;350(9091):1622-4.
4.Calman K, Downie R. Why arts course for medical curricula. Lancet. 1996;347(9014):1499-1500.
5.The UCL Medical Humanities Resource Database at 〈http://www.mhrd.ucl.ac.uk/〉. Accessed 1 July 2003.
6.Arnott R, et al. Proposal for an academic association of medical humanities. J Med Ethics. 2001;27:104-5.
7.The Nuffield Trust, a charitable foundation 〈http://www.nuffieldtrust.org.uk/〉. Accessed 1 July 2003.
8.Philipp R, Baum M, Mawson A, et al. Humanities in Medicine: Beyond the Millennium. London: Nuffield Trust; 1999.
9.Philipp R. Arts, Health, and Well-being. London: Nuffield Trust; 2002.
10.The Centre for Arts and Humanities in Health and Medicine 〈http://www.dur.ac.uk/cahhm/〉. Accessed 1 July 2003.
11.The National Network for the Arts in Health 〈www.nnah.org.uk〉. Accessed 1 July 2003.
12.Kirklin D, Richardson R (eds). Medical Humanities: A Practical Introduction. London: Royal College of Physicians; 2001.
13.Evans M, Finlay I (eds). Medical Humanities. London: BMJ Publications; 2001.
14.Kirklin D, Meakin R, Singh S, Lloyd M. ‘Living with and dying from cancer’: a humanities special study module. J Med Ethics. 2000;26:51-4.
15.Kirklin D. Responding to the implications of the genetics revolution for medical education: a humanities approach. Med Educ. 2003;37:168-73.
16.Evans M. Reflections on the humanities in medical education. Med Educ. 2002;36:508-13.
17.Clark L. Joshua knew. JAMA. 1993;270(24):2902.
18.Schultz S. A father’s eyes. JAMA. 1995;271(15):1146.
19.The Literature, Arts and Medicine Database at 〈http://endeavor.med.nyu.edu/lit-med/〉. Accessed June 21, 2003.
© 2003 Association of American Medical Colleges