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The Return to Literature—Making Doctors Matter in the New Era of Medicine

Marchalik, Daniel MD, MA

doi: 10.1097/ACM.0000000000001986
Invited Commentaries
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The rapid explosion of medical knowledge of the 19th and 20th centuries required a transformation in medical education, which, to that point, had been marked by low educational standards. To combat the lack of regulation, the 1910 Flexner Report recommended sweeping reforms. By 1930, students hoping to enroll in a medical school would need to complete courses in chemistry, physics, and biology, leaving little room for the liberal arts.

Medicine is once again changing. The impact of artificial intelligence is being felt across all medical fields, and the nature of physicians’ jobs in the new landscape of intelligent machines will inevitably also have to change. What will the role of new physicians be? And how should medical education be amended to meet those needs?

In 2017, the Georgetown University School of Medicine graduated the first group of students from its Literature and Medicine Track—the first U.S. medical school track dedicated to the study of literature. This Invited Commentary explores the work done in, and the scholarship resulting from, this novel educational program and suggests ways in which literature could be used to prepare future doctors for the evolving demands of the medical field.

D. Marchalik is director, Literature and Medicine Track, Georgetown University School of Medicine, Washington, DC; ORCID: http://orcid.org/0000-0002-6912-1252.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Daniel Marchalik, MedStar Washington Hospital Center, Department of Urology, 110 Irving St. NW, Suite 3B-19, Washington, DC 20010; telephone: (202) 877-7238; e-mail: Dan.Marchalik@gmail.com; Twitter: @dmarchalik.

We know no thing, nor what we mean.

Physician, break the story of

the stoic ghost in the machine.

Remind us why and how all joys

and sorrows will rely on love.

Compare a harmony to noise,

reveal the seat of memory,

the streams and seas of consciousness,

the dream that dreamed assembly.

Explain the need for symbol, art,

for song, for dance. For violence.

Describe again the chambered heart.

—Wendy Videlock, “Nor what we mean,” 20151

The laboratory has come to furnish alike to the physician and the surgeon a new means for diagnosing and combatting disease. The education of the medical practitioner under these changed conditions makes entirely different demands in respect to both preliminary and professional training.

—Abraham Flexner, The Flexner Report, 19102

Medicine is changing. In 1985, a PubMed search for “artificial intelligence and medicine” would have revealed 12 articles; in 2015, that number was 1,162. This new frontier of medicine is chronicled in Siddhartha Mukherjee’s April 2017 New Yorker article “The Algorithm Will See You Now” in which he describes how, using “deep learning,” artificial intelligence (AI) can be programmed to perform tasks such as distinguishing melanoma from benign lesions more accurately than expert dermatologists.3,4

The impact of AI will be felt across all medical fields. Geoffrey Hinton, a computer scientist from the University of Toronto, notes that “in five years, deep learning is going to do better than radiologists.” Radiologists will therefore need to “evolve from doing perceptual things that could probably be done by a highly trained pigeon to doing far more cognitive things.”4 Inevitably, the nature of physicians’ jobs in the new landscape of intelligent machines will have to transform. When, whether in 5 or in 50 years, machines become more accurate than doctors at various diagnostic tasks, what will the role of new physicians be? What will we need to bring to the table? And how should we prepare future physicians for this new reality?

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Considering the Past

This is not the first time that the medical curriculum has had to adapt to sudden change. The rapid explosion of medical knowledge of the 19th and 20th centuries necessitated a transformation in medical education that, to that point, had been marked by low educational standards. Though the era saw scientific knowledge expand at unprecedented speed, many schools were failing to keep pace. Even fewer had any strict requirements for matriculation and graduation.

To combat the lack of regulation, the American Medical Association created the Council on Medical Education (CME) in 1904. The CME, in turn, commissioned the Carnegie Foundation for the Advancement of Teaching to conduct an audit of, and issue recommendations for, existing institutions offering medical education. The efforts resulted in the publication of the 1910 Carnegie Foundation Bulletin Number Four—the document known as the Flexner Report that has been credited with the radical reformation of the U.S. medical education system.2

In addition to leading to stronger regulatory and licensing bodies and reducing the number of schools from 151 to 31, the report had long-lasting effects on medical school curricula in the United States. Using the Johns Hopkins University medical school as its institutional model, Flexner recommended the implementation of a broad and comprehensive set of undergraduate prerequisite courses. By 1930, students hoping to enroll in a medical school would need to complete courses in chemistry, physics, and biology, leaving little room for the liberal arts. Biochemistry was in; history and literature—out.

There is no doubt that the scientific revolution of the 20th century required a profoundly wider base of technical knowledge than ever before. Yet the transformation marked a departure from medicine’s rich tradition of valuing and relying on literature as a unique tool. There was, in fact, an irony in Flexner’s use of Johns Hopkins as his educational prototype: Osler, Johns Hopkins’s model physician teacher, was aware of the power of literature and had long been an avid proponent of reading.

Osler5 advocated for physicians to have broad liberal arts backgrounds so that they could possess “the leaven of the humanities.” He proposed that his students “before going to sleep read for half an hour, and in the morning have a book open on your dressing table.”5 From Shakespeare’s plays, to Montaigne’s essays, to Cervantes’s Don Quixote, Osler’s prescription to his students was a “bedside library.”

So what were the unintended consequences of purging the bedside library of its nonmedical texts? What got lost in this restructured approach to medical education? In many ways, this new paradigm marked a fundamental shift in our view of medicine as a whole. And while medicine rightly adjusted to meet the demands of an expanding body of medical knowledge, the pendulum swung too far. The narrowing of premedical and medical education, coupled with the increasing demands of modernizing medicine, infused the medical field with cynicism. By trading Cervantes’s windmills for Shem’s House of God, the education system took away the parts of education that were nourishing the most humane aspects of students’ development and limited their ability to handle the vast stressors of medical school.

We are all familiar with the difficulty students have adjusting to anatomy lab, to the wards, to the stress of competitive colleagues. We are also familiar with the fact that half of all medical students may experience burnout during their four years as they struggle to cope with unexpected tragedies and difficult patients.6 The common denominator driving this disconnect appears to be the students’ inability to adequately reflect on their own experience—to maintain the power to create meaning.

But what makes fiction uniquely suited to help us create meaning? One important quality is its ability to inspire introspection. In a recent interview, Tim O’Brien was asked to defend his deliberate decision to rely on fictional narratives in The Things They Carried—his collection of short stories about the Vietnam War. “The line between fiction and non-fiction is not as absolute as we think in our common-sensical world,” O’Brian explains, so when “you find yourself in a war, or with breast cancer in a hospital—what you took as true about the world goes upside down. It gets very cloudy and very ambiguous, you know—‘Do I value what I thought I valued before the breast cancer hit? Do I believe the things I used to believe?’”7

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The Georgetown Experience

In 2017, the Georgetown University School of Medicine graduated its first group of students from its Literature and Medicine track. What began as an experimental elective five years ago has quickly morphed into an integral part of the school’s curriculum. As the first U.S. medical school track dedicated to the study of literature, the program is a longitudinal, four-year endeavor in which a group of 30 first- through fourth-year students come together once a month to discuss a different work of fiction. We start each meeting with a poem as a scaffold for the day’s discussion.

This month is the beginning of a new season, so we open with a poem to help us frame the year ahead. I read from Wendy Videlock’s1 “Nor what we mean.” We ponder the poem’s use of false binaries—mind and body, harmony and noise—and consider how Videlock uses them to structure the entire poem. One student points out that the stanzas alternate between the quest to find answers to concrete concepts—the working of memories, the composition of dreams—and abstract ones—art, symbol, joy.

“It’s interesting that the poem is addressed to a physician,” someone else chimes in. “Isn’t that closer to what physicians actually have to do? Help people understand the concrete things, like illness, but also the more innately human things, like violence and love?”

A voice from a brand new first-year student: “I just love the loaded imagery of a chambered heart. It’s not only about anatomy.” And with this primer, we are ready to begin.

We dive into Karan Mahajan’s Association of Small Bombs. The narrative is unsettling. Following an explosion at a Delhi market, it invites us into the mind of a terrorist and forces us to consider perspectives many of us would prefer to leave unexplored. But it also asks us to consider the victims’ lives years after the terrorist act has been forgotten.

Such is the power of fiction: It creates an opportunity for challenging preconceived notions by placing tightly held belief systems under scrutiny. In other words, it nurtures students’ capacity for both personal reflection and perspective taking. Therefore, some of the most important work in our class occurs during discussions of seemingly nonmedical issues and from the scholarship that these discussions inspire.

Our conversation about Haruki Murakami’s Colorless Tsukuru Tazaki and His Years of Pilgrimage was centered on the inaccessible nature of suffering. For one student, it was a new framework for understanding his friend’s recent suicide attempt. For another, a second-year student about to begin her clinical rotations, it challenged her preconceived notions about the field of psychiatry. As the clock ran out and we found ourselves staying almost an hour past our allotted time, questions remained unanswered. These questions became the impetus for one student’s creation of a monthly literature and medicine column in the BMJ.8

Last year, after our discussion of Kazuo Ishiguro’s Never Let Me Go—a dystopian novel about a society in which cloned children are raised for organ harvesting—a fourth-year student stayed after to talk through the concerns that the book raised for him. The topic of organ transplants and consent came up and he, having donated a kidney to his step-uncle at 18 years old, was unsure about that decision. Six months after our conversation, he published an article detailing his regret about the process.9 That piece, in turn, inspired letters to the editor and national conversations about the ethics of living organ donation. Meanwhile, a conversation about Ben Winters’s Underground Airlines—another dystopian novel in which the United States still permits slavery—led to a student’s work on the use of literature to combat implicit bias in medical education.10

In these and other instances, literature serves as an occasion for deep reflection and for testing personal beliefs against the beliefs of others. It promotes students’ intellectual flexibility by creating a habit of assuming perspectives. The very act of reading demands that the reader receive another’s story on the author’s terms. For the duration of the narrative, readers are thrust into foreign worlds and unexpected perspectives.

Therefore, just as students can become better auscultators of chambered hearts, they can become better decoders of chambered minds. And in a world where physicians are consistently faced with varying opinions, backgrounds, and belief systems, the ability to remain flexible—to be surprised and sometimes even convinced—is a vital quality. It is the quality that will protect students from being unable to relate to their patients, and it may be the quality that will set us—humans—apart.

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Preparing for the Future

In the contemporary era of endless information, in which a medical textbook published in a student’s first year will become antiquated before graduation, physicians’ strength will not reside in possessing the greatest wealth of medical facts. AI will necessarily outmemorize the brightest medical minds. But, as Mukherjee4 concludes, “knowing, in all its dimensions, transcends those task-focused algorithms.” What will we know that AI will not? What will we offer patients beyond diagnostic precision? And how will we, as educators, best cultivate those innately human qualities that served as the foundations of medicine?

If Flexner was right that the changed conditions of the early 20th century make “entirely different demands in respect to both preliminary and professional training,”2 then the changing conditions of the 21st century are once again demanding a pedagogical reform. Perhaps the novel approach should be the time-tested one: the return to the bedside library—the return of Don Quixote.

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References

1. Videlock W. Nor what we mean. New Criterion. 2017;33:39.
2. Flexner A. Medical Education in the United States and Canada. 1910.New York, NY: Carnegie Foundation for the Advancement of Teaching.
3. Esteva A, Kuprel B, Novoa RA, et al. Dermatologist-level classification of skin cancer with deep neural networks. Nature. 2017;542:115–118.
4. Mukherjee S. The algorithm will see you now. New Yorker. 46–53.April 3, 2017:
5. Osler W. A Way of Life—Scholar’s Choice Edition. 2015.Rochester, NY: Scholar’s Choice.
6. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443–451.
7. Snow H. Interview: The Big Read author Tim O’Brien on “The Things They Carried” and finding truth in fiction. Port City Daily. http://portcitydaily.com/2014/01/13/interview-the-big-read-author-tim-obrien-on-the-things-they-carried-and-finding-truth-in-fiction. Published January 13, 2014. Accessed September 1, 2017.
8. McDaniel C, Marchalik D. The doctor’s book club—A column. BMJ. http://blogs.bmj.com/bmj/category/literature-and-medicine/. Accessed August 1, 2017.
9. Poulson M. At 18 years old, he donated a kidney. Now, he regrets it. Washington Post. https://www.washingtonpost.com/national/health-science/at-18-years-old-he-donated-a-kidney-now-he-regrets-it/2016/09/30/cc9407d8-5ff9-11e6-8e45-477372e89d78_story.html?utm_term=.9e4757b01ac7. Published October 2, 2016. Accessed September 1, 2017.
10. Humphreys C. What medical school fails to teach. KevinMD. http://www.kevinmd.com/blog/2017/04/medical-school-fails-teach.html. Published April 28, 2017. Accessed September 1, 2017.
© 2017 by the Association of American Medical Colleges