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The Shared Goals and Distinct Strengths of the Medical Humanities: Can the Sum of the Parts Be Greater Than the Whole?

Greene, Jeremy A. MD, PhD; Jones, David S. MD, PhD

doi: 10.1097/ACM.0000000000001991
Invited Commentaries
Free

Since the 1960s, faculty from diverse fields have banded together under the banner of the medical humanities, a term which unites art, literature, history, anthropology, religious studies, philosophy, and other disciplines. Arguments for the relevance of medical humanities often emphasize contributions that any of these disciplines can make to medical education, whether those involve empathy, professionalism, critical reasoning, or tolerating ambiguity. The authors argue that the constituent disciplines of the medical humanities are not interchangeable parts, but represent different perspectives and methodologies that offer their own distinct contributions to medical training. Efforts to define a role for medical humanities in medical education should pursue two strategies in parallel. On the one hand, advocates of the medical humanities should continue to make the case for the shared contributions that all of the disciplines can make to medical education. But advocates for the medical humanities should also emphasize the valuable contributions of each specific discipline, in terms that medical educators can understand. The authors illustrate this point by delineating contributions of their own discipline, medical history. Historical analysis contributes essential insights to the understanding of disease, therapeutics, and institutions—things that all physicians must know in order to be effective as clinicians, just as they must learn anatomy or pathophysiology. Analogous but different arguments can be made for literature, philosophy, and the other disciplines that constitute the medical humanities. The field of medical humanities will be most successful if it builds on both the shared and the distinct contributions of its disciplines.

J.A. Greene is Elizabeth Treide and A. Macgehee Harvey Professor, Departments of Medicine and the History of Medicine, and director, Center for Medical Humanities and Social Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

D.S. Jones is A. Bernard Ackerman Professor of the Culture of Medicine, Department of Global Health and Social Medicine, Harvard Medical School, and Department of the History of Science, Harvard University, Boston, Massachusetts; ORCID: http://orcid.org/0000-0003-0039-7784.

Funding/Support: J.A. Greene reports support from a Greenwall Foundation Faculty Fellowship in Bioethics. D.S. Jones reports support from a Scholarly Works grant 1G13LM012053 from the National Library of Medicine, National Institutes of Health, Department of Health and Human Services.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The views expressed in any written publication, or other media, do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention by trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Correspondence should be addressed to Jeremy A. Greene, Institute of the History of Medicine, Welch Medical Library, 1900 E. Monument St., Baltimore, MD 21205; telephone: (410) 955-4849; e-mail: greene@jhmi.edu; Twitter: @jgreene2.

Looking back over the century of curriculum reforms since 1910 when Abraham Flexner advocated scientific training in medical education, one finds a recurring desire to define a role for the humanities in medical education as well. Beginning in the 1960s, faculty from diverse fields banded together as the “medical humanities,” a field of growing cohesion with scholars, journals, and professional societies in several countries. Following the recent inclusion of the Critical Analysis and Reasoning Skills section in the Medical College Admissions Test, advocates are now encouraging the inclusion of medical humanities in the competencies required of medical students and residents, and in the content of licensing exams.1 Yet this work has not been easy. Scholars in art, literature, history, anthropology, religious studies, philosophy, and other disciplines compete with the basic and clinical sciences for time in a crowded and shrinking preclinical curriculum, with funding and faculty positions in equally scarce supply.

Many of the arguments for the medical humanities emphasize attributes that are common across its constituent disciplines. David Barnard,2(p628) chair of the Department of Humanities at Pennsylvania State University College of Medicine, explained in 1994 that the humanities could examine “questions of value and meaning within and around medicine.” By teaching the medical humanities, medical schools could foster certain “‘qualities of mind’: critical abilities, flexibility of perspective, nondog matism, empathy, and self-knowledge.”2(p628) In 2009, Johanna Shapiro and colleagues3(p192) similarly described how “methods, concepts, and content from one or more of the humanities” could be used to explore questions of illness, suffering, and healing: “their activities are interdisciplinary in theory and practice and necessarily nurture collaboration among scholars, healers, and patients.”

However, although appeals to inter disciplinarity are now ubiquitous in higher education, they come with certain costs. We argue that the constituent disciplines of the medical humanities are not simply interchangeable parts. They represent different perspectives and methodologies that can also make distinct contributions to medical education. We believe that efforts to define a role for medical humanities in medical education should pursue two strategies in parallel. On the one hand, advocates of the medical humanities should continue to make the case for the shared contributions that the disciplines can make to medical education, whether those involve empathy, professionalism, critical reasoning, or tolerating ambiguity. At the same time, advocates for the medical humanities should emphasize the valuable contributions of each specific discipline in terms that medical educators can understand.

We will illustrate this point by demon strating contributions that our own discipline, medical history, can offer to medical education. Historical analysis contributes essential insights to our understanding of disease, therapeutics, and institutions—things that all physicians must know in order to be effective, just as they must learn anatomy or pathophysiology. Similar (and often overlapping) arguments can be made for literature, philosophy, and the other disciplines that constitute the medical humanities.

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History and the Medical Humanities

Of all the medical humanities, history of medicine has the longest engagement with medical education.4 For centuries physicians turned to the history of their field in pursuit of both practical knowledge and professional inspiration. When the rise of clinical and laboratory science displaced history from this role in the late 19th century, physicians and historians found new justifications for history in medical education, arguing that history can ground medicine in its social contexts, foster intellectual humility, push back against the reductionism of the biomedical sciences, and socialize students into the profession and its ideals. Yet, Lester King,5(p28) speaking at a 1966 Josiah Macy Jr. Foundation conference on the role of history in medical education, focused on what he saw as the fundamental problem: “We cannot seriously maintain that it makes ‘better’ doctors in any practical sense.”

The crises of medical professionalism of the 1960s and 1970s focused attention on the potential value of medical ethics and medical humanities in medical education. When Pennsylvania State University began to plan a new medical school in 1964, its founding dean envisioned a curriculum that took the philosophical, spiritual, and ethical aspects of medicine as seriously as the biomedical sciences.6,7 A second medical humanities program opened at the University of Texas at Galveston in 1973, with the goal of “encouraging intellectual and professional growth, the cultivation of sound judgment, and the enlargement of character, virtues, and skills indispensable to good doctoring.”8(p1009) Over the next two decades, medical humanities programs appeared throughout the United States, Canada, and Europe.9

In the preface of a 1995 special issue of Academic Medicine dedicated to the medical humanities, Addeane Caelleigh and Lisa Dittrich10(p757) rejected the idea that the humanities were “soft and fuzzy.” Instead, they saw them as a set of fields “concerned with the most difficult areas of human life, the areas of personal experience through which we live and understand our lives.” Each field—ethics, history, law, literature, philosophy, and religion—also offered its own methodological and theoretical contributions. Literature helped students explore “the human condition in all its singularity and mystery.”11(p787) Religious studies could “enhance the students’ ability to practice genuinely person-centered medicine.”12(p811) History of medicine provided “a much-needed context in which to appreciate medicine’s constant values.”13(p755–756)

By the time of a second special issue of Academic Medicine in 2003, the obstacles to this vision had become clear.9 Individual schools struggled to instantiate a broad-based field of medical humanities because they had faculty expertise only in certain areas. New York University and Northwestern University, both strong in literature, had at the time little engagement with history of medicine.14,15 The University of California, San Francisco, and Harvard University, strong in history and anthropology, did not cultivate literature or religious studies.16 Relations with bioethics varied substantially.17

Amid these struggles, advocates for the medical humanities focused on contributions that could be made by any of the component disciplines. The important thing was to have someone doing some form of humanities, regardless of method, content, and mode of critical analysis. Any of the disciplines could help students explore the experience of illness, suffering, and healing and help health professionals become “more self-aware and humane practitioners.”3(p192) Specific proposals often narrowed their aim to a single target that could be achieved through any of these fields. The Project to Rebalance and Integrate Medical Education initiative (PRIME) sought “to promote humanistic skills and professional conduct in physicians,” including both patient-centered skills and critical thinking.1(p334) Ethics and humanities faculty had to “articulate a shared vision of how such education promotes professionalism.”18(p1627) Arno Kumagai and Delese Wear19(p973) emphasized another goal,

that of “making strange”—that is, portraying daily events, habits, practices, and people through literature and the arts in a way that disturbs and disrupts one’s assumptions, perspectives, and ways of acting so that one sees the self, others, and the world anew.

Each target could be achieved through any of the interchangeable disciplines of the arts and humanities.

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The Parts of the Parts Left Out of the Whole

The notion that all humanities fields are fungible can help make a medical humanities curriculum more accessible to schools with limited faculty: It does not matter if a given school has an artist, novelist, or historian, because the essential contribution is something that could be provided by any of them. And yet, by emphasizing the sorts of things that can be taught by any particular combination of disciplines, these proposals can miss other contributions that these individual fields can make to medical education. This paradoxically constrains the claims for the value of medical humanities in medical education, relegating them to valuable but generic tasks such as the cultivation of professionalism, empathy, or estrangement.

Although the value of disciplinarity could be demonstrated with any of the constituent fields of the medical humanities, we focus on the one we know best—history. Although it is certainly the case that education in history can foster professionalism and humanism, it can do much more. As we have argued elsewhere, history of medicine should be considered an essential domain of medical knowledge, with contributions that are just as important as those offered by anatomy or biochemistry.4 All medical educators agree that physicians need to master the evolving fields of diagnosis, pathophysiology, and therapeutics, fields which demand knowledge that cannot be found in laboratory sciences alone. Educators also understand that physicians need to function in a complex health care system in which medicine is just one part of broader societal responses to disease. We have developed a list, by no means exhaustive, of the key contributions that history offers medicine (see List 1). These can be distilled into five basic themes, the importance of which should be self-evident:

  1. Disease changes over time. A thorough understanding of medicine includes knowledge of both the changing burden of disease and the shifting meanings that shape the impact of disease on individuals and societies.
  2. Medicine is a product of history. Medical knowledge, technology, and practice change over time. History facilitates critical perspectives, demonstrates that innovation is not always progress, and focuses attention on the changing values and standards of what counts as effective therapy.
  3. Health inequalities persist over time. Race, ethnicity, gender, and class each reflect complex intersections of biological and social processes. Historical analyses of these categories can illuminate the causes of persistent inequalities and their possible solutions.
  4. Health care systems are in constant flux. Social, economic, and political forces shape the medical profession, its institutions, and the health-seeking behaviors of patients in a dynamic medical marketplace. By explicating current structures and their limitations, history can guide efforts at reform.
  5. Ethical dilemmas in medical practice are contingent. By identifying the social, economic, and political forces that shape ethical norms, history provides an essential approach for understanding and teaching medical ethics.

Although many of these themes can also be approached through other disciplines, they cannot simply be reduced to empathy, professionalism, and defamiliarization. For instance, physicians who would tackle the great epidemics facing medicine and society today, whether obesity, opioids, dementia, or Zika, need to understand why each has increased in prevalence over time. If answers to these questions cannot be found in molecular biology or genetics alone, they also cannot be found in philosophy or literature or visual studies. They require historical analysis. History does not just convey an attitude toward medical knowledge and practice. Instead, historical analysis—just like molecular biology or pharmacology—offers fundamental contributions to our understanding of disease and therapeutic efficacy, and to our ability to train students to be effective providers within complex and changing systems of care.

Equally strong arguments could be made about the essential contributions of philosophy, anthropology, literature, visual studies, or other humanities.20 It is possible to make all of these cases in the current language of competencies. Beyond professionalism, history can also contribute to competencies in medical knowledge, intraprofessional collaboration, practice-based learning, and the design and function of health care systems.4 Other humanities fields can address competencies in other domains that history cannot. Narrative medicine, for example, can make specific claims in domains of communication and collaboration.21

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Conclusions

Proponents of evidence-based curriculum design demand proof that the medical humanities will make better doctors. But such proof is seldom demanded from the basic sciences. When schools reduced anatomy instruction, no one conducted follow-up studies to see if the schools still graduated competent surgeons. When schools increased time devoted to genetics, no one asked for evidence that the graduates were somehow more effective clinicians. As Ousager and Johannessen22(p988) pointed out, “few, if any, aspects of medical education are able to produce empirically based evidence of their indispensability in the course of the education of a physician.” Most medical schools and accrediting agencies simply assume the value of anatomy and biochemistry. If we were to stop and think carefully about what the medical humanities can offer across the varied domains of medical education (e.g., doctors who are more knowledgeable, thoughtful, ethical, professional, etc.), then their value—both on their own and as an organized consortium—is just as self-evident.

We understand that medical schools face many pragmatic constraints in supporting medical humanities. There are not enough professors of history (or of anthropology, literature, visual arts, etc.) at medical schools to ensure that adequate courses are offered everywhere, tested through board exams, and enforced through Liaison Committee on Medical Education accreditation. But similar challenges also exist in the basic sciences. Many schools no longer employ faculty trained in anatomy or physiology. Many curricula have moved away from disciplinary approaches and toward integrated, problem-based curricula. But despite these challenges, schools have found ways to teach the basic science content that they consider essential. Something similar should be done in the medical humanities.

For this to succeed, scholars in the various disciplines of the medical humanities must articulate the essential contributions of their fields both individually and as part of the broader vision of the medical humanities. Even though anatomy and biochemistry each teach students about how the body works, they are not interchangeable fields. Similarly, even though history, literature, and other medical humanities offer vital perspective on the experience of illness and the practice of medicine, they also offer much more.

We have tried to define the crucial contributions of history, and we call on other educators to do the same for other fields in the medical humanities. When these contributions are clearly defined, medical schools can respond appropriately. The case for medical humanities will be most successful if it builds on both the shared and the distinct contributions of its disciplines. The sum of the parts can be greater than the whole.

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Acknowledgments:

The authors would like to thank the organizers and participants of the Association of American Medical Colleges Humanities and Arts Thought Leader Forum, Washington, DC, July 2017, for feedback on an earlier version of this Invited Commentary.

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