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Literature and Medicine: A Problem of Assessment

Kuper, Ayelet

Section Editor(s): Jones, Anne Hudson PhD

Review Paper

Background “Literature and medicine” is increasingly common in medical schools but not within medical education research. This absence may relate to it not being problematizable in the quantitative way in which this psychometrically-oriented community tends to conceptualize research questions.

Method Databases were searched using relevant keywords. Articles were evaluated using methodologies appropriate to their fields. The resulting information was structured around a framework of construct-appropriate assessment methods.

Results Literature and medicine is intended to develop skills as potential proxy outcomes for important constructs. Proposed tools to assess these skills are difficult to evaluate using the field’s traditional quantitative framework. Methodologies derived from the qualitative tradition offer alternative assessment methods.

Conclusion The medical education research community should take on the challenges presented by literature and medicine. Otherwise, we run the risk that the current evaluation system will prevent important constructs from being effectively taught and assessed.

Correspondence: Ayelet Kuper, MD, DPhil, Wilson Centre for Research in Education, University Health Network, 200 Elizabeth Street, Eaton South 1-565, Toronto, Ontario, Canada M5G 2C4; e-mail: (

Physicians are being exposed to a steady stream of articles about the field of literature and medicine. Such pieces have been appearing in high impact medical journals including the New England Journal of Medicine,1,2 the British Medical Journal,3,4 the Journal of the American Medical Association,5 Annals of Internal Medicine,6–10 and especially the Lancet.11–28 Literature and medicine has a well-established journal of its own, aptly titled Literature and Medicine, and has a substantial presence in journals such as the Journal of Medical Ethics: Medical Humanities 29 and the Journal of Medical Humanities. Within the field of medical education, the journal Medical Education launched a new section in February 2002 called “Arts and Humanities” to highlight an “academic discipline concerned with research and education”30—a discipline that includes literature and medicine as a major component. Academic Medicine has published two theme issues on the medical humanities.31 Interested education-oriented readers can also turn to an anthology, Teaching Literature and Medicine.32

Practically speaking, literature and medicine courses have been flourishing across the English-speaking world. By 1994, about a third of American medical schools were known to be teaching literature within their medical curricula.7 In 1998, 74% of them offered it as an elective, whereas 39% required it as part of at least one course.33 In 2003–2004, the medical humanities as a whole were represented by at least one required course at 88 of 125 American medical schools and in an elective course at 55 schools.34 In the United Kingdom, the number of humanities courses in general, and literature and medicine courses in particular,35–38 grew in response to the General Medical Council’s endorsement of the humanities as appropriate selective courses for medical students in their 1993 report, Tomorrow’s Doctors,39 and their reiteration of this concept in 2003.40 Many descriptions of such courses have been published in medical and medical education journals,13,37,41–50 as well as in online databases.51,52

Yet, despite this seemingly thriving field, questions regarding its value and legitimacy continue in the medical education literature. For example, of the 24 articles in the Arts and Humanities section of Medical Education over the last four years, seven37,41,43,49,53–55 dealt directly with literature and medicine, but another five56–60 were largely occupied with legitimizing and justifying the medical humanities. Even Medical Education’s current Arts and Humanities editor believes that the humanities are “not yet part of the mainstream of medical education.”61 This echoes Friedman’s anxiety, expressed in an article published in Academic Medicine in 2002, about the still-precarious place of the humanities, including literature, in medical training.62 It is curious that Charon and her coauthors can write increasingly confidently in high-impact medical journals about the utility of literature in medicine and in medical education,1,5,7,9 yet they appear to have to strenuously justify its importance in Academic Medicine twice in articles published five years apart.63,64 Although Academic Medicine published the aforementioned medical humanities theme issue in 2003, recognizing and describing a plethora of medical humanities courses for students at different levels of training, this issue does not include any academic articles or research papers,42 despite the primacy of such genres to that journal’s main audience. Meanwhile, although there have been books about the medical humanities65,66 and narrative in medicine67 from general medical publishers, many of the first generation of books that incorporate the theory and practice of the use of literature in medicine and medical education have instead been published by general academic publishers68–70 or (in the case of Teaching Literature and Medicine) by the Modern Language Association of America.32

It seems that literature and medicine is being accepted in medicine (and in literature,50 where it is a well-recognized subdiscipline64), and in medical schools, but not within the academic field of medical education. Why not? One potential reason for the struggle that the field of literature and medicine is facing within medical education research relates to the two disciplines’ very different discourses. Fundamentally, the role of literature in medical education may not have been addressed from within the medical education research community because it has not been problematizable in the way in which that community tends to conceptualize research questions. In other words, it may be that it is not easily incorporable into the current medical education research agenda because the constructs derived from literature and medicine are not amenable to being addressed by the tools most commonly used within medical education research. This paper, therefore, is an attempt to bridge that divide.

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It is by now a truism that medical education research is increasingly driven by outcomes and by evaluation.71 In the United States, the Outcome Project of the Accreditation Council for Graduate Medical Education (ACGME) has put a strong emphasis on educational outcomes in residency training, with a clear link between objectives and assessment,72 and the Medical School Objectives Project (MSOP) has focused on similar issues in undergraduate medical education.73 Other influential bodies, such as the Royal College of Physicians and Surgeons of Canada74,75 and Britain’s General Medical Council,40 have also adopted an outcomes-based approach to medical training. This link between measurable objectives and assessment has been driven by public expectations,72,73,76 the accountability agenda,77 and pragmatism in face of the fact that medical trainees guide their learning to meet the requirements of the evaluations that they will undergo.78–80 There has also been considerable spillover from the evidence-based medicine (EBM) movement, so central to current medical research and practice, in the promotion of evidence-based medical education and in the tools being endorsed for this process.81–84

The issues around student assessment that are thereby foregrounded have generally been addressed, in the context of medical education research, using the discourse of psychometrics.85–87 Statistical concepts used in educational testing, such as reliability and validity,88 have framed much of the discussion.71,86,89 It has been shown both that it is possible to create tests with holistic rating scales that are valid and reliable90 and that the breakdown of complex tasks into objectified component parts can trivialize the overall construct, thereby decreasing the validity of the assessment.91 We now know that reliability and subjectivity are not mutually exclusive nor are reliability and objectivity inextricably linked.80,92 Nonetheless, there has long been a movement towards using more objectively scored93 and hence more “granular” examinations in an attempt to improve reliability.94 There is also an implication “that the value of the assessment can be researched and described in numbers only.”87 The overall ethos of medical education research, then, incorporates a tendency to break down into component parts that which it is studying, whether competencies, constructs, or content, and to reduce it to numerical values that can be manipulated and classified. Similarly, the search for the “true” score, made explicit in any discussion of reliability, generalizability, and error,88 highlights the underlying positivism in medical education research, which reflects a paradigm that pervades much of modern medical education.58

The study of literature, even when placed within the medical context, is resistant to simplified analysis and is not compatible with straightforward positivism. Grappling with meaning in literature, in the context of a constructed reality, inevitably encounters a major problem with assessment in this area: there can be no one right answer when discussing a text and, indeed, this very ambiguity is one of the lessons that may be learned from literature and carried forward into the context of patient care.60 That is not to say that one should not discriminate between students’ abilities and achievements in a literature curriculum, but rather that the means of this discrimination in higher education has not engendered significant debate. Whatever the reason, it must be noted that at least two published calls for research related to such assessment in the medical humanities35,95 seem to have largely gone unheeded. A separate call for papers related to pedagogy in the medical humanities, for a special issue of the Journal of Medical Humanities that has never been published, simply assumes that only critical descriptions of individual courses will be forthcoming.96 Yet, within the medical education research community, we should not scorn literature and medicine because it does not yet have the techniques with which to respond to our evaluation-driven curricular criteria. Rather than ignoring the problems of assessment in this area of medical education, it is time for the medical education community to develop, adapt, or recognize rigorous methods of student evaluation that respect and reinforce the important competencies intended to be attained through the study of literature and medicine. To that end, this paper will outline these competencies, discuss assessment measures in current use, and survey the performance of select tools with respect to our traditional evaluation criteria. It will then explore other rigorous methodological structures that have been proposed for evaluating such measures of student assessment.

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A computerized search was undertaken of the following electronic databases: Medline (1966 to November 2005); Scholars Portal Search—Social Sciences subject area, which includes among the databases it searches the Educational Resources Information Center (ERIC) database (1966 to November 2005), Education—A SAGE Full-Text Collection (1968 to November 2005), Education Abstracts @ Scholars Portal (1983 to November 2005), and a range of other databases in areas such as sociology and psychology; Scholars Portal Search—Arts & Humanities subject area, which includes among the databases it searches the Modern Language Association (MLA) International Bibliography (1963 to November 2005, plus JSTOR’s Language and Literature collection back to 1881), BHI: British Humanities Index (1962 to November 2005) Humanities Abstracts @ Scholars Portal (1984 to November 2005), and a range of other databases in areas such as art and philosophy; and Google Scholar. Search terms used included the following, alone and/or in combination: student assessment, student evaluation, humanities, medical humanities, literature, literature and medicine, narrative, story, higher education, professional education, medical education, medical education research, qualitative methods, quantitative methods, reliability, validity. Keywords from relevant retrieved texts were iteratively incorporated into new searches. Abstracts and full-text articles and books retrieved were assessed and their references searched for further sources; where technically possible, an electronic “forward” search for articles citing or similar to relevant articles was also performed. In a series of discussions over the past months, scholars in the fields of health professions evaluation, medical humanities, and the sociology of medical education also pointed out a number of other texts that were similarly mined for further sources. The University of Toronto library system was searched by title and keyword for paper and electronic texts using the above search terms. Recent tables of contents of the journals Literature and Medicine (May 1995–July 2005), Social Science and Medicine (January 2000 – December 2005), Journal of Medical Ethics: Medical Humanities (June 2000 – December 2005), and Journal of Medical Humanities (Spring 1997 – Winter 2005) were searched manually, as were syllabi posted at the Literature, Arts, & Medicine Database51 and the Medical Humanities Resource Database.52

Given the wide-ranging and disparate nature of the items retrieved, no attempt was made at a formal meta-analysis. Individual articles were evaluated using methodologies appropriate to their fields, including tools from quantitative methods, qualitative methods, and hermeneutic* textual analysis. The resulting information was structured with the competencies to be assessed as a framework within which to explore the most construct-congruent evaluation methods and to test these for appropriateness and rigor.

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Curricular objectives for literature and medicine

Charon et al.’s conceptual framework7 provides a useful starting point for delineating explicit objectives being claimed for literature and medicine curricula. It outlines five rationales for introducing literature to medical students. One of these, narrative ethics, is presented in contrast to traditional precept-based ethics but is for our purposes an alternative pedagogic approach to the subject of medical ethics, which is already widely taught98 and has its own evaluatory frameworks. The current paper, therefore, will not address this particular rationale. Another rationale, the study of literary theory, offers interesting “new perspectives”7 on physicians, their patients, and their practice, but student learning in this area would require an a priori grounding in the methods and texts of literature. This rationale will thus also not be addressed in this paper. Instead, this paper will focus on the evaluation of objectives drawn from the remaining three rationales: the ability to respond to the patient experience, the ability to reflect on the physician experience, and the ability to develop and make use of narrative skills in practice. Each of these rationales will now be explored in turn.

Patients (and doctors) live their lives as narratives.4,10,99 A significant Narrative-Based Medicine movement has emerged, specifically highlighting the need to foreground patients’ narratives in order to imbue medicine with a holistic understanding of patients’ emotional and existential responses to their illnesses.4 Within the realm of medical education, it has been posited that literary texts selected for realism and relevance “can help bridge the gap between knowing the facts about the disease and understanding the patient’s illness experience [emphasis in the original],”100 including illuminating its important socioeconomic and cultural contexts.26,55 Stories about illness could therefore enhance physicians’ abilities to imagine and understand the experiences of their sick patients,7 potentially contributing to their capacity to provide empathic50 patient-centered care. Narrative competence, defined as “the competence that human beings use to absorb, interpret, and respond to stories”5 (whether derived from texts, from patients, or from nonprofessional encounters), is taught through the close reading of and engagement with literary texts.5 It is thought to contribute to the development of both professionalism101,102 and empathy5,8 in the physician–patient relationship. Thus, the construct of narrative competence might be conceptualized as a surrogate endpoint for these more complex constructs, with, for example, students’ abilities to identify and reflect on the emotions and experiences of characters in stories as potential surrogate markers for their later understanding of and responses to the experiences of patients and their loved ones. In short, although this has not yet been tested, the evaluation of narrative competence may be a classroom-based proxy outcome for anticipated empathy in clinical practice.

Similarly, literature provides trainees with “a vivid means of understanding the physician’s often quite lonely job.”68 Physicians, especially during the intense years of student and residency training, live outside the realm of the commonplace. Their everyday experience of death, suffering, and healing is situated outside the boundaries of everyday language. Regular encounters with emotionally challenging situations, combined with academic stressors, are reflected103 in the increased rates of stress and depression among medical students as compared to their peers.103,104 Stories and poems may perform tasks otherwise missing in medical education, wherein they “can stimulate important personal introspection about and examination of all that the physician is called on to do.”7 In other words, literature may provide trainees with the language and the tools to reflect, not about their patient care abilities, but about themselves50 and their own emotions,100 and thereby may help to heal the nascent healer.18 Nothing in the medical curriculum adequately prepares trainees for “the moment after”—the moment they walk out of a patient’s room and realize that they have just told someone that they are going to die, the moment when they must have a framework for recognizing and responding to their thoughts and emotions in order to be able to move on to the next encounter and to carry on with their own lives. By creating narrative competence, this process of emotional self-reflection could be practiced in order to provide trainees with a set of narrative tools to use in their own lives. Narrative competence and emotional self-reflective ability are therefore potential classroom-based proxy outcomes for the resilience to emotionally challenging situations that may protect trainees from existential distress and from the development of callousness and cynicism.

The study of literature could also provide trainees with useful clinical abilities that may be grouped under the general rubric of “narrative skills.” Most prosaically, reading stories and writing about them can enhance more general communication skills.41 Other narrative skills are components of the larger construct of narrative competence, which is believed to contribute not only to empathy but also to the physician’s ability to organize and meaningfully integrate the complex stories to be gleaned from patients’ histories, physical findings, and other ancillary data.7 These skills make explicit use of the narrative structure that underlies clinical knowledge.16,68,105 The ability to write about stories taken from literature, then, might become a useful surrogate outcome for the ability to construct and communicate a coherent and rhetorically sound plan for patient diagnosis and treatment. The study of literature, in which there are myriad possible interpretations, also increases students’ exposure to the concept of ambiguity.28,60,106 This may help prepare them12,64 for the uncertainty107 and ambiguity99 they will have to face as professionals in clinical practice by exposing them to ways of knowing other than the “[p]ositivist epistemology of practice” of professional training in general107 and of medical training in particular.58 Their grasp of this concept of ambiguity, as assessed through their responses to literary texts, could therefore be examined as a proxy for their preparedness for encountering it in the context of patient care.

It is possible, then, to interpret the objectives for courses in literature and medicine as being the development, in a safe, classroom situation, of a set of critical skills relevant to clinical practice. These skills are potential proxy outcomes for the higher-order objectives intended to be developed by literature and medicine. The development of narrative competence is a skill necessary for empathic understanding of patients’ experiences of illness and treatment. The development of emotional self-reflective ability is a skill necessary for the ability to maintain a caring and connected professional approach to patient care. Finally, the development of narrative skills is necessary for the construction of coherent and comprehensive clinical pictures. Unfortunately, the ability to “test these hypotheses” and “validate these measures” using the usual methodologies of North American medical education research will likely be limited by the ability to measure these proxy outcomes using the field’s traditional reductionist approaches to quantifying individual skills. The challenge therefore becomes the identification of appropriate evaluation methods that can be rigorously assessed with respect to their success in measuring these surrogate outcomes. The following sections describe several techniques that are currently used in the assessment of abilities related to literature and the humanities within both medical and other higher educational contexts. These include both assessment methods that have been used more generally in medicine in the past and newer methods that are struggling to achieve legitimacy in medicine today.

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Assessment techniques in literature and medicine

Literature and medicine courses currently use a wide variety of assessment tools, including long or short essays, essay examinations, portfolios, oral presentations, posters, case write-ups, journals, response papers, creative projects such as poems, short stories, narratives in the patient’s voice, and even objective structured clinical examination (OSCE) stations.13,37,41–43,45–49,51,52 Few course descriptions comment explicitly on the rationale for selecting the method(s) of evaluation to be used. What seems clear, however, is that multiple-choice questions and their ilk, which are the most commonly used forms of written assessment elsewhere in medical education because of their reliability and ease of administration and marking,89 have not been seen as suitable for student evaluation in this domain.

Squier,100 one of the only authors who discusses the nature of appropriate assessment for courses in literature and medicine, endorses the use of written assignments as both formative and summative assessments. However, she provides no evidence for this endorsement, nor does she propose a marking scheme or guidelines other than to “avoid an excessive focus on grading” and to encourage with such grading “self reflection, interpretation, and creativity,” focusing on giving feedback and comments rather than making “[f]ine distinctions between students.”100 Similarly, Downie writes: “There is no difficulty about evaluating a medical humanities course. It can be assessed by examination or essay or other project. This has happened in Arts faculties for centuries and there is a great deal of experience in Arts faculties of this sort of evaluation.”106 He goes on to discuss how a text (in this case, a poem) might be taught, and an essay about it would then be marked, in a standard arts class—by the presence of coherence and of an argument grounded in the text and its historical background, rather than by the direction of that argument.106 Again, he does not justify or provide evidence for his assertions. This opinion of the proper way in which to evaluate a humanities discipline is also shared by the British Quality Assurance Agency for Higher Education (QAA). Regarding undergraduate instruction in English literature and language, its subject benchmark statement, English, mandates that essays be “an essential component in the assessment process” and comments on their appropriateness to the demonstration of the skills required in this discipline.108 Benchmark statements for related subjects, such as Languages and Related Studies (which includes the study of literature in languages other than English),109 Philosophy,110 and History 111 also prominently feature the use of essays and related written assignments. The History benchmark statement even includes suggested criteria for assessment of timed essay examinations, with the specific attributes in the categories of structure and focus, quality of argument and expression, and range of knowledge appropriate to each class of mark.

Although they are not as prominent in the study of literature and in related higher education domains, portfolios, like essays, have been used in humanities-related curricula in medical education.52 They are also being used more generally in medical schools to evaluate constructs similar to those being advocated for literature and medicine, such as empathy, comfort with ambiguity, and the ability to reflect on one’s own emotional needs.112 A current general textbook on portfolio development describes a portfolio as a compilation of works, at least partially student-selected, that shows what the student has accomplished (or tried to accomplish) over time; this includes a particular emphasis on “the centrality of student self-evaluation and reflection and the opportunity to portray the processes by which the work in the portfolio is achieved.”113 The meaning of the term “portfolio” has been the subject of recent debate in the medical education literature, particularly with respect to the requirement for reflection, which some have viewed as difficult, time-consuming, and potentially unnecessary114 and others believe to be a unique and fundamental aspect of the tool.115,116 Given the otherwise widespread recognition of self-reflection as part of the definition of a portfolio, both in the education literature in general113 and within medical education in particular,117–120 within this paper the use of the term portfolio will refer to a collection of works which includes evidence of reflection.

These literatures neither engage in nor acknowledge the discourse of validity and reliability, nor do they look explicitly to qualitative methodology for sources of evidence. They discuss neither reproducibility, accuracy, nor ease of marking, and they have no criterion reference. They are nonetheless related to rhetorical arguments that have emerged from within medical education. Norman et al.,91 reviewing the literature in 1991, concluded that subjective and objectified tests of the same construct were highly correlated. These authors foregrounded the risk of trivializing certain constructs using either multiple-choice or short-answer questions, as opposed to question types, such as essays, “which require students to handle several aspects of knowledge in relation to each other.”91 They therefore accepted the use of the latter as a legitimate option for testing, particularly of higher-order constructs.91 Moreover, Schuwirth and van der Vleuten have gone so far as to say that if the goal of a test is “to set up a reasoning process or summarise information, or […] to apply a known principle in different contexts” then the only appropriate type of written question is an essay,121 particularly if one is also concerned with writing ability.122 As the following summary will illustrate, there has also been a significant amount of psychometric research, much of it controversial, on the value of essays and portfolios as evaluative techniques.

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Essays and portfolios

The construct validity of essay assessments has been specifically studied in the medical context. For example, in a 1990 study, an essay test was validated for the assessment of clinical judgment at the postgraduate level.123 In terms of essays’ interrater reliability, several studies have given conflicting results.94,124–126 There has also been research into their generalizability. For instance, the generalizability of an essay test of clinical judgment improved (and its required testing time decreased) when three nonphysicians using a detailed checklist were replaced by three physicians marking holistically.127 Frijns et al.128 showed that open-ended questions could be marked by physician-raters in a reproducible manner, although achieving a generalizability coefficient of 0.80 or above with one or two raters required between four and six hours of testing time. In keeping with our current understanding that psychometric criteria are not inherent qualities of an instrument’s format,80 the issue of reliability for marking essays is not an intrinsic problem with the test type but rather a question of the availability of adequate testing time and of expert markers. Multiple means of improving reliability, and thereby decreasing the need for those resources, have been suggested in the literature,88,121,122,125,126,129–131 although Schuwirth and van der Vleuten caution against overstructuring rubrics for marking essays to avoid trivializing the construct being assessed.121,122

Portfolios are newer to medical education, as well as more individual and process-oriented. It has thus far been difficult to establish their validity with respect to the constructs for which they have been studied in the medical context. The best established form of validity for portfolios is face validity for constructs including reflection119,132 and performance over time.119 Establishing their predictive, criterion, and construct validity for such constructs will be challenging.117,119,132,133 The authors of a study published in late 2001 of portfolios used as part of the final examination for medical students in Dundee, Scotland claimed evidence of divergent validity for constructs, such as attitude and diligence, which are not assessed by their more traditional examination components.134 A more recent study of portfolios in psychiatry residency education demonstrated modest convergent validity for psychiatric knowledge and level of training.135 The reliability of portfolio assessments has also been studied, with estimates of interrater reliability ranging from 0.1 to 0.82.119,136–138 Generalizability and decision studies have also generated a wide range of numbers of items and/or raters required for a generalizability of at least 0.8.119,135,137 Multiple suggestions of strategies to improve reliability in portfolio evaluation have been made.120,132,139 These include objectification through specific criteria and standardization.120,132 The concern remains, however, that the standardization of content and the development of specific criteria present threats to the validity of the assessment by limiting the range of student reflection and learning,119,120 perhaps without actually eliminating the problem of reliability.140

So we are now faced with a conundrum. Essays and portfolios are promoted as the most appropriate tools for the evaluation of literature and medicine, and they may allow us to tap into competencies that we cannot easily assess but which are becoming increasingly important, like empathy, personal reflection, and professionalism. However, as tools, they are not readily analyzable using the granular techniques of our traditional psychometrics, and by some measures they are not “good” enough to use for summative decisions. Nonetheless, abandoning these important constructs, and a curriculum that is designed to promote them, is too radical an option. Not summatively evaluating these competencies is out of the question as well, if for no other reason than the message it would send about their true importance in the hidden curriculum. As Cannings et al. summarizes: “In our efforts to find a truly reliable assessment, we must not lose sight of the need to occasionally assess a ‘subjective’ piece of work […]. We then have to accept that there will be some loss of reliability in the marking that follows.”130 Otherwise, Snadden warns us, if we “continue to struggle to measure the unmeasurable, […we] may end up measuring the irrelevant because it is easier.”141 Fortunately, the rigor of more subjective evaluation tools can be assessed in other ways, without relying on measurement, and examples of such assessment are beginning to enter the medical literature.

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Qualitative methods and hermeneutics as assessment

Rather than attempting to apply the rules of quantitative rigor to the qualitative, individualized world of patient experience, physician experience, and ambiguity, we can look to the increasing published recognition that some forms of assessment can be better studied, and some questions better answered, using qualitative methodology.80,87,92 Reflected in this trend is a growing understanding of the importance of “interpretation—the discernment of meaning”4 in the narrative worlds of medical practice and medical education. This may be particularly true of portfolios and essays, given the wealth of qualitative information that they provide. Analyses of essay evaluations in other disciplines have taken qualitative approaches.142 Because portfolios have been described as embodying a qualitative113 or a mixed quantitative and qualitative119 approach to student assessment, some have argued that the evaluation of portfolios as an assessment tool in health care education could also benefit from an approach founded in qualitative research.138,140,141,143,144

This has recently been tried at the medical school at Maastricht University.145 The researchers rooted their intervention in three basic premises: (1) that the value of portfolio evaluation stems from its basis in the richness of authentic personal experience, which would be lost by standardization; (2) that rater training and checklists cannot compensate for this lack of standardization to produce adequate reliability as assessed by traditional psychometric methods; and (3) that qualitative (and subjective) methods, derived from the qualitative research tradition, can offer novel approaches to student assessment. They carried out both formative and summative evaluations of portfolios intended to contain reflections on, and evidence of, personal strengths and weaknesses in relation to four physician roles (“medical expert, scientist, health care worker and person”145) as well as learning plans to address these areas. In the summative evaluations, each student’s mentor used multiple global criteria such as “the quality of the analysis of strengths and weaknesses” and “the clarity and feasibility of the learning objectives.”145 The grade assigned by the mentor, which could be either distinction, pass, or fail, was then discussed with the student, confirmed by one or two other readers, and in cases of continuing disagreement reviewed by a committee of 13 assessors (including the student’s mentor).

Having introduced two methodological criteria from the constructivist tradition146 within qualitative research, credibility and dependability, which can be used to parallel validity and reliability, they then used accepted strategies from the realm of qualitative methods for ensuring the credibility (triangulation, prolonged engagement, member checking) and dependability (audit trail, dependability audit) of their summative assessment. In terms of further research, it was suggested that their evaluation methods could be further supported through having the portfolios assessed by other committees of assessors, in the manner of an external dependability audit.145 Some might argue that such reassessment could then be used to calculate more traditional measures of interrater reliability. However, in the absence of a true hierarchy of methodologies, we should be careful to avoid imposing the criteria of one tradition onto the already rigorous methodology of another valid discourse, wherein the “mechanistic decision based on a standard of performance on a single assessment is replaced by a professional judgment based on accumulated and triangulated information across multiple sources of assessment information.”87

A third methodological criterion which is often discussed in the context of qualitative methods in assessment research is that of authenticity, defined as “the extent to which the outcomes measured represent appropriate, meaningful, significant and worthwhile forms of human accomplishments.”147 Portfolios in particular have been advocated as authentic forms of assessment119 in that they allow the evaluation of “performance in practice over a period of time, in other words they assess the application of theory and the performance of the student or doctor.”117 Essays can similarly be argued to be authentic evaluative tools for competencies such as written communication skills and narrative structure. Such authenticity allows “optimal congruence between assessment on the one hand and educational goals and the demands of future practice on the other.”92 However, the standardization of assigned tasks and the structuring of their assessment, which, as we have seen, are often advocated in the psychometric discourse to increase reliability, present a significant threat to authenticity.119

Another interesting nonpsychometric approach to the evaluation of written texts comes from Moss’s hermeneutics of assessment. This uses less rigidly constructivist methodology than the Maastricht group’s qualitative criteria, drawing instead on the classic tradition of hermeneutic textual analysis (see the Methods section, above). Moss describes hermeneutics in education as a practice based on progressive integration, in which human phenomena (whether literary works or students’ tests) are deciphered by trying “to understand the whole in light of its parts, repeatedly testing interpretations against the available evidence until each of the parts can be accounted for in a coherent interpretation of the whole.”148 Her methods highlight context and promote discussion and debate around the assessment of a series of texts, such as might be in a portfolio, carried out in a documented, stepwise manner.113 Interestingly, many of the qualitative research strategies proposed by the Maastricht group (such as triangulation, prolonged engagement, audit trail) are also advocated, albeit using different terminology, by Moss’s approach.148 Her emphasis on consensus building is echoed in the assessment approach being tried, within a more psychometrically-oriented framework, to evaluate medical student portfolios in Dundee.119

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In spite of their quantitatively-determined psychometric flaws, essays and portfolios may remain suitable tools for the assessment of many of the objectives of a literature and medicine curriculum. For example, essays are appropriate for the assessment of constructs such as reasoning and writing skills, whereas portfolios have been specifically developed for the promotion and evaluation of reflection. Essays and related written assignments therefore present an appropriate mechanism for the evaluation of narrative skills, including narrative competence and written communication skills. Most simply, they can be used to assess the ability to extract a story from a text by close reading in the way that physicians fashion a coherent history from disjointed pieces of clinical information. Their subjectiveness, although problematic within a psychometric framework, also lends itself to the exploration of ambiguous texts, concepts, and feelings. Essays written in the preclerkship, for example, about stories presented from patients’ and physicians’ points of view, can allow a student to show an understanding of a patient’s experience, to explore possible emotional repercussions of a patient’s illness on her physicians and other caregivers, and to reflect on potentially difficult professional dilemmas. By emphasizing process rather than content, this can help develop skills related to empathy and emotional self-reflection before having to experience such situations in real life. The lack of a “right answer” for such an essay can, if framed appropriately, introduce the idea of uncertainty both in literature and in medicine.

For practical reasons, formal essays are hard to assign during the clinical years. However, a portfolio of short reflections (or a section of a more general portfolio, depending on the rest of the curriculum), which builds on skills originally taught in the preclerkship, can continue to encourage and assess empathy, the process of self-reflection, and narrative skills. Having learned the appropriate language and tools with carefully selected texts, students can be taught to transfer their knowledge to the clinical setting, writing pieces about the patients they encounter and reflecting on their own responses. Because portfolios focus on personal, individual attributes and experiences,119 they are ideal for expressing the “local and particular understandings about one situation by one participant or observer”5 encouraged by narrative knowledge. Given the importance of student reflection in this context, care must be taken to create the conditions necessary for “successful reflective use of portfolios”: coaching by mentors; initial structure, especially for weaker students, with the freedom for students to move away from that structure once they are good at reflecting; eventual summative assessment; and the availability of experiences or other material on which to reflect.149 Overall, the focus remains on process, rather than on content, and summative assessment must be accompanied by extensive formative feedback as the portfolio develops over time. The provision of selected literary texts by mentors when needed can help with the issue of availability of material in the absence of appropriate real experiences. Students can also continue to reflect briefly on assigned works of literature, particularly if a series of short works is chosen to accompany their rotations. Other related items that could be integrated into a portfolio include parallel charts, in which students write “about aspects of the care of their patients that don’t belong in the clinical chart but must be written somewhere,”150 or copies of real clinical notes and letters, with patients names removed, to assess written communication skills.

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The assessment tools appropriate for a literature and medicine curriculum do not meet the psychometric discourse’s traditional evaluation criteria and, if they are to preserve their authenticity, are not likely to conform to them in the future. However, there are rigorous, usable criteria taken from another discourse, that of qualitative research, which are slowly being introduced into medical education research. From a theoretical perspective, using evaluation strategies that shun the positivist notion of truth is consistent with the objectives of a literature and medicine curriculum; given that literature is “concerned above all with qualitative distinctions,”106 qualitative measures are apposite. Reflective of the need to create assessment congruent with the learning that it drives, the emphasis on individuality and engagement within both the constructivist and hermeneutic approaches to evaluation further highlight their suitability for the context of literature and medicine.

Rather than ignore the development of literature and medicine, the medical education research community should take on the challenges that it presents. Otherwise, we run the risk that our immediate leap to objectified, reductionist evaluation systems, and our scorn of any discipline that does not comply with them, will prevent important constructs from being effectively taught and evaluated within medical education. Our students need to be taught empathy, self-reflection, and comfort with uncertainty, and our curricula need to remain open to other subjects that teach the competencies of physician as professional and of physician as person. Given the ongoing public concern with cynicism, lack of professionalism, and burnout in the medical profession, the accountability agenda demands no less.

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Support for this research was provided by the Clinician Educator Training Program, Department of Medicine, University of Toronto and by a Fellowship for Studies in Medical Education from the Royal College of Physicians and Surgeons of Canada. The author is grateful to many colleagues at the Wilson Centre for Research in Education for their helpful comments about this paper.

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    *As a method of textual interpretation, hermeneutics involves iterative analysis of the parts of a text against the whole until all of those parts contribute to a single consistent meaning. The reader must take his or her own sociohistorical position and intellectual tradition, as well as the context in which the text was originally created, into account in this interpretation.97
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    Although the technicalities of their assessment are beyond the scope of this review, other branches of the arts have also been advocated as possible sources and means of reflection. For example, work has been done using “film, art and drama”48 as well as literature to provide students with patient, family, and physician perspectives of cancer. Gordon describes students’ inclusion of both “literary and art works (both their own and others)”112 in portfolios used to assess personal and professional development.
    Cited Here...

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