Cite as: Biswas R., Podder V., Samitinjay A. Teaching Medical Humanities: Global Learning toward Local Caring, In Mahajan R, Singh T, eds: Humanities in Medical Education, 2nd ED, India: CBS Publishers and Distributors Pvt. Ltd., 2023
Key points :
1) Medical education and practice is at the crossroads driven by evolving societal requirements and clinical complexity
2) Doctor patient relationships are increasingly threatened into bitter spats rather than the transforming healing experience they were originally meant to provide.
3) Medical Humanities has the potential to bridge the current divide and should be introduced into the curriculum in a manner that can not only improve student learning outcomes but also patient healing outcomes.
4) This chapter share's practical experiences of a clinical patient centered learning ecosystem where a solution (working prototype) has made a beginning to integrate humanities and science toward improving student learning outcomes and patient healing outcomes.
Background / Introduction
Most doctors begin their teaching journeys either even as interns or post graduate residents or as newly minted faculty and some are fortunate to become part of a teaching learning ecosystem even as medical students and remain life long medical students.
This chapter traces the learning journies of a few medical students, now faculty, who have navigated their regular patient centered workflows utilizing medical humanities as a tool to not only enable improvement of their own learning outcomes but also established empathic relationships toward improved healing outcomes for their patients.
The chapter uses quotes compiled from the past publications of these medical students, now faculty. In the next few paragraphs we illustrate through our past published quotes, the role of individual patient stories and the empathy it generates to strengthen the human doctor patient bond as one of the key features of medical humanities.
In the words of one such student, we quote,
"As medical students, when we finished the basic sciences and started clinics, we immediately noticed a pleasurable difference as we no longer had to cram dull theory. The patient was our greatest teacher of medicine, as much as the dead body had been in anatomy.
The best way to learn was interviewing patients and getting to the depths of the story, which in most cases would yield the diagnosis. It was a detective game and the clues had to be meticulously elucidated. This is where our teachers played a part. They showed us how to elicit these vital clues.
We learnt not only how to hunt for information but also to love our patients. It was great to collect their stories and reflect on them over our textbooks. That was the first time we experienced our books coming alive. While our contemporaries were collecting stamps, coins, or peoples autographs, we started collecting people, live people, who were not long dead characters of a novel but would greet us from bus stops or on morning walks.
Interacting with them we experienced vitality flowing like a river in and out of our lives."
(Biswas 2003)
Reference : Biswas R, Always a medical student, Student BMJ(UK),vol 11, feb 2003, pg 41. http://www.studentbmj.com/issues/03/02/reviews/41.php, https://www.bmj.com/content/326/Suppl_S2/030241)
In the words of another medical student, we quote,
"During third year of medical school, my doctor a cardiac surgeon named Dr. DPS told that we need to do this surgery soon because of severe transvalvular aortic pressure. We took our time to manage the cost of the surgery and also took into consideration an unexpected education gap from my medical school. Finally, after a decade of the stressful journey, my operation was done successfully.
During this journey, I realized the importance of love, compassion, touch, and empathy. Now whenever I clerk any patient in the hospital and during my BMJ elective in India, I look at them and realize: “Yes, I know how it feels to be a patient and what patient might be expecting from me like I realized being a patient once.” I can make a connection of empathy and love with the patients and can understand that within every human being there is a physician inside who knows only to love and care humanity
(Poddar 2018)
https://www.kevinmd.com/blog/2018/03/patient-becomes-medical-student.html
And another student,
"A friendly, hand-on-the-shoulder chat with several PGs there, gave me a profound insight into their lives, into how they practice medicine and what their aspirations were. Almost all of them had their own governing principles, almost all of them had an awareness and insight into what was happening and why it was happening. A common theme emerged – their desire to learn and be curious was not being met largely due to a deference to authority. Months and years of indifference can render the best of us inhuman, indifferent and stoic. On some days, even I find myself detached and indifferent. However, now that I’m a young consultant myself, with a few independent powers in clinical decision making, I get back on my feet quickly. However, for PGs and junior doctors, it may not be the same – out of the box thinking is shunned, curious questioning is castigated, uncanny ideas are discarded. Consequently, young enthusiastic minds may not see the light of the day and retort to a system of learning that does not breed curiosity, but rather indifference.
I firmly believe, humanities is a direct manifestation of scientific temperament, and our prime focus should be on encouraging a sound scientific temperament and an attitude of healthy scepticism."
(Samitinjay 2022)
https://adityasamitinjay.blogspot.com/2022/01/iob-internet-of-behaviors-and-emotional.html?m=1
Main text (No reference number to be given here, write references in APA style in text i.e last name and year if one author, and between two author name and year; and last name of first author with et al if three or more authors with year. At the end list – references should be in Vancouver style)
WHY do we need humanities in the medical curriculum? (current problem statement)
“The job of the human being [in the digital age] is to become skilled at locating relevant valid data for their needs. In the sphere of medicine, the required skill is to be able to relate the knowledge generated by the study of groups of patients or populations to that lonely and anxious individual who has come to seek help.”
Sir Muir Gray, 2001
Medical humanities drives us to "study humans so that the patient is not just seen as a disease comprising a mass of signs and symptoms but is also recognized as a person with a story of his own. Such an approach not only fosters a better doctor patient relationship but also more often than not brings out a lot of hidden clues to the diagnosis." (Biswas 2003)
Reference : Biswas R, Dhakal B et al, Medical student narratives for understanding Disease and social order in the third world, Eubios Jl Asian Intl Bioethics(Tokyo) july 2003,vol 13(4) 139-142 https://www.eubios.info/EJ124/ej124j.htm)
It is increasingly noted that "there is a current disintegration of medical education and practice globally and medical student and faculty engagement in learning is often confined to rote memorization driven by an arcane curriculum that promotes plagiarism and diminishes scholarship.
Increasingly medical education has become disconnected from patients who continue to suffer due to lack of student and faculty engagement with them in a broader empathic meaningful manner." (Sarbadhikary 2021),
Reference : Sarbadhikary et al, Scholarship of Integration and the future of Medical Education and Research (MER): Student user driven, patient centered assessments with learning outcomes driving health care outcomes, Ch. In, Adkoli BV and Ray A, Eds, Medical Education Research: Theory, Practice, Publication and Scholarship, Notion Press, Chennai, India, 2021 (Accepted).
Full text draft last accessed on Jan 15, 2022 from https://medicinedepartment.blogspot.com/2021/06/draft-3a-scholarship-of-integration-and.html?m=1)
"The top-down compartmentalized structure of medical education and practice in which future health professionals were very often simply expected to learn and memorize the structure of their chosen field of medicine (and then apply it for patient care) has been recently challenged by the evidence-based health care, complexity in health care and the health informatics movements that have organically grown bottom up since the last few decades." (Biswas 2008)
Reference : Biswas, R., Martin, C., Sturmberg, J., Shankar, R., Umakanth, S., Shanker, & Kasthuri AS. User driven health care - Answering multidimensional information needs in individual patients utilizing post EBM approaches: A conceptual model. Journal of Evaluation in Clinical Practice, 2008, 14, 742-749.
"Not knowing, the chaos of real life clinical questions, a healthy skepticism, appreciation of the rapid turnover of information and the realization that active and interactive learners learn, are the energies that fuel problem-based learning in the afore mentioned bottom up movements" (Armstrong 2004)
Reference: Armstrong EC, ‘Morning POEMs (Patient Oriented Evidence that Matters)’: Teaching point-of-care, patient focused evidence-based medicine. Available at: http://www.fammed.washington.edu/ebp/media/stfm-9-03-morningpoems.doc (last accessed 16 August 2007).
HOW?
Our past and current evolving solutions to the problem :
In this chapter we shall share how we tried and are still trying to teach and learn about humans as persons with disease rather than just diseases and how there is still a large unexplored area left that needs to be covered to optimally integrate medical education with practice. With this chapter we hope to even stimulate more and more medical students to join us in our current endeavor.
HOW?
1) Integrative approach :
(integrating disease related general knowledge with humanities particular knowledge of the individual patient's life)
:
BATCH 10, SEMESTER 8)
Time: 3 Hours
Max. Marks: 100
Answer all questions
Answer each section in a separate answer book.
SECTION A
1) A 37-year-old lady, has come with 3 months history of generalized ill health and a dragging sensation in her left hypochondria. On examination her spleen is massively enlarged.
a) What are the possible causes?
b) Describe investigations and treatment. (4+3+3)
However a humanities approach would incite the same question and curiosity in the minds of students by making them think about the person in that 37 year old woman and to quote in her own words,
"In the summer of 1991, just after my 37th birthday, I began feeling an unshakable fatigue and a persistent pain in my left side.Like most people, I had had episodes of hypochondria -- could that headache be a brain tumor? -- but I had always been in generally robust health By October, I was worried enough to see my physician for a long-overdue physical.
"You seem fine," he told me, "but let's do some blood tests just to be sure." (Landro 2007 last downloaded from http://leukemia.acor.org/storydir/landro.html) |
We tried to resolve this disease dehumanization, decontextualization problem in medical education from 2006 in our lecture based large group teaching sessions by placing them side by side in our lecture as illustrated in this figure 1 here :
https://sites.pitt.edu/~super1/lecture/lec35161/003.htm that begins the lecture on CML with the disease based question paper and moves on to the patient as a person or humanities story. (Biswas 2009)
Reference : Biswas R, Umakanth S, Shetty M, Hande M, Nagra JS,( 2009) Problem based self-directed life-long participatory learning in medical educators and their audience: Reflective lessons learnt from a lecture series. Journal of Education Research, 2009; 3 (4):294-310
We have further shared these lectures as chapters in our book on narrative medicine and we quote below from few of these to illustrate how we were able to utilize these patient centered experiences as teaching tools.
The hematology lectures were shared as a chapter titled, "Hematology: the river within," where disease related general knowledge were interspersed with the personal stories of the patients along with river poetry. The chapter tried to highlight the power of personal experience and its role in enhancing the
engagement of the learner.
Not only are 'patient as person' stories transferring factual information, they highlight the limitations of textbook general knowledge. The "failure of the textbook" is common enough to warrant a discourse about the limitations of knowledge as much as a discourse about the impact of success
and failure in medical care on the individual. We believe that this format of teaching promotes deeper insight in the learner and instills a sense of
"always being humble" as a health professional."
To quote a small sample from the patient narrative in the chapter followed by a poetic line from our chapter first author,
"I returned to work at the end of March 1993, part time, wearing a wig, on the day that my short-term disability insurance ended.''
"The song of the river ends not at her banks
but in the hearts of those who have loved her..." (Chaudhuri 2011)
Reference :
Chaudhuri, A., Young, J., Martin, C. M., Sturmberg, J. P., & Biswas, R. (2011). Hematology: The River Within. In R. Biswas, & C. Martin (Eds.), User-Driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies (pp. 16-33). doi:10.4018/978-1-60960-097-6.ch002
and even addressed our work in a global TEDx conference along with our students which is archived and accessible here
https://youtu.be/76AVUQOK9LM
She subsequently wrote an integrative medical humanities article with some of our students who had by then become US based faculty of hematoncology and informatics.
Before we move on to describe HOW we have currently built on a slowly growing working model of Medical humanities education using windows of opportunity offered even in the current formative assessment curriculum, we shall take a quick look at how it all began since one of us started our teaching career a few decades ago.
WHY? (medical humanities)
From PGI Chandigarh to Manipal, Pokhara, Nepal in 1999 was a dream journey and medical humanities became a vital tool to interpret that dream over the next few years of stay. Life in pristine rural Nepal challenged all our presumptive urban training.
Quoting from our personal view at that time,
"In these remote villages there is education, which unlike ours teaches
wisdom. It teaches us to gather and grow food and to cook it if necessary.It teaches us to live harmoniously with nature and not plunder it to thehilt, a glowering testimony of which today, is our cities we proudly display. Concrete jungles of human misery, a coexistence of the rich inhigh rises and others in slums…people who couldn’t make it to the top. Our cities were signposts of development and we wanted the developing world such as those pristine rural villages to reach similar status."
