Book Chapter: Teaching Medical Humanities : Global learning toward local caring

 Title

Teaching Medical Humanities : Global learning toward local caring 

Full text available at : https://dokumen.pub/humanities-in-medical-education-2nbsped-9789354666506.html

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)

Following is an example of a typical exam question on chronic myeloid leukemia (Biswas 2008: https://sites.pitt.edu/~super1/lecture/lec35161/001.htm)

:

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 

More of these series of humanities driven lectures that we took at that time are archived in the webpage linked here:https://sites.pitt.edu/~super1/faculty/lecturers.htm#Rakesh%20Biswas (last accessed on Jan 15, 2022)

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

The same patient in the above mentioned medical humanities lecture chapter also worked with us later as an author and associate editor of our journal (accessible here : https://www.igi-global.com/journal/international-journal-user-driven-healthcare/41022)

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 the
hilt, a glowering testimony of which today, is our cities we proudly display. Concrete jungles of human misery, a coexistence of the rich in
high 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."

For the first time "a global cancer of
poverty was starkly apparent, engulfing all of us in the developed First World, cut off from that rural remote village aka the third world. 

A village, we hope still exists, somewhere replete with lush green forests and inaccessible mountain passes warding off people…who cut forests to build roads and lay the foundation for a gradual
infiltration…of more people from our world which is already struck by the
disease. A disease…born in our patronizing outlook, that gave us the
license to meddle with the affairs, of the first self-sufficient village
our predecessors destroyed with their reformist attitude. (Biswas 2002)

Reference : Biswas R, The birth of poverty, British Medical Journal (UK), 2002;325:51 (http://bmj.com/cgi/content/full/325/7354/51) 

WHY Medical humanities narrative by two student members of our team (Chandra 2013):

"Narratives from Indian medical students (authors SC and TB) touch upon the key roadblocks a medical student faces in identifying and developing these skills in India as well as their potential reward.

Teaching modules and textbooks are not sufficient to teach a medical student how to be a good physician. We learn by observing our peers and seniors, but our most important teachers are our patients. My conversation with my first patient was more of a viva-voce examination, punctuated with abrupt pauses – my voice was trembling and I was trying hard to remember all the “questions” as per the training manual. Suddenly, I looked up to find my attending standing there. A legend in the hospital, his presence made me feel even more embarrassed at my apparent ineptitude. Instead of ridiculing me however, he gently taught me an important lesson – “Talk to the patient as you would to your own family member or friend. Extend them the same courtesy, and also the same level of comfort. You’ll learn ‘what’ to ask as you grow as a physician, so do not worry about that aspect. Right now, focus on ‘how’ you will interact with him”. Emboldened and enlightened, I went back to my patient and proceeded to ‘talk to him’ rather than merely ‘taking a case’. Not only did I finish taking a complete history in a shorter time than anticipated, I also gleaned some important information, which he had not shared with the resident. This helped me consider a new differential. Over the years, I have had many such physician and patient encounters teach me the value of compassion, empathy, trust and the value of empowerment and inclusion for the patient in the decision-making process. These values enhance my personal and professional growth."

Reference : Chandra S, Price A, Biswas T, Bera K, Biswas R. User Driven Learning: Blending the Best of Clinical Medicine and Humanities to Infuse “Joy” into the Medical Curriculum. Int J User-Driven Healthc 2013;3(3):116–21. Available from: http://services.igi-global.com/resolvedoi/resolve.aspx?-doi=10.4018/ijudh.2013070109

WHY and HOW? (medical humanities) 

Similarly on our patient centered teaching learning front, we found that contrary to what generalizeable randomized controlled trial data projected, every individual was unique and had unique life trajectories and medical humanities driven students were best suited to unearthing these trajectories as documented in their published personal histories of our patients. Medical humanities transformed the personal history taking from a mere recording of the patient's habits to recording of his entire life story details (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 (Full text link last accessed on Jan 15, 2022  https://www.eubios.info/EJ124/ej124j.htm)

Following up on our aforementioned lecture strategy toward integrating medical humanities with medical knowledge, we created lectures using a blend of science and fiction as illustrated in "the story of glomerular injury" figure 2: http://consciousnotebooksequel.blogspot.com/2015/12/the-story-of-glomerular-injury.html?m=1 (slides borrowed from the lecture previously published in a medical humanities novel) where one can see how a visual of the happenings of 9/11 appear to have been lifted straight away from a cartoon in Harrison's text book of Medicine and in the lecture, one gathers the entire fictional depiction of how the microworld story of glomerular injury is also played in the macroworld inhabited by embodied humans. (Biswas 2009)

References: Biswas R, The Conscious Notebook, Nova Publishers, NY, 2009

WHY? (medical humanities) 

Embracing the afore mentioned Medical humanities driven data capture tools it gradually becomes apparent that present day outcome based research deals less with patients as individuals than as populations. Evidence based medicine struggles to apply the fruits of population based research to individuals who are often not as predictable as linear quantitative research would like them to be. (Biswas 2007) 

Reference : Biswas R, Umakanth S, Strumberg J, Martin CM, Hande M, Nagra JS. The process of evidence-based medicine and the search for meaning. J Eval Clin Pract. 2007 Aug;13(4):529-32.(Last accessed on Jan 15, 2022 from :http://www.ncbi.nlm.nih.gov/pubmed/17683292)

Soon after this we conceived the first conceptual model for our current medical humanities driven teaching learning ecosystem and published it as "user driven healthcare" in 2008. In the same paper we addressed the current global medical education "risk of training a generation of doctors who, while skilled in study interpretation and statistical methods, may fail to recognize and develop the complex reasoning skills necessary for

sound clinical judgment."

Again quoting Armstrong, "The biggest challenge for medical education facilitators has been keeping it patient-centred. It has been noted that residents and medical stu-

dents often struggle with a format where the primary focus is the patient and is question driven and where the emphasis is in large

part on process and skill acquisition rather than finding ‘the right answer’. This takes them out of their cultural comfort zone of

didactic and content-focused education where not knowing is traditionally frowned upon. It requires that they become com-

fortable saying they don’t know and embrace this as a positive phenomenon, which will over time, drive their desire to know

and keep up to date in a world of medicine where the only constant is change [Armstrong 2007]. 

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).

"To inculcate the traits required of a good physician, the mere mastery of theoretical concepts and clinical skills is not enough. The horizons of medical syllabi needs to be expanded to incorporate the shift in healthcare paradigms. A flexibly structured and adaptive program that focuses on creating a strong balanced foundation rather than merely completing pre-set syllabi is of immense benefit to both the trainee physician and society in general." (Chandra 2013)

Reference :

Chandra, S., Price, A., Biswas, T., Bera, K., & Biswas, R. (2013). User Driven Learning: Blending the Best of Clinical Medicine and Humanities to Infuse ‘Joy’ into the Medical Curriculum. International Journal of User-Driven Healthcare (IJUDH), 3(3), 122-127. doi:10.4018/ijudh.2013070109

HOW? (medical humanities) 

A solution to the above problem statements, we recognized was "user driven healthcare" that is a spontaneously evolving "medical humanities" learning ecosystem to answer multidimensional information needs of individual patients and clinicians through concerted collaborative learning between multiple online users and stakeholders, primarily patients, health professionals and

other actors in a care giving collaborative network across a web interface.' We postulated that, "User-driven health care UDHC, using medical humanities narrative tools can integrate the experiences of illness, the disease management and the

social context in ways that are supportive to every learning stakeholder. It can create  a venue to share the many narratives of a particular individual’s disease and illness.

For each and every individual patient that suffers it is possible to electronically document her/his clinical encounter with the entire social network that supports her/his health care. This persistent documentation in individual personal case reports made accessible after deidentification to all stakeholders (that include innumerable patients and caregivers) would serve as a valuable learning resource that may enable improved decision-making utilizing meaning derived from multiple dimensions of the clinical encounter. (Biswas 2008). 

Utilizing the UDHC approach, medical humanities in effect became our "discovery tool’ of new knowledge arising from different types of experiences ranging from the implicit knowledge in narratives through to the explicit knowledge that is formalized in the published peer reviewed literature and translated into clinical knowledge." (Martin and Biswas 2013) 

Martin, C. M., Biswas, R., Joshi, A., & Sturmberg, J. P. (2011). Patient Journey Record Systems (PaJR): The Development of a Conceptual Framework for a Patient Journey System. In R. Biswas, & C. Martin (Eds.), User-Driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies (pp. 75-92). Hershey, PA: Medical Information Science Reference. doi:10.4018/978-1-60960-097-6.ch006

https://www.igi-global.com/chapter/patient-journey-record-systems-pajr/49245

We began the medical humanities UDHC movement, grounded organically from 2008 and kept publishing our results from time to time. "The backbone of the system is formed by the ‘virtual volunteer physician’ network who cater to the cases, consisting of experienced physicians along with medical students. The system links them to patients in the vast underrepresented rural areas through data inclusive of the patients’ narrative of their problems, workups by local practitioners and relevant investigation reports sent directly by patients or with the help of local social workers.While one arm of the network focuses on improved patient care to the underserved rural population of India, the impact on medical students is an equal if not greater function of the UDHC system. The students enjoy a ringside view of the entire process of decision making in healthcare complete with its good and bad outcomes that raises in them the necessary emotions and empathy that promotes an integrative approach to learning through appreciative inquiry, rather than the prevalent textbook memorization approach. (Bera 2013)

Reference:

Bera, K., Seth, B., & Biswas, R. (2013). Conversational learning among medical students: harnessing the power of web 2.0 through user driven healthcare. Ann Neurosci. 2013 Apr; 20(2): 37–38.

doi: 10.5214/ans.0972.7531.200201

"The idea of sharing and learning around patients has been alive since the beginning of medicine when physicians would present their cases to a large audience to primarily learn from the inputs of other physicians (Price 2013)

Reference : Price A, Biswas T, Biswas R. Person-centered healthcare in the information age: Experiences from a user driven healthcare network. Eur J Pers Centered Healthc 2013;1(2):385–93. Available from: http://ubplj.org/index.php/ejpch/article/view/766

From this interchange many published their cases naming themselves after the disease problems they solved. In this way case reporting became a gainful activity not only in terms of scientific advancement toward patient benefits but also as an important instrument of physician fame. Figure 3 ( downloaded from 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4587042/#!po=4.09836)

shows how UDHC has adapted this tradition in the UDHC blended learning model"

Beginning in 2012, The British Medical Journal (BMJ) have initiated a Patient centered learning model also known as a global-health case-reports elective for medical students around the world (details are online here: 

https://casereports.bmj.com/pages/bmj-case-reports-student-electives/)

Reference: BMJ. BMJ Case Reports Student Electives [Internet]. BMJ 2022. Available from:https://casereports.bmj.com/pages/bmj-case-reports-student-electives/

This initiative is offered in collaboration with the institution where the first author serves as a Faculty and the elective program has followed him over three institutions from 2012 to 2022 and has been attended by students from France, US, UK, India, China, Nepal and Bangladesh many of who have published case reports with a strong medical humanities content where they have exemplified our medical humanities vision of global learning toward local caring. (Shah 2016, Webb 2018, Poddar 2019, Samitinjay 2020)

From 2015, our medical humanities driven UDHC network gradually began developing a model of person centered health research through a ‘citizen science model’  where the public can become informed and responsible shared decision-makers who help prioritize, initiate, design, organize and participate in health research.

UDHC was also promoting a clinical research foundation that would target needs of the local population through observation and engagement of interested citizens in a collaborative learning atmosphere. We have begun to train ‘patients, their primary caregivers and all interested citizens’ in the essential elements necessary to understand medicine beginning with anatomy to explain their diagnosis with examples and by introducing them to medical students and other patients who can take the time to explain options for their medical future.

This "Medical humanities" research around individual humans is very different from the current dominant paradigm of ‘population based research’ because we treat each and every patient as a research project; a perspective which would not be achieved through the traditional population based lens. This research doesn’t focus on scaling or generalization for population statistical outcomes but is content to benefit one individual at a time (as long as it is done with the support of current best evidence and ethics). The returns for the physicians and researchers in this program are in terms of learning and in being able to find the resources to meet their patient’s needs. Although their learning points are gathered and shared as ‘case reports’ publications, the emotional satisfaction one derives in meeting the needs in an impossible situation is difficult to share in words."

Reference : Purkayastha S, Price A, Biswas R, Jai Ganesh AU, Otero P. From Dyadic Ties to Information Infrastructures: Care-Coordination between Patients, Providers, Students and Researchers: Contribution of the Health Informatics Education Working Group. Yearbook of Medical Informatics. 2015;10(1):68-74. doi:10.15265/IY-2015-008. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4587042/

Our healthcare learning ecosystem is currently based offline in the Kamineni Institute of Medical Sciences, and this offline base keeps shifting with the various university locations in India where our corresponding author is based for a variable period of years. The online component of this blended learning ecosystem began on email groups, and then shifted to social media groups such as “Tabula Rasa”. It currently exists in WhatsApp groups with a global audience of medical students and physicians.

Over the last decade, we have adopted an evidence-based, medical humanities approach that enables utilizing the best available evidence toward optimizing care for individual patients. 

Our individual patient requirements have led us to adopt a blended learning platform to enable an informational support for our patients. It also helps medical students to have a platform to help patients locally while learning from global experts in an online ecosystem and we recognize this as a subset of UDHC due to the strong offline component and hence call it a "case based blended learning ecosystem CBBLE." (Poddar 2018)

Podder, V.; Dhakal, B.; Shaik, G.U.S.; Sundar, K.; Sivapuram, M.S.; Chattu, V.K.; Biswas, R.    Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment. Healthcare 2018, 6, 78.

Full text here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/

Working prototype of Health humanities integration to the medical formative assessment curriculum 

Connecting community  patient health care requirements to student learning outcomes toward peer review assessment: 

Illustration from recent real time student teacher patient learning workflow :

There are two pivotal nodes that are at the center of this learning and caring ecosystem :

1) Patient at home in the community connected to teaching hospital

 through 

2) a chain of health professionals starting with medical students at home in their community as well as their teaching hospitals and their faculty coordinator 

What follows below is from a real patient student faculty experience :

A patient in touch with a community connected hospital in Narketpally, Telangana (2000 kms from her place of residence in Bengal, gets in touch with theTelehealth physician and coordinator of the hospital at Narketpally through a whatsapp text query seeking help for her son and this patient is referred for a detailed narrative timeline to a medical student currently locked down at a distance of 1000 kms from the same patient. 

The medical student proceeds to gather the history from the patient and prepares a brief case report with the patient requirements and shares it with the global case based blended learning ecosystem CBBLE network from which the patient requirements are further shared in various other Global fora by other interested health professionals both in learning more about the problem presented as well as helping the patient. 

The first example is copied below as it happened:

Box 1:

The telehealth physician faculty coordinator receives a text message from one of his long distance patients who had even made a 2000 kms journey in the past to be evaluated for her spondyloarthrpathy symptoms and this time she needed consultation for her son and below are the deidentified verbatim text messages in Hindi (to provide a feel of the real manner in which this actually evolved):

"[5/13, 6:00 PM] Patient Spondyloarthropathy 30f: Hum ... (location) se

[5/13, 6:00 PM] Pt Spondyloarthropathy 30f:

 Mera bacha 8 saal ka hai

[5/13, 6:01 PM] Pt Spondyloarthrpathy 30f:

 Sir wo bar bar toilet karta hai

[5/13, 6:03 PM] Pt Spondyloarthrpathy 30f: Test Karwaya koi infaction nhi hai.

[5/13, 6:04 PM] Pt Spondyloarthrpathy 30f: Sir kya problem ho Santa hai

[5/13, 6:05 PM] Pt Spondyloarthrpathy 30f: Par isko constipation ka program hai

The faculty coordinator replied one hour later:

"Humare student doctor aapko phone karenge detail mein jaan ne ke liye"

The faculty Coordinator immediately posts this requirement below onto the global CBBLE whatsapp group (a global group of medical students and faculty health professionals with 200 members) :

"

[5/13, 7:21 PM] FC: Anyone here who would like to take a telephonic history from the mother of an 8 year old child with frequent urination and then share the deidentified details here for analysis?

[5/13, 7:22 PM] FC: Mother's language is Hindi

Within minutes there were a few interested medical students texting the faculty coordinator FC in pm and he chose the earliest person and within one and a half hours that student had telephoned the mother and made a summary of the patient's problem representation which was again circulated by the FC into the global CBBLE as well as other healthprofessionals groups such as one even among his batch mates who entered national medical college, Kolkata in 1987 and the subsequent inputs into the patient problem have all been captured by the same student SM in her E log book here: drsaranyaroshni.blogspot.com/2021/05/an-eight-year-old-with-frequent.html?m=1

The same student SM was instrumental in arranging a telecounselling with one of the Psychiatry department faculty members from her Medical College in Narketpally from 2000 kms away and the patients health outcomes currently appear to be evolving to everyone's satisfaction. 

This patient data was further utilized in a monthly summative assessment module for the same batch of students to test their competencies in patient care related to clinical problem solving through empathic patient data capture and continuity of communication. 

The monthly summative assessment module is part of a question paper of the month for the entire batch of 2017 and is accessible here in Q5B with 10 other questions: 

http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1

Student SM's answer is available online around the patient question in Q5B here :https://drsaranyaroshni.blogspot.com/2021/05/assignment-patient-centred-learning.html?m=1 where they are derived from standard theory of clnical problem solving but very interestingly she makes a mention of the child's problem again in Q10 which is about sharing her learning experiences of the month where she presents artwork collected from the patient and also goes on to describe many more patients where she was a part of the data capture process for our CBBLE. Although the question paper for the month of May 2021 which she answered above wasn't meant to test empathy competencies (unlike that of April 2021 available here: http://medicinedepartment.blogspot.com/2021/04/medicine-paper-for-april-2021-bimonthly.html?m=1) yet she also managed to display her empathy competencies in her answer to Q10. 

Gradual integration of traditional with competency driven curricula in a "Medical Humanities" patient centered learning framework

The definition of competency for a medilcal student health professional is: “habitual, consistent and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflections in daily practice for the benefit of the individual being served” 

This definition was shared by MEU India faculty member Prof TS and we would like to bring our attention to the last part of this excellent definition, "benefit of the individual being served," which reminds us again of the fact that the patient is the primary beneficiary of Medical education. 

The solution to the problem is to think of online formative assessments as a process of active learning by the medical student that puts the patient at the center of his learning portfolio. 

For example if someone is to learn Thyroid pathology and is to be assessed for it then the learner needs to share what active patient centered efforts she has undertaken in that process. 

Generally the process begins in understanding the life events of that real human being with the thyroid pathology and then capturing the palpable and investigational data acquired from that person's body with that pathology. (Poddar 2018)

Conclusion :

This chapter shared the personal teaching and learning journeys of the authors that is a humble attempt toward utilizing "Medical Humanities" as a tool to integrate Medical education and practice.  

Medical humanities tools of "narrative medicine" when merged with tools of information communication technology can drive multiple online users to drive patient  healthcare outcomes as well as health professionals learning outcomes, a phenomenon previously described as user-driven-healthcare and both these tools are likely to further evolve and refine toward better healthcare education and healing outcomes.