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On Patienthood
Rethinking the medical in the medical humanities
  1. Desmond O'Neill1,2,
  2. Elinor Jenkins2,
  3. Rebecca Mawhinney2,
  4. Ellen Cosgrave2,
  5. Sarah O'Mahony2,
  6. Clare Guest3,
  7. Hilary Moss1
  1. 1National Centre for Arts and Health, Tallaght Hospital, Dublin, Ireland
  2. 2Centre for Ageing, Neuroscience and the Humanities, Trinity College, Dublin, Ireland
  3. 3Department of Italian, Trinity College, Dublin, Ireland
  1. Correspondence to Professor Desmond O'Neill, Trinity Centre for Health Sciences, Tallaght Hospital, Dublin D24 NR0A, Ireland: doneill{at}tcd.ie

Abstract

To clinicians there are a number of striking features of the ever-evolving field of the medical humanities. The first is a perception of a predominantly unidirectional relationship between medicine and the humanities, generally in terms of what the arts and humanities have to offer medicine. The second is the portrayal of medical practice in terms of problems and negativities for which the medical humanities are seen to pose the solution rather than viewing medicine as an active and positive contributor to an interdisciplinary project. Paradigms that fail to recognise the contributions of medicine and its practitioners (including students) to the medical humanities, this paper argues, will continue to struggle with definition and acceptance. This paper explores the possibilities for advancing the medical humanities through recognition of the contribution of medicine to the humanities and the importance of engaging with the arts, culture and leisure pursuits of doctors and medical students. Our research shows the richness of cultural engagement of medical students, their broad range of cultural interests and their ability to contribute to research and scholarship in the medical humanities. Mutual recognition of strengths, weaknesses and differences of scholarly approach is critical to successful development of the enterprise. Recognising and building on the interests, sympathies and contributions of medicine and its practitioners to the medical humanities is a fundamental component of this task. Future directions might include introductory courses for humanities scholars in aspects of healthcare and medicine.

  • Sports and exercise medicine

https://doi.org/10.1136/medhum-2015-010831

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    Introduction—background and context

    To clinicians there are a number of striking features of the ever-evolving field of the medical humanities. The first is the perception of the predominantly unidirectional relationship between medicine and the humanities in the literature of the medical humanities, generally in terms of what the arts and humanities have to offer medicine.1 The second is the portrayal of medical practice in terms of problems and negativities for which the medical humanities are seen to pose the solution rather than viewing medicine as an active and positive contributor to an interdisciplinary project. This trend was noted by Pellegrino in terms of how medical humanism had achieved the status of a salvation theme which can absolve the perceived ‘sins’ of modern medicine, the list of which was ‘long, varied and often contradictory’.2

    This negativity was exemplified in a recent paper which described a perceived change in practice in contemporary medicine from some imagined golden era: ‘doctors now no longer consider it their role to provide the person-centred, relationship-based, holistic model of care that was viewed essential by their predecessors and held as a natural inclination of the vocation to medicine’.3

    What is missing from such perspectives is a sense of what medicine brings to the table, not only in the funding of medical humanities programmes in their quasi-entirety by medical schools and medical foundations. The long history of engagement of medicine with humanities4 ,5 also escapes mention, as does the extent to which doctors engage with culture and the humanities to provide a basis for developing the subject. Indeed, there are numerous papers describing dissatisfaction by medical students with medical humanities educational programmes which do not build on their pre-existing capabilities and cultural engagement.6

    A paradigm which fails to recognise the contributions of medicine and its practitioners (and students) to the medical humanities may struggle with definition and acceptance.7

    This paper aims to explore these themes, incorporating and describing research projects of medical students which illustrate some of the opportunities arising from a medical humanities approach which prioritises scholarship and research over teaching and which recognises the mutually enriching contribution between the humanities and medicine. Our vision of the medical humanities is that it constitutes a vital aspect of the epistemology of what it is to be human and the nature and experiences of health, illness and healthcare,4 ,8 and the original research for this paper is one of the very few studies of arts, culture and leisure pursuits of medical students.

    Our hypothesis for this paper is that the cultural milieu of medical students and doctors should be central to the ongoing evolution of medical humanities as a discipline. This study asks what sort of cultural, arts and leisure activities do medical students engage with and whether they believe such activities improve their competence and coping as both a student and future doctors.

    In addition, if it is likely that the medical humanities can sustain and protect doctors in the stress of professional life (including medical school),9 this is best built on the foundations of pre-existing interest and expertise.

    Participation in arts and culture by physicians

    The need to recognise, and build on, the existing humanities engagement of physicians is supported by a number of studies indicating that the level of such engagement is high. A seminal paper identified cultural and leisure pursuits of doctors in Norway in the 1990s.10 Their pursuits were notable for marked heterogeneity and that doctors read more for pleasure than other university graduates, were more likely to play a musical instrument and participate in cultural events, despite work pressures and the need to read professional literature. In a follow-up study in 2010, even higher levels of cultural and leisure pursuits were reported: there was also a significant correlation between the doctors’ level of cultural activity and their job satisfaction, general satisfaction, self-reported health and physical activity.11 A Dutch study has recorded similar high levels of cultural and leisure activities among doctors,12 as does a large UK survey of practicing physicians, which found that greater leisure and cultural involvement correlated with better vocational experience.9

    This level of everyday engagement with culture provides a foundation for doctors who have also been major objects of scholarship in the humanities as writers,13 composers14 and philosophers.15 Of even more importance for the medical humanities, it provides the basis for knowledge and engagement among the general body of practitioners to support the medical aspect of the interdisciplinarity which is, or should be, central to research and scholarship in the medical humanities.16

    Existing programmes

    There is little recognition of the varied cultural resources of medical students and doctors in the literature on the educational aspect of the medical humanities,17–19 which devotes much time to defining what it is,20 who determines curricula,21 who teaches this curricula, and to what ends.22 The literature exposes debate as to the philosophical and pedagogical issues of humanism and interdisciplinarity19 in the context of the medical humanities and a substantial body of evaluations by medical students of curricula provided or particular inputs such as literature.23–25Historically and in its present form, the medical humanities curriculum is driven primarily by local context, including not only the values and traditions of individual medical schools but also—and perhaps more significantly—the disciplinary credentials of local faculty and the number of full-time faculty positions in medical humanities, if any.26

    The emphasis on teaching the medical humanities often seems to identify a ‘problem’—the physicians’ lack of humanity, empathy or ability to communicate.18 Inherent in the literature is an assumption that medical students and doctors are potentially deficient in these regards, passive in their approach to incorporating their own arts and cultural experiences to their professional life, and that these deficiencies can be remedied by curricula inputs of literature, cinema, theatre and reflective writing.18 ,22 ,27 ,28

    The challenges to these assumptions are legion, starting with the focus on lack of empathy. Studies of physicians and nurses show no substantive difference in profiles of empathy:2: so why is there not an equal clamour for tackling lack of empathy among other healthcare professions and their students? The next challenge is whether or not medical humanities curricula, as currently constructed, are effective approaches to inculcating empathy. In fact, development of empathic sensibilities may in reality sit more comfortably within training paradigms arising from communication skills and psychology,30 ,31 and existing studies of empathy and the medical humanities are generally weak and suffer from a range of biases, such as self-selection of participants.25

    The uncritical acceptance that aesthetic experiences are in some way redemptive and enlightening in professional terms is also vulnerable to scrutiny. One study of aesthetics among laboratory students showed that more aesthetic activity was particularly related to higher scores on the personality factor of openness but also to lower scores on agreeableness and conscientiousness, hardly attributes that we hope to foster in professional development!32

    Viewing the students as novices rather than partners in education in the medical humanities limits the appeal and effectiveness of the enterprise. The literature offers almost no exploration of their pre-existing skills or experience in arts and humanities, their aesthetic, leisure and cultural preferences, or their predisposition to exposure to medical humanities courses, which would seem to be a prerequisite of curricular development in any other topic.

    Little seems to be known about the arts and leisure activities of medical students, or the resulting skills and strategies that they have relied on during their often arduous journey to the door of medical school. The most recent study on MedLine on the arts and leisure pursuits of medical students is almost 50 years old,33 two further studies examine the reading habits of medical students (a typical manifestation of the heavy emphasis on literature in much of the medical humanities),34 ,35 and an unpublished doctoral study in the UK on the determinants of ethical attitudes among medical students found marked heterogeneity and high levels of engagement in culture.36

    Medical students themselves have recognised this major flaw in much of the medical humanities, and Norwegian medical students have given a thoughtful prompt on building on the strategies and skills that medical students used in the past.6 In their paper ‘How to teach ballet to a swot’ they propose that medical students already have a wide range of abilities and interests and rather than needing more humanities courses they need more critical evaluation in all teaching, thus nurturing the continuous development of existing strengths.

    Arts, culture and leisure pursuits of medical students

    We therefore decided to investigate current arts, culture and leisure pursuits of medical students in an Irish medical school arising from the experience of our own elective module in 1st year in arts and health based on the cultural preferences of the students, and allied to our research programme in aesthetics and health.37

    Working with the director from our National Centre for Arts Health at Tallaght Hospital, our work with the students identified their preferred vehicle of artistic expression, and based the assessment of the module on the model of the popular Medical Classics rubric which ran from 2007 to 2012 in the British Medical Journal. This was a short reflection (420 words) on why the chosen work was of relevance to patients, students or doctors. The choices from the 1st year were reassuring in their breadth and imagination and included popular music (Cancer by My Chemical Romance), film (Flatliners), poetry (one of Eliot's Four Quartets), art (paintings by a blind Turkish artist), architecture (the new Birmingham Children's Hospital) and personal narrative (Beethoven's Heilgenstadt Testament on his deafness).38 What is also interesting is that the scope and treatment of the chosen works anticipated some of the vision of the medical humanities outlined in a definition of critical medical humanities outlined by Viney et al39 in 2015. These include a widening of the sites and scales of ‘the medical’ beyond the primal scene of the clinical encounter, (none of the works chosen dealt explicitly with clinical encounters); greater attention, not simply to the context and experience of health and illness, but to their constitution at multiple levels (seen in the broad sweep of the chosen works); and recognition that the arts, humanities and social sciences are best viewed not as in service or in opposition to the clinical and life sciences, but as productively entangled with a ‘biomedical culture’(which the writings of the students anticipated and amplified).

    The choices in subsequent years have been equally affirming of our vision of the students as partners in the enterprise of the medical humanities. This was further confirmed by those students who have elected to undertake their 2nd year research project in arts and health, with publications on aesthetics and stroke,40 the pathography of Igor Stravinsky,41 perception of music therapy for older people among healthcare workers,42 and the study of arts, leisure and culture pursuits of medical students presented here.

    Methodology

    Ethical approval for the study was secured through St James/AMNCH Ethics Committee as an amendment to a core study (The Role of Arts and Culture for Patients in Hospital). The survey sampled the total undergraduate medical student population (n=736) in Trinity College Dublin in March 2012 using a mixed survey tool to collect both qualitative and quantitative data administered by web-based survey software.

    The survey instrument was based on that in an Irish population sample used in the Arts Council Report ‘The Public and the Arts’ 2006,43 a version of which has also been used successfully with patients.44 The revised tool was tested on a small, convenience sample. No revisions were deemed necessary. An incentive (entry to a draw for €40 voucher) was offered to students who participated. The survey was issued through the official school of medicine email and a web link on Facebook supplemented by a number of face-to-face classroom briefings by the research team in February and March 2012.

    Results

    Demographics

    Of 736 undergraduate medical students, 294 began survey and 257 completed it (35%) with a slightly higher number of women (58%) respondents. Most (95%) were aged between 18 years and 29 years, and 78% of students considered themselves as Irish: the ‘international’ students originated mainly from North America and Asian countries. Nearly a quarter of respondents (24%) had a previous third level qualification, overwhelmingly (83%) in science-based disciplines.

    Participation in arts/leisure activities

    The majority of students (90%) report reading for pleasure, with over three-quarters (77%) reading for pleasure at least once a month. Over half (55%) of students attend the gym at least once weekly (20% on a daily basis, 35% on a weekly basis). A half (50%) of the students played an instrument at some time but few did so regularly, and 37% sang.

    Almost half of the students (41%) attended the cinema on a monthly basis. In terms of dance/theatre/art exhibition/readings, 75% of medical students rarely or never went to these events. In terms of accessing arts, leisure and cultural activities, 92% used their computers on a daily basis and 75% used an iPod or smart phone daily.

    Valuing arts/leisure activities

    Eighty-seven per cent of students saw their arts and leisure activities as being ‘important’ or ‘very important’ to their stress management and self care: 50% saw it as being ‘important’ to their communication with patients and relevant to empathy and reflective practice.

    When asked what their own special arts and leisure interests were, the responses were diverse, however could be categorised into arts/sports, exercise and socialising. The flavour was of interests that were both individual and sustaining, with a sense of frustration voiced on a number of occasions as to the lack of time available to indulge their arts and leisure interests while studying medicine.

    Discussion

    In setting out a brief for the medical humanities it is important to return to the cautions of Pattison:4 ,5“medical humanities should not be narrow, exclusive or cliquey, with just a few ‘insiders’ and many outsiders. It should avoid the temptation to become highly professionalised and expert dominated so that ordinary people and workers feel unable to understand or participate in it. Furthermore, it would be important for it to affirm what people are already doing and to help them to do it better, rather than make them feel ignorant or inadequate because they do not have certain kinds of cultural baggage or pleasures”.

    Indeed a pedagogical model based on students’ strengths finds a therapeutic echo in the ‘solution-focused brief therapy’ approach of Steve de Shazer and others.Solution-focused brief therapy focuses on client strengths and resilience, examining previous solutions and exceptions to the problem, and then, through a series of interventions, encouraging clients to do more of those behaviors.46

    Our survey provides insights into ‘what people are already doing’ as all students surveyed had exposure to formal medical humanities curricula, either as a pilot group or compulsory modules. The findings indicate relatively few students regularly attending theatre, ballet, classical music, poetry readings or art galleries, albeit still at higher levels than the general population. Those ‘high arts’ are commonly prominent in medical humanities curricula.

    In keeping with the findings among the general population47 and studies of inpatient populations,40 ,44 popular cinema, reading for pleasure and TV were the most common arts and leisure pursuits. Arguably there is value in using art forms that are familiar and of broad appeal, and which have an associated body of scholarship, to explore and reflect upon much more challenging material. Medfest, a UK-based film festival uses the familiar medium of film to provoke debate on challenging matters of mental health and illness http://www.medfest.co.uk/. An emphasis on the methodologies of film and media studies could usefully enmesh with the existing interests of students and doctors.48

    A novel finding of the study was the importance of the gym and yoga to medical students. During the design phase there was discussion as to the inclusion of the gym, yoga and sports as a category, yet anecdotal evidence suggested it was an important aspect of arts, leisure and culture for the study population. Over half of students reported participation in this activity at least once weekly. Yet how does this activity find an expression within the body of knowledge within the medical humanities? Apart from a minor mention in a medical humanities programme in a Turkish medical school,49 there is an almost total neglect of sport and exercise in the literature of the humanities generally as well as that of the medical humanities.

    This blindness towards an aspect of life which a range of philosophers have promoted as an a critical aspect of human development and insight, from Plato to modern times, is surprising, and particularly so given the enormous increase in interest in embodiment in the medical humanities.39 A further irony is that the claims of Huizunga and his followers that “sports and games could enhance the good life, promote the commonweal and provide insights into the riddles of the human condition”50 bear a striking resemblance to the claims of some advocates for the medical humanities!

    This neglect is commonly seen to reflect an agnosia among humanities towards sport, and competitive university sports in particular. However, attention to these aspects of students’ and doctors’ lives in the context of humanities could bear interesting fruit in terms of concepts of embodiment, philosophy, health promotion and insights into the struggles of life. An approach focusing on soccer has proved to be hugely successful in attracting students to a course on the humanities in Harvard University:51 for aesthetic philosophers and the medical humanities, football is indeed a beautiful game.47 An isolated paper from the anatomy literature provides an intriguing insight into how exercise and yoga might be usefully incorporated into the teaching of anatomy.52 Much more analysis is needed to build on what future doctors consider an important and valuable resource.

    Students value and use their arts and leisure activities to cope with challenging situations. As the medical humanities curricula continues to evolve it should look to this model of working within the familiar and comfortable, using existing strengths, to explore challenging situations and develop new skills to cope with them, and also to consider the role of new technologies. Most of the students used new technology on a daily basis to access their arts and leisure interests: 92% used their computers on a daily basis and 75% a digital device (such as iPod or iPad) or smartphone. New technology offers huge potential to bring the humanities into other environments, such as hospitals53 and to ensure patients have continued access to their important, regenerative and sustaining arts and leisure activities.54

    It would appear that medical students seek a productive use of the time available, and this is potentially a resource for medical humanities education. In terms of the ‘free time’ available to students, a majority of 3rd-year and 4th-year students at the University of Minnesota used the 24 weeks of ‘free time’ incorporated into the curriculum for education-related activities, such as research, interviewing for residencies, preparing for board exams and studying elsewhere.55

    The broader picture

    The examination of cultural engagement of medical students and doctors prompts reflection on how the medical humanities might be rethought in terms of a more positive view of the contributions and partnership of medicine. These find an echo in Werner Jaeger's perceptive view of a bidirectional relationship between medicine and philosophy in classical Greece: “In Phaedo Plato blames the early natural philosophers for their failure to consider the element of immanent purpose in the universe—a point which is closely connected with the organic view of nature. So what he looked for without success in natural philosophy he found in medical science”.56

    As Lidz notes, medicine provides for Plato a model which aids philosophy in understanding its task, while philosophy restrains the pretensions of medicine. Furthermore, it reminds us of the distinction between ends which are really worthy of pursuit and those which are only apparently so.57

    While a relatively small number of commentators have detected this contribution from the methodology of medicine to the development of moral philosophy,58 the similarities between the hypothetic-deductive method and hermeneutics,59 and parallels between reductionism in science and art,60 this aspect of the medical humanities would appear to be a topic suitable for further research. Encouragement for this is provided by the artistic and cultural outputs arising from the emerging phenomenon of Science Galleries.61

    If we examine other aspects of broader culture, other examples of the influence of medicine on the arts and humanities can be discerned, including mesmerism in German romantic literature,62 the role of his medical training and contemporary practice in Büchner's Woyzek,63 and the influence of advances in psychology and radiology on the art of Oskar Kokoschka.64 The work of Stephen Davies of Auckland on biological and evolutionary aspects of aesthetics,65 outlining a vista on art and aesthetics which positions art as an intrinsic part of our human nature, is a further aspect of the contribution of biology to aesthetics and culture.

    References to medicine and medical science abound in all of the arts, from music through poetry: Hans Magnus Enzensberger's Limbic System would be unthinkable without the advances of late 20th-century neuroscience,66 and the inspirational image of the evening spread out against the sky ‘Like a patient etherized upon a table’ in the Love Song of J Alfred Prufrock relates not to personal experience but rather to reading the accounts by William James’ account of ether-induced altered states of consciousness or ‘anaesthetic revelations.67 In both, advances in medical knowledge inform, illuminate and magnify our opportunities for the understanding of the human condition.

    Teasing out the medical in the medical humanities

    While there may be deserved criticism for dilettantism among clinicians in medical humanities, as exemplified by the Whiggish gentleman antiquarian in the history of medicine,68 and a recognition for the need for engaged clinicians to develop their academic capabilities in the humanities, to what extent should humanities academics in the medical humanities familiarise themselves more deeply with the processes of medicine, wellness and healthcare?

    For the minority engaged in substantive interdisciplinary research projects, the degree of mutual learning is likely to be significant, and probably represents the ideal focus upon which to build also credible undergraduate and postgraduate teaching. In disciplines such as bioethics, where the tradition of interdisciplinary working is more pronounced than in other fields of the medical humanities, the acquisition of a higher degree or doctorate in ethics or a related field such as philosophy or theology, would be considered to be quite normal for both clinicians and humanities scholars.

    For those not included in these areas, is there a role for a familiarisation course for humanities scholars in aspects of healthcare and medicine? In our unit we have developed a course in healthcare for artists who wish to work in healthcare settings, which has proved successful.69 It includes placements in clinical settings, and there is no indication that it has as yet subverted their critical faculties, or restricted their creativity to direct and instrumental application in medical situations. The development of such courses might also move us to encourage undergraduate students in the humanities to engage with the medical humanities, as an area of extraordinary interest and in terms of future academic and other forms of careers. In an ideal world, such undergraduate modules would include students and faculties from both the humanities and healthcare.70

    Conclusion

    It is clear that the future of the medical humanities lies in interdisciplinary engagement between medicine and the humanities, neither servile nor antagonistic, and requiring significant investment from all those so engaged. Our research has shown the richness of cultural engagement of medical students, their broad range of cultural interests and their ability to contribute to research and scholarship in the medical humanities.40–42 This gains importance in the context both of surveys of the cultural engagement of practicing doctors, and supportive engagement of many medical schools in the development of the medical humanities. Mutual recognition of strengths, weaknesses and differences of scholarly approach is critical to successful development of the enterprise. Recognising and building on the interests, sympathies and contributions of medicine and its practitioners to the medical humanities is a fundamental component of this task.

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    Footnotes

    • Twitter Follow Desmond O'Neill at @Age_Matters

    • Contributors EJ, RM, HM and DO designed, executed and wrote up a first draft of the study of medical students and arts, leisure and culture activities. EC, SO, CG and DO designed, executed and wrote up a first draft of the literature review on Plato on medicine. DO took a lead in writing the final combined paper with inputs from the group.

    • Competing interests None declared.

    • Ethics approval St James's/Tallaght/TCD Ethics Committee.

    • Provenance and peer review Not commissioned; externally peer reviewed.