2015, 1–6, Early Online
Providing context for a medical school basic science curriculum: The importance of the humanities BRITTA M. THOMPSON1, JERRY B. VANNATTA2, LAURA E. SCOBEY2, MARK FERGESON2, HUMANITIES RESEARCH GROUP* & SHEILA M. CROW3 1
Penn State Hershey College of Medicine, USA, 2University of Oklahoma College of Medicine, USA, 3University of Oklahoma School of Community Medicine, USA
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Abstract Introduction: To increase students’ understanding of what it means to be a physician and engage in the everyday practice of medicine, a humanities program was implemented into the preclinical curriculum of the medical school curriculum. The purpose of our study was to determine how medical students’ views of being a doctor evolved after participating in a required humanities course. Methods: Medical students completing a 16-clock hour humanities course from 10 courses were asked to respond to an openended reflection question regarding changes, if any, of their views of being a doctor. The constant comparative method was used for coding; triangulation and a variety of techniques were used to provide evidence of validity of the analysis. Results: A majority of first- and second-year medical students (rr ¼ 70%) replied, resulting in 100 pages of text. A meta-theme of Contextualizing the Purpose of Medicine and three subthemes: the importance of Treating Patients Rather than a Disease, Understanding Observation Skills are Important, and Recognizing that Doctors are Fallible emerged from the data. Conclusions: Results suggest that requiring humanities as part of the required preclinical curriculum can have a positive influence on medical students and act as a bridge to contextualize the purpose of medicine.
Introduction During the first two years of medical school, students encounter a medical school curriculum that is mostly an objective, scientific endeavor that requires learning factual knowledge of the science of medicine and technical skills (Shapiro et al. 2009; Polianski & Fangerau 2012; Mullangi 2014). This biomedical model of care, which focuses on the detection and treatment of abnormal body structures and functions, has been the foundation of medical education since the original Flexner report. However, overreliance on this foundation has led to key groups such as the Institute of Medicine (Cuff & Vanselow 2004) and the Liaison Committee for Medical Education (LCME 2014) to call for the inclusion of biopsychosocial and humanities-related topics in medical education. Published literature has posited that the humanities disciplines of literature, history, philosophy, religion, art, law, among others, are inextricably linked to the everyday practice of medicine. The everyday practice of medicine includes empathy, healing, alleviating suffering, and caring for those who suffer (Vannatta et al. 2005). Proponents argue that the study of humanities can provide opportunities for students to
Practice points
Requiring a 16-hour humanities course that included visual arts, literature, and history allows medical students in the preclinical curriculum of medical school helped to contextualize the larger purpose of medicine. Humanities enhanced students’ view of doctoring by encouraging their observation skills, recognition of treating patients rather than diseases, and understanding the fallibility of doctors. Requiring students to take a humanities course does not adversely affect their ability to learn the requisite basic sciences during the first two years.
enhance their patient-centered skills, such as empathy and observation, and become well-rounded physicians (Shapiro et al. 2006; Naghshineh et al. 2008; Schwartz et al. 2009; Lewis 2011; Doukas et al. 2012). While many medical educators agree integrating humanities into medical education is important (Gulpinar et al. 2009),
Correspondence: Britta Thompson, Professor, Department of Medicine, Associate Dean for Learner Assessment and Program Evaluation, Penn State College of Medicine, Office of Medical Education, H123, 500 University Drive, Hershey, PA 17033, USA. Tel: +717 531 0003, ext. 280809; Fax: +717 531 4786; E-mail: [email protected]
*Humanities Research Group: Donald Bogan, Mary Zoe Baker, Mary Kay Gumerlock, Steve Orwig, Philip Minor, Hal Scofield, Andy Sullivan, Ernesto Sanchez & Sara Tracy ISSN 0142-159X print/ISSN 1466-187X online/15/000001–6 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1018878
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B. M. Thompson et al.
some may indicate that the humanities field is too subjective and takes time away from the packed educational requirements and demands placed on an already crowded curriculum (Dittrfich 2003; Mullangi 2013). In addition, many medical students report their experience with humanities courses as vague, irrelevant to their training, and a distraction from the biomedical sciences (Kumangai 2012). Perhaps even more problematic for medical humanities courses is the lack of empirical evidence to support or validate humanities’ positive contribution toward producing better physicians (Ousager & Johannessen 2010; Mullangi 2013). One frequently cited difficulty in measuring the impact of humanities education on medical students is that most humanities courses are offered as electives. Opponents suggest that students who participate in humanities courses are a selfselected group who may already possess more empathy than students who do not elect to participate in such course offerings (Schwartz et al. 2009; Shapiro et al. 2009). Our own efforts to integrate the humanities into our medical education program have taken a variety of forms over the past 10 years. As part of our preclinical curriculum renewal process, we implemented a required humanities program to foster students’ understanding of what it means to be a physician and engage in the everyday practice of medicine. Our goal was to eliminate the peripheral role of humanities as an elective course by incorporating humanities as a requirement early into the curriculum. The objective of our study was to gain insight into how first- and second-year medical students’ views of being a doctor evolved after participating in a required eight week humanities course.
Methods Humanities courses Since 2010, all first- and second-year medical students at The University of Oklahoma College of Medicine were required to participate in two 16-clock hour Enrichment program courses that included humanities, clinical service, and research. Within the humanities, students choose from one of six different courses offered in the fall or one of four different courses offered in the spring. Clinical and non-clinical faculty were recruited to develop these courses and serve as course directors, based on their area of interest and expertise. The size for each humanities course ranged from 8 to 20 students. In addition to basic science courses and the Enrichment program, students were also required to participate in a clinical ethics course during their second year as well as a clinical medicine course and a course on patients, physicians and society. Each of the classes met two hours a week for eight weeks. Reading and writing assignments and other activities outside of class were limited to no more than two hours a week. Small group discussions, experiential learning activities, and reflective writing assignments were applied across the courses. Educational materials included films, stories, poems, biographies, and visits to the local art museum. While the content, objectives, delivery, and facilitators across the humanities courses varied, the overarching goal was to provide students 2
with a connection between the humanities and the everyday practice of medicine. The humanities courses included: Addiction Medicine, Art of Observation, Death and Dying, Medical Reader’s Theater, Photography and Medicine, Spirituality and Medicine, History of Medicine, Law and Medicine, Virtue Ethics in Medicine, and Literature in Medicine.
Data collection Data were collected from four semesters (Spring 2011, Fall 2011, Spring 2012 and Fall 2012) of humanities courses. At the end of each humanities course, students were asked to respond to the following reflection question: ‘‘How have your views of being a doctor changed, if any, as a result of this course?’’ as part of the course evaluation. Written responses to the reflection question were collected from students in each course across the study period. This reflection question was administered anonymously by a research assistant via an online survey tool. Students were emailed a link with instructions regarding how to access the question; reminders were sent at one and two weeks. To determine if the 16-hour enrichment course had any effect on basic science performance, we also looked at USMLE Step 1 performance before and after the preclinical curriculum renewal that included the 16-hour Enrichment Program.
Data analysis The constant comparative method (Merriam 2009) was used for coding the textual data. A team of analysts included a core cadre of three faculty with expertise in medical education research and medical humanities education. In addition, six faculty involved in humanities education also participated in data analysis as expert checkers (Merriam 2009). The analysts first read all of the written comments, coding the comments into units, units into categories, and categories into themes. They engaged in a series of nine iterative sessions, each lasting approximately two hours. Each session involved reading, discussion, and graphic representation of the data. As categories and themes began to emerge, the data were also systematically searched for negative cases to test the categories and themes. To provide evidence of internal validity of the analysis, triangulation was used. Multiple investigators independently analyzed the data for emerging categories and themes and came to consensus during group discussions (Merriam 2009). Further validity evidence included using four semesters and analyzing each separately and then together to ensure consistency in analysis (Merriam 2009). To help readers better understand the themes, short quotes are provided throughout. These quotes are meant as representative(s) of the textual data and are not meant to be exhaustive of any particular theme. In addition, each quote represents either a part of or the entire written reflection from a different student. The University of Oklahoma Health Sciences Center IRB approved this study. This study had no external funding source.
Context for basic science curriculum: Humanities
Results In total, 137 of 197 basic science students who were administered the reflection question responded (response rate of 70%), resulting in 100 pages of double-spaced textual data. Using the constant comparative method, a meta-theme and three sub-themes were identified. Across the courses and semesters, the meta-theme was Contextualizing the Purpose of Medicine and subthemes included the importance of Treating Patients Rather than a Disease, Understanding Observation Skills are Important, and Recognizing that Doctors are Fallible. When the data were searched for negative cases, we noted that data from one course, ‘‘Law and Medicine’’ did not fit the themes identified.
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Meta-theme
Contextualizing the purpose of medicine The overarching theme of our data indicated the humanities courses provided the opportunity for students to grasp the bigger purpose of medicine. As one student wrote, This course has changed my views of being a doctor by broadening my sense of situations that doctors face on an every day basis. Each week in this class we read a new situation, some that I could sympathize with and some I could never see myself doing. No matter the situation though, there was always some vital lesson to be learned. Even if the lesson wasn’t clear-cut, the situations we read about brought touchy issues to the surface and forced us to consider them . . . This class allowed us to begin processing difficult situations and forced us to consider how we might react. I think this will be beneficial to my future as a physician because I’ve already stopped and considered situations that I will most definitely come across. Not only that, but I have thought about the moral implications of my actions in these situations and how my actions could potentially ripple out. In addition, each story provided an example of a doctor, some served as role models and some served to show us how to not be. They began to understand that medicine was not only about learning the basic sciences in the first two years, but also building skills in areas such as the humanities. As one student wrote, ‘‘a doctor needs to know more about a broader range of topics than strictly medical knowledge in order to be effective.’’ Students felt the Humanities allowed them to look beyond the basic science content they were learning and
In addition, through the Humanities courses, students recognized ‘‘many aspects of practicing medicine that are not necessarily emphasized in medical school, but perhaps should be.’’
Sub-themes Sub-themes included the realization that, as future physicians, they would be caring for patients with diseases, not diseases of patients. They gained understanding about the vital role of observation in the practice of medicine. Finally, students began to recognize that they were not above fallibility and in some cases, realized they might find themselves as a patient rather than a physician through their fallibility.
Treating patients rather than a disease As part of contextualizing the big pictures of medicine, students were able to appreciate they would be treating patients as a whole rather than just a disease. One student wrote that during their basic sciences curriculum, the Humanities course brought medicine back to being about people instead of diseases and treatments. This course made it clear why we practice medicine and how we actually do it, things I had not otherwise spent much time thinking about. Further, Humanities helped put the personhood into medicine. One student noted he/she came to realize medicine was about ‘‘healing the person as a whole, instead of prescribing a drug that will take away their symptoms’’, and another indicated that because of the Humanities course, they could ‘‘comfortably approach a patient as they are: a person.’’
Understanding observation skills are important We noted another sub-theme related to recognition of the importance and skill related to careful observation, whether in art-based, literature-based, or history-based humanities courses. Through the Humanities coursework, students realized how to more acutely observe situations and people . . . Studying situations with which I am unfamiliar helped me to become a more empathetic and effective physician and human being. My view on being a doctor has not necessarily changed, but rather has grown. Others described the Humanities as combining
realize the importance of exploring other areas of the world that are not just the hard, lab sciences . . . that getting every single answer right all of the time is not the ultimate goal of a physician; the ultimate goal should be to live a full life and help others do the same.
art and medicine by comparing the similarities and difference in both fields. Being taught an artist’s skills allows a person in the medical profession to gain observational experience that allows them to see what others might miss.
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Recognizing that doctors are fallible To students, contextualizing medicine meant recognizing doctors make mistakes and were fallible. Regardless of the specific humanities course, students were introduced or reminded about the fallibility of doctors. A representative comment included ‘‘physicians face the same struggles that the rest of the population faces and just because they are doctors doesn’t mean that they are going to recognize that they need help and that they will seek help.’’ They realized that sometimes ‘‘the doctor is the patient and that patient struggles . . . every day.’’
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Negative cases Interestingly, data from the Law and Medicine course did not fit into the themes identified in all the other humanities courses. When asked about how their views of being a doctor had changed, the overarching theme of students in this course was their resolve to continue to be ‘‘positive’’ and ‘‘unscathed’’ about their career choice despite feeling ‘‘bitter’’ or ‘‘jaded’’ by learning about the law as it pertained to medicine. One summed it up as I find myself in a hyper vigilant state. Attention to detail is critical in the health care service industry and the importance I ascribe to this is now greater. Fear is the wrong way to characterize my current thought process but it is not far from it. The course has filled me with a general unease . . . Upon reflection, the course was invariably depressing yet simultaneously enlightening. All too often students do not know enough to even ask a question. The Medicine and Law course offered an introduction to legalese and some of the broader issues confronting physicians and patients today.
Basic science performance Because opponents of the humanities suggest that there is no time to implement humanities into an already crowded curriculum, we examined USMLE Step 1 performance before and after the preclinical curriculum renewal with the 16hour Enrichment Program using the results from two cohorts before and after the program. We are pleased to report that USMLE Step 1 performance did not decrease in the three years after implementation of the program, and in fact increased after the overall curriculum renewal which included humanities.
Discussion Our data indicated that medical students were able to Contextualize the Purpose of Medicine after participating in a humanities course during their basic science (first and second year) training of medical school. Importantly, the addition of 16-hours of humanities did not seem to pose any negative impact on students’ opportunity to learn basic science content, as suggested by no adverse effect on USMLE Step 1 scores of 4
these students. These findings suggest that study, reflective writing, and small group discussions in humanities can provide a context – that of the patient as human – for the basic science core curriculum. Students were reminded there was more to being a doctor than just learning basic sciences. They also reported that they were able to recognize that it was vital to Treating Patients Rather than a Disease, Understanding Observation Skills are Important, and Recognizing that Doctors are Fallible through the humanities courses whether through visual arts, literary writings, and history. We were not surprised that students reported developing their observation skills through the humanities courses. Others have reported that the study of visual arts can promote what some refer to as ‘‘slow looking’’ or ‘‘deep seeing’’ (Perry et al. 2011; Doukas et al. 2012). Use of humanities can improve, at least in the short-term, comprehensive and disciplined clinical observation skills (Perry et al. 2011; Doukas et al. 2012). We were encouraged that students indicated that their view of being a physician had changed because they realized it was vital to treat patients rather than diseases. Our students reported being equipped, as the Institute of Medicine implored, ‘‘with the knowledge and skills from the behavioral and social sciences needed to recognize, understand, and effectively respond to patients as individuals, not just their symptoms’’ (Cuff & Vanselow 2004). This theme is similar to other researchers who have suggested that humanities can provide space for students to reflect on their own experiences and emotions and consider what it means to be a doctor (Rodenahuser et al. 2004; Lewis 2011; Mullangi 2013; Karkabi et al. 2014). Humanities allow students to reconnect with what it means to be human, improve empathy skills, and move beyond storytelling to ‘‘story listening’’ (Hurwitz & Charon 2013). While many humanities courses have been implemented as elective courses open to only a few students, all the students at The University of Oklahoma College of Medicine participate in a humanities course. In addition, we chose to implement our requirement early in the medical school curriculum. Our results suggest the importance of implementing humanities courses and suggest that early in medical school is appropriate and beneficial. We propose that the lessons students learn from humanities courses in the first and second year of medical school might act to habituate patient-centered attitudes and skills, perhaps inoculating students against the hidden curriculum especially prominent in the clinical curriculum (Doukas et al. 2012; Polianski & Fangerau 2012). Within the humanities, the disciplines of literature, art, history, philosophy, religion, and law are usually mentioned. It is interesting to note, however, that data from the Law and Medicine course were different from the other humanities courses that were offered. Students indicated they remained dedicated and positive about choosing medicine despite their newfound feelings of fear or jadedness. If one of the goals of humanities is to habituate patient-centered attitudes and skills and in inoculating against the hidden curriculum, perhaps early in medical school, then curriculum designers should be cognizant of the types of courses that are offered.
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Context for basic science curriculum: Humanities
The theme, Doctors are Fallible, is not typically reported in medical humanities educational research. Given that this theme emerged across the humanities offerings may suggest that students come to medical school with an idealized vision of being a doctor. More research is needed in this area. We propose that medical humanities can provide the space for medical students to acknowledge and discuss medical errors. It provides the opportunity for first- and second-year medical students to vicariously experience, before entering their clinical training years, medical errors and issues such as addictions and learn how others have dealt with them, both cognitively and emotionally. Although our results span several semesters of data, the results were based on student reflections from one school immediately after the students completed the course. However, based on our data analysis techniques (using multiple coders, multiple years of data, expert checkers, and negative case investigation) and existing literature, we think our results can be meaningful to any school considering implementing humanities courses within the medical school curriculum and those who have a humanities program. Future studies should include a longer term follow-up regarding outcomes of this program and potentially include additional data collection methodology.
student reflection, assessing cultural competency, and determining efficacy of curricular innovations such as humanities.
Conclusion
References
Our study suggests that integrating visual art, literature, and history-based humanities as part of the required basic science curriculum can have a positive influence on medical students. Through our 16-hour humanities program early in the medical school curriculum, we have been able to expose students to illness, suffering, and the everyday practice of medicine. Importantly, students indicated their view of doctoring had changed after completing the humanities course in areas such as developing their observations skills, recognizing the importance of treating patients (rather than just a disease), and broadening their view of what it means to be a doctor. They also realized how fallible they were and began to explore how to live with their fallibilities as a developing doctor. We are pleased that these gains did not negatively influence basic science learning, as noted by the fact that USMLE Step 1 performance did not decrease. These data provide evidence to refute the argument that humanities should not be added to an already burgeoning basic science curriculum. The data from this study suggest that the humanities can help provide medical students in their basic science years with a glimpse into the larger purpose of medicine. These courses may act as a bridge during the basic sciences to help students focus on the patient (including themselves) as a living body – a whole – rather than an abstract concept – a disease.
Cuff PA, Vanselow NA. 2004. Institute of Medicine (US) Committee on behavioral and social sciences in medical school curricula. Washington, DC: National Academies Press. Dittrfich LR. 2003. The humanities and medicine: Preface. Acad Med 78: 951–952. Doukas DJ, McCullough LB, Wear S. 2012. Medical education in medical ethics and humanities as the foundation for developing medical professionalism. Acad Med 87:334–341. Flexner A. 2010. Medical education in the United States and Canada: A report of the Carnegie Foundation for the Advancement of Teaching. New York: Carnegie Foundation for the Advancement of Teaching. [Accessed 9 August 2014] Available from http://www.carnegiefoundation.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf. Gulpinar MA, Akman M, User I. 2009. A course, ‘The Human in Medicine’, as an example of a preclinical medical humanities program: A summary of 7 years. Med Teach 31:e469–e476. Hurwitz B, Charon R. 2013. A narrative future for health care. The Lancet 381:1886–1887. Karkabi K, Wald HS, Castel OC. 2014. The use of abstract paintings and narratives to foster reflective capacity in medical educators: A multinational faculty development workshop. Med Humanit 40:44–48. Kumangai AK. 2012. Acts of interpretation: A philosophical approach to using creative arts in medical education. Acad Med 87:1138–1144. Lewis BE. 2011. Narrative and healthcare reform. J Med Humanit 32:9–20. Liaison Committee on Medical Education (LCME). 2014. Functions and structure of a medical school: Standards for accreditation of medical education programs leading to the M.D. degree. [Accessed 26 May 2014] Available from http://www.lcme.org/publications/2015-16-functions-and-structure-with-appendix.pdf. Merriam SB. 2009. Qualitative research: A guide to design and implementation. San Francisco, CA: John Wiley & Sons. Mullangi S. 2013. The synergy of medicine and art in the curriculum. Acad Med 88:921–923. Mullangi S. 2014. Presenting the case for the medical humanities. Vir Mentor 16:592–594. Naghshineh S, Hafler JP, Miller AR, Blanco MA, Lipsitz SR, Dubroff RP, Khoshbin S, Katz JT. 2008. Formal art observation training
Notes on contributors BRITTA M. THOMPSON, PhD, is an Associate Dean for Learner Assessment and Program Evaluation at Penn State Hershey College of Medicine. Her research in medical education includes evaluating activities that promote
JERRY B. VANNATTA, MD, is the John Flack Burton Professor of Humanities in Medicine and Professor of Internal Medicine at the University of Oklahoma College of Medicine. He teaches at the medical school as well as the Honor’s College on the Norman campus. Dr. Vannatta was the Executive Dean of OU Medical School. LAURA E. SCOBEY, BS, is the Coordinator of Evaluation at the University of Oklahoma College of Medicine where she manages course evaluations for the medical school curriculum. MARK FERGESON, MD, is the CMRI Harris D. Riley, Jr., MD Endowed Research Chair in Pediatric Education and Director for the Pediatric Clerkship Program at the University of Oklahoma College of Medicine. He is an Associate Professor in the Department of Pediatrics. HUMANITIES RESEARCH GROUP is a group of dedicated faculty at the University of Oklahoma dedicated to teaching and expanding the medical humanities for medical students as well as undergraduate students. SHEILA M. CROW, PhD, holds the George Kaiser Family Foundation Chair in Medical Education and serves as the Assistant Dean for Curriculum & Faculty Affairs at the University of Oklahoma School of Community Medicine – Tulsa, OK. She is also an Associate Professor in the Department of Pediatrics.
Declaration of interest: The authors have no interest to declare.
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improves medical students’ visual diagnostic skills. J Gen Intern Med 23:991–997. Ousager J, Johannessen H. 2010. Humanities in undergraduate medical education: A literature review. Acad Med 85:988–998. Perry M, Maffulli N, Willson S, Morrissey D. 2011. The effectiveness of artsbased interventions in medical education: A literature review. Med Educ 45(2):141–148. Polianski IJ, Fangerau H. 2012. Toward ‘‘harder’’ medical humanities: Moving beyond the ‘‘two cultures’’ dichotomy. Acad Med 87:121–126. Rodenahuser P, Strickland MA, Gambala CT. 2004. Arts-related activities across U.S. Medical Schools: A follow-up study. Teach Learn Med 16(3):233–239.
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Schwartz AW, Abramson JS, Wojnowich I, Accordino R, Ronan EJ, Rifkin MR. 2009. Evaluating the impact of the humanities in medical education. Mt Sinai J Med 76:372–380. Shapiro J, Coulehan J, Wear D, Montello M. 2009. Medical humanities and their discontents: Definitions, critiques, and implications. Acad Med 84: 192–198. Shapiro J, Rucker L, Beck J. 2006. Training the clinical eye and mind: Using the arts to develop medical students’ observational and pattern recognition skills. Med Educ 40:263–268. Vannatta J, Schleifer R, Crow S. 2005. Medicine and humanistic understanding: The significance of narrative in medical practices. Philadelphia, PA: University of Pennsylvania Press.
Providing context for a medical school basic science curriculum: The importance of the humanities BRITTA M. THOMPSON1, JERRY B. VANNATTA2, LAURA E. SCOBEY2, MARK FERGESON2, HUMANITIES RESEARCH GROUP* & SHEILA M. CROW3 1
Penn State Hershey College of Medicine, USA, 2University of Oklahoma College of Medicine, USA, 3University of Oklahoma School of Community Medicine, USA
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Abstract Introduction: To increase students’ understanding of what it means to be a physician and engage in the everyday practice of medicine, a humanities program was implemented into the preclinical curriculum of the medical school curriculum. The purpose of our study was to determine how medical students’ views of being a doctor evolved after participating in a required humanities course. Methods: Medical students completing a 16-clock hour humanities course from 10 courses were asked to respond to an openended reflection question regarding changes, if any, of their views of being a doctor. The constant comparative method was used for coding; triangulation and a variety of techniques were used to provide evidence of validity of the analysis. Results: A majority of first- and second-year medical students (rr ¼ 70%) replied, resulting in 100 pages of text. A meta-theme of Contextualizing the Purpose of Medicine and three subthemes: the importance of Treating Patients Rather than a Disease, Understanding Observation Skills are Important, and Recognizing that Doctors are Fallible emerged from the data. Conclusions: Results suggest that requiring humanities as part of the required preclinical curriculum can have a positive influence on medical students and act as a bridge to contextualize the purpose of medicine.
Introduction During the first two years of medical school, students encounter a medical school curriculum that is mostly an objective, scientific endeavor that requires learning factual knowledge of the science of medicine and technical skills (Shapiro et al. 2009; Polianski & Fangerau 2012; Mullangi 2014). This biomedical model of care, which focuses on the detection and treatment of abnormal body structures and functions, has been the foundation of medical education since the original Flexner report. However, overreliance on this foundation has led to key groups such as the Institute of Medicine (Cuff & Vanselow 2004) and the Liaison Committee for Medical Education (LCME 2014) to call for the inclusion of biopsychosocial and humanities-related topics in medical education. Published literature has posited that the humanities disciplines of literature, history, philosophy, religion, art, law, among others, are inextricably linked to the everyday practice of medicine. The everyday practice of medicine includes empathy, healing, alleviating suffering, and caring for those who suffer (Vannatta et al. 2005). Proponents argue that the study of humanities can provide opportunities for students to
Practice points
Requiring a 16-hour humanities course that included visual arts, literature, and history allows medical students in the preclinical curriculum of medical school helped to contextualize the larger purpose of medicine. Humanities enhanced students’ view of doctoring by encouraging their observation skills, recognition of treating patients rather than diseases, and understanding the fallibility of doctors. Requiring students to take a humanities course does not adversely affect their ability to learn the requisite basic sciences during the first two years.
enhance their patient-centered skills, such as empathy and observation, and become well-rounded physicians (Shapiro et al. 2006; Naghshineh et al. 2008; Schwartz et al. 2009; Lewis 2011; Doukas et al. 2012). While many medical educators agree integrating humanities into medical education is important (Gulpinar et al. 2009),
Correspondence: Britta Thompson, Professor, Department of Medicine, Associate Dean for Learner Assessment and Program Evaluation, Penn State College of Medicine, Office of Medical Education, H123, 500 University Drive, Hershey, PA 17033, USA. Tel: +717 531 0003, ext. 280809; Fax: +717 531 4786; E-mail: [email protected]
*Humanities Research Group: Donald Bogan, Mary Zoe Baker, Mary Kay Gumerlock, Steve Orwig, Philip Minor, Hal Scofield, Andy Sullivan, Ernesto Sanchez & Sara Tracy ISSN 0142-159X print/ISSN 1466-187X online/15/000001–6 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1018878
1
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B. M. Thompson et al.
some may indicate that the humanities field is too subjective and takes time away from the packed educational requirements and demands placed on an already crowded curriculum (Dittrfich 2003; Mullangi 2013). In addition, many medical students report their experience with humanities courses as vague, irrelevant to their training, and a distraction from the biomedical sciences (Kumangai 2012). Perhaps even more problematic for medical humanities courses is the lack of empirical evidence to support or validate humanities’ positive contribution toward producing better physicians (Ousager & Johannessen 2010; Mullangi 2013). One frequently cited difficulty in measuring the impact of humanities education on medical students is that most humanities courses are offered as electives. Opponents suggest that students who participate in humanities courses are a selfselected group who may already possess more empathy than students who do not elect to participate in such course offerings (Schwartz et al. 2009; Shapiro et al. 2009). Our own efforts to integrate the humanities into our medical education program have taken a variety of forms over the past 10 years. As part of our preclinical curriculum renewal process, we implemented a required humanities program to foster students’ understanding of what it means to be a physician and engage in the everyday practice of medicine. Our goal was to eliminate the peripheral role of humanities as an elective course by incorporating humanities as a requirement early into the curriculum. The objective of our study was to gain insight into how first- and second-year medical students’ views of being a doctor evolved after participating in a required eight week humanities course.
Methods Humanities courses Since 2010, all first- and second-year medical students at The University of Oklahoma College of Medicine were required to participate in two 16-clock hour Enrichment program courses that included humanities, clinical service, and research. Within the humanities, students choose from one of six different courses offered in the fall or one of four different courses offered in the spring. Clinical and non-clinical faculty were recruited to develop these courses and serve as course directors, based on their area of interest and expertise. The size for each humanities course ranged from 8 to 20 students. In addition to basic science courses and the Enrichment program, students were also required to participate in a clinical ethics course during their second year as well as a clinical medicine course and a course on patients, physicians and society. Each of the classes met two hours a week for eight weeks. Reading and writing assignments and other activities outside of class were limited to no more than two hours a week. Small group discussions, experiential learning activities, and reflective writing assignments were applied across the courses. Educational materials included films, stories, poems, biographies, and visits to the local art museum. While the content, objectives, delivery, and facilitators across the humanities courses varied, the overarching goal was to provide students 2
with a connection between the humanities and the everyday practice of medicine. The humanities courses included: Addiction Medicine, Art of Observation, Death and Dying, Medical Reader’s Theater, Photography and Medicine, Spirituality and Medicine, History of Medicine, Law and Medicine, Virtue Ethics in Medicine, and Literature in Medicine.
Data collection Data were collected from four semesters (Spring 2011, Fall 2011, Spring 2012 and Fall 2012) of humanities courses. At the end of each humanities course, students were asked to respond to the following reflection question: ‘‘How have your views of being a doctor changed, if any, as a result of this course?’’ as part of the course evaluation. Written responses to the reflection question were collected from students in each course across the study period. This reflection question was administered anonymously by a research assistant via an online survey tool. Students were emailed a link with instructions regarding how to access the question; reminders were sent at one and two weeks. To determine if the 16-hour enrichment course had any effect on basic science performance, we also looked at USMLE Step 1 performance before and after the preclinical curriculum renewal that included the 16-hour Enrichment Program.
Data analysis The constant comparative method (Merriam 2009) was used for coding the textual data. A team of analysts included a core cadre of three faculty with expertise in medical education research and medical humanities education. In addition, six faculty involved in humanities education also participated in data analysis as expert checkers (Merriam 2009). The analysts first read all of the written comments, coding the comments into units, units into categories, and categories into themes. They engaged in a series of nine iterative sessions, each lasting approximately two hours. Each session involved reading, discussion, and graphic representation of the data. As categories and themes began to emerge, the data were also systematically searched for negative cases to test the categories and themes. To provide evidence of internal validity of the analysis, triangulation was used. Multiple investigators independently analyzed the data for emerging categories and themes and came to consensus during group discussions (Merriam 2009). Further validity evidence included using four semesters and analyzing each separately and then together to ensure consistency in analysis (Merriam 2009). To help readers better understand the themes, short quotes are provided throughout. These quotes are meant as representative(s) of the textual data and are not meant to be exhaustive of any particular theme. In addition, each quote represents either a part of or the entire written reflection from a different student. The University of Oklahoma Health Sciences Center IRB approved this study. This study had no external funding source.
Context for basic science curriculum: Humanities
Results In total, 137 of 197 basic science students who were administered the reflection question responded (response rate of 70%), resulting in 100 pages of double-spaced textual data. Using the constant comparative method, a meta-theme and three sub-themes were identified. Across the courses and semesters, the meta-theme was Contextualizing the Purpose of Medicine and subthemes included the importance of Treating Patients Rather than a Disease, Understanding Observation Skills are Important, and Recognizing that Doctors are Fallible. When the data were searched for negative cases, we noted that data from one course, ‘‘Law and Medicine’’ did not fit the themes identified.
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Meta-theme
Contextualizing the purpose of medicine The overarching theme of our data indicated the humanities courses provided the opportunity for students to grasp the bigger purpose of medicine. As one student wrote, This course has changed my views of being a doctor by broadening my sense of situations that doctors face on an every day basis. Each week in this class we read a new situation, some that I could sympathize with and some I could never see myself doing. No matter the situation though, there was always some vital lesson to be learned. Even if the lesson wasn’t clear-cut, the situations we read about brought touchy issues to the surface and forced us to consider them . . . This class allowed us to begin processing difficult situations and forced us to consider how we might react. I think this will be beneficial to my future as a physician because I’ve already stopped and considered situations that I will most definitely come across. Not only that, but I have thought about the moral implications of my actions in these situations and how my actions could potentially ripple out. In addition, each story provided an example of a doctor, some served as role models and some served to show us how to not be. They began to understand that medicine was not only about learning the basic sciences in the first two years, but also building skills in areas such as the humanities. As one student wrote, ‘‘a doctor needs to know more about a broader range of topics than strictly medical knowledge in order to be effective.’’ Students felt the Humanities allowed them to look beyond the basic science content they were learning and
In addition, through the Humanities courses, students recognized ‘‘many aspects of practicing medicine that are not necessarily emphasized in medical school, but perhaps should be.’’
Sub-themes Sub-themes included the realization that, as future physicians, they would be caring for patients with diseases, not diseases of patients. They gained understanding about the vital role of observation in the practice of medicine. Finally, students began to recognize that they were not above fallibility and in some cases, realized they might find themselves as a patient rather than a physician through their fallibility.
Treating patients rather than a disease As part of contextualizing the big pictures of medicine, students were able to appreciate they would be treating patients as a whole rather than just a disease. One student wrote that during their basic sciences curriculum, the Humanities course brought medicine back to being about people instead of diseases and treatments. This course made it clear why we practice medicine and how we actually do it, things I had not otherwise spent much time thinking about. Further, Humanities helped put the personhood into medicine. One student noted he/she came to realize medicine was about ‘‘healing the person as a whole, instead of prescribing a drug that will take away their symptoms’’, and another indicated that because of the Humanities course, they could ‘‘comfortably approach a patient as they are: a person.’’
Understanding observation skills are important We noted another sub-theme related to recognition of the importance and skill related to careful observation, whether in art-based, literature-based, or history-based humanities courses. Through the Humanities coursework, students realized how to more acutely observe situations and people . . . Studying situations with which I am unfamiliar helped me to become a more empathetic and effective physician and human being. My view on being a doctor has not necessarily changed, but rather has grown. Others described the Humanities as combining
realize the importance of exploring other areas of the world that are not just the hard, lab sciences . . . that getting every single answer right all of the time is not the ultimate goal of a physician; the ultimate goal should be to live a full life and help others do the same.
art and medicine by comparing the similarities and difference in both fields. Being taught an artist’s skills allows a person in the medical profession to gain observational experience that allows them to see what others might miss.
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Recognizing that doctors are fallible To students, contextualizing medicine meant recognizing doctors make mistakes and were fallible. Regardless of the specific humanities course, students were introduced or reminded about the fallibility of doctors. A representative comment included ‘‘physicians face the same struggles that the rest of the population faces and just because they are doctors doesn’t mean that they are going to recognize that they need help and that they will seek help.’’ They realized that sometimes ‘‘the doctor is the patient and that patient struggles . . . every day.’’
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Negative cases Interestingly, data from the Law and Medicine course did not fit into the themes identified in all the other humanities courses. When asked about how their views of being a doctor had changed, the overarching theme of students in this course was their resolve to continue to be ‘‘positive’’ and ‘‘unscathed’’ about their career choice despite feeling ‘‘bitter’’ or ‘‘jaded’’ by learning about the law as it pertained to medicine. One summed it up as I find myself in a hyper vigilant state. Attention to detail is critical in the health care service industry and the importance I ascribe to this is now greater. Fear is the wrong way to characterize my current thought process but it is not far from it. The course has filled me with a general unease . . . Upon reflection, the course was invariably depressing yet simultaneously enlightening. All too often students do not know enough to even ask a question. The Medicine and Law course offered an introduction to legalese and some of the broader issues confronting physicians and patients today.
Basic science performance Because opponents of the humanities suggest that there is no time to implement humanities into an already crowded curriculum, we examined USMLE Step 1 performance before and after the preclinical curriculum renewal with the 16hour Enrichment Program using the results from two cohorts before and after the program. We are pleased to report that USMLE Step 1 performance did not decrease in the three years after implementation of the program, and in fact increased after the overall curriculum renewal which included humanities.
Discussion Our data indicated that medical students were able to Contextualize the Purpose of Medicine after participating in a humanities course during their basic science (first and second year) training of medical school. Importantly, the addition of 16-hours of humanities did not seem to pose any negative impact on students’ opportunity to learn basic science content, as suggested by no adverse effect on USMLE Step 1 scores of 4
these students. These findings suggest that study, reflective writing, and small group discussions in humanities can provide a context – that of the patient as human – for the basic science core curriculum. Students were reminded there was more to being a doctor than just learning basic sciences. They also reported that they were able to recognize that it was vital to Treating Patients Rather than a Disease, Understanding Observation Skills are Important, and Recognizing that Doctors are Fallible through the humanities courses whether through visual arts, literary writings, and history. We were not surprised that students reported developing their observation skills through the humanities courses. Others have reported that the study of visual arts can promote what some refer to as ‘‘slow looking’’ or ‘‘deep seeing’’ (Perry et al. 2011; Doukas et al. 2012). Use of humanities can improve, at least in the short-term, comprehensive and disciplined clinical observation skills (Perry et al. 2011; Doukas et al. 2012). We were encouraged that students indicated that their view of being a physician had changed because they realized it was vital to treat patients rather than diseases. Our students reported being equipped, as the Institute of Medicine implored, ‘‘with the knowledge and skills from the behavioral and social sciences needed to recognize, understand, and effectively respond to patients as individuals, not just their symptoms’’ (Cuff & Vanselow 2004). This theme is similar to other researchers who have suggested that humanities can provide space for students to reflect on their own experiences and emotions and consider what it means to be a doctor (Rodenahuser et al. 2004; Lewis 2011; Mullangi 2013; Karkabi et al. 2014). Humanities allow students to reconnect with what it means to be human, improve empathy skills, and move beyond storytelling to ‘‘story listening’’ (Hurwitz & Charon 2013). While many humanities courses have been implemented as elective courses open to only a few students, all the students at The University of Oklahoma College of Medicine participate in a humanities course. In addition, we chose to implement our requirement early in the medical school curriculum. Our results suggest the importance of implementing humanities courses and suggest that early in medical school is appropriate and beneficial. We propose that the lessons students learn from humanities courses in the first and second year of medical school might act to habituate patient-centered attitudes and skills, perhaps inoculating students against the hidden curriculum especially prominent in the clinical curriculum (Doukas et al. 2012; Polianski & Fangerau 2012). Within the humanities, the disciplines of literature, art, history, philosophy, religion, and law are usually mentioned. It is interesting to note, however, that data from the Law and Medicine course were different from the other humanities courses that were offered. Students indicated they remained dedicated and positive about choosing medicine despite their newfound feelings of fear or jadedness. If one of the goals of humanities is to habituate patient-centered attitudes and skills and in inoculating against the hidden curriculum, perhaps early in medical school, then curriculum designers should be cognizant of the types of courses that are offered.
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Context for basic science curriculum: Humanities
The theme, Doctors are Fallible, is not typically reported in medical humanities educational research. Given that this theme emerged across the humanities offerings may suggest that students come to medical school with an idealized vision of being a doctor. More research is needed in this area. We propose that medical humanities can provide the space for medical students to acknowledge and discuss medical errors. It provides the opportunity for first- and second-year medical students to vicariously experience, before entering their clinical training years, medical errors and issues such as addictions and learn how others have dealt with them, both cognitively and emotionally. Although our results span several semesters of data, the results were based on student reflections from one school immediately after the students completed the course. However, based on our data analysis techniques (using multiple coders, multiple years of data, expert checkers, and negative case investigation) and existing literature, we think our results can be meaningful to any school considering implementing humanities courses within the medical school curriculum and those who have a humanities program. Future studies should include a longer term follow-up regarding outcomes of this program and potentially include additional data collection methodology.
student reflection, assessing cultural competency, and determining efficacy of curricular innovations such as humanities.
Conclusion
References
Our study suggests that integrating visual art, literature, and history-based humanities as part of the required basic science curriculum can have a positive influence on medical students. Through our 16-hour humanities program early in the medical school curriculum, we have been able to expose students to illness, suffering, and the everyday practice of medicine. Importantly, students indicated their view of doctoring had changed after completing the humanities course in areas such as developing their observations skills, recognizing the importance of treating patients (rather than just a disease), and broadening their view of what it means to be a doctor. They also realized how fallible they were and began to explore how to live with their fallibilities as a developing doctor. We are pleased that these gains did not negatively influence basic science learning, as noted by the fact that USMLE Step 1 performance did not decrease. These data provide evidence to refute the argument that humanities should not be added to an already burgeoning basic science curriculum. The data from this study suggest that the humanities can help provide medical students in their basic science years with a glimpse into the larger purpose of medicine. These courses may act as a bridge during the basic sciences to help students focus on the patient (including themselves) as a living body – a whole – rather than an abstract concept – a disease.
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Notes on contributors BRITTA M. THOMPSON, PhD, is an Associate Dean for Learner Assessment and Program Evaluation at Penn State Hershey College of Medicine. Her research in medical education includes evaluating activities that promote
JERRY B. VANNATTA, MD, is the John Flack Burton Professor of Humanities in Medicine and Professor of Internal Medicine at the University of Oklahoma College of Medicine. He teaches at the medical school as well as the Honor’s College on the Norman campus. Dr. Vannatta was the Executive Dean of OU Medical School. LAURA E. SCOBEY, BS, is the Coordinator of Evaluation at the University of Oklahoma College of Medicine where she manages course evaluations for the medical school curriculum. MARK FERGESON, MD, is the CMRI Harris D. Riley, Jr., MD Endowed Research Chair in Pediatric Education and Director for the Pediatric Clerkship Program at the University of Oklahoma College of Medicine. He is an Associate Professor in the Department of Pediatrics. HUMANITIES RESEARCH GROUP is a group of dedicated faculty at the University of Oklahoma dedicated to teaching and expanding the medical humanities for medical students as well as undergraduate students. SHEILA M. CROW, PhD, holds the George Kaiser Family Foundation Chair in Medical Education and serves as the Assistant Dean for Curriculum & Faculty Affairs at the University of Oklahoma School of Community Medicine – Tulsa, OK. She is also an Associate Professor in the Department of Pediatrics.
Declaration of interest: The authors have no interest to declare.
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