Medical Education 1992, 26, 429-432
Humanitas in medical education M. MENKEN World Federation of Neurology Research Group on Neurological Education and Departments of Medicine arid Neurology, Robert Wood Johnson Medical School, N e w Brunswick, N e w Jersey
Key words: *educ, med, undergrad; *curriculum; teaching/*methods; learning; holistic health; humanities
expects its medical schools, and the profession as a whole, to respond appropriately to the priority health problems of the entire population, within a budget that the health system of the nation can afford. ]During the past 40 years medical schools (especially in the USA) have acquired some of the charactcristics of biomedical research institutes, and the ;great majority of the schools’ clinical staff are now hired, promoted and tenured on the basis of accomplishments in basic and clinical investigation, rather than interest or experience in paticnt care and teaching. Thus it is not surprisiing that value preferences of teaching staff call for a social contract with society that limits professional responsibility, to the successful completion of research projects designed by investigators themselves. Against such a perspectivc, a population orientation in care and teaching is a perceived obstacle that might diminish the scope of the medical schools’ biomedical research mission. The resultant discordance between the goals of society and its medical schools is amplified by internal tension in the teaching staff between its researchers, who often control policy, and its clinician-teachers, ccrtainly those who are in part office-based practitioner:; in the community. It has proved difficult for most medical schools to develop and implement a balanced curriculum, needed by all students as a generic preparation for the care of individual patients, yet one that also includes a population perspective as a framework for the provision of a full range of preventive, curative and rehabilitative services, at a cost that society can afford. Clearly, these twin gomals can be nurtured if medical educators are prepared to support the principles embodied in the Edinburgh Declaration (World Federation for Medical Education 1988). Having had thc
Introduction During the second half of this century, medical schools have been exposed to two major forces calling for educational reorientation, one specific for the individual student, and the other social in character. In neither case have many schools successfully adapted with foresight or an outlook conducive to innovation. First, the traditional purpose of medical school education, to prepare each student for practice after graduation, has been modified. At the present time, virtually all medical graduates are expected to complete an extended period of postgraduate vocational training as further preparation for unsupervised practice. There is a consensus that the purpose of the medical school experience for each student at present should be to acquire the common foundation of medical knowledge and skills needed by every doctor, regardless ofthe specific field of mcdical care chosen by the doctor for subsequent postgraduate study and practice. Instead, medical students often accumulate a chefs salad of specialized facts and vocational skills in a fragmented curriculum designed by individual departments, with little coordination of effort or a sense of collcctive purpose. The second major force for reorientation of medical education has been the growing tendency of many medical teachers to disregard the health of the population as a controlling factor of major importancc in curriculum design. Society Correspondence: Matthew Menken M D FACP, 1527 Highway 27, Somerset, NewJersey 08873, USA.
429
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.V. M e n ken
opportunity to advocate the Declaration’s 12 meritorious proposals for improvement o f medical education in the activities of the World Federation of Neurology Research Group on Neurological Education, I have developed a perspective pertaining to implementation that might be of some interest for other groups o f medical educators. Put summarily, it is my view that the success of the effort to translate the Declaration’s challenge into effective action depends, in part, upon the willingness of medical schools to redress their overriding failure to provide a liberal (unrpecializedj education in human medicine, in addition to a specialized education in biomedicine needed as a generic preparation for postgraduate training.
A liberal education in medicine Medical education is a continuous process that does not cease until the doctor retires from practice. Although the need for continuing education is evident, it may be appropriate to ask, education for what? The answer usually given is that the goal of undergraduate, postgraduate and continuing education is to improve professional competence and the quality of patient care. This response is certainly correct, but is it adequate? Is there not a responsibility that doctors have as humans and citizens, along with members of other social groups, to pursue throughout life the kind of general learning that is conducive to the ‘examined life’ worth living? If so, then one of the reforms of medical education needed at this time is a programme to reinforce the preparation of medical students for a lifetime o f general learning, in addition to the advancement of self-directed learning in the vocational aspects of medical practice and care. H o w else, one might ask, can the goal ofpreparing humanistic doctors be realized? Many educators seem to assume that medical students can acquire a completed liberal education before starting medical school, since very little liberal learning is included in the medical school curriculum, or for that matter in educational courses for practitioners - even though each of us knows from personal experience that this assumption is undoubtedly false. Medicine is not only a learned profession, but also a profession of continuous learning, like teaching. Youth
is certainly capable of acquiring the skills of learning, or learning how to learn, and organized knowledge. However, history teaches that youthfulness itself appears to be an insuperable obstacle to wisdom, and that continuous general learning is a necessary component of adult life. In my view, the medical school curriculum should be realigned as a bridge between the altogether unspecialized learning of the entrant to medicine and the wholly specialized learning of postgraduate vocational training. Every doctor should, by continuous study before, during and forever after medical school, become an educated man or woman (in the arts) first, and a specialist (in a branch of medicine) second; the medical school curriculum must be reoriented to reflect this fundamental conceptual dichotomy, if the goals of the Edinburgh Declaration arc to bc fully realized.
A humanitas programme It is a question o f introducing hurrianitar into the medical school curriculum, the general learning that should be the possession of all human beings. There is more than ample historical precedent for such an innovation that also provides a paradigm for implementation. For example, when medieval institutions first shaped the university, the four faculties of learning reflected such differences of purpose. The three advanced faculties oflaw, medicine and theology represented different fields of knowledge, yet shared the common goal of vocational training for practice. By comparison, the faculty of the arts examined all fields of learning, yet without regard for practical use. T h e arts were learned for the sake of learning, and not for vocational purposes. A humanistic education was, and continues to be, possible across the cntirc spectrum of knowledge, including biomcdicinc, provided that the field is studied without training in vocational knowledge and skills. H o w can medical schools incorporate humanitas (as a minor subject) into the curriculum, alongside the biomedical inforniation that is obviously the major field of study? Until thc 20th century, there was a consensus that diligent study of the venerated books of civilization was the path to a liberal education- those books (not
Humanitas in medical edu8:ation textbooks) that were thought to provide ‘the habitual vision of greatness’. In a modern industrialized society, has the scientific method rendered the literary masterpieces of our predecessors irrelevant for education, including a liberal education in human medicine? The question is not whether the experimental method of the empirical sciences is a valid or important method of inquiry, but whether it is the only valid source of information and insight in the domain of medical education. Much doubt is engendered by the observation that so much of medical practice does not consist of problem-solving, contrary to prevailing belief. Problems are definable difficulties whose solution depends upon the scientific method of hypothesis generation, fact-gathering, and hypothesis verification or disproof. Many of the predicaments, dilemmas and challenges of everyday medical practice are difficulties, not problems, since they cannot be defined, much less solved. The laboratory method provides little help for the doctor caring for patients who are cantankerous, uncooperative, lonely, socially disadvantaged, chronically disabled, or who value herbal or spiritual remedies more than biomedicine. Under such circumstances, it often seems to be the case that the reflective (armchair) method of inquiry traditionally employed in mathematics, philosophy and theology, rather than the scientific method, helps the doctor find ad hoc care protocols for these situations -a facet of medical practice often labelled the ‘art of medicine’. I would therefore propose that biweekly great books seminars of 2 hours’ duration throughout the preclinical and clinical years, employing the dialectic teaching method, might be the most effective framework for the introduction of humanitas into the medical school curriculum. (A doctrinal or didactic approach would be inappropriate, since books, not textbooks, would be probed and pondered.) The goal is to achieve a synthesis of what has been read with what the student has experienced, to attain an understanding of ideas, not facts or even knowledge about a specific subject matter. Clearly, special emphasis should be given to the great works ofour medical predecessors, including Hippocrates, Galen, Gilbert, Harvey, Copernicus, Locke, James, Rabelais and Freud, among others. The field of
43 1
medicine has also provided many celebrated authors., . such as Descartes and Bacon, with examples by means of which to apply their methods, and authors such as Montaigne, Ibsen and Shaw with the opportunity to express their many doubts about the value of medical care. As examples of the books that might be the subject matter for 10 such seminars, I provide the following suggestions, adapted from the recommendat.ions of Adler (1977) and Hutchins & Adler (1952) for adult seminars (selected readings from each book to be chosen by the mentor): (1) Aristotle: Ethics; Martin Buber: I and Thou (2) :Sigmund Freud: T h e Origin and Development of Psychoanalysis (3) Hippocrates: On Ancient Medicine; Galen: O n the Natural Faculties (4) WilliamJames: Principles OfPsychology; G. :Sorel: Reflections on Violence (5) William Harvey: T h e Motion ofthe Heart and Blood (6) Max Planck: Where is Science Going?; Nils .Bohr: Atomic Physics and Human .Knowledge (7) ‘The Old Testament: T h e Book ofEcclesiasres; J.J. Rousseau: T h e Social Contract (8) Charles Darwin: T h e Origin ofspecies; T. Dobzhansky: Genetics and the Origin .f Species (9) Copernicus: On the Revolutions of the Heavenly Spheres; J.H. Poincark: Science ,and Hypothesis (10) Spinoza: Ethics; R. Neibuhr: T h e Nature and Destiny of Man. As it is a fact of nature that there are more born poets tlhan born teachers, medical schools will need to reward and promote mentors of such seminars appropriately, and maintain a defined budget with adequate resources. Concliisions
There is a global consensus that medical education must be reoriented to meet current and future requirements ofsociety (World Federation for Medical Education 1988; World Health Organization 1991). Medical students now require a generic preparation for postgraduate training that will enable them to respond to the needs of groups of patients (communities), and
432
'Vl. Meriken
to meet the needs of individual patients in a humanistic manner. T h e seminal proposals o f t h e Edinburgh Declaration provide a framework for reform of medical education t o promote the health of all people. During the 20th century, each student's medical school experience has become a bridge between the general, unspecialized learning o f college, and the specialized vocational training of postgraduate w o r k in a medical specialty, including primary care. As such, the medical school curriculum should reflect a blend o f the organized knowledge in biomedicine needed b y all doctors, as well as the unspecialized information and insight (kutnariitas) that extend the students' liberal education, especially a liberal education in human medicine. This will prepare the student for a lifetime o f continued learning, to stay current with the ever-changing specialized knowledge and skills needed b y all doctors in their professional capacities, and t o continue the examination o f those unchanging ideas and issues required of all educated men and women in a learned profession, especially those ideas and issues that have been debated since antiquity in a continuous dialogue. What is the art of medicine? How is thc doctor-patient relationship itself therapeutic? When should thc doctor use a harmless placebo, letting nature run its course without interference? When is it appropriate to deviate from mcdical theory and standards of practice in particular cases? What is the nature o f the mind
vis-ci-vis the brain, and h o w docs it interact with the body in the pathogenesis and treatment o f illness? These are anioug the issues that have bcen part of an unending and unbroken conversation since antiquity, reflected in the exceptional books that are part o f our cultural heritage, and concerning which Hippocrates and Galcn can communicate with Harvey, Freud, Osler, and the current faculties of medical schools worldwide as if contemporaries (Hutchins & Adler 1952). I propose that educators ensure that medical students participate throughout the preclinical and clinical years in great books seminars that examine these concepts and questions. I n m y view, the assimilation of humnriitas into the medical school curriculum is an important step in the global effort to translate thc admirable goals o f the Edinburgh Declaration into accomplishments. References Adlcr M.J. (1977) R ~ f i i r w ~ i r rEducafiori: ~q The Opwrrr,q of th" Atnwicarr Mirid. Macmillan Publishing Conipany, New York. Hutchins R.M. &. Adler M.J. (1952) The grcat conversation: The substance of a liberal education; Thc great ideas: A syntopicon. Ericychpacdia Rriforirrica, Chicago. World Federation for Medical Education (1988) The Edinburgh Declaration. AV21edica/ Educafiori 22, 481-2; Lancet (1988) ii, 464. World Health Organization (1991) C/ioti,qiry .V.lcdico/ Educafiorr: Arr A'qoida f i r A c f i o r r . World Health Organization, Geneva.
Humanitas in medical education M. MENKEN World Federation of Neurology Research Group on Neurological Education and Departments of Medicine arid Neurology, Robert Wood Johnson Medical School, N e w Brunswick, N e w Jersey
Key words: *educ, med, undergrad; *curriculum; teaching/*methods; learning; holistic health; humanities
expects its medical schools, and the profession as a whole, to respond appropriately to the priority health problems of the entire population, within a budget that the health system of the nation can afford. ]During the past 40 years medical schools (especially in the USA) have acquired some of the charactcristics of biomedical research institutes, and the ;great majority of the schools’ clinical staff are now hired, promoted and tenured on the basis of accomplishments in basic and clinical investigation, rather than interest or experience in paticnt care and teaching. Thus it is not surprisiing that value preferences of teaching staff call for a social contract with society that limits professional responsibility, to the successful completion of research projects designed by investigators themselves. Against such a perspectivc, a population orientation in care and teaching is a perceived obstacle that might diminish the scope of the medical schools’ biomedical research mission. The resultant discordance between the goals of society and its medical schools is amplified by internal tension in the teaching staff between its researchers, who often control policy, and its clinician-teachers, ccrtainly those who are in part office-based practitioner:; in the community. It has proved difficult for most medical schools to develop and implement a balanced curriculum, needed by all students as a generic preparation for the care of individual patients, yet one that also includes a population perspective as a framework for the provision of a full range of preventive, curative and rehabilitative services, at a cost that society can afford. Clearly, these twin gomals can be nurtured if medical educators are prepared to support the principles embodied in the Edinburgh Declaration (World Federation for Medical Education 1988). Having had thc
Introduction During the second half of this century, medical schools have been exposed to two major forces calling for educational reorientation, one specific for the individual student, and the other social in character. In neither case have many schools successfully adapted with foresight or an outlook conducive to innovation. First, the traditional purpose of medical school education, to prepare each student for practice after graduation, has been modified. At the present time, virtually all medical graduates are expected to complete an extended period of postgraduate vocational training as further preparation for unsupervised practice. There is a consensus that the purpose of the medical school experience for each student at present should be to acquire the common foundation of medical knowledge and skills needed by every doctor, regardless ofthe specific field of mcdical care chosen by the doctor for subsequent postgraduate study and practice. Instead, medical students often accumulate a chefs salad of specialized facts and vocational skills in a fragmented curriculum designed by individual departments, with little coordination of effort or a sense of collcctive purpose. The second major force for reorientation of medical education has been the growing tendency of many medical teachers to disregard the health of the population as a controlling factor of major importancc in curriculum design. Society Correspondence: Matthew Menken M D FACP, 1527 Highway 27, Somerset, NewJersey 08873, USA.
429
430
.V. M e n ken
opportunity to advocate the Declaration’s 12 meritorious proposals for improvement o f medical education in the activities of the World Federation of Neurology Research Group on Neurological Education, I have developed a perspective pertaining to implementation that might be of some interest for other groups o f medical educators. Put summarily, it is my view that the success of the effort to translate the Declaration’s challenge into effective action depends, in part, upon the willingness of medical schools to redress their overriding failure to provide a liberal (unrpecializedj education in human medicine, in addition to a specialized education in biomedicine needed as a generic preparation for postgraduate training.
A liberal education in medicine Medical education is a continuous process that does not cease until the doctor retires from practice. Although the need for continuing education is evident, it may be appropriate to ask, education for what? The answer usually given is that the goal of undergraduate, postgraduate and continuing education is to improve professional competence and the quality of patient care. This response is certainly correct, but is it adequate? Is there not a responsibility that doctors have as humans and citizens, along with members of other social groups, to pursue throughout life the kind of general learning that is conducive to the ‘examined life’ worth living? If so, then one of the reforms of medical education needed at this time is a programme to reinforce the preparation of medical students for a lifetime o f general learning, in addition to the advancement of self-directed learning in the vocational aspects of medical practice and care. H o w else, one might ask, can the goal ofpreparing humanistic doctors be realized? Many educators seem to assume that medical students can acquire a completed liberal education before starting medical school, since very little liberal learning is included in the medical school curriculum, or for that matter in educational courses for practitioners - even though each of us knows from personal experience that this assumption is undoubtedly false. Medicine is not only a learned profession, but also a profession of continuous learning, like teaching. Youth
is certainly capable of acquiring the skills of learning, or learning how to learn, and organized knowledge. However, history teaches that youthfulness itself appears to be an insuperable obstacle to wisdom, and that continuous general learning is a necessary component of adult life. In my view, the medical school curriculum should be realigned as a bridge between the altogether unspecialized learning of the entrant to medicine and the wholly specialized learning of postgraduate vocational training. Every doctor should, by continuous study before, during and forever after medical school, become an educated man or woman (in the arts) first, and a specialist (in a branch of medicine) second; the medical school curriculum must be reoriented to reflect this fundamental conceptual dichotomy, if the goals of the Edinburgh Declaration arc to bc fully realized.
A humanitas programme It is a question o f introducing hurrianitar into the medical school curriculum, the general learning that should be the possession of all human beings. There is more than ample historical precedent for such an innovation that also provides a paradigm for implementation. For example, when medieval institutions first shaped the university, the four faculties of learning reflected such differences of purpose. The three advanced faculties oflaw, medicine and theology represented different fields of knowledge, yet shared the common goal of vocational training for practice. By comparison, the faculty of the arts examined all fields of learning, yet without regard for practical use. T h e arts were learned for the sake of learning, and not for vocational purposes. A humanistic education was, and continues to be, possible across the cntirc spectrum of knowledge, including biomcdicinc, provided that the field is studied without training in vocational knowledge and skills. H o w can medical schools incorporate humanitas (as a minor subject) into the curriculum, alongside the biomedical inforniation that is obviously the major field of study? Until thc 20th century, there was a consensus that diligent study of the venerated books of civilization was the path to a liberal education- those books (not
Humanitas in medical edu8:ation textbooks) that were thought to provide ‘the habitual vision of greatness’. In a modern industrialized society, has the scientific method rendered the literary masterpieces of our predecessors irrelevant for education, including a liberal education in human medicine? The question is not whether the experimental method of the empirical sciences is a valid or important method of inquiry, but whether it is the only valid source of information and insight in the domain of medical education. Much doubt is engendered by the observation that so much of medical practice does not consist of problem-solving, contrary to prevailing belief. Problems are definable difficulties whose solution depends upon the scientific method of hypothesis generation, fact-gathering, and hypothesis verification or disproof. Many of the predicaments, dilemmas and challenges of everyday medical practice are difficulties, not problems, since they cannot be defined, much less solved. The laboratory method provides little help for the doctor caring for patients who are cantankerous, uncooperative, lonely, socially disadvantaged, chronically disabled, or who value herbal or spiritual remedies more than biomedicine. Under such circumstances, it often seems to be the case that the reflective (armchair) method of inquiry traditionally employed in mathematics, philosophy and theology, rather than the scientific method, helps the doctor find ad hoc care protocols for these situations -a facet of medical practice often labelled the ‘art of medicine’. I would therefore propose that biweekly great books seminars of 2 hours’ duration throughout the preclinical and clinical years, employing the dialectic teaching method, might be the most effective framework for the introduction of humanitas into the medical school curriculum. (A doctrinal or didactic approach would be inappropriate, since books, not textbooks, would be probed and pondered.) The goal is to achieve a synthesis of what has been read with what the student has experienced, to attain an understanding of ideas, not facts or even knowledge about a specific subject matter. Clearly, special emphasis should be given to the great works ofour medical predecessors, including Hippocrates, Galen, Gilbert, Harvey, Copernicus, Locke, James, Rabelais and Freud, among others. The field of
43 1
medicine has also provided many celebrated authors., . such as Descartes and Bacon, with examples by means of which to apply their methods, and authors such as Montaigne, Ibsen and Shaw with the opportunity to express their many doubts about the value of medical care. As examples of the books that might be the subject matter for 10 such seminars, I provide the following suggestions, adapted from the recommendat.ions of Adler (1977) and Hutchins & Adler (1952) for adult seminars (selected readings from each book to be chosen by the mentor): (1) Aristotle: Ethics; Martin Buber: I and Thou (2) :Sigmund Freud: T h e Origin and Development of Psychoanalysis (3) Hippocrates: On Ancient Medicine; Galen: O n the Natural Faculties (4) WilliamJames: Principles OfPsychology; G. :Sorel: Reflections on Violence (5) William Harvey: T h e Motion ofthe Heart and Blood (6) Max Planck: Where is Science Going?; Nils .Bohr: Atomic Physics and Human .Knowledge (7) ‘The Old Testament: T h e Book ofEcclesiasres; J.J. Rousseau: T h e Social Contract (8) Charles Darwin: T h e Origin ofspecies; T. Dobzhansky: Genetics and the Origin .f Species (9) Copernicus: On the Revolutions of the Heavenly Spheres; J.H. Poincark: Science ,and Hypothesis (10) Spinoza: Ethics; R. Neibuhr: T h e Nature and Destiny of Man. As it is a fact of nature that there are more born poets tlhan born teachers, medical schools will need to reward and promote mentors of such seminars appropriately, and maintain a defined budget with adequate resources. Concliisions
There is a global consensus that medical education must be reoriented to meet current and future requirements ofsociety (World Federation for Medical Education 1988; World Health Organization 1991). Medical students now require a generic preparation for postgraduate training that will enable them to respond to the needs of groups of patients (communities), and
432
'Vl. Meriken
to meet the needs of individual patients in a humanistic manner. T h e seminal proposals o f t h e Edinburgh Declaration provide a framework for reform of medical education t o promote the health of all people. During the 20th century, each student's medical school experience has become a bridge between the general, unspecialized learning o f college, and the specialized vocational training of postgraduate w o r k in a medical specialty, including primary care. As such, the medical school curriculum should reflect a blend o f the organized knowledge in biomedicine needed b y all doctors, as well as the unspecialized information and insight (kutnariitas) that extend the students' liberal education, especially a liberal education in human medicine. This will prepare the student for a lifetime o f continued learning, to stay current with the ever-changing specialized knowledge and skills needed b y all doctors in their professional capacities, and t o continue the examination o f those unchanging ideas and issues required of all educated men and women in a learned profession, especially those ideas and issues that have been debated since antiquity in a continuous dialogue. What is the art of medicine? How is thc doctor-patient relationship itself therapeutic? When should thc doctor use a harmless placebo, letting nature run its course without interference? When is it appropriate to deviate from mcdical theory and standards of practice in particular cases? What is the nature o f the mind
vis-ci-vis the brain, and h o w docs it interact with the body in the pathogenesis and treatment o f illness? These are anioug the issues that have bcen part of an unending and unbroken conversation since antiquity, reflected in the exceptional books that are part o f our cultural heritage, and concerning which Hippocrates and Galcn can communicate with Harvey, Freud, Osler, and the current faculties of medical schools worldwide as if contemporaries (Hutchins & Adler 1952). I propose that educators ensure that medical students participate throughout the preclinical and clinical years in great books seminars that examine these concepts and questions. I n m y view, the assimilation of humnriitas into the medical school curriculum is an important step in the global effort to translate thc admirable goals o f the Edinburgh Declaration into accomplishments. References Adlcr M.J. (1977) R ~ f i i r w ~ i r rEducafiori: ~q The Opwrrr,q of th" Atnwicarr Mirid. Macmillan Publishing Conipany, New York. Hutchins R.M. &. Adler M.J. (1952) The grcat conversation: The substance of a liberal education; Thc great ideas: A syntopicon. Ericychpacdia Rriforirrica, Chicago. World Federation for Medical Education (1988) The Edinburgh Declaration. AV21edica/ Educafiori 22, 481-2; Lancet (1988) ii, 464. World Health Organization (1991) C/ioti,qiry .V.lcdico/ Educafiorr: Arr A'qoida f i r A c f i o r r . World Health Organization, Geneva.
