Medical Humanities: Oxymoron or Opportunity?

1. Medical Humanities:OxymoronorOpportunity? Louise Aronson, MD, MFA Division of Geriatrics Department of Medicine University of California, San Francisco

2. Medical Humanities: Common Questions • “Medical what?” • “What does it have to do with me/ my practice?” • “Is it really anything more than entertainment?”

3. “As our understanding of the mechanisms of disease and the technology for diagnosing and healing become more complex, so too do the human questions that accompany them. Science still hasn’t found a way to break the human condition into neat parts, or to understand the nonphysical aspects of illness, wellness, mortality, values or spirituality.” Dittrich, Acad Med 2003

4. “Medical practice is poised astride insoluble tensions between the known and the unknown, the universal and the particular, and the body and the self…The question is not simply whether medicine is instrumental or imaginative…It has, rather, to do with the nature of health, the problem of pain, the sources of suffering, and the fact of death. These questions are as big as questions get…” Charon, Lancet 2008

5. Critical Question: Do the Medical Humanities help us with medicine’s ‘human questions’?

6. Other Questions • Do the ‘human questions’ matter in medicine? • How much should they matter? • Do we need to (try to) answer them to provide good medical care? • Do they matter to you? In your practice?

7. Overview of the Talk • Key terms and concepts • Controversies • History • Applications to medicine • Oxymoron or opportunity?

8. Oxymoron a figure of speech that combines two apparently contradictory terms half naked fresh frozen definite maybe Definitions

9. Medicine: the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease Humanities:   the branches of learning that investigate human experience, constructs and concerns Definitions

10. Medical Humanities • “…for lack of a better term” • Field which uses the tools and content of the humanities in service of medical education and patient care • Interdisciplinary: based on the premise that the questions posed by contemporary health care dilemmas can’t be adequately addressed by a single discipline. Campo, JAMA 2005

11. Medical Humanities: Subject Areas History Literature Ethics Performing Arts Philosophy Anthropology Linguistics Visual Art Law Languages Religious Studies Creative Writing

12. Humanities: Methods and Skills • Methods • Rigorous and systematic approach • Critical appraisal, reasoning and judgment • Analysis but also synthesis and interpretation • Exploration, evaluation, critique, questioning, integration • Reflection on thoughts, feelings, values, and experience • Skills • Observational accuracy • Expressive clarity • Ability to envision alternative possibilities • Tolerance of ambiguity, uncertainty, complexity • Appreciation of the experience of others • Engagement of emotions as well as intellect • Emphasis on value, purpose, and meaning Bolton, Lancet 2003; Edgar, J Med Ethics 2006; Hetland, Studio Thinking, 2007

14. Translation • Acknowledgement and affirmation of pt’s, family’s, caregivers’, and colleagues’ perspectives • Facilitation of critical reflection on practice to build on strengths and correct weaknesses • Nurturing of the skills essential to the art of medicine: caregiving, communication, empathy and professionalism • Support for the innate humanity, imagination, and individuality of medical professionals

15. And yet “… it’s surprisingly difficult to say with any degree of clarity what medical humanities is…Medical humanities relates to, but is not identical with, the art of medicine, for which nowadays we often use the word “doctoring.” Doctoring requires communication skills, empathy, self-awareness, judgment, professionalism, and mastering the social and cultural context of personhood, illness, and health care.” Jack Coulehan, M.D., M.P.H., Professor Emeritus of Preventive Medicine and Fellow, Center for Medical Humanities and Bioethics, Stony Brook, New York

16. Controversy I: Theoretical • A person can be good at ‘doctoring’ without studying the humanities • Medicine and the Humanities are incompatible cultures • Medicine is scientifically-based; the humanities are metaphysical, ‘soft’, hard to quantify • MH doesn’t actually use most of the methods or content of the humanities • There’s little data showing that MH actually works • The MH lack the rigor of the Humanities

17. Controversy II: Why MH? • Instrumental argument • Teach important ‘transferrable’ skills • Writing, reasoning, interpretation, observation • Personal and professional development • Inherent value argument • Being ‘educated’ instead of merely ‘trained’ • Counterculture to medicine Gillon, J Med Ethics 2000

18. Controversy III: How to Integrate? • Culture change • Revise entire curriculum through MH lens • No separation of science and art of medicine • MH as integral; medicine as truly interdisciplinary • Independent academic discipline • Like pediatrics or genetics • Own faculty, journals, courses

20. MH: History • Flexner report 1910 • Tighter standards for admission, training • Emphasis on allopathic approach • germ theory and scientific method • Medicine became more university-based but also more distinct from other parts of univ • And yet…Flexner 1925 • the medical curriculum overweights the scientific aspects of medicine to the exclusion of the social and humanistic aspects Flexner, Med Ed in US and Canada 1910; Cooke, N Engl J Med 2006

22. MH History: 1960’s • ↑ interest in 1º care, pt-centered care • In line with social movements • The right to health as political • Society for Health and Human Values • Art of clinical judgment, morality of medicine • MH Depts formed at Penn State and SIU Note: MH developed from w/in medicine, not from humanities departments

24. MH History: 1970’s & 80’s • New hostility to medical profession • Physicians as unfeeling and authoritarian • Desire for greater involvement in decisions • Notion of personalized care • ABIM task force to assess humanistic qualities in residency training • “Pre-med syndrome” NEJM 1978 • Rise of consumer advocacy among pts Dolan, Applied Med Hum, 2007

26. “I have been told that there are two pillars in medicine – science and humanism. As basic scientists build up the first pillar during the preclinical years and neglect the construction and maintenance of the second, students learn to treat patients as they might treat an experimental mouse. Idealistic notions of altruism, honesty and integrity that attracted many to the calling of medicine are mentioned in the white coat ceremony, talked about by deans, and actively discouraged through the acculturation process.” - Chen Kenyon MSII Jones, Acad Med 2003

27. MH History: 1990’s • 1990: 1/3 US med schools teaching MH • NYU literature and medicine database • Acad Med 1995 issue devoted to MH • JAMA, Lancet, etc. add humanities • 1999: 75% US med schools teaching MH • Exponential growth in med hum depts, divisions, centers and institutes

28. Competencies • 1999 AAMC Medical School Objectives • MDs must • be altruistic, recognize their limitations, and seek to understand the meaning of pt’s stories • be knowledgeable about traditional and non-trad care, seek to relieve pain, ameliorate suffering & be effective communicators • be dutiful, collaborative and care for the underserved • 1999 ACGME • Patient Care • that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Acad Med 1999; ACGME.org

29. ACGME Competencies cont’d • Medical Knowledge • about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care • Practice-Based Learning and Improvement • that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care • Interpersonal and Communication Skills • that result in effective information exchange and teaming with patients, their families, and other health professionals • Professionalism • as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population • Systems-Based Practice • as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

30. Applications: Some examples • “Humanities by any other name…” • Narrative medicine • Music and medicine • MH as patient care tool • Reflective writing • Medical education

31. “A Rose is a Rose” • Much humanities already incorporated in curricula over last 20 years but not acknowledged as such • Ethics • Case-based learning • ↑essays, reflections, portfolios • Social medicine, multiculturalism • Integrated, interdisciplinary courses

32. Narrative Medicine • Narrative defined • An event told as a story • Character and action, not argument and exposition • More than a simple relaying • “Living through, not just knowledge about…” • Making sense of events • Field which uses writing and literature to provide clinicians with the skills – “narrative competence” – to recognize, absorb, metabolize, interpret, and be moved by the stories of illness Charon, N Engl J Med 2004

33. Narrative in Medicine • Patient history/medical interview • Case presentations • Rounds, grand rounds, conferences • Chart notes and consultations • Jokes and ‘tales from the trenches’ • The medical literature • Academic and scholarly work

34. Journals with MH Content

35. Doctor Stories • Medical fiction • Invented stories about drs & pts; transcending fact to get at truth • William Carlos Williams, Chekhov , Maugham, Lam • Public writing • The New Yorker’s “Annals of Medicine” • Groopman, Gawande, Sachs • Advocacy journalism • Medical autobiography • Stories of training and practice • Klass, Connor, Verghese, Transue, Connor • Stories from practice • JAMA “A Piece of My Mind”, Annals IM “On Being a Doctor” • Essay collections: Ofri, Selzer

36. Patient Stories • Fiction and poetry about illness • Tolstoy, Moore, Bishop, Kenyon • Illness Narratives/Pathography • Lorde, Woolf, Broyard, Bauby, Middlebrook • Non-fiction Essays/Exposés about the health care system • Sontag, Fadiman • Networking/informational tool • Support organization newsletters, sick blogs, etc.

37. Music and Medicine • Neuroscience of music • Music as metaphor for creativity and communication in medicine • Physicians and musicians • Impact of illness on artists • Music therapy • Medical care of musicians van Roessel, J Learn Art, 2007

38. MH as Patient Care Tool • RCT of expressive writing • Asthma & RA pts wrote about stressful events • FEV1: 63.9%  76.3% at 4-mos p<0.001 • RA dz activity: 1.65  1.19 p=0.001 • No change in controls • Similar studies • Leukemia/lymphoma pts; family caregivers; adolescent asthma; pelvic pain; post-op; HIV Smyth, JAMA 1999

39. MH in Medical Education • Reflection and accuracy of diagnosis • Medicine residents from 2 programs • Repeated measures design • 16 clinical cases • Indep variables: case complexity, reasoning style • Reflective reasoning ↑ accuracy of hypotheses in complex>simple cases p<0.05 • Reflection improves students’ clinical performance w/ standardized pts p=.0001 Mamede, Med Ed 2008; Blatt, JGIM 2007

40. MH in Medical Eduation • Fine arts and visual diagnostic skill • RCT with first year medical students • Control group: usual H&P tutorial w/ MD preceptor • Intervention: Yale Center for British Art, 10 min study of painting, then describe to group • Pre- and post-test descriptions of photographs • Results • No signif difference in pretest scores • YCBA gp with signif higher % improvement post-test: 56% v 44% p=.001, same results year 2 Dolev, JAMA 2001

41. Medical Humanities Oxymoron Opportunity

42. “Not everything that matters can be measured, and not everything that gets measured matters.” Albert Einstein

43. “The medical humanities can be envisioned as the biocultural bridge between different domains of the university; it is one of those frail but promising connectors between the world of knowledge creation and the world of practical moral experience. What we now need are conclusions from specific teaching innovations about how useful for improving the quality of caregiving are different medical humanities programmes.” Kleinman, Lancet 2008

44. Scientific Revolutions • The evolution of scientific theory does not emerge from the straightforward accumulation of facts, but rather from a set of changing intellectual circumstances and possibilities • Max Planck: a new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it Kuhn, The Structure of Scientific Revolutions 1962

45. Medical Humanities or you decide

46. www.medicalhumanities.ucsf.edu Louise.Aronson@ucsf.edu