II. Democratising medicine: The medical humanities as forms of resistance
THE STATE OF THE UNION: Rigour and responsibility in US health humanities
Learning is not attained by chance; it must be sought for with ardor and attended to with diligence.
(Abigail Adams, wife of John Adams (second US President) and mother of John Quincy Adams (sixth US President))'
We begin, as directed by Professor Vivian Bearing’s mentor in Margaret Edson’s play Wit, with a text—the opening sentence of a recently published article in the Journal of the American Medical Association's feature ‘The Arts and Medicine’;2
We—an internist specializing in palliative care . . . and a medical anthropologist ... — recently spent a year training surgery interns in the use of narrative medicine techniques to influence their development as compassionate surgeons.
(Kirkland and Craig 2018: 1532)
As scholars and educators ourselves in the health humanities, we deeply respect and appreciate the creative and thoughtful work of colleagues in the field, and it is not our intention to disparage anyone in this chapter. However, the above sentence illustrates three specific and enduring challenges regarding the arts and humanities in medical education. There is the question of expertise: who teaches? There is the question of content and methodology: what is taught and how? And finally, there is the question of evaluation: what are the goals, and how are they met?
In this chapter, we address all three of these challenges, but we devote more time and words to the first section, which addresses expertise. We believe that content, methodology, objectives and evaluation flow from the qualification and experience of the teacher or teachers.
Expertise: Who teaches?
“We—an internist specializing in palliative care . . . and a medical anthropologist ...”
Well over a decade ago, one ot our colleagues, a literary and film scholar, casually mentioned to an emergency medicine physician at the same institution that the position tor director of the medical humanities programme there had just been posted. The physician responded with interest: “I might apply for that.” Our colleague was taken aback: “How can you do that? You’re not a humanities person.” She immediately countered, “1 read books. I can teach literature,” to which he replied, “Oh, I watch HR. I guess I can do an appendectomy.”
There are many such anecdotes in the field of health humanities, which seemingly rest on the assumption that if one has made some study of literature or art history, for example, then one is qualified to teach a text or interpret a painting. This assumption is further propelled by the fact that medical education and clinical practice uniquely qualify physicians to teach the arts and humanities in those settings because it is, after all, their domain. Moreover, the thinking is that the relevant sense making ot texts and images arises more from a physician’s experience—real and memorable—and less from a humanities scholar and educator’s expertise.
In their discussion, ‘Exploring the Surgical Gaze Through Literature and Art,’ the co-authors cited above announce their disciplinary identities; however, they do not provide any information about additional education in narratology, or literary theory and criticism, despite the fact that they are, in their words, “using narrative medicine techniques.” Yet, in clinical settings, there are rigid and recognisable spheres of practice where a nurse can do one thing but not another—such as delivering medications but never prescribing them—or where a doctor can do a bowel resection but would never empty a bedpan. Thus, such disregard for the qualifications to teach narrative medicine may be notable but, we would argue, is actually commonplace and rarely challenged when dealing with the arts and humanities. Where clinical expertise and disciplinary knowledge unquestionably matter in healthcare education and practice (you wouldn’t seek out a historian or a physical therapist if you needed a hysterectomy), when it comes to the arts and humanities, expertise and credentialing seem to matter very little or not at all.
Analysing the long-standing tension between the arts and the sciences, Catherine Belling (2017) quotes molecular biologist P.J.G. Butler, who claims that scientists are simply better educated than those in the humanities. His evidence is his enjoyment of discussions with colleagues about music, theatre and the visual arts. Belling (ibid.: 22) argues that simply “consuming (enjoying, appreciating, criticizing) an imaginative work does not require an understanding of how it works.” She illustrates her point with two imaginary conversations: the first between two scientists, both of whom have seen a recent production ot Macbeth. They chat about the play, exchanging thoughtful and well-supported opinions, applauding the special effects and wondering about parallels with contemporary politics. Similarly, a painter and a poet, both of whom have recently undergone routine screening mammograms, talk together about that experience, making observations and comparing notes about the probability of false positives and unnecessary biopsies.
The first conversation is, as Belling (ibid.) aptly and brilliantly exemplifies, the equivalent of Dr Butler’s engagement with the arts and humanities; he simply disregards the fact there is more to interpreting Macbeth than reading, viewing and considering it. The two scientists do not need to “understand prosody, dramatic form, the evolution of English orthography, the political context of the play’s first performance, or the history of its production.” In contrast, the poet and painter are under no illusion about their ignorance ot “the physics of ionizing radiation or the pathology visualization needed to generate the conclusion that their breast tissue looks normal.” While it may not occur to the scientists that there is a whole lot that they neither notice nor apprehend, they are satisfied with simply discussing the experience, evaluating its quality and exploring its meaning to the end of “the social processing of a cultural object. ” However, there is and should be a distinct and profound difference between the “social processing of a cultural object,” whether it be Will Shakespeare or Judy Chicago, and a deep understanding and recognisable expertise in the theories and methods ot the humanities disciplines.
Moreover, confounding the question of authority—who teaches the health humanities?—is the question of purpose: why are they being taught at all? Here again, there have been and continue to be very different and distinct viewpoints, one ot which is best illustrated by the American Association ot Medical College's stated opinion in a 2017 report on the arts and humanities, where health humanities potentially provide “fundamental lessons in professionalism, ethical discernment, and communication with patients,” leading to greater joy, more empathy and better care. However, from the outset of the enterprise, leaders in the health humanities have had a very different perspective. For example, one of the earliest rationales for the emergent field of the humanities in medical education included the prescription tor a bright line drawn between the clinical performance ot medicine and the critical work of the humanities, between an enterprise dedicated to the inculcation of human values and an enterprise dedicated to the exploration of human values. In the 1971 proceedings of the first session of the Institute on Human Values in Medicine, K. Danner Clouser (1979: 50) warned about appropriation and distraction: “The humanities should remain academic disciplines and not get caught in the role of specialists on bedside manners and professional etiquette. Basically ours is an academic role even in the medical school.” A decade later, Anne Hudson Jones (1984: 32) returned to the already controversial notion that studying the humanities makes one more humane: “This expectation makes me very uncomfortable. This expectation is a burden . . . for all ot the humanities.”
There is, then, a long-standing tension between the instrumental justification for the humanities in medicine, which ostensibly enables and promotes more caring professionals and better caring practices—what physician and philosopher Jeffrey Bishop (2008: 17) deems the “dose effect” of the humanities—and the intellectual practice of the humanities. As literary theorist Jonathan Culler (2005: 38) notes, it is not at all surprising that the human in the humanities leads us astray because “our language proposes a strong link not just between the humanities and the human being but between humanistic thinking and even humane behavior.” Peter Brooks (2014) also elaborates on the contusion that humanities scholars and educators, in any academic setting, are somehow engaged in moral education, that they are teaching humanity. He writes:
Studying the humanities may—or may not—makes us more humane. It’s important that the humanities affirm what they can do, the kind of ethics they promote in their practices of interpretation, while making it clear that they are not directly in the virtue business.
However, it’s not only senior humanities scholars like Culler and Brooks who challenge the expectation that exposure to and exploration of the arts and humanities will instil certain virtues and values most memorably captured with the acronym created by the Gold Foundation for Humanism in Medicine: integrity, excellence, compassion, altruism, respect, empathy and service (I.E.C.A.R.E.S.). More than any other organisation, Gold has effectively reinforced the connection ot humanistic healthcare with the integration and deployment of the arts and humanities in US medical education.’ In an opinion tor in-Training: The agora of the medical student community, Steven Lange (2016) writes ot his and his classmates’ experience with lectures and small groups with humanities content that are “touted as a panacea to medicine’s current evils: lack of physician empathy, inadequate patient care, dependence on technology, et cetera.” Such curricula, Lange notes, assume that “humanities, the field proper, possesses a humanism that can be extracted and added to the biologism of medical science.” In fact, Lange argues, the ‘dose effect’ approach contradicts the very nature of humanism—the theory that upholds the human being as the end-in-itself and as the supreme value—by objectifying it:
That some are willing to believe that medicine needs nothing more than another class . . . does not humanize it, but . . . further subjugates it to the Western model of scientific and evidence-based thinking that is based in the assessment of outcomes. The scientific legitimization ot the humanities betrays the purpose ot instilling humanism in medicine, and makes humanism another area of study — alas, a Wednesday morning lecture.
If the understanding of, and from, the humanities in medical education and clinical practice is primarily that of an instrument to foster compassion and empathy; tolerate ambiguity; inculcate virtues and values; and perform nonnative behaviours, and what David Doukas and Rebecca Volpe (2018) ot the Project to Rebalance and Integrate Medical Education call “comportment,” then no real expertise is necessary—just time, motivation, enthusiasm and good posture. Anybody, including a molecular biologist, internist or anthropologist, can do it.