Content and methodology: what is taught and how?

". . . spent a year training surgery interns in the use of narrative medicine techniques ...”

On an April afternoon, two black men walked into a Philadelphia Starbucks, sat down and waited to meet a colleague. They asked to use the bathroom but were refused, as they hadn’t purchased anything. They were then asked to leave but declined. The manager called the police, and the men were arrested “on suspicion of trespassing.” Over eight million viewers watched the video on Twitter. The men were released from custody without being charged, the manager was fired and the company announced a shutdown of all US stores for a mandatory half-day training ot its 175,000 employees. Kevin Johnson, Starbucks CEO, issued the following public statement: “Closing our stores for racial bias training is just one step in a journey that requires dedication from every level ot our company and partnerships in our local communities” (Fitzpatrick 2018). Both the incident and the corporate response provoked outrage in light of the historical and contemporary legacy ot racism in the US, especially given the recent killing of unarmed black boys and men by police officers. A halt-day ‘training’ would not only seem to be inadequate but also disingenuous given the complexity around the issues of race and ethnicity in America. Moreover, do we know it such interventions make any difference in attitudes and behaviours at all?

When the co-authors of the above-cited text use the word ‘training,’ they are speaking the native language of the medical setting. Their learners are surgery residents, often called ‘trainees,’ who are in the process ot being ‘trained,’ systematically instilled with the knowledge and skills of their chosen specialty. In this particular setting, there is an emphasis on the utilitarian merits ot a given text or image rather than on the cultural, aesthetic, intellectual and political elements of it. Words such as ‘train,’ ‘use’ and ‘technique’ stand in contrast to processes such as ‘education,’ ‘exploration’ and ‘interpretation.’ The co-authors state an end point, “the use of narrative medicine techniques,” one that is presumably achievable and demonstrable.

However, the complex and subtle materials that they use—a painting, a poem—only muddle the implicit precision ot ‘training’ and intentional specificity ot ‘techniques. In the body of the article, the co-authors must ultimately resort to more imprecise and nebulous descriptors of content and methodology such as ‘difficulty,’ ‘trouble,’ ‘suflering’ and ‘limits.’ They seem to be at cross-purposes: one can interpret a painting or a poem, but by their very nature, these works are unmanageable and unruly. Simply asking surgery residents to respond to a question about a painting such as: “What do you see?” or about a poem, such as: “What do you think?” is neither training nor educating. The response to such questions in a humanities classroom would be more questions: What does the painting or poem mean? How can you make an argument tor its meanings? What are the specific elements in the painting or images in the poem to support them?

Peter Brooks (2008) writes about the intense intellectual and moral energy in trying to get those interpretations right: “Participating fully in such a process, one comes away with an understanding that there is an ethics of reading,” and, we would add, viewing a work of art. It is not then a matter ot “Anything goes!” or “What do you feel?” but a matter of proof that is as rigorous as science. Thus, teaching humanities disciplines with increasing complexity involves a fuller engagement with whatever text is under study—a film, a painting or Mary Shelley’s Frankenstein. This kind ot critical practice alerts learners to language in ways that they may not have recognised: the words that health professionals and patients use when attempting to understand one another, the plots of the stories patients tell, the themes and tones of various narratives, the pervasive but unspoken issues around power in healthcare settings, the layers of complexity in seemingly uncomplicated decisions and routine procedures, and the unspoken worldviews and values informed by cultural practices and religious beliefs.

In contrast to the connotations of hierarchical authority and transferrable skills captured in the phrase ‘training surgical interns’ is an approach that offers both teachers and learners the opportunity to examine critically the nature ot their personal beliefs and values, and the beliefs and values embedded in the learning environment and institutional policies and procedures. This approach requires that both teachers and learners step out of their respective comfort zones to raise difficult and complex issues and disturb their reliance on a biomedical approach to healthcare—in other words, pursuing a “pedagogy ot discomfort” (Boler 1999).

Evaluation: what are the goals, and how are they met?

". . . to influence their development as compassionate surgeons. ”

Several years ago, an eminent physician-poet visited a medical school to speak, read and provide wit and wisdom in support of that institution’s nascent humanities programme. During one informal discussion among many about content, methodology and assessment, the question arose as to whether what happens in humanities classrooms makes any difference at all in the lives of physicians. The eminent physician-poet responded with a passion, marked by a fierce belief that such activities along with much in medical education represented an act of faith.

The co-authors cited above seem to be counting on that self-same act of faith in their explicitly stated goal of influencing the development of compassionate physicians through the arts and humanities—specifically, narrative medicine. Their endeavour rests on the assumption that exposure to painting and poetry will be both professionally and culturally transformative by taking surgical residents “from their conventional training in operating rooms and hospital wards into a space where they could grow in proficiency in perspective-training and build their tolerance for ambiguity” (Kirkland and Craig 2018: 1532). The belief that humanities content and inquiry are the major site—perhaps the exclusive site—at which humanistic virtues and values such as compassion, empathy and altruism are developed, instilled and encouraged in surgery residents as well as medical students remains a long-standing and misguided supposition. Again, we return to Clouser (1979: 50) who noted, 40 years ago, that this not only “robs humanities of its true calling, but it absolves other departments ot a responsibility that should be shared by all. To compartmentalize the responsibility tor humanizing is to confuse virtue and knowledge.”

A commitment to developing compassion and fostering empathy should be the concern of the basic medical sciences, bedside teaching and conventional activities such as rounds in operating rooms and hospital wards.

Were there a blood test to quantify compassion, humanities scholars and educators might hypothesise that our students’ titres would increase steadily through engagement with literature and art. But, in the absence of such an objective measure, how can we be sure? To be clear, we are not advocating for the familiar and reductionist methods of the dominant paradigm in medical education, those measuring competencies and outcomes. In ‘Sharper Instruments: On Defending the Humanities in Undergraduate Medical Education,’ Catherine Belling (2010) writes about how the very lack of precise definition of terms in what constitutes ‘humanities’ presents significant obstacles to their study in medical settings. Any coursework that purports to improve the doctor—patient relationship, the professional development of students or the resilience of working professionals is often thrown into the bucket of the arts and humanities along with narrative medicine, literature, visual arts, history, bioethics, communication and even global health.

There are, however, strategies that can inform us about some of the critical hoped-for effects of humanities inquiry—such as the discomfort noted above that some materials can provoke, as well as the implications of cultural and sociopolitical contexts in which texts and images are embedded. These include open and candid dialogue, honest written reflections and critical and close readings in written format. Narrative and textual analysis of students’ writing is also an option. Finally, there are the tried-and-true traditional course evaluations. None of these is provided by the co-authors of this article with the exception of some description about discussing imaginative works and about sharing written responses to them.

Perhaps because of the limitations of the ‘Arts in Medicine’ feature, readers are left wondering not only about the specifics of the experience but also what learners took away from it. For example, there are no sample discussion questions; no descriptions of areas of focus, introductions of linguistic or aesthetic vocabularies, or explorations of various interpretive frames. There is no substantive evaluation report from participants. We would argue that it is highly unlikely that the development and deployment of a basic or clinical sciences educational activity, course or curriculum would ever be published in a medical journal without any data regarding outcomes and assessments. Essentially, the co-authors offer readers an enactment of what Belling describes as the social processing of a cultural object. An enriching experience, to be sure, but arguably not one that they can demonstrate “enlarge[s] . . . our capacity to provide compassionate care.”

That is not to say that humanities inquiry in healthcare has no potential to make a positive difference in the way it is practised. But this cannot occur without a self-conscious critique of what we read, say, do and write. We want to overthrow any notion that the health humanities are sites of the ‘culture club’ or ‘self-care,’ that we are cultural overseers and that our disciplines hold the key to turning healthcare into practices that are caring, fair and accessible to everyone. We want to confront the fact that in our classes and certainly elsewhere in medical education, there is evidence of domination and oppression. We want to develop what Patti Lather (1990: 13) once called “the skills of self-critique, of a reflexivity which will keep us from becoming impositional and reifiers ourselves.”

Conclusion

The Association of American Medical Colleges (AAMC) is a not-for-profit organisation dedicated to medical education, patient care and scientific research whose members include all accredited US and Canadian medical schools, over 400 teaching hospitals and health systems and over 80 academic societies. The association serves nearly 175,000 faculty members, 89,000 medical students and 129,000 residents. In summer 2017, AAMC leadership convened a ‘thought forum,’ bringing together active scholars, educators, clinicians and administrators to understand the current landscape of the arts and humanities in medical education and to create parity with the biosciences and social sciences.⁴

A summary report was published in the AAMCNews under the headline ‘Focusing on Arts, Humanities to Develop Well-Rounded Physicians’ with the following lede: “Learning about history, visual and performing arts, and literature can help physicians develop empathy and professionalism—skills that will lead to deeper connections with patients.” Beneath is an image of a white male, in profile, focusing on a canvas as he prepares to daub paint on a figure in the foreground. The caption reads: ‘Penn State College of Medicine student . . . creates a copy of a Van Gogh painting based on a partner’s description. The class emphasizes the importance of open-ended communication in medicine.’ Notwithstanding the visual reification of what has been traditionally the most acceptable and appropriate representation of a future doctor—the white male—the image also reinforces how unnecessary it is to provide even the semblance of a logical argument or a measure of statistical support for a connection between this student’s crude imitation of a famous artist and his improved communication skills with future patients.

The article goes on to describe some of the courses and activities offered to US medical students in the arts and humanities and includes a graph that proudly reports the 119 institutions that require such educational work. However, not included are any criteria to specify what these institutions identify as arts and humanities education: a semester-long elective in the history of medicine? a visit to the local art museum? a workshop on improvisational theatre? shadowing the hospital ethics committee? We simply do not know, and while we do not have specific data ourselves, we do have anecdotal knowledge that many medical schools identify content that spans communication skills, professional development, clinical ethics decision-making, cultural competency training and health disparities as arts and humanities.

Such imprecision would never occur in scientific disciplines and only strengthens the longstanding belief that the arts and humanities can be taught by anyone, can foster virtues and values and cannot be effectively evaluated. However, scholars and educators in the humanities whose primary appointments are in health sciences centres and medical schools find themselves often and understandably conflicted. That the AAMC leadership came out as a staunch and public supporter of the arts and humanities in medical education is crucial—and affirming. However, we are still the Other, we are still vulnerable and we are—consciously or unwittingly—still in danger of being complicit in claiming a causal relationship between good doctoring and humanities inquiry, and in framing our intentions and outcomes within the real or imagined boundaries of science with its ordered, privileged language when we employ words such as ‘training,’ ‘skills,’ ‘practices,’ ‘interventions’ and ‘competencies.’ For Lange (2016), the humanities in his medical school experience simply instrumentalise doctors just as medicine instrumentalises patients: “Narrative competence is no longer a quality of a humanistic doctor, but a quantifiable asset of his or her efficiency.”

Artist and activist Audre Lorde once warned that the master’s tools will never dismantle the master’s house. While instrumentalising the arts and humanities may secure our faculty positions and increase our popularity on curriculum committees, we must continue to support and advance the expertise of our colleagues; to develop and implement rigorous courses for our students; and to critique and challenge the checklist mentality of our institutional leaders as they push pedagogies (hi jour like ‘narrative,’ ‘reflection,’ ‘resilience’ and ‘self-care’ under the catchy catch-all of‘the arts and humanities.’

Notes

1 The Adams Papers, Volume 3. Letter from Abigail Adams to john Quincy Adams dated 20 March 1780. Archived and published online by the Massachusetts Historical Society.www.masshist.org/publications/

apde2/view?id=ADMS-04-03-02-0240.

• 2 The Journal of the American Medical Association (JAMA) is a leading peer-reviewed medical journal with an extremely broad readership. It is published 48 times per year by the American Medical Association and includes original research, reviews and editorials, while the journals impact is 44.405. JAMA is widely read by clinicians, researchers and educators across a variety of specialties and disciplines.
• 3 The Arnold P. Gold Foundations overarching goal is to provide compassionate, collaborative and scientifically excellent care and to support clinicians throughout their career, so ‘the humanistic passion’ that motivates them at the beginning of their education is sustained. The Gold Foundation supports a wide-ranging number of grants and programmes, including the White Coat Ceremony for matriculating medical students in the United States, and is one of the most important sources for the inclusion and use of the word ‘humanism’ to define and describe what are considered to be important and desirable values and behaviours of medical professionals: www.gold-foundation.org.
• 4 See the American Association of Medical Colleges website at www.aamc.org.

References

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