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Bruce Campbell MD - Head and Neck Surgeon and author of A Fullness of Uncertain Significance: Stories of Surgery, Clarity and Grace

A Fullness of

Uncertain Significance:

Stories of Surgery, Clarity, and Grace

Bruce H. Campbell, MD FACS

A Fullness of Uncertain Significance - Norbert Blei August Derleth Award
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For a brief period in the late 1970's, Rush Medical College sponsored the "Dayton Ballis Essay Contest on Humanities in Health Education," inviting students to reflect on medicine within the larger context of society. As best I can determine, Rush discontinued the essay contest but recognized students with the Dayton Ballis Humanities Award for Academic Excellence in the Humanities Related to Medicine through the mid-1980s. Then, nothing.


In 1978, I was a 23-year-old second year medical student at Rush. My undergraduate humanities courses at Purdue surprised and inspired me, especially medical sociology (shoutout to Sidney Stahl, PhD), American history (shoutout to Robert E. May, PhD) and bioethics (shoutout to Jan Wojcik, PhD). I read books, essays, and poetry by Richard Selzer, MD, William Carlos Williams, MD, Loyal Davis, MD PhD, Lewis Thomas, MD, and Dr. X. I admired physician-writers. I wondered how I might incorporate the humanities into my career as I entered medical school.


Lacking humanism, medicine is in danger of becoming increasingly inhuman in an increasingly technological world.

There was an inherent tension between "traditional" and humanistic approaches to patient care. Doctor-patient relationships of the previous generation were, by-and-large, paternalistic. It was perfectly natural to "hide" terminal diagnoses from elderly dying patients, and to refer to patients by the disease they had rather than thinking of them as people. I heard stories of neurologists withholding medications from patients so students could observe classic symptoms. There was no thought of "shared decision making." There was no public oversight of medical research. Patients had little access to information about illnesses.


As a nursing assistant, I sensed that medicine was changing. The senior attending doctors I observed were often WWII and Korean War Veterans who practiced in a white male-dominated hospital with few subspecialists. Hours were long, treatment options limited, and house calls common. My younger role models had been in Vietnam and/or had been anti-war activists. Most were inspiring, dedicated, compassionate, and gifted. Some, though, viewed their patients with indifference or worse. Society was going through seismic shifts and I knew that the "old school" approach would soon be gone.


The medical armamentarium was changing, as well. Antibiotics needed to be updated frequently, since they were routinely overused, leading to antibiotic-resistant bacterial strains. Radiation therapy and imaging technology were very limited by today's standards; I remember the hospital's first CT scanner which was only able to view the brain. Chemotherapy, some of it based on WWI trench warfare agents, was toxic and rarely effective. Smoking was widely prevalent (65% of US white males smoked in 1965) and tobacco-related cancer rates were still climbing. Cancer was a death sentence; I could not imagine the career of a medical oncologist in those days.


Good things were on the horizon, though. DNA's structure and function had been described only about 25 years before and new discoveries explored genetics and immunology. The brand new Belmont Report, which provided basic ethical principles for biomedical research in the wake of the Tuskegee Syphilis Study, revolutionized the concept of informed consent. Medicare, Medicaid, and the Surgeon General's Report on Smoking and Tobacco—all about ten years old—changed everything.


Still to come were HIPAA, IRBs, PPOs, HIV/AIDS, MRSA, SARS, DRGs, PCR, MRIs, HPV-related cancers, Lyme Disease, EMRs, and COVID.



So, when I wrote, "Do We Need the Humanities In Contemporary Health Education?" I was lamenting the loss of humanism over the preceding century and pointing to visionaries who saw a different way forward. I believed that their work would change medicine during my lifetime.


Re-reading this 45 years later offered me some surprises:


  • Good people were thinking about these issues with clarity and rigor long before my generation

  • People have always recognized that humanism must be part of any health professions curriculum, yet there has always been pushback

  • The basic arguments have not changed

  • Although innovative ideas abound, the resources have diminished

  • Despite the best of intentions, the humanities have made little headway

  • The humanities failed to counter the influence of technology, corporate greed, and moral injury in healthcare


Still, I still hold to the essay's conclusion: Lacking humanism, medicine is in danger of becoming increasingly inhuman in an increasingly technological world.


My essay (which I admit reads like a college term paper) took Second Place in the 1978 Dayton Ballis Essay Contest. Some of the references no longer exist. Many of the thought leaders quoted here are gone, yet a new generation of humanities scholars has emerged and continues the good fight.


My dive into this topic when I was in my early 20s impacted my entire career. Reading this again reminded me of my optimism and showed me how long I have been interested in the medical humanities.


Still, I am shocked how little has changed—and probably regressed—over the past 45 years.



 

Dayton Ballis Prize - Medical Humanities - Health Education

The award letter. They misspelled my middle name (it is "Hegstad," my mother's maiden name), but I accepted the $150 anyway.

I did not earn another nickel for my writing for about 35 years.

 

May 12, 1978

 

Do We Need the Humanities In Contemporary Health Education?

 

Bruce H. Campbell

Second year medical student

Rush University

 

 

Douglas Hubble (1967) has noted that:

 

medicine has travelled in three hundred years from a practice based on the teachings of Galen to the study of the humanities as a necessary discipline for all physicians, and from there to the neglect of such studies as the call of the craft and the studies of the physical sciences ancillary to medicine became more insistent. (p. 56)

 

The effect of this shift has been the elimination of humanities and humanistic exposure from the educations of physicians, nurses, pharmacists, administrators, and other members of the health care team. As medicine can be viewed as an aspect of societal and personal as well as organic intervention, this shift can be viewed as depriving health professionals of a valuable resource for evaluation and treatment of the individual as he or she exists within the framework of society.

 

This paper will examine the need for a "holistic" or "humanistic" approach to medicine, the need for the humanities in developing this holistic approach, the teaching of the humanities in medical schools, the difficulties inherited from the "art vs. science" tradition of a medical education, and, in summation, whether or not the humanities are needed in contemporary health education.

 

 

The Humanities, as defined as "promoting human culture," originally included only the study of Greek and Roman literature. A newer definition, as related by Hubble, widens the humanities to include "any system of thought or action which is concerned with merely human interests." (p. 50). Howard Mumford Jones (1960) equated the ends of humane learning with the Latin word pietas, "meaning reverence for life, for tradition, for individual honor, and for such hints of divinity as are vouchsafed imperfect man." (p. 87). From within the syntax and philosophical smoke emerges a challenge to health education to train professionals who are societally—as well as medically—competent and who understand themselves as well as they understand their patients.

 

The concept of "holistic medicine" has reemerged as practitioners realized that the body is an expression of its emotional, mental, and spiritual, as well as physical, components, and in order to correct dysfunction in one, all components must be considered. However, with the explosions of medical science and medical specialization, reductionism and unnatural divisions of treatment have occurred. "The psychiatrists have been given the mind, the clergymen the spirit, and the regular health professionals are left with only the body." (Miller, 1974, pp. 68-69).

 

Medicine has become a technology in the past one hundred years. Technology does not demand humanism; a civil engineer can design a bridge without regard to its aesthetics and the bridge will function very capably. However, medicine, of all the technologies, is most occupied with man. While the girders, struts, rivets, and guy wires of the bridge will function steadily in a wide variety of conditions, the same cannot be said of man. Technology is not evil, but advances must be combined with health-giving ways of life to be useful to the individual. Investigators must explore the whole person—disease, body, feelings, mind, and even spirit. (Miller, р. 65).

 

A unified concept of disease, proposed by George L. Engel (1977), encourages the health professional to search for each patient's biological, social, and emotional dysfunctions in illness. Engel stresses that psychosocial factors are an aspect of clinical science and must not be disregarded as simply "kindness" or "bedside manners." (Werner & Korsch, 1976, p. 325). Traditional medical education has found that training is necessary to enable the student to view an organ system as a component of the physical man. Logically, training should also be necessary to enable the student to view the physical man as one component of an individual and that individual as one component of a society.

 

The holistic approach to medicine is not necessarily intuitive. An acquaintance with the humanities is a vital part of the development of the holistic approach. Miller notes that

 

...to look at the medical situation from such expanded points of view calls for an expanded health professional. A few in every generation seem born that way and they are famous and revered in their communities. We believe that others can learn similar sensitivities, similar skills, and a similar breadth. One requirement of such an education will be that the practitioner get to know himself as a human being, his emotional place in nature, his subpersonalities, the strengths and weaknesses of his will and intuition, and so forth. (р. 70).

 

While traditional education enables students to master the technology of medicine, the humanities can provide contrasting experience in the abstract. This heightened awareness, when used in medical practice, permits the practitioner to examine both the patient's and his or her own experiences within a greater context.

 

Humanities study facilitates the approach of health professionals toward moral decisions, as well. No humanistic discipline is dogmatic, and none can teach "right" values, yet the traditional technological approach to medical education avoids or ignores these dilemmas completely. Nevertheless, moral decisions are often required in medical practice. Edmund D. Pellegrino, MD, Director of the Institute on Human Values in Medicine, states that "the humanist is not automatically able to handle these matters, but at least he comes out of a tradition that addresses them." (Hunt, 1972, p. 84). The wisdom of the centuries can be used in contemporary health education as a framework for assisting in the development of each student's awareness of human variation. In this sense, the humanities are useful aids in developing a paradigm of society each student can carry away from the classroom and the clinics.

 

Medical school faculties, although generally not happy to share curriculum time with the humanities, realize that the most significant objective not presently being accomplished in medical education, second only to increasing physician manpower, is to "instill in medical students a compassionate humanitarian concern for patients as persons." (Houser, 1971, p. 126). Physicians must be trained as humanists to fulfill their societal roles. Hubble defines four roles for the humanistic physician: the doctor as personal physician with humanism as a guide to physician-patient interaction, the doctor as investigator and researcher with a humanistic perspective, the doctor as administrator "insisting on the care of the unfortunates who have no or little value, in economic terms, for the community," and the doctor as an agent of society in his or her role as citizen. (pp. 64-72). The faculties apparently realize the importance of the development of these roles, but often assume that this development occurs intuitively or by role-model emulation on the clinical floors. The fact that the faculties see a need for "instilling a compassionate humanitarian concern" where none exists now should indicate that a change is needed in the educational process in order to make this objective a reality.

 

Humanities instruction in contemporary health education is extremely varied. 82 of the 117 medical schools in this country have some instruction in medical ethics and often other humanities ("Teach ethics," 1978, p. 196), but the extent of "infiltration" into the curriculum is often very tenuous. The humanities presently taught include ethics, philosophy, literature, history, social sciences, and behavioral sciences, of which Dr. Pellegrino notes that "the unifying principle is a concern for teaching and learning about the centrality of human values in medical practice and decision-making." (McElhinney, 1976, pp. ix-х). The objective of the inclusion of these courses into curricula is the ultimate production of humane technologists.

 

The extent of humanistic course integration depends on the school's administrative commitment, the availability of financial and human resources, the cooperation and understanding of the other faculty members, the flexibility of scheduling, and the enthusiasm of the students. Programs are well established at schools such as Hershey Medical Center at Pennsylvania State University, The University of Tennessee Center for the Health Sciences, The University of Florida at Gainesville, The University of Kansas Medical Center, The University of Texas Medical Branch at Galveston, and Yale University, among others. Other schools' programs are non-existent or just underway.

 

The variations in approach reflect the variations in philosophy and resources between the institutions. The College of Medicine and Dentistry of New Jersey, for example, has a required eight-week clerkship entitled "The Practice of Medicine" which utilizes team-teaching in the classroom and a clinical preceptorship designed to expose students to the role of the physician in the community and the society, (McElhinney, p. 182-87) while The University of Tennessee offers seventeen electives in addition to programs for its students and community. (pp. 254-60). Yale University established the position of Chaplain to the School of Medicine in 1967, and the chaplain carries out his unique work in addition to the other humanities faculty. (pp. 50-57).

 

The humanities are taught by lawyers, ethicists, theologians, and social scientists in addition to physicians. Measuring the effect of these programs will be difficult, though, since it will take a generation of new health professionals entering medicine to determine if the programs are capable of producing humane technologists.

 

In the meantime, the programs expect to experience a great deal of pressure from the basic and clinical science faculties. There is a long history of conflict dating to the nineteenth century when science began its infiltration into the craft of medicine. Jones (1960, pp. 81-83) had detailed three basic conflicts between science and the humanities which apply to this discussion. First, science aims to banish the personal equation, while the humanities perpetuate it. Secondly, science is principally of the present looking to the future, while the humanities' main staple is the past. Thirdly, science is involved in predictive, statistical judgements, while the humanities, which rely on the appearance of genius, are incapable of predicting that appearance. These are the underlying conflicts in the "arts vs. science" debates heard in curriculum planning committees. The scientists have gained the upper hand in the control of medical education and, with the vast accumulation of technology to be presented to the students, are reluctant to yield precious teaching time to a discipline which can be viewed as non-scientific at best and irrelevant at worst.

 

Students are often less than enthusiastic about the inclusion of the humanities as a part of their professionalization since they, too, expect a technological education. The humanities courses are viewed as only "para-vocational" and as competing with the more demanding basic sciences. Students entering medical school do not necessarily have much background in the humanities and, therefore, do not necessarily have much interest in them either. Pre-meds feel no compulsion to explore non-science courses during their undergraduate years since the sections of the Medical College Admission Test which examined their command of the humanities were eliminated last year. Sir Eric Ashby noted in 1958 that "the enthusiasm of students for such courses can only be elicited by teaching of unusual quality." (Hubble, p. 62). This may be even more true now than it was twenty years ago.

 

 

In view of the difficulties in development, administration, teaching, and reception of such programs, the question arises: Do we need the humanities in contemporary health education? The answer must be a firmly committed "Yes." Yes, because the physicians, nurses, pharmacists, administrators, and consumers need to know how the medical system operates. Yes, because the patients deserve to be treated with knowledge of their biological, social, and emotional components. Yes, because each practitioner will be better able to understand him or herself as an individual. And yes, because health professionals must understand how individuals compose a society, and how that society can affect its members.

 

Health professionals do not need to read all of Talcott Parsons' work to understand the basis of the sick role, nor do they need to memorize the history of medicine form Hippocrates through Galen, Sydenham, Harvey, Freud, Osler, and on to the present to obtain an historical perspective. Health professionals should, however, be in possession of a firmly rooted and broad-based understanding of medicine, the individual, and society in order to treat their patients' ills rationally and humanely.

 

Without this overview, medicine becomes a fragmented technology devoid of the ability to comprehend its own greatest objective—the maintenance of a healthy individual within a healthy society. Lacking humanism, medicine is in danger of becoming increasingly inhuman in an increasingly technological world.

 

 

 

References

 

Houser, HW (1971). Health care research series No. 17: Objectives in American medical education: A survey of medical faculty opinions. University of Iowa Graduate Program in Hospital and Health Administration. Iowa City.

 

Hubble, D (1967). Towards a humanistic technology. In Ross, ASC (Ed.), Arts v. Science: A Collection of Essays. Methuen and Co., LTD. London.

 

Engel, GL (1977). The need for a new medical model: a challenge for biomedicine. Science, 196:129-136. Link

 

Hunt, LL (Ed.) (1972). Proceedings of the first session. Society for Health and Human Values, Institute on Human Values in Medicine. Philadelphia. Link

 

Jones, HM (1960). Development in humanistic scholarship. In Boewe, CE & Nichols, RF (Eds.). Both Human and Humane: The Humanities and Social Sciences in Graduate Education. University of Pennsylvania. Philadelphia. Link

 

McElhinney, TK (Ed.). (1976). Human values teaching programs for health professionals, 3rd edition. Society for Health and Human Values, Institute on Human Values in Medicine, Philadelphia. Link

 

Miller, SZ (1974). A new humanism in medicine. Synthesis, 1: 63-70.

 

Teach ethics in medical school? (1978). Patient Care, 12: 196-97.

 

Werner, ER & Korsch, BM. (1976). The vulnerability of the medical student: Posthumous presentation of LL Stephens' ideas. Pediatrics, 57, 321-28. Link



The Humanities In Contemporary Health Education: Fighting the Same Battle 45 Years Later


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