The essay below is from the Kern Institute Transformational Times issue of 4/9/2021. I am convinced that when educators see the value of students and trainees in all health care professions engaging meaningfully in the humanities, change will happen. Our young colleagues will take better care of those who suffer and be healthier people themselves. Unfortunately, finding ways to get the humanities into curricula will always be a "good" idea that threatens to displace something else; a kind of educational "zero-sum game." How do we move past this mindset?
Stories are the primordial means through which we make sense of, and convey the meaning of, our lives.
- Rita Charon and Craig Irvine
My medical student group gathered to debrief and discuss their very first experiences observing physicians caring for patients. One student presented a case of a teenager she saw in her clinical mentor’s office with mild muscle aches. This teen had a couple of relatives who were afflicted with a rare, devastating inherited disease. The boy’s few vague symptoms could, possibly, represent the disorder’s very earliest manifestations. Or the symptoms might be nothing, at all.
“What did you decide to do?” I asked.
“We told him to exercise and take Advil. We also ordered genetic testing and asked him to come back in a few weeks to check the results.”
“Thanks. That was a very complete presentation,” I responded. “Does anyone have any questions?” Someone wanted to know more about the genetic testing. Someone else asked about other potential diagnoses. We discussed those.
“A couple more questions,” I said. “Did the doctor find out how all this might be affecting the young man? Is he aware that he might have the same disease his relatives have? What’s do you think is going on inside his head?”
The student’s eyes widened. “I don’t know. We didn’t ask.”
I could not help but wonder whether the students might have been more curious about this teenager’s underlying story had they heard it a few months before they started medical school instead of a few months after.
Empathy levels will decrease. How soon does that happen?
As a profession, we lose our “vicarious empathy,” or our ability to have a visceral empathic response to another person’s stressful experience, very early on. A 2008 study from the University of Arkansas for Medical Sciences (UAMS) demonstrated significant drops in empathy during medical school, especially during the first and third years. Men (like me) who chose surgical specialties had the greatest loss of vicarious empathy.
Of course, no one plans to jettison their empathy along the way from being a normal person to becoming a physician. The losses likely occur as we seek to model ourselves after people who are a step or two ahead of us along the path. When I talk to first year students in MCW’s Healer’s Art course, they all affirm that they will listen to their patients, think first and foremost of the patient’s well-being, and always act with justice and equanimity. Yet, some would not recognize the people that they will become once they emerge, transformed, from residency a few years later.
Professionalism vs. Humanism
How do we address this nearly imperceptible transformation from empathic lay person to crusty physician?
One way is to reflect on the values of both “Professionalism” and “Humanism.” In medical schools, we strive to nurture professionals, which we might define as “physicians with attributes, skills, and demeanors with which they will practice high-quality medicine with integrity and empathy.” This is, of course, an admirable goal. “Humanism,” on the other hand, is broader than professionalism. These are the qualities we hope everyphysician brings to the table from childhood and that must be nurtured and enhanced, not lost, throughout the process of becoming a physician.
This is where integrating the humanities into medical education and training comes in.
Broadly defined, the medical humanities are interdisciplinary endeavors that draw on the creative and intellectual strengths of diverse disciplines, including the humanities, social science, and the arts in pursuit of becoming a good physician. They tap into literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology, and history. It’s basically the intersection of Medicine with Everything Creative. The goal is to draw on the humanities to expand a physician’s capacity to be humanistic, compassionate, and empathetic.
Think of an example from your own life:
Remember a novel you read and loved in high school. If the narrative grabbed you, you dove into the protagonist’s story and couldn’t put the book down. You didn’t worry that you “cared too much” for the protagonist or their struggles. You actively attempted to understand what each character was thinking, and you figured out why they did the things they did, even when their actions might have seemed, at first, inexplicable. Your heart rate soared when you anticipated danger and you wiped your eyes when they suffered. Your blood boiled when they were betrayed. When you finished the book, you encapsulated the arc of the story and shared it with your best friend. You paid attention to the story. You were able to retell it to others. It changed you.
Ideally, as physicians, we should be similarly curious and fearless as we delve into our patient’s narratives. We safely encountered narratives in the library. We should be able to do it at the bedside, as well. Right?
Yeah, but does reading a novel really make me a better doctor?
It does, actually. In an 2013 article in Science entitled, “Reading Literary Fiction Improves Theory of the Mind,” the authors studied people who read literary fiction, popular fiction, nonfiction, or nothing at all. They discovered that those who read literary fiction demonstrated improved “theory of the mind,” that is, “the human capacity to comprehend that other people hold beliefs and desires and that these may differ from one’s own beliefs and desires.” The article further showed that the same readers had stronger “theory of the mind” in both cognitive (the ability to understand others’ beliefs and ideas) and affective (the ability to understand others’ emotions or have empathy) realms. These were exactly the attributes that were lost during medical training in the UAMS study.
Narrative Medicine: Attention. Representation. Affiliation.
Rita Charon, MD PhD, and her colleagues at Columbia University developed the field of Narrative Medicine over twenty years ago bringing their “close reading” approach to clinics, classrooms, patients, ICUs, and bedsides. Participants first read and discuss a short story, poem, piece of artwork, or other creative work. Then for a few minutes, they each respond in writing to a simple but ambiguous prompt “in the shadow” of the piece they shared. Then they each read aloud what they have created and discuss as a group what they have learned through this process.
Dr. Charon teaches that these short, group-based exercises sharpen learners’ listening capacities and drive the “self” to engage in new ways with the “other.” “Reading and listening are muscular acts,” Dr. Charon writes. “It makes us wonder about the spaces between the lines and forces us to join with the storyteller to enter the world they describe.”
I have shared close reading exercises with MCW medical students, residents, and faculty over the years. These opportunities to read and write together have been gratifyingly well received. Other faculty, staff, and students have developed programs featuring writing, storytelling, art, improv, music, and other creative endeavors.
Many students embrace these approaches, and faculty members deeply enjoy the engagement, but we still struggle, as have many other medical schools, to truly integrate the humanities into medical education for all our trainees.
Where do we begin to integrate the humanities into medical education?
In 2020, the Association of American Medical Colleges (AAMC) released a report on the Fundamental Role of Arts and Humanities in Medical Education. The AAMC recognizes that the “arts and humanities are essential to the human experience,” and by “integrating arts and humanities throughout medical education, trainees and physicians can learn to be better observers and interpreters.” The report offers resources and examples for students and educators who want to explore the topic. As Deepthiman Gowda, MD, the Assistant Dean for Medical Education at the Kaiser Permanente Bernard J. Tyson School of Medicine has said, “Humanities have a role in addressing the problems in health care.”
There is, too often, a chasm between physicians and patients, and medical training, paradoxically, seems to widen that chasm. The humanities, well used, can assist in bridging this gap. Substantively integrating the humanities into medical education could sustain and enhance the empathy students bring to medical training and provide them tools to remain resilient, deeply compassionate, attentive caregivers.
Curricular change is hard. We will know we have succeeded when our youngest colleagues hold onto their empathy even when it sometimes seems easier to let it go.
For more reading:
Principles and Practice of Narrative Medicine. Rita Charon, Sayantani DasGupta, Nellie Hermann, Craig Irvine, Eric R. Marcus, Edgar Rivera Colón, Danielle Spencer, and Maura Spiegel, eds. Oxford Press. 2016
Howley L, Gaufberg E, King B. The Fundamental Role of the Arts and Humanities in Medical Education. Washington, DC: AAMC; 2020.
Bruce H. Campbell, MD FACS is editor of the Kern Transformational Times. He is a Professor of Otolaryngology & Communication Sciences and is on the faculty of the Center for Bioethics & Medical Humanities at MCW. He is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.