Health humanities: Lessons learnt in designing and implementing a curricular framework and student feedback through an interventional study

INTRODUCTION

Conventionally, practitioners of the ancient Indian medicinal system, Vaidya, have been considered the most methodical and holistic in their curative measures due to the importance of acquiring foundational qualities such as good speech, logical reasoning, empathy, and humility, along with basic education.¹ However, as a result of the interaction with a conceptually different western medicine during the British rule of India, aided by advances in its thought and technology as well as well-equipped institutions and free medical texts, medical education in India had a major impact from the West.^2,3 Simultaneously, the Flexner report, in 1910, prescribed the biomedical model, accepting scientific knowledge and its advancement as the defining ethos of a modern physician, mistakenly assuming that students come for medical training with a strong grounding in liberal arts, having been educated in humanities and fine arts as well as the sciences. Instead of supplementing the humanities, the sciences replaced them during premedical education.^4,5 While the system profited from the scientific advances, it has led to an imbalance in the art and science of medicine, and hence, the middle of the twentieth century saw efforts to realign the professional commitment of the physician and correct this imbalance through medical humanities (MH).⁶ The study of MH has since been used to increase understanding of the human conditions, expose students to the critical analysis of ideas, understand the role of the professional in a society, develop self-reflexivity and provide them with pockets of expertise and lifelong interests.^7,8

The dictionary meaning of ‘humanities’ is ‘learning or literature concerned with human culture, especially literature, history, art, music and philosophy’. MH has been defined by Evans ‘as an integrated, interdisciplinary, philosophical approach to recording and interpreting human experiences of illness, disability and medical intervention’.⁹ It includes interdisciplinary as well as multi-disciplinary approaches in diverse fields such as literary arts, visual and performing arts, history of medicine and bioethics, amongst many others.¹⁰

As a separate field of study and practice, the use of arts and humanities in medical education is perceived to serve an important goal: that an attention to human interactions and creativity would create more empathetic and compassionate doctors with a wider worldview and broader perspective, leading to better health outcomes for patients.^11,12 Our study was designed to describe the experiences of participants and facilitators in designing and implementing a formal coursework in health humanities within the medical curriculum.

METHODS

RESULTS

The student’s choices (n=150) for 1st professional year and (n=136) for 2nd professional year showed fairly even distribution in all the offered choices with literature (23.3% and 15.4%), photography (30% and 26.5%), painting (27.3% and 22.8%), film studies (19.3% and 15.4%) and dramatics (19.9%).

A structured feedback provided by students (n=123) at the end of the 2nd professional year coursework stated that 63.4% students believed that medical colleges should provide a structured outlet/programme to demonstrate their work in the field of arts. 74.7% of students responded that the faculty conducted the sessions engagingly and interactively, allowing them to openly convey their thoughts and feelings without being judged (71.5%). The majority of the students were not in favour of assessment for the humanities (59.3%). Furthermore, 65% of students perceived that the coursework encouraged them to think more empathetically and enabled them to expand their views and perspectives (70.7%), and would help them become better doctors in the future (65%). The majority of students (73.1%) believed that it would be beneficial to include students in the preparation of the curriculum, while 44.7% of students did not prefer humanities courses as electives after college hours, and 22.7% remained undecided on the matter (Fig. 1).

Close

FIG 1.

Students feedback on humanities sessions

Export to PPT

The students suggested adding more areas, such as music, singing, dancing, and psychology, to the choices offered in the curriculum.

The challenges in designing and implementing a humanities curriculum, identified through faculty reflections, are described in Table 1.

DISCUSSION

Medicine is only a minor determinant of health in the human population alongside other social factors and we have to view health and medicine as a cultural enterprise occurring in the society and concern illness and healing not only with healthcare providers and patients but also their families and community and study health within the context of its socio-cultural determinants, beyond the boundaries of medicine and clinical encounters. This formed the central theme around establishing the Department of Health Humanities and Social Sciences at our institute and introducing a formal framework for humanities in the medical curriculum to understand human experiences of health and healthcare, and work explicitly towards health humanities teaching, practice, as well as research.²³

The introduction of humanities modules, as well as the encouraging feedback we received from the students at Level-1 of Kirkpatrick’s model of evaluation, has previously also shown favourable outcomes in many foreign universities on the improvement of knowledge and attitudes amongst medical students²⁴ and there exist separate MH departments/groups with similar guiding philosophies at institutes such as St John’s Medical College, Bengaluru; KEM Hospital and Seth GS Medical College, Mumbai; Kasturba Medical College, Manipal Centre for Humanities, Manipal Academy for Higher Education, Manipal and University College of Medical Sciences, Delhi amongst others. Although many scholars have argued that the humanities have been narrowly judged to merely support the goals and priorities of medicine, thereby diminishing their values and possibilities.²⁵ Dror²⁶ also asserts that the humanities have been ‘medicalized’, limiting their potential contribution from the perspective of health. These precisely strengthened our belief in taking the non-instrumental approach of health humanities in our coursework. Besides, a coursework that avoids didactic teaching and concentrates instead on using imagination and creativity could be the rationale behind the encouraging response from the students. And even though the medical curriculum is tightly packed with voluminous academic subjects and arduously acquired skills, making the addition of any new course content overwhelming, the study of the humanities has always been deemed pleasurable by students.²⁷

While it is true that in its ornamental role, humanities often seem valued primarily for the enrichment and comfort it offers to the physician⁸ and overworked medical students may subscribe to this relaxing and stress-reducing aspect of studying humanities,²⁸ but such concerns often overlook the effect of reading a good poem or gazing at a work of art in an environment of rigorous enquiry on the reader or the viewer. Kirklin²⁹ argues that poor teaching may lead to unitary, predefined conclusions about humanities texts and performative processes, rather than the texts or the processes themselves. It highlights the overwhelming response from the students about our sessions and the freedom to convey their thoughts and feelings without being judged.

We acknowledge that mere perceptions shared by students cannot account for the learning gained through such sessions. Not having a summative assessment limits the evaluation, but many others have also highlighted difficulties in assessing humanities modules.³⁰ Wershof Schwartz et al.³¹ specifically mention that subjective outcomes, such as empathy, professionalism, and self-care, are difficult to measure, despite an effort to quantify the impact of humanities courses. Bleakley³² also remarks that it may be akin to measuring the immeasurable.

Jones³³ concludes that the philosophy behind such a humanities course is to provide medical students with skills that enable keen listening, accepting diverse and multiple perspectives, as well as acknowledging ambiguous and contradictory responses. Garden³⁴ observes that such skills are merely manifestations of empathy and must lead to action with the intention of reducing the suffering of others. Brody³⁵ also reminds us that the ultimate goal of the humanities is to make a difference in practice through the moral development of practitioners guided by wisdom and virtue. Many studies suggest that exposure to humanities courses during medical training has been found to be successful in creating more humane doctors.^36–38

This is our first experience in the vast field of humanities, and we did not utilize the 6 steps of curriculum development; however, we plan to develop further on this to provide a better structure to the curriculum. It would also be fruitful to receive feedback from multiple sources and future batches through interviews and focus group discussions, and to analyze the affective domain using validated scales to provide better generalization. However, while it is an indigenous coursework with sessions and artworks, as per our experience and experts from our network, we believe the guidelines we followed to design our coursework and sessions might generate similar responses across students and colleges.