Learning medical sociology through an innovative ‘Elective study module’ integrating humanities with medicine for undergraduate students of a medical college in Bengaluru, India

INTRODUCTION

A key to transforming medical education for the 21st century has been the proposal to move from ‘informative learning’ to ‘formative learning’; while informative learning is about acquiring knowledge and skills with the purpose of producing ‘experts’, formative learning is about equipping students with values (in addition to knowledge and skills) with an aim to produce ‘professionals’.¹ While the knowledge and skills domains of learning remain the focus areas of undergraduate medical education currently, teaching on affective domain relating to attitude and emotions² remains suboptimal, being mostly taught as a ‘hidden agenda’ of medical schools by facilitating learning from role-models. Of late, the National Medical Commission has initiated efforts to make it more explicit by introducing mandatory ‘Attitude, Ethics and Communication’ (AETCOM) training for all medical students.³ In 2023, the introduction of an elective programme—a special study module that is voluntarily chosen by the medical student—provides an opportunity to offer a supervised, immersive and self-directed learning experience in basic/laboratory/clinical sciences. We describe our experience with a programme of study in ‘medical sociology’ (defined as the study of social patterning of health) through innovative use of humanities in medicine. The objectives were to explore the role of social determinants in health (primary objective) and to explore the role of music artists in raising awareness about issues related to societal well-being (secondary objective).

METHODS

The DoCTRINE (Defined Criteria To Report Innovation in Education) reporting guidelines were adhered to in the drafting of this manuscript.⁴ Our elective module, called ‘Community Health and Rock Music’ (CHaRM), was a 2-week training programme between the pre-final and final years of study. It was proposed to the office of the Vice-Dean in 2022 by the faculty (PM) with the rationale of community health being a regular subject within the MBBS curriculum while ‘rock music’ (defined as a kind of music with a heavy beat that is played and sung, usually loudly, by a small group of people)⁵ would be an exposure to the ‘counter-culture’ outside of the medical world.⁶ This was approved by the Vice-Dean’s Screening Committee and the module was offered over two weeks in March 2023 as an afternoons-only programme.

On day 1 of the programme, students were introduced to the broad domains of learning² and the purpose of the elective programme. They were then asked to answer questions as to the aetiology of common morbid conditions seen often during clinical postings: the cause of tuberculosis, and malnutrition in children. They were then taught to illustrate these figuratively as follows: Mycobacterium tuberculosis (cause) → tuberculosis (effect), and inadequate protein–calorie intake (cause) → protein energy malnutrition (effect). Last, they were challenged to keep their minds open as to how these simple linear illustrations would be redrawn differently by the end of the programme. To encourage active participation in the debriefing sessions, the early ‘ice-breaker’ discussion centred around individual student hobbies and its meaning to each one of them personally.

RESULTS AND DISCUSSION

Seven (4 girls and 3 boys) of 143 students who were offered a range of elective options volunteered for this elective programme. The main reasons cited for taking up this elective were its uniqueness or the student’s personal interest in music (Table II).

The advantage of viewing the music video (with or without lyrics) was that the skilled artiste(s) was/were able to grab our attention immediately, arouse our sympathy and get us involved with the characters that were being portrayed. The discussions that followed the viewing of the music video followed by the specific activity (either a field visit or a clinic visit) helped challenge the students to think through and come up with their own interpretations regarding the characters or situations. It also helped identify hidden prejudices, which are difficult to acknowledge in a typical classroom setting with the regular human biology subjects in the medical curriculum. This is referred to as the ‘instrumental purpose’ of the use of arts/humanities in medicine.¹⁵

The second message conveyed through this teaching– learning method was an exposure to the ‘counter-culture of arts’. Given that medical college entrance requirements ensure that typically the academically smart students from schools are the ones who enter medical college, several students may grow up thinking themselves to be superior. The rigour of the medical course curriculum and the separation of the medical college from the main university system in India also ensure an insular training removed from the rest of the ‘outside world’.¹⁵ This elective course helped expose medical students to the unique ability of music artistes to communicate important social issues through interesting storytelling by use of lyrics and videos, in a way that is not possible through traditional teaching using medical textbooks, especially for complex social determinants of health.

The students submitted personal portfolios that were 500 to 800-word reports: 5 were handwritten and 2 were typed. Their feedback on the ‘process of learning’ appreciated the balance of formal and informal interactions in the class; the refreshing approach to studying social determinants of health, sociology and epidemiology; use of case-based learning; the practical and reality-based learning along with the ardent discussions on socially taboo topics and social problems that made it feel very personal. The verbatim reports are given in Table II.

Key lessons learnt were reported as a clear appreciation of social factors as determinants of health; multifactorial causation of diseases; hidden issues not taught in traditional medical curriculum that could be covered in such an elective module; personal growth in a short span of time; importance of teamwork; and importance of empathy in being a better doctor and offering holistic care (Table II).

Important feedback for future offerings were also provided with regard to total duration, structure of class, and to continue the elective with its optimal mix of academics and fun (Table II).

All 7 student assessments ‘met expectation’, with 4 of them being graded as ‘exceeding expectation’. This was based mainly on reflective narratives—those that had descriptions of the day-to-day activities were graded as ‘meeting expectation’ while those that had descriptions detailing how it was a transformative experience for them with details of what values or thought processes were challenged within them were graded as ‘exceeding expectation’. Similarly, participation in verbal discussions or sharing social media posts relating to social determinants of health outside of class timing were also graded as ‘exceeding expectation’.

A few limitations of such an elective posting are highlighted here. First, it is acknowledged that rock music may not appeal to several teachers or students. However, this can be replaced with folk music, theatre or book-reading as the art form that can be used to teach relevant aspects of social medicine. However, the main objective in our programme was to use the energy and angst associated with rock music to raise concern about ‘structural violence’, which is violence exerted systematically (though indirectly) by everyone who belongs to a certain social order and is participant to maintaining that order.¹⁶ In addition, while undertaking the assessment there is the need to admit that there are inherent difficulties in assessing higher-order imbibing and internalization of the learning of health determinants in such a course. For the student, personal portfolio is only a self-report of participation and learning in the short-term; it does not capture the effect of this course on their long-term behaviour and impact;¹⁷ further, it is dependent on written expressive skills. For the assessor, inherent subjectivity remains a major concern.

In summary, this innovative elective posting provided an exposure for the students to medical sociology, wherein they learnt voluntarily in an immersive, fun and non-patronizing manner on how social factors (e.g. caste, class, gender, religion, educational status, age, etc.) influence human health. It also provided an opportunity to understand basic social epidemiology; that is, how these social-structural factors affect health and how to quantify the burden of disease and measure of association between risk factors and disease outcomes. Further, the students were made aware of how those in the field of arts raise concerns about social issues. For the elective course to be deemed useful, it should move from informative to formative to transformative learning.¹ This is an innovative, experiential, student-centric, replicable and scalable model of learning that may help in making better, more empathetic doctors.