Medical Humanities in South Asian medical schools Shankar PR Affiliation: Dr. P. Ravi Shankar Professor, Medical Education KIST Medical College Lalitpur, Nepal. Address for correspondence: Dr. P. Ravi Shankar KIST Medical College P.O. Box 14142 Kathmandu, Nepal. E-mail: [email protected]

Abstract: Medical Humanities (MH) is using subjects traditionally known as the arts in pursuit of medical educational goals. MH programs are well established in developed nations like the United States, United Kingdom, Canada, New Zealand and Israel. MH has a number of advantages in medical education. I have been involved with MH programs in two Nepalese medical schools during the last four years. MH programs are important for medical schools in South Asia. I share certain challenges to be overcome and issues to be considered while starting these programs.

Subjects traditionally grouped under the humanities like paintings, music, literature, sculpture, philosophy, sociology, anthropology and others are widely used in educating doctors in developed nations. In this essay I plan to introduce the reader to the Medical Humanities, very briefly describe a few established programs around the world, discuss why Medical Humanities (MH) is needed in medical education, highlight my experience with MH and chalk out a plan for introducing MH in South Asian medical schools. What are the Medical Humanities? Dr. Kirklin from London, England, an international expert in MH defines it as ‘an interdisciplinary, and increasingly international endeavor that draws on the creative and intellectual strengths of diverse disciplines, including literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology and history in pursuit of medical educational goals’.1 MH can be regarded as subjects like history, literature, philosophy, ethics, anthropology, sociology, theology, psychology and others concerned with the specific experiences of health, disease, illness, medicine and health care, the practitioner–patient relationship and, above all, the clinical consultation as an arena for human experiences.2 MH is history, philosophy, sociology, anthropology, art and those fields of knowledge relevant to the understanding and practice of medicine in general and clinical situations in particular.3 Modern allopathic western medicine is also called ‘scientific’ medicine and science is at its heart. All medicines and treatment modalities are continuously being investigated using the tools of modern science to further refine them and make them more effective. Science has contributed tremendously to the growth and development of

allopathic medicine. But concentrating only on science and neglecting the ‘art’ of medicine has had many deleterious consequences. In the early 1970s these consequences came to the limelight in western industrialized nations. MH programs were developed to try to address these problems and give doctors an exposure to the arts and introduce them to the ‘art’ of medicine. Selected MH programs from around the world: MH programs are well established in the United States (US), the United Kingdom (UK), Canada, New Zealand, countries of Western Europe and Israel. In many medical schools MH started as a voluntary module and slowly a case was made for introducing the discipline formally in the curriculum. Literature, paintings, fine arts, drama, photography have been used to learn MH. Many medical schools offer a number of elective courses in MH and students can select a particular one according to their interest and aptitude. Other schools have a core subject area in the humanities but students can choose electives according to their interest. In certain schools MH is restricted to particular years of study while in others it is spread throughout the course. Small-group, activity based learning is used in the majority of medical schools. Retreats and weekends in scenic places away from the noise and pollution of the city have been used to promote interest and deepen understanding. At Nova Scotia, Canada the module offers a large number of electives to students.4 Students can choose particular courses according to their interest and do summer research projects in the humanities. The University of California, Irvine, College of Medicine in the US informally started a literature and medicine elective in 19975 emphasizing small-group, interdisciplinary learning and the use of creative projects. The

program aims to enhance aspects of professionalism including empathy, altruism, compassion, and caring toward patients, as well as to improve clinical communication and observational skills. It contains elective or required curriculum across all four years of medical school and required curriculum in two residency programs. In Ohio, US the human values in medicine (HVM) program has ‘Love in literature and medicine’ as one of the most sought-after electives.6 The program has 120 required hours in medical humanities, social sciences, and behavioral sciences. There is a mandatory HVM month in the fourth year. Students can choose from lectures, seminars, and short courses during the first, second, and third years of medical school. At the University of Tel Aviv, Israel a course on the Philosophy of Medicine was introduced in the year 2002/3 comprising formal lecturing, questions and answer sessions and exercises.7 In Turkey, a preclinical MH program, ‘The human in medicine’ (HIM) has been conducted for the last seven years.8 The authors concluded that the multidisciplinary, preclinical HIM program could be a good starting point to complement the biologic perspective of medical education with a social and humanistic perspective. Why MH is needed in medical education? There are many advantages to learning MH. Students gain greater clarity and insight into patient problems and the patient perspective and can identify better with clinical situations and patients. MH serves three main goals: the study of the human aspects of medicine using traditional arts disciplines of history, philosophy, sociology and literature; the intersection of medicine and the creative arts; and the training of more insightful and compassionate doctors.9 Medical biography offers medical students a framework about how other doctors have dealt with and responded to challenges and

tough professional situations. Literature provides glimpses of ‘whole person understanding’ and is directly beneficial to the practice of medicine.10 The arts, especially literature can provide insights into common shared human experiences, individual differences and the uniqueness of each human being and can enrich language and thought.11 Literature may introduce students to problematic, unfamiliar life situations12 and add on the limited scenarios encountered in day to day life. Doctors and healthcare professionals find it difficult to understand and empathize with what the patient is going through. A study of literature and art may help in the process of identification and understanding. Painting can highlight the different non-verbal ways in which feelings or attitudes can be expressed. Literature, painting and other fine arts can encourage reflection among students and practitioners. MH can encourage creativity which allows new ways to solve clinical problems and deal with uncertainty in clinical practice. Illness changes the way patients relate to their daily life and they struggle to find meaning. Patients expect help from their doctors and healers in their adjustment effort. Images, music and poems may help in finding the way.13 My experience with MH programs: I conducted a voluntary MH module at Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal. The module was based on small group, activity-based learning. Interactive discussions, brainstorming sessions, role plays and analysis and interpretation of excerpts from the literature and the arts and analysis of case scenarios were the learning modalities used. Interested basic science and clinical students participated.14 At KIST Medical College (KISTMC), a new medical school a voluntary

MH module was conducted for faculty members, medical and dental officers.15 Participants enjoyed the module but had problems with certain issues explored using role plays and with some of the literature excerpts. A module for students titled ‘Sparshanam’ (meaning touch in Sanskrit, an ancient South Asian language) has been conducted for first year medical students of the institution since the last two years.16 The module uses small group work, case scenarios, facilitator inputs, role-plays and debates are used. Paintings have been widely used in the module.17 Starting MH programs in South Asian medical schools – the way forward: MH programs due to their advantages and benefits have an important role in South Asian medical schools. In South Asia arts and the humanities have been neglected in both school education and during the medical course.18 Students are admitted to medical school only after twelve years of schooling with the subjects of Physics, Chemistry and Biology in the last two years. Students are not usually familiar with interpreting paintings and art appreciation. Entrance to medical school is tough and students have little opportunity to read beyond their course. This is also true during the medical course and post graduation. Thus students and doctors may not be familiar with and comfortable with the humanities. Also in South Asia medical students are younger and do not need to have a graduate degree before entering medical school. The learning and assessment system emphasizes rote learning and reproduction of factual information. Electives are not common and individual medical schools do not have much freedom or authority to tailor courses to their own requirements. Faculty members interested in MH and the arts may be few. MH is usually taught using small group, activity-based learning strategies and many faculty members are not comfortable with the same. In the west the

curricula and methods adopted in different MH programs vary between medical schools. I think a diversity of approaches to and areas covered has been the major strength of MH programs. Encouraging plurality in the curriculum and teaching-learning methods is not common in our region. These are among the many hurdles and challenges which have to be considered while starting MH programs in our region. I think MH can be started as voluntary module. The first step may be workshops for interested faculty members so that they can be introduced to MH, objectives of teaching MH to medical students and approaches to teaching/learning the discipline. The objectives of the program can be defined at a regional or national level but I feel each school should be free to draw up its own programs and learning approaches. MH is regarded as ‘fun’ by students and teachers and provides a period of relaxation and reflection. It is vital to continue the fun and not make MH dry and didactic like other subjects in the medical curriculum. In our modules students were not in favor of formal assessments. There is a wealth of material available from western sources some of which can be used in our modules. Some information and activities can be modified to suit our context. We should also develop material from a South Asian context. The language of MH teaching may also be an issue. In South Asia due to a variety of reasons the language of medical education is English. However, in most cases English may not be the language used for communicating with patients. We had also used English as the language of MH learning in Nepal and this had both advantages and disadvantages.19 We however, also use Nepalese for role-plays and for creative activities. The multiplicity of languages will make it difficult to choose an acceptable language of instruction. During initial sessions evidence for impact of MH modules on empathy,

professionalism and other skills and attributes of participants should be obtained. Measuring these skills may be difficult though there have been instruments developed for the same. As MH programs become more established a case can be made for their introduction in the curriculum. Finding time for one more discipline in a crowded curriculum will be difficult and we should consider reducing or removing topics from the curriculum depending on criteria to be worked out. Linkages may have to be developed with humanities educators outside medical schools and they can be involved in developing and supporting MH programs.

Conclusions: MH aims to offer a contrasting perspective of the arts to the scientific one which dominates modern medicine. MH programs are common in US, UK, Canada, Western Europe, New Zealand and Israel. MH has a number of advantages in medical education and can help in producing more ‘humane’ doctors. MH programs are necessary in South Asian medical schools. They can be started as a voluntary module using small groups and activity-based learning. The module should be fun and accepted by students. There are a number of challenges to be addressed and overcome.

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Medicine 2003; 78: 997-1000. 7. Rudnick A. An introductory course in philosophy of medicine. Journal of Medical Ethics 2004; 30: 54-6. 8. Gulpinar MA, Akman M, User I. A course, 'The Human in Medicine', as an example of a preclinical medical humanities program: A summary of 7 years. Medical Teacher 2009; 21: 1-8.

9. Hooker C. The medical humanities a brief introduction. Australian Family Physician 2008; 37: 369-70. 10. Downie RS. Literature and Medicine. Journal of Medical Ethics 1991; 17: 93-6, 98. 11. Scott PA. The relationship between the arts and medicine. Medical Humanities 2000; 26: 3-8. 12. Macnaughton J. The humanities in medical education: context, outcomes and structures. Medical Humanities 2000; 26: 23-30. 13. Peterkin A. Medical humanities for what ails us. Canadian Medical Association Journal 2008; 178: 648. 14. Shankar PR. A voluntary Medical Humanities module at the Manipal College of Medical Sciences, Pokhara, Nepal: Participant feedback. Teaching and Learning in Medicine 2009; 21: 248-53. 15. Shankar PR. Creating and maintaining participant interest in the medical humanities.

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http://medhum.med.nyu.edu/blog/?p=215. Accessed on September 16, 2010. 16. Shankar PR, Piryani RM, Thapa TP, Karki BMS. Our Experiences With ‘Sparshanam’, A Medical Humanities Module For Medical Students At KIST Medical College, Nepal. Journal of Clinical and Diagnostic Research 2010: 4: 2158-2162. 17. Shankar PR, Piryani RM. Using paintings to explore the Medical Humanities in a Nepalese medical school. Medical Humanities 2009;35:121-122.

18. Shankar R. Arts and humanities: a neglected aspect of education in South Asia. http://blogs.bmj.com/medical-humanities/2008/07/17/arts-and-humanities-aneglected-aspect-of-education-in-south-asia/. Accessed on September 16, 2010. 19. Shankar PR, Piryani RM. English as the language of Medical Humanities learning in Nepal: Our experiences. The literature, art and medicine blog http://medhum.med.nyu.edu/blog/?p=175. Accessed on September 16, 2010.

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About the author: Dr. Shankar is Professor of Medical Education at KIST Medical College, Lalitpur, Nepal. His areas of interest are Medical Humanities, small group learning and rational use of medicines. He has been involved with MH programs at two Nepalese medical schools. He has about 30 publications on Medical Humanities and is a member of the editorial board of BMJ Medical Humanities. He is a fellow of the PSGFAIMER Regional Institute.