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March 2018, Volume 68, Issue 3

Opinion / Medical Humanities

A proposed elective in medical humanities

Nausheen Bakht  ( Combined Military Hospital (CMH) Bahalpur c/o NUMS )

Abstract

The social contract between medicine and society is being renegotiated and demands the reorientation of healthcare. Neither society nor doctors are happy with the way modern medicine is being practised. An obtuse focus on medical sciences and a myopic view of medical humanities (MH) has been incriminated. MH reflects on healthcare-related topics in the light of shared human experiences. It addresses the genuine concerns of patients and their attendants. It also helps inculcate humanistic values in doctors by enhancing ethical understanding, cultural sensitivity, mutual respect, empathy, communication skills and decision-making. MH originated in the 1960s and 1970s in the United States while in the United Kingdom, the emphasis on MH started in 1990s and 2000s. MH departments are now working in most medical schools in the West. Unfortunately, MH has failed to draw sufficient attention in Pakistan. To break the inertia and ride the tide of time, an elective in MH is being proposed.

Keywords: Medical humanities, Humanities, Elective, Pakistan, Social contract.

Introduction

The World Health Organisation (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".1 The definition may sound "utopian, inflexible, unrealistic and unlikely," but nonetheless demands borrowing inputs from multiple non-medical domains.2
Globally, the way modern medicine is practised, is nothing to write home about. Genuine concerns of the patients and the people who matter to them often remain un-addressed. The exaggerated emphasis on molecular reductionism is causing an annihilation of humanitarian instincts in doctors. On the other hand, it takes a Herculean effort on part of the healthcare professionals to remain motivated to practice. Their well-being is jeopardised resulting in substance use, burnout, deliberate self-harm, divorce and suicides. To address these issues, efforts are being made globally to teach a variety of subjects in medical colleges which were previously taught in the faculty of Humanities.3 It is not only the content of these courses, but also the aim behind teaching them that matters.Arts, Humanities and Medical Humanities: Art is as an outlet of expression, a manifestation of creativity. It mainly encompasses literature (prose, poetry, short stories, novels, etc.), visual arts (drawing, painting, sculpting), performing arts (music, dance, theatre, etc.), media arts (photography, cinematography, etc.) and culinary arts (baking, chocolateering, etc.). The words arts and humanities are often used interchangeably.4 The word \\\'Humanities\\\' originated from the word \\\'humanism\\\' which is an attitude towards other people. \\\'Medical Humanities\\\' (MH) reflects on topics like health, disease, medicine, health care and doctor-patient relationship, etc in the light of shared human experiences.5,6 It links cognition and affect and brushes off layers of apathy by combining medicine with understanding of human thinking, emotions, expression, imagination, language and culture.7,8
Advantages: The social contract between medicine and the society is being renegotiated. In turbulent times like these, electives in MH offer solace. There is evidence that training doctors in MH helps inculcate humanistic values in them by enhancing ethical understanding, cultural sensitivity, mutual respect, empathy, communication skills, and decision-making.9 MH highlights individuality, celebrates differences and promotes plurality. These electives not only provide a stimulus for innovative problem-solving, but also deal with uncertainty in clinical practice in a creative and intellectual manner.10 MH education hones imagination, self-awareness, creativity and counters burnout by offering a good break from routine.11 Learners report pleasurable experiences.12
Medical Humanities and Pakistan: Although MH departments are now working in most medical schools in the West, the term was first coined in the United States (US) in the 1960s and 1970s.13 In the US, students complete a four-year bachelor\\\'s degree first, in which they take courses in MH which are often a mandatory part of the curriculum. Medical colleges in Pakistan follow the United Kingdom (UK) model where students go to medical school directly from secondary school.14 In UK, emphasis on MH started in 1990s and 2000s.15 Unfortunately, MH has not received the attention it deserved in Pakistan till now. Perhaps this obtuse focus on medical sciences (MS) is compromising the quality of our doctors. A reorientation of healthcare is direly needed.16
An Elective in Medical Humanities — Rationale: The proposed elective in MH is expected to meet a lot of difficulties and opposition, and perhaps from all quarters including the government, civil society, faculty, administration, students and parents. But we must remember that resistance to change is an established phenomenon. Breaking the inertia and riding the tide of time demands taking the stakeholders into confidence who need to work in close collaboration with each other so as to make this module a success.
The Proposed Elective: The elective will be activity based, problem oriented and interdisciplinary in nature. It will be student-driven, relevant and would demand inputs from multiple professionals. A designated focal person will be appointed to liaison with guest speakers and look into the technical and logistic affairs. Teacher and student guides will be prepared.
The elective will be of one-month duration. Six working days per week will be utilised, from 0800 hours to 1500 hours for coursework. On Saturdays, short local educational trips will be arranged. Evening duties of participants will be off for one month.
Learning Environment: A safe, secure, cosy, noise-free, comfortable, welcoming and friendly environment is mandatory. All facilitators will be trained to make learning enjoyable and fun.
Keeping the number of participants and the requirement of the facilitator in view, the elective may be conducted in the conference room, auditorium, library, wards, outpatient departments (OPDs) and cafeterias.
Audio-visual aids, information technology (IT) arrangements, air conditioning, lighting, seating arrangement and sound system will be checked beforehand. Designated technicians will remain available throughout the course of instruction for rectifying issues, if needed.
The Learners: The elective will be offered to fourth-year medical students during the summer break. The intake will be 15-20 learners. The participants will also be given a copy of the curriculum outline, a brief description of the module and a student guide.
The Facilitators: All facilitators will be instructed to promote interaction and active participation from the students so that they feel at liberty to ask questions as and when required. They will be asked to introduce concepts in a phased manner, do scaffolding and liberally quote examples from the arts and literature to promote understanding.
The facilitators will be provided a copy of the curriculum outline, a brief description of the module and a student guide. The variegated content of the module demands taking interested physicians and public health professionals on board. Services of non-physician guest speakers who are expert in Humanities will also be required. Faculty development workshops may be conducted if warranted.17
The Curriculum: The one-month module will concentrate on three core areas of instruction:

1. Medicine and Arts,
2. Ethics and Medicine,
3. Contemporary Issues in Medicine.

Timetable along with the modalities of teaching have been worked out2,11,17,18 (Table).



The Learning Outcomes: This exploratory module aims at introducing the participants to:

1) The field of MH

2) Reflection and critical thinking

3) Self-awareness by helping participants explore own personal values

4) Greater respect for perspectives, different from theirs

5) Ambiguity and uncertainty

6) The human dimensions of medical practice

7) The concept of pluralism

8) The concept of cultural sensitivity

9) Barriers between "us" and "them" (professionals vs patients, next of kin and the          society at large.)

10) Verbal and written communication skills, research and critical analysis skills

11) A more ethical practice of medicine

12) A greater awareness of ethical dilemmas in practice and research

13) Attitudes important for clinical practice in a social context

14) Analysis excerpts from the literature and arts from medical practice point of view

15) More empathic medical practice

16) Principles of teamwork

17) More creativity, imagination and passion in their work18,19

18) Costs: All costs will be borne by the medical college and the focal person will              timely liaise with cafeteria, book shop, IT and transport departments like for a            smooth execution.

19) Honorarium will be provided to guest speakers.

20) Facilitators will be requested to recommend books, documentaries, movies,              dramas, songs, paintings prior to start of module so that ample copies may be
kept in the library for participant use.

21) Daily arrangement for refreshments, tea and water for participants and
facilitators will be done.

22) Audio-video aids (laptop, multimedia, sound system, collar microphones, learner      response system (LRS), extension wires, Wi-fi connection (for presentations on
Prezi, live conference at distant sites) will be made available.

23) Stationery (pencils, A-4 size papers, rubbers sharpeners, colour pencils, crayons,    white boards, whiteboard markers, flip charts) will be provided.

24) Bus and a driver will be required for Saturday trips.

25) Cars and drivers may be needed for pick and drop service of guest speakers.

26) Assessment: For the first three weeks since its inception, only weekly formative      assessment will be done on the basis of:

27) Class participation: Students\\\' ability to justify, criticise or debate on assigned topics during class.10

28) Weekly analytical essays: Weekly essays done by students at week 1 and week 2 will be compared to those done at week 3 and week 4, to discern progression of analytical skills.

29) ortfolio: Students will convey their understanding of each topic discussed through posters, mock newspapers, murals, montages, pictures, cartoons and collages during the course and as home assignment.

Evaluation

On day one: The students will be asked to identify reasons for opting for the module and what they perceive will be its structure, content and educational impact.
During the elective: They will evaluate each session by filling out an anonymous evaluation form. Areas assessed will include the environment; each facilitator\\\'s professionalism, their ability to facilitate sessions, create a non-threatening and friendly atmosphere, informality, sense of humour, session design, selection of excerpts from literature and arts, and creating interest among the participants. The appropriateness of resource material, content and structure of module used will also be commented upon.19
On completion of the module: They will draw a comparison between their current and the-then held opinions as well as present short presentations on lessons learnt.

Conclusion

It is said if we always do what we have always done, the results will be no different. The results of our obsession with MS are evident in societal protests against young doctors, media trials of medics, litigation charges against consultants and burnout in physicians themselves. The war \\\'us\\\' against \\\'them\\\' is being waged in every corridor of our society on a daily basis. It is high time we wake up and set our priorities straight. MH seems a promising endeavour, worth giving a try.

Disclaimer:
This is the updated and modified version of the author\\\'s assignment written as part of Master of Health Professions Education (MHPE).
Conflict of Interest: None.
Source of Funding: None.

References

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14.  Mc Cullough M. Bringing drama into medical education. Lancet. 2012; 379: 512-3.
15.  Shah N, Aly SM. Teaching of medical humanities in medical universities of Pakistan. J Pak Med Assoc. 2015; 65:414-7.
16.  Shapiro J, Coulehan J, Wear D, Montello M. Medical Humanities and Their Discontents: Definitions, Critiques, and Implications. Acad Med. 2009; 84:192-8.
17.  Gupta R, Singh S, Kotru M. Reaching people through medical humanities: An initiative. J Educ Eval Health Prof. 2011; 8:5-10.
18.  The Medical Humanities. Special Issue, Acad Med.2003; 78953-1074.
19. Medicine and creativity. Special issue. Lancet. 2006; 368:S1-64.

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