Loss and Tomorrow's Doctors: how the humanities ...

The International Journal of Person Centered Medicine

ARTICLE

Loss and Tomorrow’s Doctors: how the humanities can contribute to personal and professional development Victoria Tischler BSW MSocSc PhD PGCHE CPsychola, Arun Chopra MBBS MMedSci MRCPsychb, Neil Nixon BSc (Hons) MBBS MMedSci MRCPsychc and Lynne McCormack BEd BSc MSc PhD CPsychol MAPSd a Lecturer, Division of Psychiatry, University of Nottingham, Queens Medical Centre, Nottingham, UK b Consultant Psychiatrist, Nottinghamshire Healthcare NHS Trust, Nottingham, UK c Consultant Psychiatrist, Nottinghamshire Healthcare NHS Trust, Nottingham, UK d Assistant Professor, Centre for Applied Psychology, University of Canberra, Australia Abstract Background: Previous research notes the benefits that the study of humanities can bring to medical education and professional practice. Empathic skills, holistic care, acknowledgment of differing values and patient-centred practice are said to be promoted by engagement with humanities. This qualitative study sought the views of students about the value of such engagement and asked them to reflect on their experience of medical humanities training. Methods: A focus group study was used to explore the views of medical students taking a humanities training course. A number of themes were derived from the data using Interpretative Phenomenological Analysis (IPA). Results: The themes indicated the value of humanities-based courses beyond improvements in patient-centred practice. Engagement with the humanities was found to address the loss and disillusionment that students felt on entering medical school and progressing through their training. The humanities offered opportunities to improve their confidence, reconnect with previous interests that had been subsumed by their medical studies and time to reflect on their choice of career. Students also identified with a peer group and with teachers who acted as role models which may encourage them to consider particular medical specialities. Conclusions: We argue that humanities training should be valued in the medical curriculum in terms of improving professional practice and developing healthy coping strategies to manage the stress of a demanding vocational career. Keywords Arts, holism, medical curriculum, medical humanities, professionalism, psychiatry Correspondence Address Dr. Victoria Tischler, Division of Psychiatry-Behavioural Sciences, A Floor, South Block, Queens Medical Centre, Nottingham, NG7 2UH, UK. E-mail: [email protected] Accepted for publication: 24 May 2011

Introduction ‘From treating patients as cases...good lord deliver us’ (Robert Hutchinson) Patients want their doctors to understand them, their hopes and aspirations, their fears and their dilemmas in order to place their illness and its treatment within the context of their lives. With scientific and technological advances in medicine, the risk of the practitioner becoming detached from their patient and treating them as a case, as they accumulate necessary facts and figures about them, is troubling [1]. The 2009 GMC document, Tomorrow’s Doctors [2], recognised this risk of detachment and advocated a 547

more humane approach to medical education that included developing appropriate attitudes and behaviours. Many medical schools now offer humanities-based courses as one of the ways in which to develop holistic and patientcentred attitudes. These courses are said to improve communication skills, ethical understanding, ability to empathise and cognitive skills [3]. In addition, the arts have a role in helping students develop the ability to tolerate uncertainty as all is seldom revealed in art. In specialties such as psychiatry, speech and patterns of thought, if accurately presented in pieces of literature, can be a useful and accessible route to identifying psychopathological constructs.

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Tischler, Chopra, Nixon and McCormack

There are difficulties with this approach. For example, how do you show that these ambitions are met? And, do you need to turn to the arts to help students acquire empathy? Further, many students are reported as feeling ‘shortchanged’ when they are compelled to study the arts, especially when they expected to be pursuing more ‘scientifically rigorous’ subjects [4]. Because of these difficulties, humanities courses, where available, are usually offered as student-selected components for the interested, rather than delivered as part of the core curriculum. There are accounts from experienced and early career professionals of the benefits they gained from attending such courses [5,6]. However, there is a lack of qualitative evidence of students’ perceptions of humanities training, which the current study aimed to address.

Methods The participants were medical students who attended a course: the ‘arts in psychiatry’ at an English medical school. Activities and topics included drama, music, creative writing, psychiatric photography, art therapy, cinema appreciation, classical and cultural depictions of madness and a visit to a community arts project. Most sessions were co-led by humanities academics and clinicians; one was led by an artist who identified himself as a mental health service user. All sessions were designed to be highly participative. For example, students acted, painted and wrote poetry. A focus group study was used to gather data. All 13 students taking the ‘arts in psychiatry’ course were invited to take part via letter. Six responded and agreed to participate. There were 3 male and 3 female participants with a median age of 23 years. Two were of Asian ethnicity and 4 were UK British. There is no recommended number of participants in a qualitative study. Typically, sample sizes are small with around 3 to 6 participants, because of the indepth analysis required [7, 8]. The focus group was facilitated, audiotaped and transcribed verbatim by a researcher independent of the module organisation and delivery (LM). Interpretative Phenomenological Analysis (IPA) was used to examine the data. This approach focuses on lived experience and how participants make sense of their experiences. IPA is concerned with the phenomenological uniqueness of the individual within their social context. It engages the interviewer in a reflexive, double hermeneutic relationship; that is, it values the researcher’s skills in trying to interpret the participant’s making sense of his/her experiences. Theoretically, it is committed to the whole person. As such, it empathically aims to bring meaning to the complex interweaving of expressed language, thinking and emotions [7]. In addition, guidance for analysing data from focus groups was considered [9]. Such a qualitative approach aims not to produce generalisable data, but to achieve theoretical generalizability; that is, findings that can be used to develop concepts, understand phenomena and theoretical propositions that are relevant to other set548

Loss and Tomorrow’s Doctors

tings and other groups of individuals [10]. Two researchers (VT, LM) analysed the data independently and then conferred to cross-check themes and check for disconfirming evidence. The themes arising from the data are presented and discussed below. Pseudonyms have been assigned to protect anonymity. Quotes from participants are used to illustrate the findings.

Results Loss and disillusionment Loss was a common issue for the participants. This was related to loss of interest in issues outside medicine and loss of self in choosing a consuming vocational career path. Disillusionment was expressed in the perceptions they had about medicine prior to attending medical school and the realities that they were exposed to: I’ve always had this romantic view of medicine in some ways being sort of creative and you know, imaginative and being like the sole link to everything ‘cause everybody has a body and everybody gets ill…but then it’s not like that (Michelle, female) Participants noted ruefully that to gain entry to medical school they had to demonstrate excellence across numerous domains, yet many of these, including interest in humanities and artistic and musical talents, were devalued and neglected once medical studies commenced: When people are filling out their personal statements for medicine they put down all these nicely wellrounded things that they do and then it all just disappears (Sarah, female) It was noted that medicine takes over and that being a medical student can be limiting in terms of selfdevelopment and having time to explore outside interests: You kind of forget everything you loved at school (Sarah, female) One student in particular (Rachel) expressed ambivalence about her career choice, alternating between ‘loving’ and ‘hating’ it and disillusionment regarding the reality of medical studies. This was related to the lack of opportunity to study subjects outside medicine. It was suggested that the formulaic nature of medical studies and modern medical practice was incompatible with outside interests. Others concurred with her views, suggesting that they felt like ‘drones’: I thought that all university courses had options…like people who do English can do modules in philosophy or psychology or German……I thought medicine was the same and I’d have the opportunity to like choose The International Journal of Person Centered Medicine Volume 1 Issue 3 pp 547-552


a module in philosophy…to me that’s what university’s about, it’s about self-development and trying out new things (Rachel, female) The issue of opinions and expressing these arose several times during discussion. It was noted that it was hard to express opinions, perceiving that medical school valued facts above feelings and opinions: I wanted to give my opinion because it’s the thing that just gets ripped away from us as soon as we turn up (Rachel, female) Rachel also noted that there was little time to ‘grow up’, which was linked to mental health problems in later life: I’m sure if they did a survey on us, mental breakdowns and alcoholics, [we’d] come out so bad because they don’t give us any time to grow up after school and find ourselves (Rachel, female) Ambivalence about career choice was a common theme. Participants felt courses such as ‘the arts in psychiatry’ represented their last chance to engage with humanities and offered a temporary escape from medicine. The breadth of knowledge associated with the humanities was appealing to participants: [I’m] scared that it’s the last time [to study humanities]…I think I’m determined not to let it slip away after doing this…I was so interested [in humanities] and [I’m] still so interested but I haven’t had the time to properly like this, relax, and enjoy them (Guy, male) Holism and doctor-patient roles Students recognised that studying humanities helped them to relate to patients as human beings with some finding a new appeal in psychiatry as a result. One session in particular had a powerful impact on the students. It was run by an artist who was also a mental health service user. This contributor had informed the students that the last time he had been in the hospital where the teaching took place, he had been forcibly detained under the Mental Health Act: I really learnt how mental illness has affected the family, it was quite tough when he said he went home and his mother was crying…it gave me a lot of insight (Henry, male) More generally, students talked about recognising holism in medical practice and the importance of acknowledging the limitations of their role as a health professional: The patient has a personality…they’ve got a life and a personality, and creativity (Michelle, female)

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I think the most dangerous thing in medicine is doctors and medical students thinking they’re above everyone else… and this reminds you that you’re not (Sarah, female) The concept of well-roundedness was noted several times during the discussion. This relates to the perception of medicine being a holistic profession. One student referred to historical perceptions of doctors as well-rounded individuals: You know, like the Renaissance period and the Venetians and the Greeks, the best medics, the best medical people also did things like write poetry. They were very well-rounded (Henry, male). Reflection, discussion and reconnection Participants valued the time for reflection that was a central part of the course. They also valued the opportunity to reconnect with interests outside medicine and to meet likeminded others. The pace of the course was considered important in contrast to the core curriculum which is heavily timetabled with little free time. It was noted that laughter occurred often when issues relating to this theme was discussed. A clear affinity existed between participants, which may suggest that students had bonded during the course and that they also shared similar views and values: I felt like I could relax through the course…it just gave you sort of more time to relax and think about things… Just to kind of think about what’s gone before and what’s to come and how we feel about that (Sarah, female) Students appreciated being given permission to spend time engaging with the material and to reconnect with a different or suppressed side of themselves. A number of students noted that their opinions were valued in group discussions. They felt enabled to express their opinions and this built confidence: I think part of the joy is just talking about it, just reading books,…just to talk about what we’re reading, talk about the most interesting thing in the films, you don’t usually talk about that, well I don’t anyway (David, male) Normally in a word because swer…Its kind talk more and male)

clinical session I won’t say a single you’ve got to give a factual anof encouraged me to participate and have more confidence (Michelle, fe-

Some talked about their confidence improving in other clinical areas: [If] I can pretend to be someone having a psychotic episode [in acting session] then I can probably talk The International Journal of Person Centered Medicine Volume 1 Issue 3 pp 547-552


to an old lady and ask her if I can actually listen to her heart murmur and not be too scared (Rachel, female) Identification and respect Students identified with the course co-ordinators and with each other. The opportunity to meet like-minded people was perceived as a benefit of the course. Again, there was much laughter and shared agreement related to this theme. Students felt accepted by others on the course. This seems important given that some experienced ridicule from peers when they disclosed that they had chosen to study humanities: All my friends laughed at me, made fun of me [related to choosing the course]…could you like be doing anything more stupid (Sarah, female) It was nice seeing a different side to everyone and realise that you’re not the only one, you’d rather be reading [a novel] than reading a text book (Rachel, female)’. The interaction between course leaders and students had a powerful impact on participants. In particular, the respect shown towards students was commented upon. The course appeared to help break down barriers between teacher and student: Part of this course is ‘yes, you’re a real person, nice to meet you, what’s your name?’ (Rachel, female) It’s nice to talk about what you’re feeling…how does this music make you feel. I haven’t been asked that in years… Even if we’re asked something in medicine, it’s like what are the causes of this. Nobody ever asks you ‘what do you feel about this patient’. (David, male) The course leaders acted as role models for the students. The teaching sessions where the contributors participated in activities such as acting, music and creative writing were particularly noted and encouraged students to express their feelings and opinions. Some suggested that their interest in psychiatry as a speciality increased as a result of the course content and those teaching it: It’s like they have a human side to them… I’d like to be a psychiatrist like that’ (Sarah, female) She [teacher] got involved, I was really impressed (Michelle, female)

Discussion The results from this study go beyond course-specific outcomes such as improvement of communication skills, to 550


more global themes of loss, holism and roles, reflection time, identification and respect. The findings raise important issues about the inclusion of humanities in medical curricula and contain more universal messages related to medical school recruitment and coping and vocational careers. The value of developing interests in humanities while a student and after qualification should be considered. The benefits include improving communication skills, developing personal values and inculcating a sense of wonder [1]. The findings from this study suggest that such activities can additionally offer the chance to take time out, develop as a ‘well-rounded’ individual and may be viewed as healthy coping strategies in dealing with a stressful, vocational career. The propensity for doctors to use maladaptive coping, e.g., by using drugs and alcohol is well known [11]. With the growing awareness of the nature of the stresses that are part of medical careers, improving resilience has become an important area of study. Self-awareness and developing personal values have been identified as factors that improve resilience [12]. The humanities provide relatively safe encounters where doctors can test and develop their beliefs and, in doing so, perhaps improve their resilience. Collier and colleagues, [13] describe this process memorably; ‘When we read alone and for pleasure our defences are down - and we hide nothing from the great characters of fiction.’ Medical studies provide opportunities to develop critical reasoning abilities however this is usually in relation to evaluating facts, particularly with the emphasis on evidence-based medicine. Our findings suggest that humanities teaching provided opportunities for students to think about themselves and their reactions to patients that allowed an exploration of assumptions and prejudices. Humanities teaching offered a meaningful way of involving patients as educators that was appreciated by students. The patients were seen as experts in art who encouraged students to explore their own creativity. This approach went beyond the rhetoric of involving patients in medical education that often results in sessions on communication that can reinforce doctor-patient role modelling and miss opportunities for genuine patient-student collaboration [14]. Involving patient-artists made students more aware of the ‘personality’ that lies behind a patient, thus promoting holism and patient-centred practice. Students felt that the pace of medical school left little time to reflect on their experiences. They reported that humanities teaching provided them with the opportunity to relax and consider their experiences. In a previous qualitative study that examined the views of students from different disciplines attending a humanities course, medical students described the course as ‘fun’ and the authors of the paper suggested that this might equate the humanities with ‘non-serious’ study [15]. The current study suggests that the relaxation time provided students with space to reflect. This seems particularly important given the commitment involved in the choice of a vocational career. The participative nature of humanities teaching may also promote reflective skills. Writing reflective pieces has been shown to improve students understanding of the The International Journal of Person Centered Medicine Volume 1 Issue 3 pp 547-552


complexities and idiosyncrasies of individual consultations [16]. In this study, students were surprised when they were asked about how they ‘felt’ about a patient. Medical humanities might help them develop reflective skills, discuss their feelings and find a medium through which they might express themselves. The opportunity to relate to clinicians with similar interests can provide positive role models for students and this might be another factor that encourages them to consider a particular specialty. The clinicians who co-led the sessions had interests in the arts. The students were clearly aware of their enthusiasm for the subject matter and this might have been a factor that made them effective role models [17]. The same approach could be used in other specialities to increase their attractiveness to potential trainees. Indirect benefits of humanities teaching were reported. We were surprised that students reported an increased sense of confidence in their practical skills and ability to approach patients. This newfound confidence might be related to an improvement in the ability to improvise, an important aspect of patient-doctor communication. The similarities between improvising ‘jazz’ music in sessions have been compared to the ‘improvisation’ in patientdoctor communication [18]. It seems important to value medical students in a holistic way, for educators to explicitly identify values in themselves and to offer students formal opportunities to develop, for example, their creative talents. It is important that this message is reflected and valued at the highest level to counter the view that humanities may be frivolous, tokenistic and an ‘add on’ to clinical practice. It could be argued that such teaching should be integrated throughout the curriculum and not limited to student-selected components as it is in many medical schools currently. Students in this course were in the fourth year of their studies. The theme of loss illustrates the emotional impact of choosing a career path that offered limited opportunity to engage with other interests and the pursuit of which subsumed previous hobbies. A key strength of this research is the use of qualitative methods. Some previous studies that have examined medical humanities courses have attempted to measure students’ beliefs about their progress in pre-determined domains such as ethical reasoning ability and communication skills. By adopting a qualitative approach, novel areas of concern to students such as loss, respect and identification were highlighted. Students perceived humanities-based training as a way of addressing losses that they felt whilst progressing through the mainstream curriculum. Our findings cannot be generalised to the entire medical student population. Our sample consisted of students who had chosen an arts course, some of whom had some previous humanities experience and therefore had an implicit interest in either the arts, psychiatry or both. Indeed, it might be inferred that these students were strongly committed to pursuing these interests as they took up the module despite experiencing some ridicule from their peers. However, this might not be the case as only 4 of the 13 students who at551

tended this course had chosen it as their first choice of special study module. The majority (seven) had been allocated to this course as their second choice. Whilst we are mindful of the selection bias that this might involve, the participants represent 5% of the medical student intake that year. It would seem important for future studies to seek the views of those who were not motivated to select humanities courses and who did not participate in the focus group to assess whether there were any negative views about medical humanities training as have been reported previously; for example, students lacking a theoretical basis from which to fully benefit from teaching [15]. Although the results might represent a polarised viewpoint, it is reasonable to assume that many amongst their peers might hold similar views about loss, respect and identification and feel disillusioned by the constraints of the mainstream medical curriculum and the perceived need to conform to the ‘drone medical student’ persona described above. This assumption needs further exploration and testing in a range of different settings. This would take account of differing selection practices to medical schools, e.g. graduate entry courses and those institutions where the humanities are integrated within the course and where they are optional to the core curriculum.

Conclusions Participants expressed a range of benefits from participation in humanities teaching. They felt that the provision of this type of course validated their interest in the humanities. The request from some participants that coffee breaks were timetabled indicates the extent to which students may have become disempowered due to the highly structured and didactic teaching they experience in their medical training. Participation in humanities teaching may help to encourage students to develop their social skills which has longer term benefits, for example in team working abilities later in their careers. This anecdote raises the question of what medical schools might be doing to ‘tomorrow’s doctors’ and whether medical humanities courses might be an antidote to the ‘tick boxing’ that now pervades the curriculum.

Acknowledgements The participation of the students who generously gave their time to take part in this study is gratefully acknowledged.

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