J Med Humanit (2015) 36:321–336 DOI 10.1007/s10912-014-9285-5
The Humanities in Medical Education: Ways of Knowing, Doing and Being J. Donald Boudreau & Abraham Fuks
Published online: 8 April 2014 # Springer Science+Business Media New York 2014
Abstract The personhood of the physician is a crucial element in accomplishing the goals of medicine. We review claims made on behalf of the humanities in guiding professional identity formation. We explore the dichotomy that has evolved, since the Renaissance, between the humanities and the natural sciences. The result of this evolution is an historic misconstrual, preoccupying educators and diverting them from the moral development of physicians. We propose a curricular framework based on the recovery of Aristotelian concepts that bridge identity and activity. The humanities and the natural sciences, jointly and severally, can fulfill developmental, characterological and instrumental purposes. Keywords Medical humanities . Humanism . Aristotle . Phronesis . Professional identity . Character development
The language of human science is irreducibly equivocal and continually adapts itself to particulars. Mary Hesse Models and Analogies in Science
Background A series of inquiries into professional education in the United States was recently published (Cooke et al. 2010; Foster et al. 2006). These reports signaled professional identity formation as a primary concern. The process was described as a commitment to professional values and behaviors, accompanied by the human sensibilities and dispositions necessary to specific practices. The recommendations pointed to an education aimed at character development and the nurturing of virtues. While this may come as no surprise with respect to pastoral, priestly and rabbinic practices, it articulates a dimension that has been insufficiently developed in medicine, a profession that is nonetheless also concerned with a form of ‘ministry’. J. D. Boudreau (*) : A. Fuks Faculty of Medicine, McGill University, Montreal, Canada e-mail:
[email protected]
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The blossoming of the medical humanities as a self-identified field is in large part a response to perceived failings in the contemporary practice of medicine. There are widespread complaints that physicians treat patients as cases or bearers of diseases rather than as individuals who are ill. While the advent of technological interventions is seen as beneficial, they can also become barriers to interchange between caregivers and patients. Diagnostics and therapeutics often represent a series of interventions with little thought to the physician-patient dyad through which they are effected. This discourse reflects in part the strong influence of biomedical sciences whose nomothetic perspective is necessary to medicine’s successes. The search for an idiosyncratic and individualized view of the patient has prompted a turn in medical education in which the humanities, understood as contemporary academic disciplines, provide a counterbalance to a modern medicine, thoroughly cloaked in, if not choked by, a scientistic understanding. Scientism is generally thought to depend on neutral detachment while humanism is expected to foster inter-subjectivity. The former suggests harshness and intellectual rigor while the latter connotes warm-heartedness and social engagement. However, such basic presumptions have been characterized by conceptual fuzziness. How is it that we started to believe there was something in the humanities that made us more ‘humane’, i.e., more benevolent, sympathetic and concerned for human welfare? Why do we often encounter, stripped of any hint of irony, the admonition ‘humanism must be promoted within medicine’―as if one could contemplate a medicine dissociated from humanity? What assumptions underlie the following statement by philosopher William Stempsey, “….our introduction of philosophical studies into the medical school curricula is at least partly an attempt at ‘remedial humanization’” (1999, 7) Why, indeed, do we presume that the humanities are the route to humane practice? Proposals to ‘humanize’ medicine generate a series of questions we consider in this paper. We postulate that attempts to introduce the humanities are bound to fail, based as they are on perceptions that construe medicine a priori as antithetical to humanism. However, it was not always so. We propose a return to a venerable developmental framework within which the humanities can assume an appropriate and productive place in medical school curricula.
The humanist turn and the academic divide ‘Humanism’ is a polysemous term whose meaning has evolved since its ancient origins. From a contemporary perspective, the term refers to a framework that places humans, or humanity as a whole, at its centre. It stresses the inherent value and potential of human life. This differs from notions thought to have prevailed in antiquity. While classical humanism referred to human nature—with reason representing the supreme force of that nature—it did not consider itself isolated from theistic beliefs (Jaeger 1943). The word ‘humanities’ derives from humanus, which in classical Latin held various meanings: proper to man, benevolent, refined and polite, learned or erudite. ‘Humanitas’ entered Latin in the second century BCE. As with the ancient Greeks, the term referred to those qualities that distinguished the human from the bestial and was tied to human reason―the capacity to deliberate and choose and express these choices through language. It also signified a virtue, i.e., good feelings towards mankind. Humanism has been seen as constitutive of medical practice for over 2,000 years. Between 44 and 48 A.D. Scribonius Largus, writing a commentary on medicine, considered that medical practice has three characteristic features: humanitatis (love of mankind), misericordiae (mercy), and professionis voluntatem (the purpose of the profession) (Hamilton 1986).
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‘Humanist’ originates from humanista and referred to a teacher of classic literature. The 16th century humanista studied pagan (Latin and Greek) literature rather than divinity or theology. A humanist, then as now, was not necessarily a courteous or compassionate individual. The term studia humanitatis is thought to originate from Cicero who used it to imply all that pertains to humanity. It made reference to all the disciplines that shape a person: oratory, music, sports, poetry, dialectics and philosophy (Proctor 1988). A curricular exemplar bearing the label studia humanitatis emerged, adumbrated by Petrarch, in the first half of the 15th century. Paul Oskar Kristeller (1961) has traced the evolution of strains of learning, the humanist as well as classic and scholastic, during the Renaissance. He believes that the studia humanitatis evolved into a limited area of study; it came to exclude logic, natural philosophy, theology, mathematics, astronomy, medicine and law. This left a narrowly framed program of studies comprised of classic literature, poetry, history and moral philosophy, along with the grammatical and rhetorical traditions of the Middle Ages. This division segregated medicine into a category with the natural sciences of the time and cleaved it from the study of moral philosophy, literature and history. It foreshadowed the dichotomy we describe below and constrained the intellectual basis for medicine. Robert Proctor (1988) suggests that the goals of learning in antiquity had been to understand humans in relationship to a greater whole―to nature, the eternal, the divine and the infinity of all things. The ancient Greeks and Romans were bound to contemplate their relationship to a universe conceived as unified, cohesive, complete and perfect; they gazed outwards to (and with) a universal organizing principle. In the Renaissance, the focus of interest changed; scholars became intent on looking inwards. The notion of a ‘personal self’ emerged―a self that is unique, autonomous and rational. Furthermore, it was assumed that this entity could be perfected. Pica della Mirandola (quoted in Proctor 1988) suggests that a personal self is created: “We have made thee neither of heaven nor of earth, neither mortal nor immortal, so that with freedom of choice and with honor, as though the maker and molder of thyself, thou mayest fashion thyself in whatever shape thou shalt prefer” (13). Petrarch, often described as the ‘father of humanism’, championed philosophy as “dialogues which aim to heal the soul” (Saarinen 2011, 44). This notion of the therapeutic utility of learning was a contrast to the scholastic philosophy prevalent earlier. Proctor refers to this shift from the eternal to the personal (and perhaps from the transcendent to the therapeutic) as the ‘humanist transformation.’ Disciplines considered to have minimal impact on the shaping of the personal self (e.g. geometry and arithmetic) and thus irrelevant to ‘philosophical therapy’ were cleaved from the educational roster. Proctor argues that conditions were thus set in motion for the great academic divide between the sciences and the humanities. This split, which achieved its zenith under positivist philosophy, has been influential in forging the character of modern medicine. One result is a clinical medicine enthralled by the positivist framing of the natural sciences with a consequent loss of the idiographic perspective so necessary to clinical practice. The Renaissance also witnessed a gradual decrease in the influence of Aristotelian philosophy in deference to a renewed Platonism. A bellwether of this waning of Aristotle’s influence was the uses made of the Nichomachean Ethics, previously considered a guide to life, and the Eudemian Ethics in universities during the Italian Renaissance. David Lines (2002) finds that Aristotle’s philosophy remained an important curricular component but concludes that the Ethics came to be used for different purposes. These texts came to be valued as objects for philological analysis rather than philosophical vade mecums. By the end of the Renaissance, propelled by the progress of mathematics, astronomy and the experimental methods of Galileo and Malpighi, Aristotle was displaced as an ideal guide for the ‘right way of life’.
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The scientific revolution is generally thought to have been heralded by Copernicus’ 1543 book on astronomy. The following description of Copernicus by the historian Jacob Bronowski (1973) is emblematic of the evolution in thought catalyzed by the humanist transformation: “A central thrust of humanism is the revolt against Aristotle….. an attack on the syllogistic logic of Aristotle.” What Bronowski refers to here is Aristotle’s logic and, more specifically, the grounding of physics (or natural philosophy) on that logic. While this enlightenment critique is not an indictment of Aristotle’s moral philosophy, it paved the way for a post-enlightenment interpretation of intellectual history that diminished Aristotle’s ideas on the nature of intellectual and moral virtues. It undercut his telic view, i.e., one that expresses purposes or ends. This veering away from an Aristotelian understanding of a virtue-based moral life and a fundamental ethos of praxis may have been reflected in a diminished presence of these concepts in magistral medical lectures and clinical instruction in Western Europe. Knowledge, which had previously been communally contextualized and integrated, was, during the Renaissance and beyond, discoverable in and by the individual, not tethered to any divine kinship. Knowledge became fractured and distributed. In the Enlightenment, theoretical abstraction, with its assumption that discoverable universal truths exist for both autonomous individuals and for humanity as a whole, came to prevail. Though not antithetical to a scientific medicine, such concepts are poorly aligned with medicine as a human activity that is prudential, practical and personal. Stephen Toulmin (1988) has described the advent of an exclusively scientific worldview as a harbinger of an incomplete medicine. We thus inherit the following legacies: i) A split between the natural sciences and humanities such that these domains are now viewed as irreconcilable dichotomies―opposite and antithetical. This has led inevitably to a recurring preoccupation with integration accompanied by a yearning to see the bridging of a perceived gap leading, in turn, to sophisticated attempts at intercalation, interdigitation and correlation of curricular content (Boudreau and Cassell 2010); ii) a solipsistic turn with increasing attention to development of the self rather than to an ‘other-directed’ virtue-based, moral framework and; iii) a diminished sense that medicine is, to cite Sir William Osler’s (1913) famous essay “A Way of Life”, a product of a continuing process of personal development and maturation. This is amplified by educational outcome measures that reward the acquisition of knowledge and skills and pay little attention to the holistic and human attributes inscribed in the mission statements of most medical schools.
Bridging the divide The impetus for introducing the humanities in medicine stems from the intellectual legacies described previously coupled to a burgeoning awareness of shortcomings of the positivist influence on medical practice. Indeed, the term ‘medical humanities’ is of recent origin, following on the heels of the growth of medicine as a science in the 19th century. The first allusion that we could find to it dates to less than a century ago when in an oration the physician Charles Dana (1922) posited culture as the unifying thread for medicine and the humanities. Within a few years, the historian George Sarton (1936) was writing about ‘medical humanism’, invoking a practice of medicine that went beyond facts, theories and techniques to include “immortal ideals of justice, beauty and truth.” Definitions of the medical humanities were subsequently proposed. Martyn Evans (2002) described the field as: “studies concerned with the specific experiences of health, disease, illness, medicine and health care, with the practitioner-patient relationship and, above all, with the clinical consultation as a focal arena for such experiences.”
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The first department of humanities in an American medical school was inaugurated at Pennsylvania State University in 1967. The American Society of Bioethics and Humanities was founded in 1998 through the consolidation of associations from the fields of bioethics, and health and human values. The U.K Association of Medical Humanities was founded in 2002. The humanities have been welcomed as prerequisites to medical education. The body that sets standards for medical schools in the U.S., the Liaison Committee on Medical Education, states: “Through its requirements for admission, a medical education program should encourage potential applicants to acquire a broad undergraduate education, including studies of the humanities, the natural sciences and the social sciences” (LCME 2012). The standards make no further pronouncements that might elucidate a role for the humanities within the medical program itself. Involvement of humanities disciplines in medical education has unfolded in phases. The 1960s to 1980s featured literature and philosophy. Studies in philosophy gravitated away from epistemology and metaphysics towards axiology and deontology; some have decried that philosophy in medicine is in danger of being totally engulfed by bioethics (Stempsey 2007). Of late, the nature of literature in medicine has taken on a new dimension—that of narrative competence (Charon 2011; Holmgren et al. 2011). Initiated by sociologists and anthropologists, professionalism has emerged as a particularly influential movement (R.L. Cruess and S.R. Cruess 1997). Other disciplines, including psychology, history, gender studies and religious studies have made important contributions. The visual and performing arts are increasingly popular, particularly in elective-type offerings. A measure of the insurgence of the humanities in medical education is the voluminous literature devoted to the topic. Several journals are dedicated primarily to this domain. One of the first compendia to review the topic, The Role of the Humanities in Medical Education, was published by Donnie Self (1978) 30 years ago. The education journal Academic Medicine issued special thematic issues in 1995 and 2003. The roles attributed to the humanities in education may be seen to fall into two camps. In one, such studies represent a catalyst for the formation of compassionate healers by serving as morally contagious art forms. In the other, they equip nascent medical practitioners with useful cognitive capabilities. This duality is reflected in the debate on clinical empathy. Some argue that it is a receptive and affective experience; others claim that empathy is projective, subordinate to and dependent on cognition (Verducci 2000; Goetz et al. 2010). At the developmental pole, the humanities are seen to contribute to the formation of a cultivated and insightful person and, by extrapolation, a holistically-inclined and enlightened physician. They are purported to promote empathy and compassion, evoking the Bildung tradition of self-cultivation and cultural identity. In discussions situated at this pole, metaphors such as shaping, nourishing, developing, forming and transforming abound. At the instrumentalist pole, the medical humanities are valued for their potential in honing clinical skills. This idea is based on the precept that the mind is composed of specific, independent, albeit interconnected, complex and malleable abilities, sometimes referred to as ‘faculties of the mind’ (Proctor 1988, 100). What the faculties comprise is arguable but the following are commonly mentioned: attention, perception, reason, judgment, memory, emotion, imagination, insight and intuition. Many disciplines are considered useful in training these faculties. In this discourse, action-based descriptors are often encountered. For example, the performing arts can ‘stretch’ perception; ethics can ‘exercise’ reason; philosophy can ‘fine-tune’ critical analysis; literature can ‘trigger’ perspective taking. The belief is that the humanities can challenge, stimulate and refine the faculties. Lastly, a commonly cited benefit is ‘disciplining’ the mind to be critical, curious, creative and at ease with uncertainty.
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Contributions of the medical humanities: a panoply of metaphors The incorporation of the study of the humanities into medical curricula has been described and defended by a variety of goals and constructs. The most common are noted below. a) Balancing An oft cited rationale for teaching the humanities is that they serve as a counter-weight to science. Using the balance metaphor, the following image is evoked: on one scale sit the marmoreal natural sciences—uni-dimensional, rational, value-neutral, computational, hierarchical and rigorous. On the opposite scale are the soft humanities and liberal arts—multidimensional, imaginative, tolerant, relational, affective and intuitive. This counterpoint is grounded in the belief that science and humanities are incommensurable and immiscible entities. This is a reflection of the old dialectic between the Geistes- and Naturwissenschaften with the unfortunate consequences of polar opposites, of winners and losers. This model sustains the notion that while both are considered requisite ingredients to medical practice, they are not compatible, with a constant risk of one being overwhelmed by the other, i.e., the weightier one. For example, according to Catherine Belling (2010), “….the humanities are so valuable to medicine, for [they] offer a counterpart to the necessary reductions of the natural sciences.” In a similar vein, Jane Macnaughton (2011) speaks of a calibration of the humanities with the scientific. A recent expression of the quest for balance is the American initiative entitled PRIME (Project to Rebalance and Integrate Medical Education). PRIME places itself squarely in the instrumentalist camp as it aims to build “skill sets in visual observation, textual reading and interpretation, oral reasoning and writing” (Doukas et al. 2012). b) Assuaging and healing The humanities have also been characterized as balms, and rescue or healing agents. This is based on the assumption that biomedicine is sick at its core and that the humanities are endowed with curative potency. These tropes can be powerful. Edmund Pellegrino (1987) has stated: “Medical humanism has achieved the status of a salvation theme, which can absolve the perceived sins of modern medicine.” The following statement is particularly graphic: “One of the aims of recent curriculum reform has been to release medical education from its scientific straitjacket…” (Jackson 2002). The healing potential of the humanities is intimated when they are seen as agents of remediation or compensation. Howard Brody (2011) has described the medical humanities as having three personalities, one of which is the supportive friend. They offer relief from the stress and turmoil of the daily lives of physicians. Characterized by Johanna Shapiro (2012) as the ‘ornamental’ dimension of humanities education, the intent of literary and artistic education is to provide a means of regeneration and an antidote to burn-out. c) Compassion boosters It is often claimed that the humanities can invigorate medicine by potentiating compassion, based on a belief that the physical sciences are inherently corrosive. It has been suggested that the humanities may “combat a perceived loss of empathy over the course of medical training”, and make medicine more holistic (Schwartz et al. 2009) A historian has claimed that “[the study of medical history] is the best antidote we know against egotism, error and despondency…it teaches our students to venerate what is good” (Cordell 1904). A startling illustration of this attitude is a paper entitled, ‘Humanities in medicine: treatment of a deficiency disorder’
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(Hook 1997). In it, the author cites one of Osler’s last lectures, in which he likened the humanities to the thyroid hormone. As well as an invigorating agent, the humanities are advertised as endocrine modulators, leading some commentators to speculate on what might constitute the ‘optimal dose’ of medical humanities (Gordon 2008). d) Aesthetic learning and democratization An exemplar of a humanities-based medical curriculum can be found at the Peninsula Medical School recently opened in Exeter, U.K. It has promised a ‘radical integration’ of disciplines. The school reports that it has incorporated the humanities seamlessly throughout the educational blueprint by reformulating them as process and perspective rather than content (Bleakley et al. 2006). It aims for theoretical unity by accentuating intuitive learning (the process) and foregrounding of artistry (the perspective). The program envisages an educational experience in a context where there has been a ‘democratization’ of the physician/patient and teacher/student relationships and where ‘science’ is viewed as qualitative, imaginative, discursive and aesthetic as well as quantitative, evidence-based, value-neutral and analytical. Aesthetics are considered as pertinent and valuable to the natural sciences as they are to the humanities and clinical work.
Critiques of the humanities in medical education A recent review of the medical literature on the humanities in undergraduate education found few reports of empirical findings on educational impact and even fewer articles expressing reservations about the value of the humanities in medical training (Ousager and Johannessen 2010). In their discussion on the paucity of evaluation data, the authors studiously avoid being construed as having a narrow focus on objective results and argue that interventions of a subjective or values-based nature are not amenable to standard assessment protocols. While this methodological limitation is incontestable, the absence of sustained efforts at program evaluation should prompt critical reflection. Crucial questions become apparent. Can the rationales for the humanities in medicine and the models for teaching them respond to perceived needs? What benefits might such programs provide and how can they be documented? An interesting critique of the role of the humanities in medical education comes from outside the frame, so to speak. Scholars in the arts and humanities are wary of developments in these fields. The instrumental use of the humanities in medicine strikes some critics as fraught with the risk of their ‘medicalization’ and abduction by a powerful biomedical system, a system that sees the humanities as a utilitarian means to a misconstrued end. Shapiro (2012) has described this as a model of acquiescence. As a counter-point, she posits a model of resistance in which the humanities serve a subversive, fifth-columnist role committed to questioning the foundations of contemporary biomedical thinking. The goal in this resistive mode is to unearth the presuppositions of scientific medicine and open a space for debate. In this way, the humanities are seen as injecting a healthy dose of skepticism and providing a mirror for introspection. Although Shapiro considers that the humanities can “catalyze emancipatory insights,” she concludes that neither benign acquiescence nor radical resistance captures the complexity of humanities teaching experiences. While this picture may be apt for a scholarly critique, viewing the humanities as ‘subversive’ runs the risk of once again inadvertently supporting an oppositional dialectic of Geistes- and Naturwissenschaften.
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The vision of the humanities as a sort of miracle worker, rescuing medicine from the allure of scientism and mitigating the damage done through the objectifying tendencies of biomedicine, has been subject to increasing criticism. A single-minded focus on the integration of epistemologies is diversionary because of its reliance on artefactual distinctions between them. Efforts at balancing have done a disservice to both the natural sciences and the humanities by caricaturing the former as emotionally desiccated and hailing the latter as inspired revelation. Attempts at reorienting the medical humanities have taken diverse forms. At one extreme is the ‘Manifesto for Medical Studies’ (Chambers 2009). It argues that the medical humanities should cease being subservient and assume hegemonic status by affirming themselves as the ideological lenses through which medicine must be studied. In the process of making medicine the object of scrutiny, the humanities will supposedly be vivified. In some sense, critical social theorists such as Michel Foucault, notably with his Birth of the Clinic: An Archeology of Medical Perception, may have served that purpose. Solutions of a less radical nature have been proposed. Several decades ago, the ethicist Diego Gracia (1985) advocated for a ‘new’ medical humanities, referring to the emerging social sciences. Another insightful publication from the same period provides a helpful launching platform for a way forward. Michael Schwartz and Osborne Wiggins (1985), after analyzing attempts at integrating medical science and humanism, stated that such efforts may “…..prove inadequate because they merely graft a kind of remedial humanism onto a fundamentally technological and biomedical practice” (332). They condemned initiatives that treated the humanities as if they were a flavoring ingredient and argued that the biomedical model is a myth and medical practice needs to be reconceptualized: “Medical practice becomes intelligible only when its moorings in a fundamental domain of human experience are clarified and delineated” (Schwartz and Wiggins 1985, 333). They suggested that effective renewal might emerge out of a phenomenological approach and a belief that there is no such thing as interpretation-free understanding. Such ideologies are now discernible in a few health sciences programs, for example, the ‘human science-human care’ theory of nursing (Watson 1985). To conceive of the humanities as simply a counterpoint to the natural sciences diminishes both disciplinary traditions. These dual domains share assumptions and expectations and are mutually reinforcing. They require a fundamental re-alignment in the context of medical education. A new mindset must transcend the attachment to dichotomies (or trichotomies, if one sunders the social from the human sciences). Continuing to regard the ‘humanities’ as the flag bearer of ‘humanism’ positions them falsely in competition with the natural sciences, and paradoxically disempowers them. The humanities are inseparable from medical practice as cognate disciplines and not specifically because they may inculcate humaneness.
Curricular conceptualization with an Aristotelian armature As illustrated in many of the commentaries already cited, perhaps most persuasively by the psychiatrist Michael Schwartz and the philosopher Osborne Wiggins (1985), too many efforts to introduce the humanities into medical curricula have been based on the presumption that the current armature is basically sound and that the humanities can be an additive thereto. For example, traditional attempts to provide students with a basic overview of the history of medicine have relied on a series of lectures plugged in to the curriculum or as electives. The result is that faculty and students understand these add-ons as peripheral to core objectives and of marginal relevance. It would be more effective to define specifically what the medical humanities are designed to accomplish within a reframed curriculum and then proceed with the requisite restructuring to achieve those goals. We suggest that the following three elements
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must be addressed: the guiding ethos for medical practice; the desired character of the physician; and, the frames that help accomplish these outcomes. We propose that the humanities can help us address each of these foundational issues by providing essential philosophic, developmental and pedagogical concepts necessary to the task. Medical practice requires a blend of intellectual pursuits: theoretical, practical, productive and performative. In its quotidian practices, it relies on trustworthy, often normative generalizations, and their application to individual cases. Its practitioners are engaged in an intellectual, physical and emotional performance– those who are superb execute it with poise and grace. Notwithstanding the multifaceted nature of medicine, the physician is primarily engaged in a practical activity. Medicine aims to promote health and to relieve suffering, and its ultimate aim is the well-being of the patient. A threat to well-being is perceived when persons suffer impairments of function that interfere with the attainment of their purposes and goals in life. Thus, well-being, as lived and understood by the patient, is the touchstone of medicine and must also serve as the fulcrum upon which a medical education program is constructed. Over the past three decades there has been a resurgence of interest in Aristotelian philosophy as an approach to understanding human conduct. In his extraordinarily influential book, After Virtue, Alasdair MacIntyre (1981) rejects the ethos of liberal individualism and subjectivism (which he refers to as emotivism) and reaffirms Aristotle’s core concept of the virtues. Aristotle’s idea of moral selfhood has been described by the educational philosopher Kristján Kristjánsson (2007) as “essentially other-entwined and other-dependent for its formation and sustenance” (177). This orientation is grounded in the idea that moral thinking is derived from a profound sense of respect and obligation to others. Intentionality is directed towards the ‘other’ and actualized in a community of social beings (a polis); it stands in contrast with a focus on self-actualization which, as we have seen, was catalyzed and promoted by the original studia humanitatis. It is noteworthy that Aristotle’s moral philosophy has recently been promoted as the conceptual framework for moral education at the primary and secondary levels of schooling (Carr 2011). Such insights offer a critical opportunity for medical education. The role that the medical humanities can assume in the preparation of new generations of physicians should be reoriented against this backdrop. Aristotle’s categorizations of practical knowledge, techné and phronēsis, can shed light on the unique nature of clinical medicine. Techné is often construed as ‘technical thinking,’ i.e., a mode of reasoning in which a plan or design is applied towards the production of a particular state of affairs. In colloquial usage it may have deprecatory overtones invoking notions such as ‘by rote’ or ‘theory-averse’. These descriptors are misleading. Techné is initiated by finding the first principles of things, considering the complexity of individual concrete cases while not losing sight of general rules or norms, and taking into account opportunity, chance and luck. Through a process of deliberation, it ultimately converges on a particular course of action. Aristotle considered several human activities, notably navigation and medicine, as paradigmatic of techné. This activity is not to be confused with theory (theoria) which, as understood by Aristotle, was knowledge as a necessary, universal and invariable thing. Medicine, an activity marked by contingencies and unavoidable indeterminacy, is more aligned with techné than theoria. Toulmin (1988) underlines this basic but critical point when he says: “The patient is not merely an individual who happens to instantiate a universal law. His clinical state is local, timely and particular, and universal theories at best throw only partial light on it” (345). To consider medicine purely as techné is, however, an incomplete characterization. The concept of phronēsis is also required. Making a clear distinction between phronēsis and techné is a difficult proposition. Joseph Dunne (1993), who has tried to unpack what Aristotle left as implicit and fragmented in his written corpus, suggests that the differences reside largely in the relationship of actor to activity and can be understood through the application of an ends/
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means framework. The actor in techné, a doer or maker, produces outcomes (e.g. a safe journey for the navigator or health in the case of a doctor). These outcomes are external to and exist beyond the self. In contrast, in phronēsis, the end is in the self. Phronēsis is not about making; it is about being and becoming. Dispositions to choose in a certain manner, through repeated use, become embedded and embodied. The actor’s moral compass is revealed and altered in the process of making particular decisions. A unique, reflective moral being emerges through the cumulative effects of having made specific choices. The process unfolds most effectively when the ‘actor’ is faced with circumstances and dilemmas that are increasingly complex. Phronēsis thus combines disposition, reasoning and action. A person endowed with phronesis, the phronimos, changes personal attributes through habitual action and practice. In short, techné can be considered to encapsulate the performative dimensions of medicine (the ‘doing’ of the physician) while phronēsis describes the emergence of settled character states appropriate to the medical persona (the ‘being’ of the physician). These concepts can be applied directly to the domain of medical education, particularly if one accepts the supposition that the educational process must result in formation of a unique professional identity ─ physicianhood or physicianship. We have previously described the first iterations of an undergraduate medical program focused on identity formation that revolves around the concept of physicianship (Boudreau et al. 2007; Boudreau et al. 2011). Physicianship refers to the desired personal qualities and behaviours of the medical practitioner. It is grounded in the notion that the physician fulfills two complementary roles, that of healer and professional. Healing is considered the doctor’s primary obligation while professionalism describes the manner in which the profession has organized itself to deliver healing services. Physicianship is inescapably moral in nature—its philosophical pedigree has been described elsewhere (Fuks et al. 2012). A physicianship-based curriculum illustrates the relevance of Aristotelian conceptual anchors. Techné is oriented towards instruction; the teacher qua teacher has an external end—the student’s acquisition of new knowledge or skills. Phronēsis has an internal end, namely, the assimilation of values and excellence in ethical decision-making. Phronēsis is accommodated through guided and habitual practice within a particular community, i.e., a medical apprenticeship. We are hardly the first to emphasize the importance of phronēsis. It has been described as an avenue for moral formation through concrete mentorship (Kinghorn 2010). It constitutes an approach to ethical reasoning and represents a method for understanding critical reflection (Kaldjian 2010; Birmingham 2004). While these applications are concordant with our proposal, we extend the concept of phronēsis to the entirety of medical education. Given that phronēsis must, by its very nature, respond to a moral aim or intention, ultimately translated into a specific course of action, the explicit and unambiguous specification of the perceived goal of clinical action is a critical first step. As previously noted, the goal relevant to this discussion is a patient’s well-being, i.e., requiring help in overcoming the impairments of function that interfere with the pursuit of achievable goals. A phronimos will attempt to accomplish this task in the right way, to the right extent and at the right time. A medical school, in fulfilling responsibilities for selecting appropriate candidates, transmitting desired values, equipping and guiding their students will necessarily marshal all academic disciplines, the medical humanities and the natural sciences, in service of that aim. Salient issues in today’s medical schools tend to be of the following type: What are genetic footprints of malignant transformation; the immunological pathways in asthma; the evidence for use of insulin replacement in steroid-induced hyperglycemia? These are not to be gainsaid as targets of medical instruction, but, they need to be complemented by questions such as: What is a lived body, an embodied self, and an embedded moral person? What do we mean by function and functioning? What is impairment and how does it differ from disease, illness and sickness?
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What are suffering and healing? The array of questions is not currently a central preoccupation of medical teachers. If only the first set is seen as germane, the so called ‘basic sciences’ recruited to the task will include histology and embryology but exclude hermeneutics and ethnography. In a curriculum which foregrounds identity formation, where external ends such as the discovery of disease and the mending of altered physiology are not the sole concern of education, the cadre of disciplines relevant to its mission is more inclusive. All intellectual traditions―we think of them as ‘foundational frames’―that can address these issues become germane.
Specific foundational frames of a physicianship-based curriculum We have developed a series of examples that illustrate the curricular frames entailed by an instrumental and utilitarian view of the humanities and social sciences, seen not as antithetical to the natural sciences but with their own defined curricular aims and objectives. These concepts are further inflected by the Aristotelian developmental perspective introduced above. It is important to note that we view these new elements as synergistic, not competitive, with those in traditional undergraduate medical programs. Finally, these are intended to serve as exemplars, not as exhaustive lists. a) conceptual frame The contemporary medical perspective is nomothetic. Spurred by the success of clinical trials over the past half century and the influence of massive societal investments in science and technology, research has dramatically reconfigured clinical medicine. This has also incorporated the perspectives of the bench scientist and epidemiologist, emblematized by the advent of evidence-based medicine. These disciplines aim to produce verified and reliable information from large samples and multiple replicates—their immediate relevance is necessarily to the population studied and its cognates. Yet, having such data is only half the journey. A translation or transposition of such findings to the individual patient visiting a specific clinician is required and for that, an idiographic framing is necessary. The concept of personalized medicine may help towards that end, yet to date it operates by splitting populations into smaller and better characterized subsets. The point of view remains top-down. What we need to learn and teach is the view from the dyad. This is perhaps best exemplified by paraphrasing the clinician’s question as to why is this person—with his or her particular genetic individuality, developmental experience, psychological shape and life in a particular biological and social environment—in my clinic today (Childs et al. 2005)? It follows that the clinician must apprehend and comprehend the particular narrative that shapes the search for the answer sought jointly by patient and caregiver. This viewpoint, focused on the individual, can perhaps be taught in medical schools by anthropologists, skilled in ethnography and the collection of stories, in concert with developmental biologists, who can demonstrate the sensitivity of an organism’s development to local experiential conditions. Though the overall framing of the curricular problem is moral engagement, the particular impetus to this intellectual reframing is the recognition of a different model of the patient, not as broken machine, but as ailing human. The impetus is genetic, epigenetic and developmental, in their broadest perspectives, and implanted in a world of relations. b) Nature of knowledge Jerome Bruner (1986) has described the distinction between “paradigmatic” modes of knowing and those that are “narrative”. The former construes reality using rules and deductive
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reasoning while the latter extracts meaning through stories, figurative language, hermeneutics and abduction. Rather than the imperative of diagnosis whose telos is far short of the clinical goal and whose demand for simplicity and parsimony flattens identity and erases individuality, we turn to understanding the patient’s story as the first step towards comprehension and a crucial step towards healing. Thus, the professor of literature, criticism and rhetoric can work with internists, pediatricians and family physicians to teach the elements of stories, their construction and modes of exemplification. We should consider abandoning the ‘typical case’ which eliminates both person and story and move towards stories in all their personalized and detailed richness. In some real sense, this is what personalized medicine should be—incorporating personal idiosyncrasies as well as genetic mutations. It is in this richness of exemplars, that the novel offers its greatest heuristic value in medical education. The novelist is able to capture and describe persons in all their complexities and shades of meanings. By studying classic descriptions of ailing characters and their relationship to the worlds they inhabit, students will learn to appreciate human details generally absent in the traditional medical case record. Not only is the hospital or clinic record a second or third hand abstraction of the patient’s actual concerns, it is completely defoliated of any details of the individual’s persona and life world. The novelist’s eye and facility for language can bring into view nuances that escape our medicalized attention. Thus, literature should be studied not to familiarize students with narratology but rather to teach clinical medicine. After all, medical students yearn to become good physicians, not literary critics. c) Model of health and illness The old and hackneyed machine model gained a new injection of energy with the developments in organ transplantation, cardiac implantable devices and the increasing use of artificial joints by an aging population. At the same time, the burgeoning of chronic illnesses that require longitudinal care and an emphasis on quality of life and functional capacities, undermine the machine metaphor with its implicit promise of return to a pristine state with serial replacements unto the scrapheap. Perhaps the medical historian in concert with the physiologist can remind us of Walter Cannon’s (1932) homeostasis as an alternate and more accurate model for describing and understanding the ill patient and the aims of therapy. Thus, illness becomes ‘dystasis’ and modifications of the patient and his lived environment are the means of restoration to a new state of equilibrium. The clinical commitment (and goal) is a return to a state of balance at any stage of illness, not a facile promise to cure all ills. The philosopher and theologian can help students explore how the ‘good life’ can vary in meaning and import for different persons and their families. Cannon’s homeostasis is physiological kin to Aristotle’s eudaemonia—the patterns of life that lead to wise and good decisions enabling individuals and their communities to flourish. d) Living persons Traditional medical curricula often launch the course of study with dead, rather than living, persons. It would appear to us more appropriate to begin with the subject of actual medical attention, namely, the person in life, whether ill or well. Thus, we may start with the study of personhood and engage the disciplines of psychology, human development and anthropology in concert with biologists, geneticists and embryologists. The nature of personhood has evolved in time, and we can align ourselves with historians and philosophers to understand the contingent nature of the individual and necessary engagement with and definition by family and extended network of relationships. It might seem more appropriate to start holistically and later delve into the details of organs, tissues, cells and nucleic acids. Many
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curricula are structured in the converse fashion, starting with the structure of DNA and never quite arriving at the fully developed whole person until late in the preclinical training when the students’ attention has already been engaged by the study of diseases. e) Society It is evident that persons, patients and diseases are contextualized in their bodies, families and societies. Yet, we seem to have reduced each to its apparent elemental state and prefer to deal with reified diseases and rootless patients. Paradoxically, we then teach students about the socio-economic gradient and health. There is a need to develop a nuanced and contextualized understanding of illness, and we must recruit colleagues in economics, sociology and environmental engineering to teach collaboratively with faculty from public health, infectious diseases and epigenomics. Given that the problems our students will need to address in their own careers will be multifaceted and require interventions by teams of care-givers, we must teach using examples that are complex, complicated and uncertain in their outcomes. Our simulations must come closer to the students’ future realities and we cannot do so in academic silos. Parenthetically, such initiatives will serve to develop links between medical schools and their host universities, to mutual benefit. f) Relationship of physician and patient Given that the care of the patient is the defining act of the physician, then the doctor-patient dyad and the bond formed between these persons must be a recurrent theme in medical curricula. The fields of anthropology, sociology and psychology have long traditions of scholarship that can enlarge the perspectives of the internist and psychiatrist in teaching medical students to engage with their patients and also become mindful of their own behaviours, thoughts and affects in the clinical relationship. The phenomenologist can provide frameworks from the lifeworlds and horizons of philosopher Hans-Georg Gadamer (Ramberg and Gjesdal 2013). The neuroscientist can teach the clinical power of placebos. Once again, the narratologist and novelist can offer finely wrought literary “case descriptions” of the connexional dimension of healing and explain how metaphors must be shared and private ones unearthed to facilitate the explication of meanings (Suchman and Matthews 1988).
Conclusion Aristotle’s concept of the phronimos and that of human nature and conduct as described by the philosopher John Dewey provide roadmaps that can help the teacher understand the process of character development which medical students experience on their trajectory towards physicianship. Dewey (1938, 47) argues that one’s habit-forming proclivities are reinforced and sedimented in particular directions through experiences; he points out: “In a certain sense every experience should do something to prepare a person for later experiences of a deeper and more expansive quality. That is the very meaning of growth, continuity, reconstruction of experience.” He adds, “Collateral learning in the way of formation of enduring attitudes, of likes and dislikes, may be and often is more important that the spelling lesson or lesson in geography or history that is learned” (Dewey 1938, 49). For Dewey, people’s habits embody their character. This proposition implies that the pedagogic focus should be more on the means and path to learning than on narrowly defined intended outcomes. The learning of new skills and knowledge, without losing sight of preexisting habit and/or tradition, is conceived as a
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means to personal growth. There is a ‘product beyond the activity,’ i.e., the learner acquires a new skill or expanded data base. And, there is also a product ‘inherent to the activity,’ i.e., the learner’s character development. The conditions favorable to such maturation require a relational space between teacher and learner that is characterized by emotional support and unrelenting guided reflection. The relationship must be nurturing and non-judgmental, and the learner must be encouraged to challenge received truths. It is often qualified as a ‘safe space’ i.e., a space where one can develop resilience and a sense of fearlessness. The teacher as mentor serves in loco parentis. Also, the process of acquiring prudence and wisdom unfolds most effectively when the ‘actor’ (in this case, the nascent medical professional) is faced with circumstances and dilemmas that are incrementally ambiguous and multilayered—experiences that are ‘deeper and more expansive’ (Dewey 1938, 47). Those planning medical curricula would be wise to engage their colleagues from philosophy and educational psychology to help elucidate these ideas and to learn how to construct longitudinal mentorship programs. The conceptual basis of these programs need to acknowledge that the boundary between ‘being’ and ‘doing’ is porous and that, through a maieutic process, mentors can catalyze and guide personal transformations in learners. It should be noted that in all these examples, the engagement with specialists from the humanities and social sciences involves joint efforts and often, team teaching. This is procedurally a far cry from simply assigning some curricular time to the teaching of humanities as elements set apart from the mainstream. Second, these subjects are all viewed as foundational and instrumental, no less than the traditional offerings in biochemistry and pathology. Finally, there is an implicit ‘hidden curriculum’ for medical faculty members themselves who may learn from their colleagues in other enriching disciplines. The mandate of medicine and our touchstone is the patient’s well-being. We have outlined a pedagogical and clinical practice in which all disciplines that contribute to the resumption of a patient’s capacity to pursue achievable goals and purposes are enlisted in the task. This mindset has the potential to leapfrog over futile preoccupations with the integration of the ‘basic’ and ‘clinical’ sciences. The humanistic and scientific aspects of medicine, married with an eye to patients’ well-being, merge into one coherent, stereoscopic image. We view the humanities and social sciences as incorporating elements of both character development and instrumentality. The concept of phronēsis is particularly apt in representing the characterological and behavioural outcomes of guided intellectual activity and growth in ethical virtues and moral development. Osler (1899) cautioned physicians to “care more particularly for the individual patient than for the special features of the disease.” This entreaty requires the medical practitioner to appreciate, to the extent possible, the peculiarities, preferences, perspectives and peccadillos of an individual patient. The physician must be educated to see, hear and understand the person who is the patient. This demands a fusion of the practical and particular to the abstract and generalizable. It calls into question, not the pertinence, but the sufficiency of the natural sciences. Medical practice must rest on knowledge that is idiographic as well as nomothetic and is enriched by the language of the human sciences. Knowledge of persons as well as personhood is needed for the medical student and the practicing physician to develop optimally his or her persona as a phronimos. The humanities hold promise in revealing an idiographic understanding of patients. We submit that they will thereby provide an entry to caring “more particularly for the individual patient.” Acknowledgments Dr. Boudreau is an Arnold P. Gold Foundation Associate Professor of Medicine, and he wishes to recognize the foundation’s financial support during the period that the manuscript was conceived. We thank Professors Al Miller, Maria Miller, Irene Gammel and Faith Wallis for their critical review of early drafts of the manuscript. We are deeply appreciative of the thoughtful editorial advice provided so frequently and offered so graciously by Sylvia Fuks Fried of Brandeis University.
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