Jane Macnaughton

The humanities in medical education: context, outcomes and structures.

There is now a context for teaching humanities in undergraduate medical education via special study modules (SSMs). This paper discusses the instrumental and non-instrumental role of the humanities in the education of doctors. Three courses are then described and compared. The most successful of the three is a SSM which had the following characteristics: it was voluntary, it was an integral part of the curriculum, and it was examinable.

Researching the benefits of arts in health

Purpose – This review article seeks to draw on experience in the UK to describe the different forms that arts in health activity can take and to examine the challenges for research in this field.Design/methodology/approach – A case study is used to describe the kind of arts in health project that intends to enhance the social capital of its community and to show how difficult it is to measure the effects of this work using conventional measures of health improvement. However, those who are responsible for providing funding for arts in health are increasingly demanding results that indicate a measurable health gain from the projects.Findings – A literature review of the evaluation of arts in health projects in the UK has shown that few aim at direct health improvement but rather at intermediate indicators of health gain, such as raising awareness of health issues and social activity and participation. This suggests that artists instinctively locate their work as having value within a social model of health...

The dangerous practice of empathy

An important role for the medical humanities is to stimulate imaginative insight into the lives and experience of others through literature and other art forms. The idea is that such exposure will develop “empathy” as an attribute useful in clinical practice. Those interested in medical humanities have promoted the importance of this concept, and the “practice of empathy” has become an icon of the growing medical humanities movement in the USA and the UK. US physicians have even gone so far as to adopt empathy as one of the accredited “skills” required by the American Council for Graduate Education. However, another crucial role of the medical humanities is to provide a critical watching brief on the way in which medicine can highjack complex ideas, confining and defining them in its own terms, and changing their meaning and impact. I would suggest that this has happened with the notion of empathy and that it is worthwhile examining the concept and discussing whether it makes sense to regard it as a clinical skill at all. I am not sure that empathy, in the sense of emotional identification, is possible. I also query the way that empathy has become an object of measurement among some physicians. Both of these concerns (about definition and measurement) derive from a fundamental problem with the philosophy of human nature espoused by traditional medical practice: that of regarding the patient as an object whose physical being, psychological responses, and emotional experiences can all be broken down, accessed, and recorded. Even David Hume, who thought that a “science of man” was possible, was cautious about how knowledge was to be obtained. As he says in his A Treatise of Human Nature: “We ourselves are not only the beings, that reason, but also one of the objects, concerning which we reason.“ In clinical practice, the patient is the object of a physician’s scrutiny; the doctor maintains an objective distance. But empathy requires understanding of subjective experience: the patient feels something and the doctor should access comparable subjective feelings and “stand in the patient’s shoes”. This relationship, I would suggest, has to be one of subject and subject rather than object (patient) and subject (doctor). Some of the complexities become more apparent by considering empathy in psychotherapy. Carl Rogers advocated “person centred therapy”, an approach to psychotherapy which involves the therapist practising “congruence, empathy, and unconditional positive regard”. However, in developing his ideas, Rogers discussed the potential limitations of his view of empathy with the philosopher and theologian, Martin Buber. Buber’s view was that empathy was impossible in a therapeutic situation because of a mismatch of perspectives: “You [the therapist] have necessarily another attitude to the situation than he [the patient] does…You are not equals and cannot be. You have the great task, self-imposed—a great self-imposed task to supplement this need of his and to do rather more than the normal situation.” Buber argues that the problem for the clinician or therapist is one of keeping the patient in objective relation to himself because of his “great task”. In his book I and Thou, Buber describes his view of human connectedness. He distinguishes between two modes of relationship, “I/Thou” and “I/It”. The former describes a relationship whereby two people encounter each other in an authentic way, without objectification of the other. “I/It” is his term for the kind of interaction that necessarily takes place in the clinic. One person meets the other not as a fellow being but as a conceptualisation or type of a person: as “doctor” or “patient”. A full experience of mutuality or understanding is not possible. As clinicians we may regard patients as biochemical machines that need fixing; as wayward children who need to be led to eat correctly/stop smoking/exercise; as boxes of molecules to which we can add other corrective molecules. Mary Midgley in Science and Poetry characterises this way of seeing as “atomisation”. Clinicians atomise their patients (psychologically and physically) but at the same time are expected to relate to them as complete entities, or essences. This can require many shifts in perspective during the course of a single consultation. If the kind of inter-relation that Buber describes is not appropriate for the clinical situation, does that mean empathy is not possible? Patients and doctors are physical beings who have some shared ideas of what it feels like to be in their bodies; to feel heat, cold, pain, or numbness. If I lay my cold hand upon a patient’s abdomen, I—as a person with skin sensitive to heat and cold—appreciate how my hand might feel and attempt to warm it or at least warn the patient that it might feel cold. However, as an emotional and cognitive being, what I am feeling and thinking is not apparent to the person who is with me. Their only access to my mind lies in what I say and how I look. As Edith Stein, a student of the Edmund Husserl, wrote in The Problem of Empathy: “What another person experiences at a certain moment is not directly given to me. But the presence of the other is directly given, and so is the awareness that the other is an experiencing self. This cannot be compared with other modes…of experience. The experience of another is unique. This means that other modes of experiencing only are of partial help in explaining how the subjective becomes intersubjective. It also means that there is no doubt about who is experiencing primarily, and who is sharing, or experiencing, the experience of the other.” It seems, then, that it is possible for us as clinicians to have some empathic understanding of what it might be like to be in someone’s shoes physically, but not psychologically. All that is possible psychologically is an awareness of the other as an experiencing being; and, if we are open enough and take time to ask, they can tell us what that experience is like. But are we in danger of missing a lot if we do not have some access to, or understanding of, a patient’s “real identity”. Returning to the claims of medical humanities, is it possible for clinicians to draw understanding of the experiencing other from their own encounters in Buber’s “normal” situation, where two people interact without any therapeutic relationship turning one of them into objects? Literary encounters would certainly not fulfil Buber’s requirement that intersubjectivity is the key to experiencing another person. The reader cannot experience intersubjectivity if she or he is not present in the world of the book. But although the reader is not physically present, an attentive reader can certainly be psychologically present. In her autobiographical novel, The Bell Jar, Sylvia Plath’s character, Esther, describes a severe depressive episode, unrelieved by sleep: “I saw the days of the year stretching ahead like a series of bright, white boxes, and separating one box from another was sleep, like a black shade. Only for me, the long perspective of shades that set off one box from the next had suddenly snapped up, and I could see day after day after day glaring ahead of me like a white, broad, infinitely desolate avenue.” This masterful metaphor of the blinds induces fear with a sense of monotony and pointlessness—what the character herself must be feeling, in fact. As readers we have direct access to what is in the fictional character’s mind: the writer is describing it for us. We have no such interpreter for the clinical situation. But it is important to exercise caution here. What readers experience in response to writing is not an authentic I/Thou experience. It is possible to shed tears in response to a particularly powerful passage, but then switch easily to the real world without the lingering distress that a real problem of this kind would cause. I suspect that this is also the case for doctors’ empathic responses to patients. I can be close to tears with a patient, but 10 minutes later engage in a light-hearted conversation with a colleague over coffee. The sadness, or fear, or whatever feeling I have experienced is not sustained, and is so different from what the patient is feeling that it seems disrespectful to suggest that I somehow participate in his or her experience. I have suggested that true empathy derives from an experience of intersubjectivity and this cannot be achieved in the doctor–patient relationship. But all is not lost. Doctors do not need to feel the distress of their patients themselves to do something about it. We may have a momentary mirroring of that patient’s feeling within us, but what we maintain is sympathy (feeling for not with the patient) and the need to respond. It is potentially dangerous and certainly unrealistic to suggest that we can really feel what someone else is feeling. It is dangerous because, outside the literary context, where we are allowed direct experience of what a fictional patient is feeling, we cannot gain direct access to what is going on in our patient’s head. As Stein says, only “their presence is directly given”—so our assumptions may be wrong and our response may be based on a false assumption. Any mirroring of feeling will always differ quantitatively and qualitatively from that patient’s experience. A doctor who responds to a patient’s distress with “I understand how you feel” is likely, therefore, to be both resented by the patient and self-deceiving.

The Conscientiousness Index: A Novel Tool to Explore Students' Professionalism

Purpose Measuring professional behavior is problematic not least because the concept of professionalism is difficult to define. The authors describe a measurement tool that does not rely on qualitative judgments from respondents but, nonetheless, clearly correlates with individuals’ subjective views about what constitutes professional behavior. Method The authors devised the Conscientiousness Index (CI) of medical students’ performance in years 1 (n = 116) and 2 (n = 108) in 2006-2007. The CI scores were based on a range of objective measures of conscientiousness, including attendance and submission of required information (such as immunization status or summative assessments) by a deadline. The validity of this instrument was tested against (1) staff views of the professional behavior of individual students and (2) critical incident reports. Results The trait of conscientiousness, as measured by the CI, showed good correlation with the construct of professionalism as perceived by staff views of individual students’ professional behavior. There was also a relationship with the frequency of critical incident reporting. Together, these observations support the validity of the approach. Reliability and practicality were also acceptable. Conclusions The results suggest that the CI measures a scalar objective trait that corresponds well with professional behavior as perceived by staff members in an undergraduate medical school. The individual decisions making up the CI are objective and easy to collect, making it a relatively simple and uncontroversial method for exploring students’ professionalism.

Medical humanities' challenge to medicine

Medicine is predicated on a view of human nature that is highly positivist and atomistic. This is apparent in the way in which its students are taught, clinical consultations are structured and medical evidence is generated. The field of medical humanities originally emerged as a challenge to this overly narrow view, but it has rarely progressed beyond tinkering around the edges of medical education. This is partly because its practitioners have largely been working from within a pervasive medical culture from which it is difficult to break free, and partly because the field has been insufficiently armed with scholarly thinking from the humanities. This is beginning to change and there is a sign that research in medical humanities has the potential to mount a persuasive challenge to medicines ways of teaching, working and finding out. This article problematizes medicines narrow viewpoint, grounding its critique in philosophical ideas from phenomenology and pragmatism. I will reflect upon the historical context within which medical humanities has emerged and briefly examine specific examples of how its interdisciplinary approach, involving humanities scholars with clinicians and medical scientists, may develop new research directions in medicine.

A Hole in the Heart: confronting the drive for evidence-based impact research in arts and health.

The field of arts and health, and associated academic discussion, is beset by a number of interlinked challenges which make it vulnerable to academic dismissal or, at best, poor visibility. One of these is a preoccupation with developing an evidence base of impact. This is compounded by resistance to definitions, disagreement over what constitutes appropriate evidence of success and inadequate consideration of the mechanisms of arts and health practice, as opposed to outcomes. We argue that increased attention should be paid to the description, analysis and theorising of the practice itself as the basis upon which the findings of impact studies can be understood and accepted. A literature review identifies some important emerging themes in community arts and health practice and some lacunae in need of further investigation. We conclude that an interdisciplinary theoretical framework for the practice could make a valuable contribution to the academic status of the field.

Should medical humanities be a multidisciplinary or an interdisciplinary study

Research on interdisciplinarity is essential for the future of medical humanities The forthcoming annual conference of the Association for Medical Humanities addresses the substantial topic “Medicine and the humanities: towards interdisciplinary practice”. The organisers envisage the following objectives for the conference: These eminently practice-centred objectives require, of course, to be approached in the spirit of what we might call “interdisciplinary theory”, that is, theoretical reflection on interdisciplinarity. Interdisciplinarity is perhaps easier to claim than it is to demonstrate, and putatively interdisciplinary work frequently turns out to be merely multidisciplinary, in the sense of involving relatively disconnected contributions from different disciplines—contributions which, taken in isolation, exhibit no real trace of contact with any other discipline beyond their own. Too often one attends discussions that consist in a succession of speakers presenting essentially discipline based perspectives, with little or no genuinely crossdisciplinary dialogue among them. Medical humanities requires, however, that we attain more than this, for reasons including those that are set out below. The forthcoming conference is, therefore, both timely and important; its objectives moreover are challenging. For instance, in considering “the interface between medicine, health care, and a range of humanities disciplines” we need to ask whether the interface is a single meeting point of all the disciplines involved or whether a number of different shared boundaries might be involved. Would those sharing a boundary all recognise it to be a boundary, and would they see it in the same terms, for instance, with curiosity, suspicion, lack of interest, bafflement, distaste? Do the …

‘Risking enchantment’: how are we to view the smoking person?

The idea of the smoking person portrayed in public health has been criticised as being based on too narrow a view of human nature. This article discusses that view: that of a person with a stable core and epiphenomenal ‘behaviours’ that can be removed by rational persuasion or Pavlovian manipulation, and examines social scientific critiques of it. The social sciences explore the meanings smoking has for individuals and portray human identity as malleable, the result of ongoing interactions with human and non-human others. Aspects of smokers’ experience revealed in qualitative research – descriptions of cigarettes as ‘companions’ or ‘friends’, deep reliance, sensual pleasure – are sometimes difficult to articulate but can be given full voice in the context of the literary arts. We explore some examples of these sources and argue that a complete picture of smoking meanings is impossible without reference to them. We take a pragmatic approach, following the philosopher William James, who argued that emotional and spiritual experiences contribute to the truth of human existence as much as material explanations, to suggest that this understanding should be part of a critical but supportive engagement with public health research in order to develop more nuanced and humane approaches to smoking cessation.

Art in hospital spaces : the role of hospitals in an aestheticised society.

There is a keen interest in hospital design in the UK fuelled by the largest hospital building programme ever undertaken within the NHS. Architects and NHS planners are gaining advice and inspiration from the growing evidence‐based design movement. Part of this movement is interested in the role of artworks in creating soothing, therapeutic environments. This paper draws on the experience of a research project on the role of art in a new hospital in the North East of England to suggest that there might be an additional cultural role for art in hospitals, and for hospital buildings. The paper examines the wider evidence for this and the history behind it, and places the idea within an aesthetic framework with reference to research results from the study.

“How do you feel?”: oscillating perspectives in the clinic

“The body is originally constituted in a double way: first, it is a physical thing, matter […] Secondly, I sense ‘on’ it and ‘in’ it: warmth on the back of the hand, coldness in the feet.” These words were written by Edmund Husserl, the 20th-century philosopher and founder of phenomenology, the philosophical study of human experience. For Husserl, this duality of experience is a unique feature of human existence. Humans are both physical matter, like kettles, trees, and rocks; but they are also capable of having conscious experience. On the one hand, we are physical objects; on the other hand, we are consciousness. What is the relevance of this dual existence to medicine? We consider the philosophical basis for this view and its potential importance to clinical consultations. In his Ideas II, Husserl uses the example of two hands touching each other in order to reveal the uniqueness of human existence. When the right hand is the active, touching one, it is at the same time touched by the left hand. If we consciously decide to reverse the roles and concentrate on the left hand as touching, we can still experience both dimensions: the active touching and the passive being touched. In order to be touched one has to be a thing among things, a physical object. Such an object is always open to the possibility of being touched. But in order to touch one needs to be able to sense the touching. One needs a consciousness that can perceive the touching. Our embodied consciousness contains both aspects. With this idea in place, let us now turn to the clinical situation, which can be seen as containing an objective and a subjective component. The physician is often construed as an objective observer, palpating, listening, looking and examining an object that is laid before her: the patient’s body. The patient is a subject, experiencing pain, discomfort, or relief. However, we would suggest that the situation is more complex. The patient’s view of her body might become objective, while the physician’s presence is often also subjective, because it perceives and senses as only subjects can. The physician’s approach is traditionally characterised as objective and active. She guides the patient’s telling of her story by structured questioning, aided by appropriate encouraging and empathic responses, to achieve the main task of the consultation, which may be to make a diagnosis, review treatment, or decide on further action. The development of a relationship with the patient is seen as facilitating these tasks, and involves the doctor knowing a lot about the patient’s life, and the patient very little of the doctor’s. When it comes to touching the patient in the course of a physical examination, the doctor’s stance is the same. Her hand becomes an instrument on which her whole sensory awareness is focussed in order to detect the slightest abnormality in the body beneath it: a lump that should not be there; a roughness where it should be smooth; dullness where it should be hollow. This concentration on the touching hand requires a kind of shutting out of the world to the extent of being unaware of the rest of the patient attached to that part being examined. Doctors have been criticised for this, but this is crucial to the practice of the examining art, like a musical performance in which the pianist is absorbed only in the music under her hands. But of course, unlike a pianist and her piano, doctors are made of the same stuff as their patients. Aware that being touched by cold hands may be uncomfortable, the doctor will try to warm them; conscious that rough hands are unpleasant, she will keep them supple with cream. Medical students are taught to watch the face of a patient they are examining, but in fact it is the touching hand that gets the message if there is a problem, because the body can touch back. The examining hand can sense even a slight quiver or tensing of muscles if it finds a painful area, even before the patient utters a word. This touching back not only gives information to the objective examiner, it transforms the doctor into an experiencing subject. So we can see that throughout the consultation the doctor oscillates between the position of an experiencing subject encountering another subject (“I must warm my hands so they are not cold to the touch”), to objective examining instrument (analysing the physical flesh under her hand), and back again. Let us now turn to the experience of the patient. When lying down on the examination bed the patient cannot help but feel like an object, a thing laid out for scrutiny. Anyone who submits herself to the gaze of the doctor may feel her body become a medical object. But at the same time, the patient is also thinking about the touch as it feels to the physician. Thoughts might include: am I clean enough; how does she feel about touching me there; does she think I am fat? The patient presents herself to the touch and judgment—real or imagined—that ensues. In this sense the patient recognises the limits of the physician’s objective stance. A further objectification takes place in the clinical setting. When entering the CT scanner, for example, some feel they are being converted into data points, sliced by the x-ray making its way down their torso. When a patient is shown ultrasound images of her own body, these images are unrecognisable to her as images of her body. Even if she feels curious about the images and the processes they capture, it is still hard for her to reconcile these objective images with her subjective feeling of her body. These experiences, especially when repeated, may lead to a sense of alienation from one’s body, and indeed to treating that body as an aberrant object over which one has little control. The patient is a subject, but a subject that is objectified. So how are we to think about the subjective and objective perspectives in the clinic and why is it important for clinicians to recognise these different ways of experiencing? Our suggestion is to try to move from viewing the physician’s perspective as objective and the patient’s perspective as subjective towards a greater appreciation of the oscillation from one position to the other. This oscillation does not denote an inconsistency. On the contrary: it marks the unique duality of the human body, which is capable of both subjective experiencing and of being experienced by others as an object. Recognising the oscillation as key to understanding human experience in its openness and vulnerability might serve as a step towards contesting the expectation that doctors should be purely objective in their clinical practice. Recognising this oscillation between subjective and objective, active and passive, roles can also introduce a second-person perspective that is available to the physician. This perspective, that of being there without pretending to stand in their patient’s shoes, avoids patronising assumptions and does not objectify the patient. We suggest that the second-person perspective (‘I can see that you are feeling bad’) may offer a way of improving communication in the clinic by emphasising the subjectivity of the physician—her normal exchange with another human being—despite her objective role. Emphasising the subjectivity of the clinician may make her more approachable to the patient, and enable the patient better to share her illness experience. By recognising each other’s subjectivity both physician and patient stand to gain. The physician gains a more natural mode of expression, and the patient has a feeling of being listened to by a fellow human being who neither purports to stand in her shoes, nor to be completely objective. Finally, this reconciliation may also create a shared world of meaning in another way. When the physician observes the patient objectively, she also sees the patient’s body as an instance of an anomaly or pathology. From this point of view the patient presents as a “case”. But from the patient’s subjective point of view, their illness is a way of being, a particular world they inhabit. By bringing closer the objective and subjective points of view and recognising the constant oscillation from one to the other, we may also bridge the gap between the view of illness as a pathology and illness as a way of being, and so reduce the distance between these two contrasting perspectives present in the clinic.