Organizing A Medical School To Teach Humanistic Mediciine

Most medical schools do a very good job teaching scientific biologic medicine (BioM).  When it comes to teaching humanistic medicine (HM), however, the story is not so clear.  It's not clear for a reason – although BioM and HM must go hand in hand in the actual practice of medicine, HM is universally treated less directly and with less intensity.  Most medical schools have some introductory classes during the first year or two of school, and they hope that exposure to “excellent examples” in the clinical rotations will lead their students in the right direction.

(For a decent definition and extensive examples of what HM entails, see here - http://buddshenkin.blogspot.com/2024/06/the-pressing-cogency-of-humanistic.html.)

Let us pose this question: IF A MEDICAL SCHOOL WERE TO TAKE SERIOUSLY ITS RESPONSIBILITY TO PRODUCE GRADUATES WHO WERE WELL PREPARED TO PRACTICE EXCELLENT HM, WHAT WOULD THEY DO?  

How might they organize themselves to accomplish this task?  If you are going to do a job seriously, you want to organize yourself seriously.

FIRST, they would set a formal goal.  Say, formally, that they will seek to ensue that their graduating students excel in HM.  The students are their ultimate test.

SECOND, they would adopt a set of measures, so that if they are going to pride themselves in producing students with excellent training in HM, they can take that pride rightfully.

What are those measures to be?  There are two general measures we have in medical school.
 
One is testing – it's pretty easy to devise tests in BioM, and students face lots of them – the basic science courses have their own written tests, just like college course tests.  It would be possible to devise similar tests for basic HM subjects.  (E.g., “name the three basic types of doctor-patient relationships as described in the Szasz and Hollender paper.”)

A second one is time spent learning under tutelage, as medical students spend months in general surgery, months in internal medicine, etc.  During these rotations, residents and staff teach and observe the students as they perform tasks, and they judge whether or not the student has grasped the basic concepts and skills, and whether or not they need more training.

This second method of measuring is much harder to do in medical school.  For one thing, who is to say that the house staff and attendings know much about HM themselves?  Many don't; in fact, many incarnate excellent counter-examples – they implicit message to students should be, don't be like that!  So what to do?

The answer to this might be, organize the concepts, and organize the teaching staff.

FIRST, the medical school should establish a core list of HM experiences and knowledge for every student, a set of expectations that each student will have been exposed to by graduation.  Have you had a patient that you know will die?  Have you been at the bedside when a patient dies?  Have you been debriefed by a sympathetic teacher to examine what the patient went through, what the family went through, what the staff went through, what you went through?  

That's just one example.  Every medical school should have a core list of experiences that every one of its student will have had by graduation.  The students should know what this list is, and be able to fill it out as their undergraduate career progresses.  If they have trouble filling out some of the needed experiences, they should have a faculty advisor to help them find the missing parts.

SECOND, just as in college we have core requirements for a major, and distributional requirements outside of that major, there should be a set of alternative courses and experiences that involve HM for each student to choose from, so that some wider exposure to the HM side of medicine can be obtained, some windows opened.  There could be mini-courses in narrative medicine (telling the story of the patient so that the patient's malady has some meaning,) spiritual medicine (religion, faith, and higher powers), medical sociology and anthropology (roles of doctors and patients, expectations in different societies), or medicine and illness in literature.  There could also be rotations in particular areas that require HM particularly, such as hospice care or oncology, or visits to patients in non-acute facilities and in their homes.

What the core HM curriculum is and the alternative HM curriculum is would change through the years, but it would be important elements to have.

THIRD, it would be important to assemble a faculty devoted to HM.  It is most likely that scattered among all the doctors and all the officials and all the departments and divisions at the medical school, there are many individuals who are devoted to the ideals of HM.  It is likely that they are not organized, that they know many like souls, but they do not have concerted efforts.  Bringing together these self-identified HM oriented faculty in an advisory body, where they could trade ideas and observations and advise the administration would most likely constitute a great leap forward.

For the didactic and conference courses that are directly devoted to HM issues, there are faculty already teaching some or these courses, and recruiting others should not be hard.  In each clinical department, the odds are that there are departmental members who are interested in and even devoted to the HM mission in medicine.  There might be more in psychiatry than there are in urology, but they are there.  Sometimes older members of the department, or even retired members of the department, will be particularly skilled in HM and eager to pass on their knowledge and experience.  But it could well be helpful for each department to have someone who is specifically implicated to survey the experience each student is having, and help each one get a thorough exposure to HM as seen by that particular department and that particular leader.  There will be variation that way, but that's a good thing.  Let the experiences vary and let the students figure it out!

FOURTH, there needs to be some centralized organization of the HM curriculum.  If it's everyone's responsibility, it's no one's responsibility, says managerial science.  There might be someone in the upper echelons whose responsibility is HM.  This person should be responsible for the HM curriculum, the HM teachers, the HM measurements, and for ensuring that every single student is getting good education in HM.

This HM official would be the one to shepherd curriculum development, to liaise with all the teachers, to meet regularly with students and student groups to get feedback, to organize courses and lectures and dinners and trips – the whole nine yards.

Note: even with increased centralized organization for HM, I am NOT recommending increased bureaucratization and centralized authority.  The administrative center for HM should be called “Support for HM.”  Their call to the departments should be, “What do you need?  How can we help you.”  It is a good plan to have centralized goals and objectives, and decentralized implementation.  

And now, to repeat in different words, because every call to action needs repetition, the “this is what I just said” section.

• There should be a core list of HM experiences and knowledge for every student, a set of expectations that each student will have been exposed to by graduation

This list should be continually adjusted by faculty and student consensus
Each major experience should be followed by debriefing, where reflection with a faculty member or surrogate is pursued
Each student should have a check list of experiences the student has had, and whether or not there has been debriefing and teaching following the experience
The HM knowledge and experience of each student should be measured

• There should be administrative centralization for HM, which would

Continually review and adjust expectations for students
Make liaison with all clinical placements for students to survey and augment HM experiences in the departments
Maintain relationships with all independent HM-related activities to enable student participation
Maintain direct student relationships to monitor and enhance HM student experiences
Coordinate mentor relationships, both faculty and alumni and others

• Each clinical department should have a designated officer for HM, who would both teach directly and be a resource for experiences throughout the department, and a liaison with HMS administration and with other HM departmental officers.   

Diversity of departmental approaches should be nurtured and respected.  This would be a perfect opportunity to utilize more senior departmental doctors, and even retirees.

If a medical school is to be justifiably proud that its graduates have obtained firm mastery of many aspects of HM, just as medical schools are traditionally proud of its graduates' skills with BioM, the medical school needs the structure and the data for that pride.

Excellent medical care needs humanistic medicine as well as biologic medicine to be practiced; they are partners, and HM needs to be taken as seriously as BM.  Organizing for the task is necessary.  I hope the medical schools can take the HM task seriously.

Budd Shenkin

August, 1982, and July, 2024

 

August, 1982, and July, 2024

I think that Kamala might be elected in a landslide. It's too early to tell, but if she were a stock, I'd be a buyer.

I have looked at the stock market since I was in my 20's. I can't say I've had constant success – I haven't – but I made enough to buy my first house when I was 33, and I took formal courses on technical analysis of the stock market at Golden Gate University with the great hank Pruden in the 1980's, and I know something about it.

I've also followed politics since the age of maybe 10. I remember the headlines about the Korean War – Inchon Landing! I remember when Truman fired MacArthur – I supported Truman. I know something about it.

What do the stock market and politics have in common? While both of them have issues of substance that one can seek to understand – they are called “policies” in politics and “fundamental analysis” in the stock market – both of them are governed by popular mass psychology. So, that's where I think the overlap is.

A lot of technical analysis works off charts – in fact, technicians are sometimes called “chartists.” The chart of stock prices shows a picture of popular opinion of what a stock is worth through a time period. Technicians try to make use of these charts to find common elements through time to be able to recognize recurrent phenomena. In other words, standard pictures that you can recognize that you have seen before.

I remember August, 1982. There had been a long decline in the market; there had been a stubborn inflation and then a rise in interest rates engineered by Paul Volker at the Fed, with the intention of producing a recession that would cool prices down. You can see it in the first half of this chart.

Opinion on stocks was negative, and prices reflected that negativity. In fact, opinions were so negative that some technicians (but not fundamentalists) were predicting a stock market rise, although they didn't know when, because when opinion swings strongly one way, that's a contrarian sign that there is a reversal in the future. You just don't know when.

But for here, let's just concentrate on the decline – prices were going down. They kept going down and down, everyone got depressed, and finally, even the most optimistic started to get depressed. They capitulated to pessimism – that's the technical analysis official term for what happens at such a time, capitulation. There is no one left to sell stocks, because everyone has already done so, and the last sputter is the capitulation.

And then, all of a sudden, very suddenly and unexpectedly, something happened, and prices turned around on a dime and started to shoot up. They shot up fast. Volume climbed – everyone started to pile in. No one knew why, but there it was in front of you. Mass psychology sees big changes fast. And that chart shows what the turnaround looks like. It's not tentative – not only do prices start to rise, but they do it on big volume (lots of shares traded,) out of seeming nowhere.

So, my thesis is that we could change the x-axis (the abscissa) from the first years of the 1980s to the last year or two in the 2020's, and change the y-axis (the ordinate) to Democratic popularity and “good job” ratings, and we then have picture of political mass psychology.

The popularity of Biden and the Democrats was constantly tending downward. The final event in this series was the June 27th debate. What a horror show! I was watching it alone on my blue leather couch in the TV room, and within three minutes I said – “Disaster!” Confused and slate white, mouth agape, words hard to find, Biden looked about 95 years old. He shuffled. He kind of rallied later, but the damage was done, and everyone could see it. The Democrats were cooked – put a fork in them. Even Trump didn't quite know what to do, the breakdown was so complete. His choice of JD Vance just over two weeks later reflected the capitulation; Trump thought he had it won, so he might as well get a fire-breather.

Not so fast, old man, not so fast. The last sputter of a bear market can be deceptive. Unlike the stock market, here we can discern a clear change that led to the public perception change – Biden withdrew and Kamala stepped in with authority – with great authority! How she has grown! Poised, confident story-telling, taking her time as she builds to the climax, the wind clearly in her sails. Hey, man, that was the bottom! The debate was the bottom. Look at what's ahead. It's not tentative, the financial contributions to Kamala are the equivalent of stock volume, which tracks enthusiasm – it's a bottom followed by a breakout to the upside.

So, we could trace some of the fundamentals – all the issues of the Democrats are more popular than those of the Republicans, for instance, they just have to be recognized by the people.. But the charts will tell us if we have identified it correctly. In the stock market it's the earnings that come in later, after the turn, the fundamentals follow the technicals. Politically now, the chart predicts that the polls will turn, more money will roll in, more endorsements, some good debates, etc. That will come. But right now, we're just looking at the chart, and if thing go as I think they will, we're looking at our first woman president next year, and preservation of the Biden legacy, and the much hoped-for political demise of Trump. Personally, I think it could well be a landslide.

But, in both stock market and politics, you never really know. As they say in sports, that's why they play the game. And to quote my father quoting an old English apothegm, “There's many a slip twixt the cup and the lip.”

Budd Shenkin