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