The art of clinical medicine demands the inclusion of humanities and social sciences in medical selection and education.
The practice of medicine is based on the application of science for the improvement of human health. Medical practice is an art, which mandates empathy and compassion. It requires much more than the coldness often associated with analytical minds. Entrusting physicians with human lives demands a combination of humaneness and sound scientific temperament. However, the existing admission criteria for pursuing medicine and the curriculum selectively focus on the science to a near complete exclusion of humanities.
Irrelevant scientific foundation: The belief that medicine is pure science is common. The criteria for admission to medical colleges in India demand a detailed study of physics, chemistry and biology to the complete exclusion of humanities and social sciences. Understanding Newtonian mechanics and the current botanic classification is compulsory despite their irrelevance to the medical practice. Knowing the differences between an alkene and an alkyne is hardly necessary. Yet, few people including medical teachers appreciate the fact that organic chemistry is far removed from the insights into biological chemistry required for understanding human health and disease.
The admission requirements focus on science content rather than on the prerequisite that aspiring physicians need to understand the scientific process, logic and problem-solving. The admission processes are essentially tests of memorisation rather than an assessment of aptitude. Pre-med science courses do not develop scientific logic and skill; they only encourage and identify competitive memorisers. The science-only policy is not only restrictive but also selects many candidates with limited aptitude for medical practice.
Lopsided focus: The curriculum with its exclusive emphasis on science makes for deficient training. The fashionable focus on biology and the reduced emphasis on social determinants of health make physicians short-sighted and leave them without an understanding of long-term solutions to common diseases. The spotlight on pathology and disease with a failure to understand illness and patient reality often leads to problems in communication, patient dissatisfaction and doctor shopping. The single-minded pursuit of cures for chronic conditions, which we can only control at present, diminishes the importance of healing, making the transition from medical student to physician problematic. The absence of communication and counselling skill training in the curriculum makes it difficult for doctors to convey bad news about diagnosis. The lack of training in negotiation skills for discussing treatment plans often results in poor compliance and medico-legal problems due to discrepancies between the views of patients and doctors on clinical reality.
The art of medicine is based on an understanding of human nature, the cultural context and social expectations. Issues like stigma attached to certain diseases (tuberculosis, leprosy, cancer, HIV) have a huge impact on seeking medical help and on compliance with treatments. Pure biological strategies employing only medication do not have the desired effect and require psychological and social approaches as well. The patients' right to information, their views on the choice of treatment and obtaining consent for particular procedures and therapies require an understanding of not only the law but also social issues. Mobilising personal and family resources and support is often crucial and demands an understanding of psychological and cultural issues. A discussion of costs and benefits of different treatment options requires an understanding of the available financial resources and constraints.
The science-only focus is also the result of a belief that the science can be “taught” while the humanities required for medical practice are “caught” by students during training. Learning the art of medicine is consequently left to serendipity and chance.
Humanities in medicine: There is a growing realisation that there exist many interfaces between medicine, the arts, humanities and social sciences. Medical humanities are now considered an interdisciplinary field and include the humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theatre, music, film, visual arts and creative writing) and their application to medical education and clinical practice. Social science perspectives help to understand how science and medicine are placed within cultural and social contexts. They inform us of how culture interacts with the individual experience of illness and with medical practice. Studying local cultures and religions allows for an understanding of the personal and social explanations of suffering.
The arts and literature help to build and nurture observational and analytical skills. They encourage empathy and self-reflection essential for the practice of humane medicine. They provide insights into the human situation, on suffering and on our social concerns and responsibilities. They also offer a historical perspective of the practice of medicine.
Narrative Medicine includes story-telling, film, mass media and literature. William Osler was one of the first to propose for medical students a bedside library that included Shakespeare, Montaigne, Plutarch, Aurelius, Epictetus and Emerson. The reading tastes of people have changed over the years and others have attempted to renew the list with the inclusion of Moby Dick, Pride and Prejudice, Don Quixote, The Adventures of Sherlock Holmes, The Final Diagnosis and Surely You are Joking, Mr Feynman. Orwell, Medawar, Asher and De Bono are on many lists as are religious texts.
Cinema captures the complex reality of life. Cinematic and tele-visual texts rely on the narrative to make meaning and allow for the exploration of “truths” and “themes” in modern medicine. Good stories presented from different perspectives add to the understanding of the human condition. They enhance manifold the insights into health and disease, normal and abnormal, and the human response to pain and suffering.
The application of ethics to the practice of medicine is complex and requires formal training. Applying the principles of autonomy, beneficence, non-maleficence, justice, dignity and honesty to everyday practice requires diligence and discussion. The complex situations faced by physicians are often due to conflicts between two rights.
Medical humanities movement: Many medical schools in the West have established departments of medical humanities. They offer regular and elective courses and have a dedicated faculty, recognised syllabi, interest groups and book clubs. Recent advances include online med-humanities communities, web-based resources, searchable databases and comprehensive blogs and discussion boards.
Some medical schools also allow for the selection of a small proportion of undergraduates majoring in humanities or social sciences instead of in the traditional pre-med curriculum. They are required to take only basic high school biology and chemistry courses. They are exempt from the medical entrance examination but are judged on their school and college grades. Evaluations of such programmes have showed that the academic performance in medical schools of those with a humanities or social science background is equivalent to those who chose the traditional pre-med route.
Medical humanities and India: Medical humanities are not formally taught in medical colleges in India. The few institutions which have attempted to incorporate these in the curriculum have done it informally and without a comprehensive and rigorous approach to the field. Not many medical schools regularly discuss ethics in medical practice; few debate the complex issues involved. The emphasis on medical humanities is minimal and dedicated departments are non-existent. Munnabhai MBBS and Wit are rarely part of the curriculum.
The way forward
For decades, the medical profession has debated whether pre-med courses and admission tests produce good doctors. There is no single formula of what will make a good doctor. Many would argue for a later age for increased emotional maturity for entry into the medical college (say, after a bachelor's degree) and for hard working students who have demonstrated a commitment to serve the community and have lived life. Good scores in science do not always translate into a sense of mission. Nor do they automatically result in an interpersonal skill to become well-rounded and caring healers.
Medical colleges in India should establish departments of medical humanities. The curriculum should include courses in these subjects with minimum requirements for all physicians. There is a definite need to reconsider the science-only entry criteria for medicine and include humanities in the pre-med curriculum. Opening up medical training to older students majoring in humanities is an option worth considering. People in general and the best doctors in particular are those with open minds and broadly experienced in both humanities and science.
(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)