Humanities in Medical Education: Some Contributions

Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities. (Pellegrino, 1970)
The human arts are the good arts of Aulus Gellus, the liberal arts, those that free a man’s mind from the tyranny of others. (Pellegrino, 1976)

The plan is to describe five ‘qualities of mind’ which are very important to medicine and which are distinctively contributed to by humanities in medical education. ‘Qualities of mind’ is meant to include items like ‘mind-set’, ‘attitude’, ‘awareness’. ‘perspective’, and ‘intellectual skills’. It is hard to make a case of such nebulous characteristics in a vocational school setting.

The ‘qualities of mind’ engendered by the humanistic disciplines, which will be described briefly, are: critical abilities, flexibility of perspectives, non-dogmatism, discernment of values, and empathy and self-knowledge. They are very similar to each other, bearing a distinct family resemblance.

In a medical school there seems to be an overwhelming amount of memorization, checklist, and cookbooks. This must be the most crippling, stupefying, and depressing feature of medical education to these bright and inquisitive young minds when they first arrive. And it never changes: the students simply adapt, they become molded.

Vocation learning that is task oriented must simply go on with what works, with what is immediately needed - whether it is a gadget, a business arrangement, a theory, or a therapy. The goal is clear - just learn the process and do it. By contrast, humanistic studies - art, philosophy, history, and literature - do not share this sense of immediacy.

Without the press of immediate practicality or pay-off, there is opportunity to play around with ideas - to seek, invent, try out, explain. This is the atmosphere in which imagination and critical thinking develop and flourish. In focusing on a work of art, a literary classic, a historic period, one can try out different interpretations, looking at it from different points of view.

‘Flexibility of perspectives’ is quite closely allied with ‘critical ability’ , yet different enough to be described separately. Professional education is often described as a kind of conceptual ghetto. Each profession has its own ghetto. Its members get locked in a certain way of seeing the world, themselves, their relationship with that world, and their role within it.

That may be what is meant by being ‘professionalized’. It is a way of viewing everything - certain things and relationships are highlighted, others fade into the background; certain causal chains predominate, others are barely noticed. In other words, one’s perspectives become highly specialized.

This is strengthened and reinforced throughout our professional education - by teaching, by emphasis, by exam, by the concepts we use daily, by our special language, by the handed-down view of what is significant. We get locked in. Our perceptions , thoughts, and lines of reasoning get channeled; our circuitry gets etched in.

‘Flexibility of perspectives’ is believed to be the most important contribution of the humanistic disciplines to medical education. The ability to quickly and easily shift perspectives when appropriate, to see with ‘new eyes’, is a valuable clinical as well as personal skill.

This ‘quality of mind’ bears close resemblance to the others and is nurtured by the same kind of intellectual exercises which train critical ability and flexibility of perspectives. Nothing promotes misguided certainty more than being locked into the kind of single perspective.

Seeing no alternatives, unable to imagine other possibilities, one becomes dead certain of whatever it is he is perceiving within the parameters and categories of his own limited vision. That is why flexibility of perspectives works as a corrective to incipient dogmatism.
But there are other ways to counteract it.

Through history, for example, we can come to know, understand, and appreciate a belief system other than our own. And when through history we see how frequently the unquestioned truth of a prior time were the falsehoods and myths of a later time, some doubts must inevitably be cast on those matters of current confidence.

We cannot help but be humble-struck, wondering what the next generation will do with things we are so cocksure of today. Particularly the history of science and medicine is helpful in this regard. We find gifted scientist being certain but wrong; we find unexamined assumptions; we find mistaken theories sometimes winning out; etc.

Through history our students gain a sense of discovery and of open-endedness of science. They acquire a mind-set ready to question, an openness to new clues, and a serious regard to recalcitrant data. In short, non-dogmatism.

Because this ‘quality of mind’ is probably the most obvious and frequent contribution of the humanities, it must here receive the most intense attention. In fact, with the enormous emphasis on biomedical ethics from the early 1970’s, it may seem downright commonplace. But values include far more than moral values.

They include others, such as political, aesthetic, and personal values, which tend to be overlooked in the intense concentration on moral values. The humanistic disciplines are heavily value-laden. But they are self-consciously so. They have the vocabulary, conceptual apparatus, and strategies for dealing with values.

Medicine, after all, is riddled with values. From its key concepts (disease, life, death, role of medicine, etc.) to diagnosis and therapy (what is ‘indicated’, trade-offs, lab values) to the delivery of health care (allocation, rationing, research-funding, etc.) medicine is value-laden. Not to identify these values is to be manipulated by them.

Empathy and self-knowledge, unlike the other qualities described, are more directed at interaction with persons than with observation, knowledge, and ideas.
Literature is probably the most direct way to illustrate this phenomenon. In literature we vicariously live many other lives. We are led by the writer’s skill to see life of others through a completely different mind-set.

Through such vicarious experience we surely learn about others in the most unique of all ways - by empathy, by ‘becoming’ them, by taking on so many of their characteristics that we begin to think, act, and react like them. We learn what it is like ‘to put ourselves in someone’s else’s place’, ‘to see it from the other person’s point of view’.

It is not only empathy and tolerance that flows from identifying with other persons, times, and beliefs. It is self-knowledge as well. We do not really know and understand ourselves until we see that, how, and why we differ from others. This, then, sets the agenda and motivation for self-investigation and reconstruction.

Prepared by
R. Sjamsuhidajat
Department of Medical Education, FKUI

excerpted from
“Humanities in Medical Education:
Some Contributions”
K. Danner Clouser (1990)
The Journal of Medicine and Philosophy 15:289-301

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