Humanities in psychiatric education? Wherefore art thou?

Dr Vinodini Vasudevan
Dr Maxwell Pickard

In a post-graduate (and pre-graduate) curriculum packed with important subjects vying for attention and import, what place do medical humanities have, if any? In this article we consider the primary arguments for, and against, medical humanities as part of medical education, and how it might be most effective.

What the devil is Medical Humanities anyway?

This is a devilish question. That we ask this question at all may be because we are doctors and have a need for a clear definition that fits well within our system and is easier for us to work with. The question that then arises is whether humanities can be defined? Is it too much of an abstract concept to be defined within the confines of a diagnostic system?

The study of the Humanities has its initial roots in the Classical Period. Apollo himself was the god of music, poetry, and medicine. The scholars of antiquity understood well the relationships between art and health. Medical education and education in the arts took place side by side (1). Da Vinci, for instance, was able to see this relationship.

The separation of humanities from medicine is relatively new. Perhaps a strict definition of medical humanities is not required. Perhaps it is not even advisable. What medicine does need, always has needed, and arguably always will need, is examination of how medicine fits in with the “big picture” of human experience. The core strengths of medical humanities are the imaginative non-conformist qualities and practices.

Why Medical Humanities?

Crawford et al argue that though medical humanities as a discipline has made advances, more integration is needed in the future as health humanities (2). This may be in the form of allied health professionals, patients and carers, those traditionally marginalised from medical humanities becoming involved. This will help health humanities to evolve, share knowledge and teach future generations of practitioners (2).

It has been argued that humanities should be part of any medical educational curriculum to help develop better patient relationships. A counter argument is that medicine must be evidence-based and medical humanities is not sufficiently so to warrant inclusion, at least on a compulsory basis. We are now scientifically documenting what was known intuitively in the past, as evidencing the place of therapies using art and drama in easing psychiatric suffering, which gives medical humanities some legitimacy.

Medical humanities offer different ways of thinking about human culture, behavior and experience to in turn influence health care practice. The most relatable example may be of developing better patient relationships as mentioned earlier. One way of doing this is being able to validate how the patient feels and being able to read in between lines. This then brings us to skills around empathy. If we agree with the principle that empathy is part of good clinical practice, we must ask then ask whether empathy can be learned or if it is an unmalleable trait. If (and it remains an “if”) empathy can be cultivated then it has been argued that there is a role for Humanities in the curriculum. (3)

Even if empathy can be improved in some, it does not mean it can be improved in all. Would the introduction of medical humanities be effective for every potential or active doctor in improving empathy, would it improve the empathy of the already empathic, or would it be a remedial intervention for those with observed poor empathy (which in itself could be due to a variety of causes, such as innate psychopathy or burn out and poor morale)?

These questions are, at present, unanswered. The answer, as always, will depend on evidence. However, this area is not easy to research and will ultimately require long term dedicated outcome-based research. Nevertheless, we must not conflate absence of evidence about efficacy with evidence of ineffectiveness. We must speculate initially and confirm afterwards, and even without good evidence we can fall back on the Royal College of Psychiatrists Motto “Let Wisdom Guide”.  O’Donnell puts it well when he -based medicine deals with populations; clinicians deal with individuals”(4).

The question of content

What content should “Medical Humanities” have is an important question, and it is best answered by changing the question. Medical Humanities is (potentially) a vast field, which can go on to include anthropology, history, theology, mythology, sociology, philosophy, and every mode of art one could conceive of. It would be impossible to train doctors to be “experts” in medical humanities.

Whilst we should be mindful of the content of medical humanities, specific content is not the key. Medical humanities invokes different and novel ways of thinking about medicine, or the experience of medicine (and health) that might (and usually does) get lost in the day to day demands of clinical practice. Realistically, the aim of medical humanities is not to know the content of one area, but to stimulate thinking and feeling.

Events like attending plays/dramas/relevant films/role playing/simulation training may be added to the curriculum as these are the modalities from which humanities as a subject has arisen and evolved into (3). With reflective practice becoming established in medicine, appropriately selected events can be tied to senior clinicians’ personal development plans and continuing professional development points.

Humanities should be part of clinical work, as suggested by Bloch S, “They (clinicians) need to be struck forcibly by the relevance of the experience, with explicit mention of the clinical issues illuminated by a particular short story, painting, film and so forth” (3).

From a practical view, adding another subject to an over subscribed curriculum is fraught with problems. Recent advances have given medical humanities its own space in its own right, with journals, conferences, and there is also an interest in how much it can help biomedical fields. A recent summary of the future of medical humanities in the U.K. described the current state as medical humanities being able to establish itself only by appearing as the “domain of pleasant (but more or less inconsequential) meets – lurking hopefully, poetry books in hand, at the edges of the clinical encounter’s ‘primal scene’. This is obviously a caricature, but with some truth. What then will critical medical humanities look like? Fitzgerald et al explore the cross over areas between medical humanities and biomedical sciences to see if both can hold the patient as the center of care (5).

Voluntary, compulsory, or something In-between?

Aside from considering what medical humanities education should look like, there is another issue. Should it be compulsory (and possibly subject to examination) or voluntary? Neither is a particularly attractive option. Making medical humanities compulsory is not easy, for it requires above all engagement and the cynical, tired, and busy are not easy to engage. On the other hand, if it is purely voluntary, it is not only more easily marginalized, but the very persons it might most usefully help (those somewhat shut off from the broader aspects of the human in medicine) are the ones least likely to participate.

We would argue that it suggests the nature of content should be one chosen by the student (voluntary content) whilst the analysis, speculation, and reflection that accompanies the content should be required (compulsory). This fits with reflective practice’ becoming not only the norm but required.

The flip side

Psychiatry lends itself to speculation, reflection and “thinking outside the box”, and is arguably the most fertile ground for medical humanities. Yet even here, there is debate and disagreement.

There are some who feel that not all psychiatrically unwell patients are able to describe their symptoms or themselves narratively and if students are taught to understand only this concept, then patient care will be compromised. Angela Woods speaks about blind spots in the dominant medical humanities approach to narrative, including the frequently unexamined assumption that all human beings are ‘naturally narrative’(6). She also analyses this further keeping in view philosopher Galen Strawson’s influential article ‘Against Narrativity’.

Then there are some that feel that as fields of literature and art struggle against better funded counterparts, they are trying to fit under the umbrella of medical humanities by  “insisting that literary fiction promotes empathy (7)and that learning languages prevents Alzheimer’s.” (8)

We spoke about how arts and literature can help psychiatrists, but what about the harm it could possibly cause?

Lets think about how mental illness presents in art, and literature. It might improve understanding of mental illnesses in the general population, but there are also instances of very rare conditions such as multiple personality disorder feature in popular films and books and it would be easy for the general public to form the impression that it is a condition more common than schizophrenia. Baldin recently discussed this topic and wondered if psychiatrist should write fiction. He concluded that “Psychiatrists are dealt a rough hand by fiction”, and that it would be helpful both to address stigma, and for psychiatrists themselves (via reflection) to write fiction (9).

Conclusion

Successful Medicine brings about desired change in the patient. Though literature can make a person rethink their world, not all of it is life altering in a positive way and some literature and poems can actually have a negative impact. Rothfield argues that whilst literature can be used therapeutically, it opens the field to criticism when dealing with less obvious change. For example, certain pieces of work raise important questions because they may be difficult and upsetting, maybe even depressing, but do not actually go on to cure depression.  He gives the example of Franz Kafka, a German writer who fused realism and fantasy, whose work has been variously interpreted as exploring themes of alienation, existential anxiety, guilt, and absurdity. Just because a piece of work elicits a certain feeling in people, does not necessarily translate into people making a change based on the discomfort (10).

Despite the criticisms, and the paucity of evidence on medical humanities, medicine is still left with a number of perennial problems. Frequent complaints of poor communication, lack of understanding, being either too “medical” or lacking “humanity”. The reasons for these are complicated and layered, but they are problems still. We can also add in frequent burn out, high levels of mental ill health and even suicide. Neither patients nor doctors, it seems, are particularly happy or satisfied with the state of medicine.

Education, too, is changing. With the development of information technology and AI, the demands on modern medicine change too. It is not so important for a modern doctor to remember the biochemical abnormalities found in an obscure disease when this information can be found in seconds via computer systems. One could reasonably speculate that artificial intelligence will start to encroach (and rightly so) on many aspects of medicine. Our education is changing from learning lists to problem solving skills and reflective practice.

If one considers the future, medical humanities should offer a road forward. It should be evaluated and modified, critiqued and refined. Everybody should be considering not just medicine, but the experience of medicine, and it is here that medical humanities should stake its claim.

References

  1. Schlozman S. Humanities and the practice of medicine. In Wedding D, Stuber M, editors. Behavior and medicine, 5th edition. Hoegrefe; 2010. p258–269.
  2. Crawford P, Brown B, Tischler V, Baker C. Health humanities: the future of medical humanities? Ment Health Rev J. 2010;15:4–10
  3. Bloch S. The art of psychiatry. World Psychiatry. 2005;4(3):130–4
  4. O’Donnell M. Evidence-based illiteracy: time to rescue “the literature”. Lancet. 2000 Feb 5; 355(9202):489-91
  5. Fitzgerald D, Calland F. Entangling the medical humanities. In Whitehead A, Woods A, editors. The Edinburgh Companion to the Critical Medical Humanities. Edinburgh University Press. 2016.
  6. Woods A. The limits of narrative: provocations for the medical humanities. Med Humanit. 2011;37(2):73–8.
  7. Julianne C. Scientific American. Mind. (internet) 2013. Novel finding: reading literary fiction improves empathy. Available from: https://www.scientificamerican.com/article/novel-finding-reading-literary-fiction-improves-empathy/
  8. Craik F IM, Bialystok E, Freedman M. Delaying the onset of Alzheimer disease. Neurology. November 09, 2010; 75 (19)
  9. Baldin, H. Should Psychiatrists write fiction? BJPsych Bulletin. 2018; Vol 42 (2): 77-79
  10. Rothfeld B. Hyperallergic (internet) March 23 2015. The problem with the medical humanities. Available from: https://hyperallergic.com/177969/the-problem-with-the-medical-humanities/