Louise Younie, Clinical Reader in Medical Education, Barts and The London, QMUL

Published in JHH 18.3-Shifting the paradigm

The balance between science/technology and art has shifted so far towards the former that the latter is a pale shadow, a fragile remnant of what had for centuries been crucial to the work of the doctor.
Kleinman, 2008

I was talking last week with two medical students on a summer internship exploring flourishing and creative enquiry. Through their honesty and courage our conversation turned to the discomfort of one student, regarding the ambiguity and uncertainty of the project and the conviction of the other that this creative enquiry and human flourishing work is the first academic project ‘that has really made sense to me’. Our focus is the human dimension or artistry of clinical practice, difficult to articulate, yet vital to our work on the wards and in clinics. Students still emerge into clinical practice understanding disease, but with a much less well-developed understanding of the other, themselves or the space in between (third space). Shapiro describes the silencing of personal voice in medical training, where students learn to present ‘cases’ through an impersonal passive voice, not only reducing the three-dimensional patient to a two-dimensional caricature, but simultaneously hindering the student from engaging their own humanity (Shapiro, 2009). Does this matter?

The defended doctor

It is unarguably true that meeting a caring doctor, who connects with kindness and compassion in our hour of utmost vulnerability, offers a lifeline of hope, healing and humanity (I speak as a previous cancer patient, but many patient testimonies bear witness to the same) (Broyard, 1992; Youngson & Blennerhassett, 2016). Further, disconnection with the self, a macho, emotionally neutral, detached clinical approach may contribute to some of the cynicism and burnout engendered in the medical profession (Youngson & Blennerhassett, 2016). Despite the importance of the humanity of both the doctor and patient, educators seeking to humanise the medical education curriculum still find themselves in an ‘uphill battle’ (Tilburt & Geller, 2007).

This can be explained at least in part by biomedical theoretical dominance (Kuper & D’Eon, 2011; Tilburt & Geller, 2007) and a neoliberal discourse, the former engendering focus on ‘hard science’, disease, cure, objective knowable facts, the latter focusing on responsibility of the individual for their predicaments (eg the patient should eat less, exercise more) (Sointu, 2020) rather than considering structural and institutional forces (Wilson, 2007; Benor, 2014). Holistic, societal and interpersonal understandings are rendered ‘soft stuff ’ in a linguistically problematic way. This denotes them as less reliable sources of knowledge (Tilburt & Geller, 2007).

Language and leadership

Cribb and Bignold (1999) have called out the need for bilingualism across the divide that separates ‘objectifying’ from ‘humanising’ currents in medical education. Heath (2016) writes about rebalancing biomedicine with the ‘fullness of [the patient] humanity’ drawing on ‘knowledge and wisdom from across the full range of human understanding’. Kleinman (2013), in talking about the doctor-patient encounter, makes the case for ‘a flow of emotions…a real life exchange that is human as much as technical’. Change is clearly needed in medicine, and this time of Covid-19 pandemic, while leading to psychological fragility in the workforce, might also create opportunity for positive systemic change (Park et al, 2020). Organisational psychologists drawing upon research suggest the way forward is grassroot engagement in system change, where there is visible, vulnerable, humanistic leadership in a culture of self-care and equal voice (Park et al, 2020). In support of these suggestions the authors of a pre-pandemic paper titled Humanising healthcare, describe needing to change leadership style in order to reach people – for example showing vulnerability and humility, or seeking the wisdom of individuals and communities they were hoping to serve, rather than coming in as experts (Youngson & Blennerhassett, 2016).

This is role-modelling, on a meta level, what is needed to humanise our patient or student encounters. When we meet our patients we can draw on our biomedical knowledge, but humility within the human domain allows us to listen. Interesting research into imposter syndrome found that physicians suffering with imposter syndrome were equally as good at making diagnoses but better in the interpersonal domain (Tewfik, 2021). This makes sense. Feeling uncertain helps us to recognise that we cannot be the expert in another’s life, how they suffer and what they need right now, we can only ever partner in this venture, learning as we go.

‘It is unarguably true that meeting a caring doctor… offers a lifeline of hope, healing and humanity’

Co-creation and compassion

Educators could similarly invite the human dimension of care through seeking the perspective, ways of seeing and wisdom of the students they serve. For example, last year we introduced a new assessment into the Year 3 GP placement. Instead of trying to teach students compassion, we invited students to work collaboratively to explore the concept of compassion through creative enquiry and make a presentation to their GP tutors.

‘When we meet our patients we can draw on our biomedical knowledge, but humility within the human domain allows us to listen’

This grassroots approach positions the students differently, as explorer of the human dimension and allows space for students to communicate what they see and hear in healthcare through their own eyes and through chosen arts-based languages of expression. Students engaged to different extents with the creative enquiry dimension (unsurprising given it is the first year and no previous examples existed). Some students added images to their power points, others drew and wrote poems, there was even a musical written and sung by medical students based on different clinical encounters. Students’ reflective accounts describe joy at the unusual level of freedom of expression offered in this assignment and note how the topics are qualitatively different to their usual academic requirements such as on clinical topics such as cancer. I expect with evaluation now under way that we will find some students more cynical.

‘Everywhere I go I find a poet has been there before me.’
Sigmund Freud

Emotional awareness

Vulnerable leadership is one approach to enabling the human dimension in medical education as described above. Developing understanding for self and other is another important aspect of this work. Branch et al (2001) argue for the importance of self-awareness as part of the humanising agenda, becoming aware of our emotions arising in encounters with patients, or recognising our own values, beliefs, needs, culture as clinicians. Feudtner & Christakis (1994) promote the idea of self-ethnography in medical education, to consider the social and emotional domains of medical students’ lived experience. I have found creative enquiry invites a kind of enriched self-ethnography with layered meanings full of personal significance, which through stories and images rapidly leads the student into the human dimension – the patients and the doctor individually or even simultaneously in one image (Younie, 2011). In this image the student paints the patient story, using the student’s favourite artist style (Vincent Van Gogh), and describes in the accompanying reflection that the dark colours represent not only the patient’s depression but also her own heaviness after listening to the patient’s sad story.

In summary the human and biomedical dimensions of care are both essential to our work as doctors, like the DNA double-stranded helix, they are woven together and continuously connected. The biomedical strand of this helix is thick and strong, but the human dimension strand is yet to be well articulated, developed and enabled in medical education. A good starting point may be with vulnerable leadership and creative enquiry.

References

Journey through arts-based inquiry in medical education. Doctor of Education, University of Bristol.

Benor DE (2014) A new paradigm is needed for medical education in the mid-twenty-first century and beyond: are we ready? Rambam Maimonides medical journal, 5, e0018–e0018.

Branch J, William T, Kern D, Haidet P, Weissmann P, Gracey CF, Mitchel LG & Inui T (2001) Teaching the human dimensions of care in clinical settings. JAMA, 286, 1067–1074.

Broyard A (1992) Intoxicated by my illness. Ballantine Books.

Cribb A & Bignold S (1999) Towards the reflexive medical school: The hidden curriculum and medical education research. Studies in Higher Education, 24, 195–209.

Feudtner C & Christakis DA (1994) Making the rounds: The ethical development of medical students in the context of clinical rotations. Hastings Center Report, 24.

Heath I (2016) How medicine has exploited rationality at the expense of humanity: an essay by Iona Heath. BMJ, 355, i5705.

Kleinman A (2013) Medical sensibility: whose feelings count? The Lancet, 381, 1893–1894.

Kuper A & D’Eon M (2011) Rethinking the basis of medical knowledge. Medical Education, 45, 36–43.

Park B, Steckler N, Ey S, Wiser A & Devoe J (2020) Co-creating a thriving human-centered health system in the post-covid-19 era. NEJM Catalyst innovations in care delivery, 2.

Shapiro J (2009) The inner world of medical students, listening to their voices in poetry. Radcliffe Publishing.

Sointu E (2020) Challenges and a super power: How medical students understand and would improve health in neoliberal times. Critical Sociology, 46, 851–865.

Tewfik B (2021) The unexpected benefits of doubting your own competence [online]. The University of Pennsylvania. (accessed 3 October 2021).

Tilburt J & Geller G (2007) Viewpoint: The importance of worldviews for medical education. Academic Medicine, 82, 819–822.

Wilson BM (2007) Social justice and neoliberal discourse. Southeastern Geographer, 47, 97–100.

Youngson R & Blennerhassett M (2016) Humanising healthcare. BMJ, 355, i6262.

Younie L (2011) A reflexive journey through arts-based inquiry in medical education. Doctor of Education thesis, University of Bristol.