Making medicine whole -- Medical humanities

by Darla Brown

Medical ethics and history
Health and human spirit
Health care and the arts
Preserving the human connections

On night duty and desperate for rest, the third-year medical student was counting down the minutes until the end of her shift at Memorial Hermann Hospital. When just her luck, she got a call from the chief operating room resident saying that she was needed to take a medical report. Reluctantly she answered the call with a certain amount of resentment in her mind.

“So what brings you here?” she bruskly asked the patient, staring at the blank chart in her hands. When she received no response, she glanced up to see a woman bleeding and in obvious pain. Seeing the fear and pain in her eyes, the student immediately turned all of her attention to the patient, who had just suffered an abortion induced by physical trauma at the hands of an abusive boyfriend. She was consumed with giving the patient the best care and compassion she could – forgetting all about her lack of sleep and her desire to go home. She even went to check up on the patient once more before leaving the hospital that night. The patient weakly smiled at her, “Thank you. You gave me just what I needed by listening to me.”

“In that moment, the student realized that becoming a physician means more than arriving at the correct diagnosis and providing appropriate treatment – that there is a human, healing side to medicine as well,” said Rabbi Samuel Karff, coordinator of the Health and Human Spirit Program.

Helping students to realize this human side of medicine is the goal of the humanism program, which is presented in all four years of The University of Texas Medical School at Houston curriculum.

“One is changed by going to medical school, from one probably with few, if any, care-taking responsibilities, to one who has to learn not only technical skills but values. These values allow one to be granted the privilege of being admitted to the private world of the patient and making interventions that may hurt on the way to healing that person,” said Stanley Reiser M.D., Ph.D., holder of the Griff T. Ross Professorship in Humanities and Technology in Health Care. “Our medical education emphasizes certain values that may not have been so critically applied in the life of the student before.”

Over the last 15 years, the humanism program at the Medical School has developed three value-laden areas: health and the human spirit, medical ethics and history, and health care and the arts. This nontechnical side of medical education aims at helping students remain connected to the caring and healing aspects of their chosen vocation and teaches them how to translate these ideals into their professional lives.

“All medical schools now have ethics programs and a number have history courses, but very few have a serious program in health care in the arts as we do,” Dr. Reiser said.

Medical humanities have their roots in humanism, which relates to the set of ideals and values that define people. Most people think of humanities as relating to a liberal arts degree, but they also serve an important role in medical education, Dr. Reiser said.

“Patients benefit from physicians who understand there are two parts to medicine: one, the how of medicine involves technical learning, but if that were the only feature of a doctor’s knowledge, the doctor would not do well because the second part is why and when to do something,” Dr. Reiser said. “Humanities complement the technical education given at medical school – and is essential for becoming a complete doctor.”

Medical ethics and history

The medical ethics component of the humanism program focuses on the doctor-patient relationship as well as the physician’s relationship to society and colleagues. “Medical ethics can guide us in making proper use of physical and technical aspects of doctoring and are also important in self-development,” Dr. Reiser said.

Ethics courses are required throughout the medical student’s education and also are featured in problem-based learning sessions – where small groups discuss the cases of former patients – and in ethics rounds in some of the clinical specialties.

“An intense exposure of students to medical ethics has never been more important” said Stanley Schultz, M.D., dean of the Medical School, professor of Integrative Biology and Pharmacology, and holder of the Fondren Family Chair in Cellular Signaling. “During the past 50 years there has been an explosive increase in biomedical knowledge, and technology that has increased the physicians’ ability to understand, diagnose, treat, manage, and cure disease. But all of these advances for the good are accompanied by the potential to do harm.

“The ability to sustain life at both ends of the spectrum from the premature infant to the nonagenarian and beyond, genetic typing, genetic engineering, sperm cell research, and cloning, just for examples, have raised ethics questions undreamed of not many years ago. Physicians will be expected to play a role in resolving many of these issues.”

The physician’s principle of “do no harm” often comes into play when students tackle ethical issues. “Many misunderstand the do not harm ethic,” Dr. Reiser said. “We teach the students that this is not to be taken literally because there are very few things you can do that ‘do no harm.’ This ideal is a challenge to every doctor to practice in a way that minimizes the chance of harm. To do no harm is avoid preventable risks.”

A blue-book credit ethics series open to the medical school community has featured speakers addressing such topics as stem cell research and medical research in Nazi Germany.

The Medical School also offers a medical history series each year, with Medical School faculty and outside speakers addressing medicine’s past and its bearing on the present and the future.

“Studying medical history helps us understand from previous generations the rationale for doing and not doing certain things, and seeing that our work in medicine is connected to that of our predecessors, who have developed traditions and ideas that make us who we are,” Dr. Reiser explained.

Health and human spirit

The idea of “human spirit” in the Medical School’s curriculum focuses on human values and innermost feelings – be they religious or secular.

“We define spirit as a person’s innerworld of passion, belief, and meaning – something to live for even in the face of serious illness. The human spirit drives meaning, which drives the will to live” said Karff, who has coordinated the Health and Human Spirit Program for the last four years.

The spirit aspect of the program also teaches future physicians how to understand and relate to the patient as a whole.

“We are teaching students that there is a person in the patient and that they are not just a member of a disease category. We are trying to help them connect with the patient by finding out how the disease is affecting patients and their spirit,” Dr. Reiser said.

“We teach students that at times they may need to heal the spirit as part of healing the body,” said Karff, who is retired from the congregation Beth Israel of Houston.

The Health and Human Spirit Program is presented to the first-year students through the “Introduction to Clinical Medicine” course and gross anatomy lab, where a film by Tom Cole, Ph.D., shows how medical students respond to human dissection.

“We use the film as a metaphor of engagement and detachment. We’re tilted too much toward detachment in medicine today and we need to restore the balance,” Karff explained.

There is a series of electives for first- and second-year students that promote the importance of listening, observing, and caring for the patients.

In the “Kinder, Better Doctors” elective, students work with families in the critical care and LifeFlight waiting rooms of Memorial Hermann Hospital.

“We are there six weeks, so we have the opportunity to bond with the families and follow their progression through the hospital,” said Lynn Cutrer, manager of patient and community relations, who teaches the course.

Here the students receive hands-on training on how to listen, how to thoughtfully deliver bad news, how to express compassion, how to maintain hope, and how important it is not to overlook the family while caring for the patient.

“They get a very clear picture of what families go through when they have a very sick loved one,” Cutrer said. “And we teach them that as physicians, when treatment options are exhausted, they cannot abandon the patient.”

The third year provides the most intensive immersion into the Health and Human Spirit Program, which is an integral part of all rotations. “We have a one-hour discussion with the rotation leader and myself on the spiritual aspect of being a physician,” Karff said. “We use actual cases from last year’s third-year class and talk about them. The cases don’t focus on the biomedicine but on the physician as a healer of the spirit.”

In the third and fourth years there is the Essentials of Medicine clinical elective led by Judianne Kellaway, M.D., associate professor in the Department of Ophthalmology, who has been very committed to the Health and Human Spirit Program since its start, Karff said. The course focuses on such topics as teamwork, breaking bad news to patients, and empathy.

“These elements are essential for physicians to master since they will use them daily when in clinical practice,” Dr. Kellaway said. “While it is never easy to break bad news to a patient, it is important for our students to have the experience of role playing and practicing and discussing these topics in small groups.”

Dr. Kellaway said the students’ connection to the vocation of medicine and to the caring of patients actually begins and is evident before they are accepted to medical school

“That’s why we interview more than any school in Texas and maybe the nation, because the person behind the paper is so important. The MCAT (Medical College Admission Test) scores and GPA don’t reveal the heart, the calling, and the dedication to service,” Dr. Kellaway said. “In our first session of the course we look at the personal statements from their medical school applications, and for the vast majority, that human connection is very apparent.”

Through such exercises as creating a physicians code and writing down their medical principles, Dr. Kellaway said she hopes students will not forget about these ideas once they graduate from medical school.

“We review our commitment to medicine and write a code that is placed in a sealed envelope. I want them to review it again after they finish their residencies to see what was important to them as doctors in training,” Dr. Kellaway said.

Health care and the arts

Although at first glance they may seem mismatched, the marriage between medicine and poetry isn’t an odd pair, Dr. Reiser said.

“Appreciating poetry is important to a doctor. The poet uses language to describe emotions – and doctors do that every day,” he said. “Doctors listen to patients and they gain insights from words, pauses, and silence. Poetry can profoundly help doctors become better at their craft.”

The Health Care in the Arts lecture series is held in alternating years at the UT School of Public Health and the Medical School. A UT Committee that decides the curriculum and speakers has representation from Rice University and the University of Houston.

“These other institutions have great music schools and literature departments and so forth, and we rely upon their cooperation to bring this program together,” Dr. Reiser said.

The program brings in speakers, musicians, and actors who reveal the relationship of the arts and medicine. For the last four years, visiting professor Megan Cole, who starred in the play “Wit” and has appeared on television in such shows as “ER” and “Judging Amy,” has shared her gift of acting and speaking with medical students, showing them how to talk, listen, and relate to their patients. Most recently she presented a course on empathy in medicine, and this spring she introduced a new course on medicine and literature.

“Megan brings to us a unique perspective rarely if ever heard at an academic health center -- how actors get inside the characters they play,” Dr. Reiser said. “With the examination of literature and the arts, we see how creative people explore the meaning of life and human existence. This can help us to appreciate the effects we have as doctors.”

First- and second-year students get a chance to enhance their observational skills by observing works of art at the Museum of Fine Arts, Houston, through the elective “Art of Observation.” Developed by Glenn McDonald, M.D., assistant professor of renal diseases and hypertension, the class uses portrait art and medical photographs to emphasize basic physical diagnostic skills.

“Students need to realize that no matter how helpful technology has become, it is no match for a good set of eyes and a brain,” Dr. McDonald said.

Preserving the human connections

“Physicians cannot begin to heal others until they, themselves, are healed,” said Jose Bayona, M.D., M.P.H., assistant professor in the Department of Family Practice and Community Medicine and director of the first- and second-year elective “Healer’s Art.”

Created by Rachel Naomi Remen, M.D., of the University of California San Francisco School of Medicine, “Healer’s Art” helps students and faculty understand the importance of preserving and strengthening their humanity, their sense of caring for themselves and others, and reassuring open-heartedness in their work.

Through five sessions in an off-campus location, Dr. Bayona and co-course director Cutrer, along with a diverse group of faculty and students, discuss retaining one’s humanity as a physician, the awe and appreciation of medicine, and loss and grief.

“As physicians, we are busy fixing things and lose contact of the richness of others and the beauty of the moment. This course seeks to demystify what happens in the health-care environment and teaches us to be more aware of those special moments in our own practice,” Dr. Bayona said. “It helps them to value and preserve the human dimension in health care.”

Translating that value to actual clinical care is the biggest challenge, Dr. Kellaway said.

“You take a clinical environment that is stressful and tiring and has a lot of interplay with differing personalities, and sometimes these humanistic ideals fall off the priority list,” she said. “We help the students in their clinical years retain that priority while still taking good care of the patients and being a good member of a good team. The humanism training gives them the tools to better handle these stresses and stay true to their role as a healing physician.”

The medical humanities will have a more solid footing in the Medical School’s curriculum and in future students’ education thanks to the creation of the new Center for Health, Humanities, and the Human Spirit (see sidebar at right).

“This strengthened stance will help us to teach that in order to be a first rate physician you have to master the biomedicine -- and we are grateful for high-tech medicine.

But, that is not enough! The great physician is not only a first-rate clinician but a healer as well,” Karff said.