Nusrat Shah  ( Dow University of Health Sciences, Karachi, Pakistan. )
Syed Moyn Aly  ( Department of Medical Education, College of Medicine, Taif University, Saudi Arabia. )

The purpose of this position paper is to start a debate on the need for including Medical Humanities (MH) in the undergraduate medical curriculum of Pakistan and to guide decision making in this regard.


Introduction

Fifty years ago, C.P.Snow, a scientist and a writer, first started the debate on whether medicine is a science or an art, or both? He asserted that society cannot progress unless the two cultures of science and humanities are brought together.¹ Another great educationist, Abraham Flexner, the man who reformed medical education in the United States of America (USA) hundred years ago, said, a professional physician is one who treats not just the illness, but cares for the whole human being. He recommended that physicians must be trained as scientists as well as humanists.²
As healthcare becomes more and more complex due to commercialization, patient consumerism, advances in information technology, vast amount of medical knowledge and litigation, public\'s expectations from the medical profession are rising. They now demand that physicians be not only medical experts but also communicators, collaborators, managers, health advocates, scholars and professionals. Providing ethical and humane care is central to all these roles of medical profession.³ Therefore, integrating Medical Humanities (MH) in medical curriculum can help to develop more compassionate, humane and professional physicians, thus leading to better health outcomes for patients.⁴

The challenge of Medical Education in Pakistan

Medical students in Pakistan are disillusioned with their profession and harbour feelings of uncertainty, anxiety and doubt about their future roles and responsibilities. Our graduates lack motivation and commitment towards the practice of medicine. One reason for this may be that our medical curriculum lays an overwhelming emphasis on competencies related to biomedical sciences, is not context based and does not educate students in professionalism and communication skills, competencies which can help them deal with real life problems of our patients. As a consequence, our people have more faith in homeopaths, hakeems, unani (Greek) medical practitioners, spiritual healers and quacks, than in doctors. This scenario calls for some drastic reforms in our medical curriculum.^5-7
The system of medical education in Pakistan follows that of UK where students go directly from secondary school into medical school. Once in medical school, students\' learn only what is specific to their training as a doctor. On the other hand, students in USA complete a four year Bachelor\'s degree first, where they take mandatory courses in humanities and liberal arts such as language, history, literature, drama, music and philosophy which may help to increase their intellectual breadth. In addition, humanities has been a part of medical curriculum in USA for the last thirty years (since 1960s and 70s) whereas UK only incorporated it in 1990s and 2000s. Including liberal arts and humanities courses in our medical curriculum can help in developing a more humane and professional attitude, which will hugely benefit our medical graduates and consequently our patients and the society as a whole.^8,9

Defining Medical Humanities

The term medical humanities can be defined as an interdisciplinary field including literature, history, philosophy, anthropology, art, drama, film, music and dance, being applied to achieve the goals of medical education. The word humanities comes from humanism which can be defined as an attitude towards other people or generally "love of mankind" and a study of medical humanities gives us the knowledge and skills to develop this attitude. It is more precisely a depth of understanding rather than a particular content of knowledge and aims to produce physicians who will honour the dignity and humanity of their patients and colleagues as fellow human beings.^10,11
In other words, MH concerns the human side of medicine, and links the interdisciplinary enquiry with the practice of medicine, medical education and research. Furthermore, MH combines medicine with understanding of human thinking, emotions, expression, imagination, language and culture.¹² It consists of humanities (philosophy, ethics, history and theology) and arts (literature, theatre, cinema, music and visual arts), integrated in the medical curriculum.¹³
Arguments supporting incorporation of Medical Humanities in the Medical Curriculum

Relevance, practicality and importance:

The General Medical Council in Tomorrow\'s Doctors has recognized the need to bring about a radical change in undergraduate medical education. It stresses upon education of future doctors, rather than training. The good doctor is required to maintain an attitude appropriate to a high level of professional practice, which includes a blend of scientific and humanitarian approaches in order to think critically, be open-minded, be compassionate and have concern for the dignity of patients and their families.¹⁴ Various disciplines of MH can help in developing these humanitarian values and a reflective attitude towards life and self.
Art and literature can teach future doctors to guard against treating people like objects and incorporates the right values in them. Learning a new language can help bridge the cultural differences, making doctors more aware of the traditional norms.¹⁵ Literature, painting and other visual arts can help learners be more imaginative, creative, self-aware and compassionate.¹⁶
Performing arts and drama can be used effectively to help students explore their own and others\' values, beliefs and behaviours. The following two examples of devised theatrical performances can illustrate how student\'s perceptions about their subjects can change. Both these performances included narration, poetry, music, dance and movement.⁷
One of these projects was called "Dead Man Talking" and was about body donation. Its evaluations showed that most of the students were forced to think about the generosity of the person who donated his body to science for dissection, and that why would somebody do that and whether they themselves would be able to do that.⁷
The second project called "Perfect" was about reproductive issues including cloning, in-vitro fertilization, abortion, adoption, genetic identity, parenting, and rights of children. The evaluations showed that students were able to explore their own and others perspectives on various reproductive issues and how it would influence their interactions with patients. One student remarked, "Now I see how creativity can be used to solve problems…I was able to understand that others have opinions different to my own and see their reasoning is valid also". Another student observed, "I learnt to see medicine in a different perspective, not only in text books but in plays and in poems and other literature."⁷
This innovative learning opportunity seems to foster communication, cross-disciplinary collaboration, adapting to new ways of learning and to work flexibly within a group. This could go a long way to promote development of reflective and well-rounded professionals.⁷
Shapiro and Hunt have also shown how illness-related theatrical performances deeply influence student learning. Two theatre shows addressing HIV-AIDS and ovarian cancer were presented to an audience of 150 medical students, faculty, community doctors and patients. Evaluations showed students felt better understanding of these illnesses, greater empathy for the patients and new insights in patient care issues.¹⁷
The study of history can remind students about the transient nature of medical knowledge and about how important it is to keep up to date with new research. Philosophy can promote organization of thought process, constructing an argument and ultimately reaching a logical conclusion. These skills can help students develop critical thinking, clinical reasoning and evaluation of patient information to reach a correct diagnosis.¹⁸

MH and Professionalism

Teaching of MH is very much relevant to developing medical professionalism since self-awareness, critical self-analysis, understanding of other peoples\' feelings and life experiences, recognition of multiple perspectives, and tolerance of ambiguity is a goal common to both. MH can play an important role in teaching "narrativity" which is the ability to acknowledge, understand, interpret and act on other peoples\' stories. Students can write their patients\' stories or write about their own personal experiences with patients, families, colleagues and teachers.¹⁹
Arguments against incorporating Medical Humanities in the Medical Curriculum
There are several critiques to the teaching of humanities. Many students complain it is boring, impractical and irrelevant. Some think it may be relaxing and enjoyable but not important for their education. Others say it should be offered as electives, so that students who are not interested should be relieved. Still others object that since humanities teachers are not doctors, they cannot train students in relevant clinical skills. In addition, students have been known to feel threatened and uncomfortable when asked to reflect on and share their values and attitudes about poems, stories or music.¹⁹
MH has also been criticized for involving too much time and the content being too overwhelming. Similarly, placement of humanities within an already overcrowded curriculum is a controversial issue. Moreover, some people think that if bioethics is a part of curriculum, that should be enough substitute for humanities.^19,20
However, the main critique of humanities in medical education is a lack of evidence about its effectiveness in producing more humane and empathic doctors.²¹

Will MH overburden the curriculum?

The argument about burdening the already overcrowded curriculum can be countered by the fact that study of humanities is usually pleasurable and may serve as a good break from the routine laboratory and clinical work. Students can use this time to develop creativity, imagination, self-awareness and empathy and also to relax, have fun, and thus counter the burnout.¹³

MH and Bioethics

Bioethics has evolved into a scientific field which is dominated by rules and focuses on abstract principles, whereas, MH has a more humanistic approach of looking at the world. Literature, drama and poetry encourage students to realize how their emotions can help them to be more empathetic, and thus be good healers and better individuals. MH also motivates students to consider important questions which give them a broad cultural and emotional outlook about their profession, e.g. where do they fit in their profession? How do art and science overlap in patient care? What is the role of language, culture and historical practices in healthcare? How do different people experience the same illness? Therefore, while both are valuable, one cannot be substituted for the other.²⁰

Evidence of effectiveness of MH

A literature review by Jacob and Helle showed a vast number of studies (224 out of 245) either praised or provided short-term beneficial effects of humanities on medical education. However, only 9 studies provided evidence of long-term impact on future doctors\' knowledge, attitudes and behaviors towards real patients.²¹
This lack of evidence on long-term outcomes may be due to the methodological difficulties in conducting such studies. Furthermore, some people think the impact of humanities is not worth investigating because unlike scientific fields which can be tested and proved, effects of social sciences like humanities are not measurable.²¹

Teaching Medical Humanities

Types of MH courses

MH can be taught in the form of elective or voluntary courses, compulsory courses, or as special study modules along with the core curriculum. The advantage of special study modules is that they are freely chosen by students, are regarded as an integral part of their degree, and are a part of student assessment.¹⁸
Teaching MH as elective courses has been criticized on the basis that it may be considered as an add-on or an optional activity which is separate from the core curriculum, and may give an "irrelevant" feel to the students. Therefore, it has been suggested that MH should be integrated with the entire core curriculum (alongside both basic and clinical sciences), so as to bridge the gap between the science and art of medicine.¹⁹

Who should teach MH?

Medical humanities can be taught by physicians belonging to community health sciences and preventive medicine and other interested physicians who should first receive training in humanities disciplines. Apart from full time faculty, part time faculty of non-physician experts in humanities disciplines can be hired from other universities.²²

How to teach MH?

MH can be taught in small group discussions, faculty and guest lectures, clinical case presentations, literary readings, essay assignments, videos, documentary films, self-study, drama, art exhibitions, street plays, ward rounds, seminars, case conferences, student-patient interviews and offering electives in their fields of special interests.^22,23

Assessment and evaluation of MH

Assessment of MH can be done in the form of a class essay on a topic which has been discussed or about a book on literature or philosophy, which has been read by students. Students can be asked to justify, criticize or debate the topic. In addition, analytical exercises can be given at the beginning and at the end of a course, to see whether their analytical skills have improved or not.  These exercises can be in the form of two paragraphs of contrasting arguments and the students can be asked to identify the arguments and suggest whether they were valid or not.¹⁸
Evaluation of MH courses can be done by means of a questionnaire which asks students about what they thought of the structure, content and educational value of the course. Secondly, the two analytical exercises done at the beginning and end of course can be compared to assess the degree of improvement of analytical skills.¹⁸


Conclusion

Medical education in Pakistan is only focused on giving scientific knowledge and skills to medical students. However, by following this approach we are not achieving our objective of producing professional and humane doctors. Our curriculum needs a radical reform to produce "good doctors" who, in addition to having scientific knowledge, are sensitive and humane enough to honor the dignity of the patients and understand the context of their patients\' problems. This will promote mutual respect, understanding and good clinical decision making which is more likely to satisfy and benefit the patients and ultimately the society.
As Bates has highlighted "The task and the dignity of human being consist in the individual\'s willingness to live up to an ideal, as well as to be of help to others".¹¹

1. Snow CP. The Two Cultures and the Scientific Revolution. Cambridge, UK: Cambridge University Press;1960
2. Doukas DJ, McCullough LB, Wear S. Reforming Medical Education in Ethics and Humanities by Finding Common Ground With Abraham Flexner. Acad Med 2010;85:318-23
3. Frank,JR. (Ed). The CanMEDS 2005 physician competency framework. Better standards.Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2005
4. Hooker C. The medical humanities-a brief introduction. Aust Fam Physicians 2008; 37: 369-70
5. Minai FN. Professionalism in residency training. J Coll Physicians Surg Pak 2009; 19: 675-7
6. Ramaswamy R. Embracing the unknown: introducing medical humanities into the undergraduate medical curriculum in India. Indian J Med Ethics 2012;9:174-6
7. Shaikh A, Humayun N. Medical Ethics in Undergraduate Medical Education in Pakistan: Towards a Curricular Change. In Contemporary issues in Bioethics. [Online] [cited 2014 Oct 14].Available from: URL: http://cdn.intechopen.com/pdfs-wm/31748.pdf
8. Greaves D, Evans M. Medical humanities. Editorial-J Med Ethics: Medical Humanities 2000;26:1-2
9. McCullough M. Bringing drama into medical education. Lancet 2012; 379: 512-3
10. Kirklin D. The Centre for Medical Humanities, Royal Free and University College Medical School, London, England. Acad Med 2003; 78:1048-53
11. Bates DG. Humanism in undergraduate medical education. Can Med Assoc J 1971;105: 258
12. Hurwitz B, Dakin P. Welcome developments in UK medical humanities. J R Soc Med 2009;102: 84-5
13. Batistatou A, Doulis EA, Tiniakos D, Anogiannaki A, Charalabopoulos K. The introduction of medical humanities in the undergraduate curriculum of Greek medical schools: Challenge and necessity. Hippokratia 2010; 14: 241-3
14. General Medical Council. Tomorrow\'s doctors: recommendations on undergraduate medical education. London: GMC, 1993
15. Naqvi HA, Hussain A. Medical education: value base teaching. J Pak Med Assocc 2011; 61:1027-8
16. Shapiro J, Rucker L. Can Poetry Make better Doctors? Teaching the Humanities and Arts to Medical Students and Residents at the University of California, Irvine, College of Medicine. Acad Med 2003; 78: 953-7
17. Shapiro J, Hunt L. All the world\'s a stage: the use of theatrical performance in medical education. Med Educ 2003; 37:922-7
18. Macnaughton J. The humanities in medical education: context, outcomes and structures. Med Humanities 2000; 26: 23-30
19. Shapiro J, Coulehan J, Wear D, Montello M. Medical Humanities and Their Discontents: Definitions, Critiques, and Implications. Acad Med 2009; 84: 192-8
20. Friedman LD. The precarious position of the medical humanities in the medical school curriculum. Acad Med 2002; 77: 320-2
21. Jakob O, Helle J. Humanities in Undergraduate Medical Education: A Literature Review. Acad Med 2010; 85: 988-98
22. Jones AH, Carson RA. Medical Humanities at the University of Texas Medical Branch at Galveston. Acad Med 2003;78: 1006-9
23. Gupta R, Singh S, Kotru M. Reaching people through medical humanities: An iniative. J Educ Eval Health Prof 2011; 8: 5.