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| INVITED EDITORIAL |
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| Year : 2016 | Volume
: 4
| Issue : 2 | Page : 166-168 |
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Medical humanities in medical schools in India
Pathiyil Ravi Shankar
Department of Medical Education, Xavier University School of Medicine, Oranjestad, Aruba
| Date of Web Publication | 20-Dec-2016 |
Correspondence Address:
Pathiyil Ravi Shankar
Xavier University School of Medicine, Santa Helenastraat #23, Oranjestad
Aruba
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2321-4848.196191
How to cite this article:
Shankar PR. Medical humanities in medical schools in India. Arch Med Health Sci 2016;4:166-8 |
Scholars do not agree on a common definition of the medical humanities (MH). Dr. Deborah Kirklin from the United Kingdom (UK), an international authority on the subject describes MH as an international and interdisciplinary endeavor that utilizes the creative and intellectual strengths of disciplines traditionally known as the humanities to pursue specific goals in medical or health professions education.[1] In recent years, MH programs have been initiated in many developing countries ranging from Turkey, the Middle East, and South East Asia. In India, Dr. Satendra Singh and colleagues at the University College of Medical Sciences, New Delhi, India are initiating a number of initiatives in MH.[2] There is interest in MH at the Seth Gordhandas Sunderdas (GS) Medical College in Mumbai, Maharashtra, India and at the PSG Institute of Medical Sciences and Research (PSGIMSR) in Coimbatore, Tamil Nadu, India among various institutions. The Centre for Community Dialogue and Change (CCDC, www.ccdc.in) conducts workshops on theatre of the oppressed (TO) in various institutions and has done pioneering work in popularizing TO among educators in India.[3]
| Medical Humanities | |  |
A voluntary MH module had been conducted at Pokhara in Nepal.[4] In addition, modules have been conducted at KIST Medical College in Lalitpur, Nepal for some years.[5],[6] With the increasing number of faculty pursuing courses in medical education in India there is a favorable climate toward the introduction of MH in Indian medical schools. Educators are increasingly recognizing the importance of creating empathetic doctors. MH is a broad area and various institutions around the world have pursued different approaches to MH. There are certain common characteristics of MH modules that have been mentioned previously.[5],[6] Most modules use small groups, active learning strategies, reflection, narratives, creative writing, paintings, and photography. MH developed in the 1970s predominantly in the United States (US) in recognition of and to counter the increasingly dominant role of science in the medical curriculum and the decreased emphasis on the art of medicine. Europe, Argentina, Israel, Australia, and New Zealand were additionally the pioneers in introducing the discipline.
| Mh as a Discipline | | |
MH at present, is not a specialization or subject of study for medical school faculty and there is a lack of faculty trained in MH unlike for many other specializations. This means that MH in most institutions is driven by the creative energy and enthusiasm of faculty interested in the subject. In the West, degree programs in MH are offered and there are faculty from the humanities employed in medical schools. In India, there has traditionally been a divide between medicine and the humanities that can be difficult to bridge. Additionally, at present, teachers with a humanities background are not employed in medical colleges. Not having enough motivated faculty could be a challenge in both initiating and expanding MH. School managements and the academic leadership will have to identify interested faculty, workout issues of compensation and formulate policies to ensure that they remain motivated. MH has been characterized by its “fun” nature and provides students with an environment to deal with stress and grow as individuals and practitioners.[5],[6] A rigid centrally imposed curriculum may compromise the “fun” nature of MH. Accrediting agencies can develop a set of competencies to be achieved and provide individual colleges and/or universities the freedom to develop strategies on how to achieve these. With the increasing body of educators this can be a suitable option though it may entail more flexible criteria and accreditation guidelines in India.
| Mh as Expressive of Local Culture | | |
A recent article mentions that MH may be expressive of Western culture and has been limited by a scholarly and pedagogical emphasis on Western cultural artefacts.[7] Additionally, in India and many other countries including Nepal, medical education is imparted in English. This creates both advantages and challenges that have been mentioned previously.[8] India has a rich cultural tradition and a number of languages. As MH develops it is important to ensure that local traditions and voices are represented. The patient voice should be heard and the discourse of medicine should not be limited to the educated English speaking elite. At the same time, as India has a multiplicity of languages, the use of the “mother tongue” should not result in students from other Indian states feeling left out and discriminated against.
| Health for All | | |
Modern medicine is increasingly being dominated by technology and is becoming expensive and dominated by large corporations. Despite improvements in many areas, India contributes disproportionately to the global burden of disease and a recent article advocates a radical restructuring of the healthcare system and an explicit acknowledgement by the government and civil society of healthcare as a public good if universal access is to be achieved.[9] Issues of health economics, health advocacy, and ensuring universal access could be an important part of MH modules.
| Introducing a Mh Module | | |
MH courses have been conducted at different years during the medical course at various institutions. In India, some issues related to MH are being addressed during the recently introduced foundation course. Some Indian educators have opined that the first year may not be a good time to initiate a MH module as students are still adjusting to a new environment. A few sessions during the clinical years or at the start of internship can reinforce the concepts. In offshore, Caribbean medical schools having sessions during the clinical years is difficult as students complete their clinical rotations in the US and Canada. The first challenge for a faculty member interested in starting a MH module would be to linkup with likeminded faculty and obtain the support and endorsement of the administration and the educational leadership.
| Evidence-Based Medicine | | |
Modern medicine increasingly relies on an evidence-based paradigm and on randomized clinical trials (RCTs) as the gold standard of evidence. Many authorities are beginning to highlight the limits of RCTs and of the value of the evidence obtained from RCTs in the care of individual patients. In a chapter titled “Shaky evidence” in his book The midnight meal, a pioneer in the field of MH in the US, Dr Jerome Lowenstein addresses the limitations of evidence obtained using RCTs.[10] RCTs are conducted among a limited number of individuals who meet strict inclusion, exclusion criteria, and who are not on other medications and do not have comorbid conditions. Women and children are often excluded from RCTs. Extrapolating the results to the world of clinical practice may be difficult. The influence of the pharmaceutical industry on clinical trials is strong. Additionally, trials showing negative or equivocal results are less likely to be published than those with positive results.
| Narrative Writing | | |
Narrative and reflective writing has been widely used in MH. In a recent article, three pedagogical pillars that educators can use to help learners engage more fully with narrative, develop critical awareness of narratives, and feel more at home in the health humanities have been suggested.[11] Narrative humility (an awareness of one's prejudices, and expectations), engaged pedagogy (the protection of students' wellbeing) and structural competency (attention to sources of power and privilege) have been mentioned. India has a rich storytelling tradition and narrative writing and reflective writing should be widely used in the medical curriculum. Students should get the opportunity to write about and reflect on their different experiences both inside and outside medical school.
| Art Appreciation | | |
Art appreciation sessions have been used in MH modules in many countries. These sessions have been shown to improve visual diagnostic skills among students. Art appreciation could be used as well in MH sessions in India and increasingly, paintings and artworks are available online. In India, traditionally paintings and artworks have concentrated on religious themes but there is plenty of contemporary art dealing with various secular topics.
| Possible Topics | | |
At the Xavier University School of Medicine in Aruba, the topics addressed during the MH module are empathy, what it means to be sick, the patient, the patient–doctor relationship, and the medical student.[12] The sessions are activity-based and case scenarios, role-plays, debates, literature, and paintings are used to explore various aspects of MH. In the West, with large immigrant populations there is an emphasis on dealing with diverse populations. Death and dying could be an important topic for MH. During the latest MH module at Aruba, a session on death and dying was conducted. The traditional Vedic philosophy of Ancient India had dealt extensively with death and dying and how to prepare oneself for death. A challenge in modern secular times will be the fact that for many individuals death and dying are inextricably linked with religion.
| Possible Advantages of Mh | | |
Modern medical education is dominated by the sciences. MH can offer the contrasting and yet complementary perspective of the arts in the education of future doctors. Literature can provide students with insights into shared human experiences and can enrich language and thought.[13] Young medical students have limited life experiences and literature can introduce them to unfamiliar life situations.[14] MH can offer students an opportunity to meet and interact with students from other disciplines and can broaden the view of medical students. MH can demand an emotional response from participants and help them better understand patient stories. Critical appreciation of fine arts and paintings can strengthen the visual observation skills of medical students.[15] Many other potential advantages of MH have been mentioned in the literature. Studies have attempted to evaluate the short and medium-term impact of MH. Measuring the long term impact of MH is challenging and may be difficult. The author of a recent article mentions that it may be akin to measuring the immeasurable.[16] There are substantial differences in the nature of the studies, interventions, and the target population.
| Moving Forward | | |
The way forward for a large and diverse country such as India is to empower universities to provide broad guidelines for MH sessions considering the local linguistic and cultural mores. In India, especially in the field of medical education, the universities have seen some of their power and influence reduce. Additionally, in India there is a trend toward specialized medical universities. This may have many advantages but with regard to MH it may result in reduced interaction between medical and humanities educators and problems with interdisciplinary education. Slowly, there is increased activity in the field of MH in the country. There is a sense of cautious optimism that medical educators and curriculum planners will be able to soon introduce MH sessions in a good number of medical schools.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Kirklin D. The Centre for Medical Humanities, Royal Free and University College Medical School, London. Acad Med 2003;78:1048-53.  |
| 2. | Singh S. Multiple ingredients and not just spoonful of humanities. Urol Ann 2014;6:180. [ PUBMED]  |
| 3. | Singh S, Khosla J, Sridhar S. Exploring medical humanities through theatre of the oppressed. Indian J Psychiatry 2012;54:296-7. [ PUBMED] |
| 4. | Shankar PR. A voluntary medical humanities module in a medical college in Western Nepal: Participant feedback. Teach Learn Med 2009;21:248-53. |
| 5. | Shankar PR. Developing and sustaining a medical humanities program at KIST Medical College, Nepal. Indian J Med Ethics 2013;10:51-3. |
| 6. | Shankar PR, Piryani RM. Taking medical humanities forward. J Educ Eval Health Prof 2011;8:7. |
| 7. | Hooker C, Noonan E. Medical humanities as expressive of Western culture. Med Humanit 2011;37:79-84. |
| 8. | Shankar PR, Piryani RM. English as the Language of Medical Humanities Learning in Nepal: Our Experiences. The Literature, Art and Medicine Blog. Available from: http://medhum.med.nyu.edu/blog/?p=175. [Last accessed on 2016 Jan 25]. |
| 9. | Patel V, Parikh R, Nandraj S, Balasubramaniam P, Narayan K, Paul VK, et al. Assuring health coverage for all in India. Lancet 2015;386:2422-35. |
| 10. | Lowenstein J. Shaky evidence. In: Lowenstein J, editor. The Midnight Meal. Ann Arbor: The University of Michigan Press; 2008. p. 90-6. |
| 11. | Tsevat RK, Sinha AA, Gutierrez KJ, DasGupta S. Bringing home the health humanities: Narrative humility, structural competency, and engaged pedagogy. Acad Med 2015; 90:1462-5. |
| 12. | Shankar PR, Rose C, Toor A. Student feedback about the medical humanities module in a Caribbean medical school. Education in Medicine Journal 2016;8:41-53. |
| 13. | Scott PA. The relationship between the arts and medicine. Med Humanit 2000;26:3-8. |
| 14. | Macnaughton J. The humanities in medicine: Context, outcomes and structures. Med Humanit 2000;26:23-30. |
| 15. | Wellbery C, McAteer RA. The art of observation: A pedagogical framework. Acad Med 2015;90:1624-30. |
| 16. | Bleakley A. Seven types of ambiguity in evaluating the impact of humanities provision in undergraduate medicine curricula. J Med Humanit 2015;36:337-57. |
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