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 Table of Contents  
MEDICAL EDUCATION
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 112-119

Medical humanities in medical colleges in India: Travellators and speed breakers


IMU Centre for Education, International Medical University, Kuala Lumpur, Malaysia

Date of Submission27-Apr-2020
Date of Decision12-May-2020
Date of Acceptance13-May-2020
Date of Web Publication20-Jun-2020

Correspondence Address:
Dr. Pathiyil Ravi Shankar
IMU Centre for Education, International Medical University, Kuala Lumpur
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_70_20

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  Abstract 


India has the largest number of allopathic medical colleges in the world. Recently, a competency-based undergraduate medical curriculum and an attitude, ethics, and communication skills module have been introduced. Medical humanities (MH) programs are becoming increasingly common globally. MH uses methods from the humanities and are interdisciplinary in nature. In this article, the author discusses different facilitating factors (travellators) and hindering factors (speed breakers) for the introduction of MH in medical colleges in India. Among the travellators are a large body of faculty members with interest and experience in medical education, a favorable attitude toward MH, strengthening of physical and information technology infrastructure in institutions, a diverse and talented student body, use of movies as a stepping stone to MH, many institutions obtaining deemed university status, a talented group of faculties, the positive effect of MH on student well-being, reduced stress and an atmosphere of spirituality, and a sense of purpose. Among the speed breakers are large student numbers, traditional architecture of medical colleges, lack of a separate department of medical education, being affiliated to external universities and challenges in modifying the assessment system, the language of MH sessions, and imbalance in medical education units. The article ends by providing the details for a MH module, a framework for student assessment during the module, and rubrics which can be used/adapted for student assessment and provides a scheme for assessment of the new module within the curriculum. This can be adapted by individual institutions to best suit their circumstances.

Keywords: Health humanities, India, medical colleges, medical humanities


How to cite this article:
Shankar PR. Medical humanities in medical colleges in India: Travellators and speed breakers. Arch Med Health Sci 2020;8:112-9

How to cite this URL:
Shankar PR. Medical humanities in medical colleges in India: Travellators and speed breakers. Arch Med Health Sci [serial online] 2020 [cited 2020 Oct 25];8:112-9. Available from: https://www.amhsjournal.org/text.asp?2020/8/1/112/287369




  Introduction Top


As of early April 2020, there were 535 medical colleges in India which provided undergraduate medical education to about 79,000 students.[1] India has the largest number of allopathic medical schools in the world. Recently, the undergraduate medical curriculum has been revised and a competency-based curriculum has been introduced. An attitude, ethics, and communication (AETCOM) module has been introduced from August 2019.[2] The module uses interactive sessions, small group activities, and case scenarios to discuss among other topics ethical issues and communication skills in medical practice.

Medical humanities (MH) programs are becoming increasingly common all over the world. They use methods, concepts, and content from one or more of the humanities disciplines; employ these methods to create more self-aware and humane practitioners; and are interdisciplinary in nature.[3] Recently, the term “health humanities” has been put forward as being more encompassing and promoting multidisciplinary and interdisciplinary inquiry.[4]

Medical/health humanities have been well established in medical schools in North America, Europe, Australia, and New Zealand, but evidence on the long-term impact of incorporating MH into the medical programs is sparse.[5] An article published in 2012 had examined MH with special reference to Indian medical schools.[6] The purpose, possible methods, and the impact of a curriculum on student learning were briefly examined. The Indian Journal of Medical Ethics had brought out a special issue on MH, and the editor of the special issue had also provided her thoughts about introducing MH in the undergraduate medical curriculum in India.[7] MH has been mentioned as a method of rehumanizing “high tech, no touch” medicine to “high tech, hi-touch” medicine, and the author emphasized cinemeducation and narrative medicine.[8]

The article will be based on a contextual discussion and interaction with medical and health science educators in a selection of medical colleges in India. The author will also draw on the published scientific literature. The article provides an overview of enabling factors (travellators) and hindering factors (speed breakers) with regard to the introduction of MH into the undergraduate medical curriculum in India. One of the limitations of the article will be the lack of hard data in some areas to support the arguments. Medical humanities/Health humanities (MH/HH) is still very much an area of evolution in Indian medical colleges. There are faculty members who are carrying out innovations in the teaching–learning of the discipline but have not yet written and published their findings.

At the end of the article, the author will discuss the framework of a MH module and put forward a framework for assessment. The evaluation of the module will also be briefly discussed. Rubrics for student assessment are also provided. These can be modified by individual institutions to suit their requirements. The author also provides practical ideas for implementation of the module in individual institutions.


  Enabling Factors (Travellators) Top


A large body of faculty with interest and experience in medical education

The Foundation for the Advancement of International Medical Education and Research (FAIMER) has a main institute at Philadelphia in the United States and four regional institutes in India at Mumbai, Ludhiana, Coimbatore, and Manipal. The institutes offer a 2-year part-time fellowship in health professions education and has created a large body of educators in India with knowledge of the latest developments in education and an openness to change. The major lessons learned from the FAIMER institutes were summarized in a recent article.[9] A large number of FAIMER fellows are now in senior positions in institutions. The Medical Council of India has established zonal and nodal centers for faculty development, which has also contributed to the development of medical education. A number of institutes also conduct in-house and regional/national faculty development programs.

Certain institutions due to a variety of reasons were more favorably disposed toward MH/HH, and faculty members are keener to participate in MH sessions. In my opinion, increased number of faculty and academic leaders having higher degrees, diplomas, and fellowships in health professions education could be a contributory factor. Many faculty members may not have been exposed to MH, and the solution would be to expose more and more of them to the discipline. Medical educators with a keen interest in MH/HH shall play an important role in this sensitization.

A favorable attitude toward the medical humanities

The faculty and the educational leadership at many institutions have a positive attitude toward MH. A number of factors may have contributed to this. The exposure to new ideas in medical education is an important factor. The Centre for Community Dialogue and Change, a group based in Bengaluru, conduct “Interactive Theatre workshops for Medical Humanities” at various institutions in the country. They also organize training for the facilitators.[10] Workshops have also been organized during health professions education conferences. The workshops have served as an introduction to MH for many individuals; is enjoyable, creative, and thought provoking; and has played an important role in creating a favorable climate. The introduction of the AETCOM module has underlined the importance of communication skills, attitudes, and ethics and created a strong interest in MH, especially as the module is mandated by the Medical Council of India. Many institutions are also either going for or are already accredited by the National Assessment and Accreditation Council (NAAC). The introduction and development of novel courses and programs is one of the NAAC accreditation criteria, and this has generated interest in MH as a novel course or program.

Strengthening of physical and information technology infrastructure

In recent years, many institutions have invested in physical and information technology infrastructure. Most now have high-speed internet to access various online resources. They have invested in small group learning rooms and areas where small group interactive sessions can be conducted. A number of resources related to MH are available online and have been mentioned in a book chapter.[11] A good internet connection makes it easier for faculty and students to access these resources.

A diverse and talented student body

Many of these institutions attract students from various states in India and from abroad. There is a diverse student body with good language skills, especially in English, which is the language of instruction. Many colleges have a number of student-led clubs and societies such as a drama club, music club, literature club, photography club, dance club, and movie club, which have created a favorable climate for MH to take root and maybe flourish. Strengthening and harnessing the power of these clubs could be a good first step.

Movies as a stepping stone to medical humanities

In a previous article, the use of movies in medical education had been examined in detail.[12] India produces over 2000 movies in various languages every year.[13] Due to the familiarity with English, Hollywood and other English movies are also popular. Many faculty members have been using clips from movies during their educational sessions. On an occasion, complete movies have been screened followed by an activity of individual reflection. Movie clips are also being used during faculty development programs. Movie clubs in colleges also screen movies and support this activity.

Deemed university status

Many institutions have obtained deemed university status, which provides them with greater freedom and flexibility to design and implement teaching programs and modify assessment systems. This can provide a fillip to introduce the small group learning methods and “new” assessment methods best suited for MH. Many universities have a favorable attitude toward innovation, and decision-making can be quicker.

A talented group of faculties

Faculty members have interests outside medicine. This ranged from music, singing, painting, dance, photography, movies, embroidery, and knitting among others. Many are keen to use their talents to drive a creative MH curriculum forward. Their certificates, fellowships, and degrees in medical education have provided them with the knowledge and skills to design and implement a new module.

An atmosphere of spirituality and a sense of purpose

Some of the institutions were founded by religious leaders or religious denominations, while a few others were founded by visionaries who wanted to improve the health and educational status of their regions. The original sense of purpose is still present in many of these institutions and could support the development of MH, which encourages holistic development of medical students.

Promoting medical student well-being and inculcating professional values

Studies in medical colleges in India have shown high levels of stress among medical students. At a medical college in Odisha, 66.9% of students suffered from anxiety, 53% from stress, and 51.3% from depression, with the incidence being higher among students of higher semesters.[14] A recently published systematic review concluded that the pooled prevalence rate for depression was 39.2%, for anxiety was 34.5%, and for stress was 51.3%.[15] The prevalence was higher among female students. MH has been shown to reduce stress and burnout among medical students. A study conducted at five medical schools found that previous exposure to MH was positively correlated with positive qualities such as empathy, tolerance for ambiguity, wisdom, emotional appraisal, self-efficacy, and spatial skills and negatively correlated with physical fatigue, emotional exhaustion, and cognitive weariness.[16] This has been mentioned as an instrumental use of MH and used by many proponents as an argument toward introducing and strengthening the discipline. Though MH is only now being introduced in Indian medical colleges, evidence from elsewhere supports this use of MH/HH.


  Inhibiting Factors (Speed Breakers) Top


Large student numbers

Most medical colleges now admit a large number of students every year. Most are authorized to admit 150, 200, or even 250 students a year. This has the advantage of strengthening the finances of the institution, but creates a “large” student body which can be difficult to handle. Schools also have good faculty numbers and maintain the mandated faculty student ratio, but the faculty are specialists in different subjects and work in different departments. Inter-departmental collaboration is only now beginning to develop. Lectures continue to dominate as the mode of instruction and lecturing to a large group of 250 students is no easy task. Incorporating small group sessions will be challenging in terms of workforce and resources. The maximum size which can be handled at a time could be fifty students divided into five or six groups, and the batch of 250 will have to be divided into five units. Team-based learning (TBL) is an instructional strategy which can be applied in these settings. TBL uses small-group, activity-based learning in a large class setting and provides students with opportunities to apply their knowledge through a sequence of activities including individual work, team work, and immediate feedback.[17] TBL is cost-effective in terms of the use of highly skilled faculty resources and could play an important role in Indian medical colleges.

Traditional architecture of medical schools

Most medical schools have been constructed in the traditional pattern with large lecture halls and laboratories. Many have large atria and other spaces which are built more to impress and less for the purpose of being utilized as learning or interaction spaces. With a few modifications, many of these could serve as informal learning spaces. Most lecture halls are much longer than wider and have fixed seating. Traditional amphitheater-like seating is also common. As I mentioned before, institutions have invested in creating a few small-group learning spaces, but these may not be enough to meet the requirements of the large student body. In a recent article, the authors mention that in the West, the development of the fundamental physical features of higher education appears to have stopped over 150 years ago.[18] The authors of a recent article develop the concept of a networked learning landscape model considering the shift away from a lecture-based curriculum toward more active and collaborative learning models.[19] Development of collaborative informal and formal learning spaces, multi-use multi-scale spaces, and serviced learning spaces has been recommended. Traditionally, educators have not been involved in the design and maintenance of learning spaces, which should be closely aligned with the curriculum. The educational leadership and faculty should have key inputs in the process of creating and maintaining these spaces.[20] Creating spaces for formal and informal small-group learning and for interdisciplinary and interprofessional collaboration will be a challenge to be addressed in medical colleges in India.

Lack of a separate department of medical education

Recently, all colleges have a medical education unit (MEU) and a curriculum committee as mandated by the Medical Council of India. MEU faculty have multiple responsibilities. They have clinical and teaching duties in their own area of specialization in addition to their MEU responsibilities. Faculty struggle to find time for their medical education responsibilities as their departmental duties get priority. In addition, there may be no scheme to reward faculty members for the additional responsibilities they are undertaking.

Being affiliated to an external university and challenges in changing the assessment system

Most medical colleges in India are affiliated to external universities, and many states have a separate state-wide university for the health sciences. Changing the assessment system (especially summative assessment) is a challenge for most faculty as this is under the purview of the university. Assessment during MH sessions at a medical school in Aruba, Dutch Caribbean, was carried out using a combination of methods; in-session assessment using a structured rubric (50% of total marks); a reflective writing assignment (20% of marks); and on the basis of professional attitudes, empathy, and other skills shown during the interaction with a standardized patient (30% of marks).[21]

The issue of assessment of the humanities, behavioral, and social sciences was addressed at the Lancaster Medical School in the United Kingdom.[22] The authors closely aligned assessment with the problem-based learning curriculum which is followed. The format consists of a scenario and a set of four questions. Answers are in the form of extended short answers and may require one or two paragraphs of free text. These methods are not commonly used in medical schools in India though many faculties are familiar with them and are slowly introducing them especially during internal assessments. The deemed universities have the advantage of greater autonomy over their systems of assessment. These “newer” methods may be faculty and resource intensive and may create more pressure on the system. The AETCOM module recommends the use of some of these methods of assessment.

The language of medical humanities sessions

Due to various reasons especially the British colonial influence, the language of medical instruction continues to be English. English has the advantage in ensuring easier access to resources and literature on the subject, most of which are in English. However, this has the disadvantage of excluding a substantial proportion of the population who may not have enough fluency and knowledge of the language. In Nepal, the sessions were in English but the role-plays were conducted in Nepali. In addition, in India, there are many languages, and students from other states may not be familiar with the local language. MH programs in developing nations have been mentioned as being expressive of western culture.[23] There are a number of reasons behind this. The predominant cultural landscape in the developing “South” has been shaped by the Western culture through music, movies, and the Internet. The language of medical education in most schools is English or some other colonial language. Most students are educated in English-medium schools in India where all subjects are taught in English, while the national and the regional language are taught as second and third languages.

Less role for educators in medical education

A medical education department is recommended to have a mixture of persons from both medical and educational backgrounds. At present, all medical colleges in India have MEUs, but not many have a separate department of medical education. The ideal skill mix includes organizers, thinkers, innovators, and motivators.[24] It may also be necessary to earmark potential candidates from the medical school staff and groom them as educators. In India, with a few exceptions, the units/departments are dominated by medical doctors. Getting a broader mix of general educators, psychologists, and psychometric personnel is important. The nonmedical personnel should have an open attitude and get familiarized with the “language” of medical education as soon as possible. MH may require collaboration with humanities departments and general educators. In India, this involvement is not common. Dr. Ramaswamy and her team are a notable exception and bring a fresh perspective to MH.

[Table 1] mentions possible solutions to these challenges from my perspective. I conclude by putting forward possible suggestions for a MH module in medical colleges in India and also share possible principles to consider while creating an assessment framework. Practical suggestions for implementing the module in individual institutions are also provided. As I had mentioned previously, the actual module should be driven by the creative strengths and enthusiasm of faculty members at respective medical colleges.
Table 1: Possible solutions to the challenges enumerated in the text

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The outline of a medical humanities module for medical colleges in India

Recently, medical colleges in India have switched to a competency-based medical education (CBME). A recent article had examined the prerequisites toward implementing CBME in Indian medical colleges.[25] Trained faculty members, administrative support, and formulation of entrustable professional activities at the subject level were mentioned. I am personally of the opinion that subjects should be learned in an integrated manner, There is a much greater emphasis on the behavioral and social sciences ranging from initiating holistic student development during the foundation course, emphasis on medical ethics, communication skills, reflective writing, team work, professionalism, and early clinical exposure among others. The AETCOM skills module emphasizes the development of correct attitudes, ethical practice, and good communication skills among medical graduates. The module aims to create a proper balance between the five roles of an Indian medical graduate, which are clinician, leader and member of health-care team, communicator, life-long learner, and professional.[2] MH/HH can be offered as a part of the AETCOM module. The discipline can account for a certain percentage of the grade of the AETCOM module (may be 20% or 30%). MH aims to provide students with a perspective on what it means to be a patient, a doctor, a caregiver, and a student of medicine among others using art and literature. Offering the discipline as a part of the AETCOM module may make it easier for curriculum developers to “sell” the humanities to academic leaders and faculty.

Based on my experience in other countries and institutions, a MH module can be offered throughout the undergraduate medical curriculum. These will employ small-group learning methods and be closely integrated with social and behavioral sciences. The maximum student size per session should be around 50, and these students can be divided into five groups of ten students each. There should be a minimum of two faculty facilitators, though three will be better. At the beginning of the second semester, three activity-based sessions, one on empathy, one on the medical student, and the other on the dead teaching the living, can be facilitated. At the beginning of the sixth semester sessions on what it means to be sick, the patient and the patient–doctor relationship will be suitable. At the start of the eighth semester, suitable topics will be abortion, the caregiver, and death and dying. [Table 2] shows the proposed learning objectives of different sessions, which can serve as the basis for faculty members in designing and facilitating their own sessions.
Table 2: Proposed learning objectives of medical humanities sessions

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A detailed learning module can be offered as an “elective” to interested students during the clinical phase of the program. Some initial discussions about this elective and the hands-on and experiential learning it will offer students are ongoing. The elective will, however, not be discussed further in this article.

Student assessment during the module

The three pillars of assessment will be student participation during sessions, the creative/reflective writing assignments, and their interaction with a real/standardized patient. A proposed division of marks has been mentioned previously. I would recommend a similar division to that described in a medical school in Aruba.[21] Students' active participation during the session is important, and they should be able to “put themselves” in the position of different characters during the role-plays and other activities. Each student should have participated in at least two role-plays during the module, and one of this should be a “major character” could be a general rule of thumb for the module. Students should be encouraged to play a role of the opposite gender. The facilitator can maintain a record of student participation. A rubric to gauge student participation during sessions is shown in [Table 3]. The rubric is a compromise between completeness and practicality. It should not be very long, otherwise facilitators will find it difficult to use in practice, but at the same time, it should capture the important aspects of student involvement.
Table 3: Rubric to evaluate student participation during sessions

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Student interaction with a real/standardized patient during an OSCE can be evaluated using a rubric shown in [Table 4]. Reflective and creative writing assignments will form an important part of the module. A framework to grade the assignment is shown in [Table 5].
Table 4: Rubric to evaluate student interaction with a real/standardized patient

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Table 5: Framework to grade reflective/creative writing assignments

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Preparing to offer a module

The first step for the curriculum committee/academic leadership would be to identify an individual who will be the focal point for the module at the institution. This individual should then form a core group of like-minded faculty members who will drive the module forward. It is recommended that at least 40% of the members be clinicians. This group can decide on how to offer MH at the institution. This article provides an outline of the module, the learning objectives for different sessions, and an assessment scheme and rubrics, which can be modified as per the requirements of the institution. The session should be conducted in small groups of not more than fifty students. Each session should be facilitated by at least two (preferably three) facilitators. The facilitators should be trained in small-group facilitation and it will be nice if they have an interest in the arts and literature.

Students should be able to empathize and put themselves in the position of different characters during the sessions. The lesson plans for the sessions should be created and finalized. Small-group learning activities such as case scenarios, group work, group presentations, role-plays, paintings, video and movie clips, music clips, and debates can be used. MH could be offered as a pilot module with a “selected” group of students and detailed feedback obtained before it is offered to the wider student body. The facilitators of the module should have a forum (face to face or online) where they can meet weekly during the initial stages to address problems and chart the way forward.

Evaluation of a medical humanities module

The Kirkpatrick model of training evaluation consisting of reaction, learning behavior, and results will be suitable for evaluating a MH module after being introduced.[26] The first level of student reaction to the educational program has been widely used with regard to MH programs. Measures of learning have also been used. Effects on behavior and on long-term results are still weak. A recently published study showed that medical students who completed a formal scholarly concentration in biomedical ethics and MH had a positive impact in reinforcing knowledge and skills in clinical ethics, improved self-care and reflective practices, a refined sense of professional identity, and improved productivity.[27] For a newly introduced MH module, student feedback about the program obtained at regular intervals, throughout, and at the conclusion of the module will be important. [Table 6] shows a proposed feedback form which can be used to obtain student feedback about the sessions. Feedback from faculty facilitating the module will also be vital. A semi-structured interview or a focus group discussion can be used for obtaining this feedback. Obtaining data on changes in behavior will be more difficult though we are evaluating how students interact with a patient under examination conditions in the OSCE. The newly introduced module will be a part of regular curriculum and program evaluations at the institution and the university.
Table 6: Rubric used to obtain student feedback on the sessions

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The rubrics were developed by the author following a thorough review of the literature and with inputs from various faculty members who were involved in facilitating the module and in assessing the students and also with inputs from the curriculum committee and the academic leadership at a medical school in Aruba and another school in Saint Lucia. As mentioned, each rubric was a compromise between comprehensiveness and practicality (the faculty member or the student should be able to complete the rubric/questionnaire quickly). The rubrics were pilot tested before use and inputs were obtained from participants about ease of understanding of the parameters/statements and ease of use. The internal consistency of the rubrics was measured where suitable using Cronbach's alpha, and they showed good internal consistency. The rubrics have been used for over 7 years at two different institutions among a multinational and multicultural group of students and by a multinational and multicultural group of faculty members. The rubrics could be further validated and if required, modified before use among students and faculty members in Indian medical colleges.

Indian medical colleges have the unique opportunity to initiate MH based on broad guidelines from the accrediting bodies and universities but modified on the basis of their vision, mission, student and faculty interests, and unique local circumstances. Faculties and the educational leadership have to pick up the gauntlet!

Acknowledgment

The author would like to thank Dr. Vinutha Shankar, Dr. Medha Joshi, Dr. BV Adkoli, Dr. Lakshmi, and Dr. Radha Ramaswamy for their critical inputs on the earlier drafts of the manuscript. He would like to thank the organizers of and all the participants in the workshops and sessions he had facilitated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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