COVID underlines value of humanities in medical education

Towards the end of January 2015, Professor Jenna Healey, Jason A Hannah Chair in the History of Medicine at Queen’s University in Kingston, Ontario, ended her lecture to the third-year medical students on the history of epidemics by projecting a slide of the Ebola virus above her as she recapped the top 10 things they needed to know.

The following year, she spoke beneath a picture of the Zika virus.

On 27 January 2020, a picture of the novel coronavirus that had recently been identified in Wuhan, China, filled the screen above her as she made her last point about epidemics: “This will happen again, and it will happen to you.”

That same day, Canada confirmed its first case of COVID-19. Seventy-two hours later, the World Health Organization declared a “public health emergency of international concern”.

Soon, retired Queen’s University professor Jacalyn Duffin noticed an uptick in her ‘Thucydides Index’ which records journalistic references to the Greek historian, whose writings about the 5th century BC Plague of Athens are central to what medical students are taught about the history of medicine, and which “increases every time there is a new disease”, she says.

According to Molly Worthen, a history professor at the University of North Carolina at Chapel Hill in the United States, while the humanities might seem distant from the pressing needs of society in the midst of the COVID pandemic, if anything, the present crisis underlines the need for humanities education in medicine.

“Studying history, sociology, anthropology and related disciplines gives people in the medical world a much broader context for understanding the broader culture and community and history that produces the health situation in front of them embodied in a patient,” she says.

The programmes, which can be found across North America and in other countries including Britain, Brazil and Singapore, can have different structures. At the Lee Kong Chian School of Medicine in Singapore, the courses are part of a stand-alone stream. The ethics course at Queen’s is a stand-alone course while Duffin’s teachings on the history of medicine are integrated into the medical curriculum.

“When the students studied anatomy, I gave an hour on the history of anatomy, when they had physiology, I gave an hour on physiology,” says Duffin.

In the medical curriculum at the University of Ottawa, Ontario, there are mandatory sessions in such areas as medical ethics, philosophy and history, as well as para-curricular workshops that lead to a medical humanities certificate that is included in the medical graduate’s official record.

SOBRAMFA-Medical Educaço Médica Humanismo founded by Dr Pablo González Blasco in Sao Paulo, Brazil, offers a number of non-resident extracurricular courses that make innovative use of films and literature to train physicians in humanistic patient-centred medicine that foregrounds ethics and human values.

The argument for medical humanities is twofold. First, studying the humanities helps produce better clinicians, though when we spoke, Worthen quickly underscored that “to reduce the value of the humanities to giving doctors a softer touch when they speak to families is a rather pinched view of the power of humanities education”.

Second, it provides doctors themselves with perspective from which to deal with their own emotions, especially during the COVID crisis.

Dr Alan Bleakley, emeritus professor of medical education and medical humanities at Plymouth University Peninsula School of Medicine in the United Kingdom, told University World News that his interest in medical humanities began in the late 1990s.

In 2000, he led a research project that included filming doctors and surgical teams to examine their communication practices and found that they communicated in a top-down, undemocratic manner, by “telling, giving information or confronting, and not asking open-ended questions” of either students or patients.

A year later, Bleakley invited a group of Royal Shakespeare Company actors to work with senior doctors and surgeons to challenge their “habitual one-way ‘prescriptive’ communication style [and] to engage them with supportive, open-ended questions and dialogue. It was an eye-opener for the doctors”.

While medical science can tell you how your liver works, it cannot teach how social and cultural structures affect patients’ access to medical care and outcomes. Nor does it teach about the nature of pain or suffering or loss.

“That comes from literature and it comes from reading poetry and looking at art,” says retired neurologist Dr Thomas Murray, who was awarded his medical degree almost six decades ago and who, in 1992, founded the Medical Humanities programme at Dalhousie University in Halifax, Nova Scotia, Canada.

Among the most powerful works of art dealing with disease is the wood-cut, The Dance of Death (Danse Macabre), executed in 1493 by Michael Wolgemut. In it, three skeletons dance to the music of another skeleton who plays a recorder, while still another appears to be rising from its grave. A more recent work is Edvard Munch’s 1907 painting The Sick Child, which is suffused with the pain of the woman kneeling at the child’s bedside.

Blasco’s programme uses music, films, operas and literature to train medical students and doctors to reflect on emotions and the human condition writ large. In one group of seminars, 40 students attended 15 operas, including Verdi’s La Traviata, Puccini’s Madama Butterfly, Mozart’s The Magic Flute and Don Giovanni, and Gounod’s Roméo et Juliette.

In addition to giving them the librettos, Blasco prepared the students by showing clips of operas in films. The two-minute clip from Philadelphia sees Tom Hanks’s character, a lawyer dying of AIDS, explain to his lawyer, played by Denzel Washington, both the meaning of an aria and invites him “to feel the pain in the singer’s voice”, says Blasco. After seeing the operas, Blasco’s students spoke of the characters as being archetypical, “so virtues, passions and deficiencies show up sharply and are well defined”.

Many students commented on how the music, language and the events on the stage touched their emotions in ways they didn’t usually experience them. Equally importantly, Blasco says, “was how the characters’ live presence [on stage] deeply affected them”.

In this seminar and others, including one during which medical trainees listen to Elvis Presley’s Suspicious Minds, students are reminded that all human beings are complex, a point Blasco underscored with the quip, “Both doctors and patients are humans and, therefore, are complex. If you want certainty, it’s better to move to another field, like engineering.”

In sessions which featured popular Brazilian music, the doctors and medical students were often silent after the music ended. Soon someone started speaking, telling about how the music made him or her feel, what emotions the music tapped, Blasco says. “Then the other students began talking.

“The music had created a safe space for the students to deal with those intangible issues, emotions that they are not able to talk about with a faculty member in Brazil’s medical schools that emphasise medical sciences.”

This openness to their own emotions, Blasco told University World News, is the sine qua non of medical students and doctors being open to patients’ emotions and their narratives of their illnesses.

While sometimes disparaged with the phrase ‘soft skills’, or as Blasco put it, “being in a room over there”, the empathetic skills developed by humanities education is crucial to positive patient outcomes.

Dr Joyce Zazulak, who teaches in the department of family medicine at McMaster University in Hamilton, Ontario, told University World News that research shows that, for example, diabetes is much better controlled in those patients who perceive their doctors to be more empathetic.

“If the patient feels that the doctor has istened to them in a deep way, that the doctor is beginning to understand the impact of the disease on their life, then the patient is more likely to be satisfied with that care, more likely to complete the course of antibiotics if the disease was something like pneumonia,” she says.

Tolerating ambiguity

Hollywood stereotypes of the all-knowing and self-assured doctor bear little resemblance to the doctors being educated today.

“We want to foster in the medical students the ability to tolerate ambiguity,” says Professor Susan Lamb, who holds the Jason A Hannah Chair in the History of Medicine at the University of Ottawa, “whether the ambiguity or uncertainty is technical or clinical, or if it emerges from their patients’ emotional or social situations. Physicians must be able to make decisions within the context of ambiguous or incomplete knowledge.”

Part of this training is devoted to philosophy and ethics. Readings in the history of ethics show medical students both how great thinkers through the ages have defined ‘just’ or equitable human interactions, and, equally importantly, the rhetorical techniques that thinkers’ efforts encompass and define human behaviour. Such sessions foreground the question, “How do we know what we know?”

Lamb teaches the history of medicine and her curricular and para-curricular workshops go beyond the factual history of medicine. For example, medical students engage with ideas such as the social construction of disease in which viruses are politicised and personified by a dominant group to help perpetuate racist or sexist public health policies.

One of Lamb’s workshops focuses on the case of the white American gynaecologist and surgeon, Dr J Marion Sims (d 1883) to explore the importance of perspective and context in medicine.

Lamb and her medical students work through various historical contexts (technology, racism, slave, class and gender) to critically examine Sims’s determination to perfect a surgical technique for repairing the vesicovaginal fistula (essentially a tube that formed between the uterus and bladder following difficult childbirths that was both painful and through which urine could flow).

Sims eventually perfected the difficult technique by practising on countless black mothers who were enslaved and, therefore, unable to consent. The operations were performed without general anaesthesia, which had not been discovered yet. Through close study and discussion, learners discover that the women in Sims’s family and social class were also plagued by the condition and demanded the same operation (again, with no anaesthesia).

The students must, therefore, grapple with a staple of medical ethics: the question of what constitutes consent. It was one thing for Sims’s female relatives and even friends to ask for the operation, Lamb told me, it was quite another to practice on enslaved black women’s bodies, whose legal status debarred them from giving real consent.

“What the medical students also learn about is the importance of examining each aspect of the context in order to formulate a sound evaluation of what’s going on, what’s at stake and how to move forward in their understanding of medical decision-making,” Lamb says.

In the nineteenth century, Sims’s white patients were so grateful they raised money to erect a statue in his honour in New York’s Central Park; in 2018, activists successfully called for its removal.

At McMaster, Zazulak runs a visual literacy programme, ‘The Art of Seeing’, which is embedded in the core curriculum and is also designed to make family residents explore their reactions, their biases and help them with critical thinking skills and deepening their imagination.

Zazulak teaches the medical students to learn to look and, then, learning to look again. Her aim is to help the residents understand what pieces of art they are drawn to and why, and what pieces of art they are repelled by and why. “Our research shows that this programme has helped with things like [patient] perspective-taking and nurturing their empathy.”

When I asked what genre of art worked best, Zazulak answered: “It’s easier to work with representative art, of course. And then when you use abstract or contemporary art it’s a bit more difficult. But the great thing about working with modern art is there’s no right answer. And that’s important when you are a physician, to be able to deal with uncertainty and not always knowing the answer.”

Each of the professors and doctors I interviewed also stressed an additional aspect of the doctor-patient dyad that is not widely understood by the general public, ie the ways that social and cultural factors impact on the diagnostic situation. Indeed, sociocultural determinants of health did not become a medical subject heading in the online search engine PubMed until the late 2000s.

And yet, “whether you are employed, literate, which race you are perceived to be and your gender all have a huge impact on the well-being of people as anything biologic doctors investigate and find ways of manipulating”, says Duffin.

She also points out that since, on the whole, doctors come from a more privileged sector of society, they have trouble imagining what life is like for those who live in a different demographic. Literature, she says, is particularly useful in opening doctors’ eyes and underscoring for them how less fortunate people view their lives, and that they may not interpret their situation as doctors do, or even understand the medical information doctors give them.

Bleakley’s students habitually report how their studies of literature improved diagnostic sessions and deepened their understanding of diagnostic language. After they have learned from artists and writers to use their senses more closely and listen to language differently, the students’ senses are more highly tuned to pick up diagnostic cues and clues from patients during the physical examination, he says.

Studying and writing poetry leads the students to “notice the importance of metaphors in diagnostic reasoning”, and thus to a clearer idea how medical language can be structured.

Operating on a war footing

While researching this article during late April and the first few days of May, the government of Ontario was saying that were the third wave to reach the predicted crest of 18,000 new COVID cases per day (from the approximately 4,000 cases then being recorded), Ontario’s doctors were going to have to begin rationing medical care based on a triage protocol published at the end of March. (On 4 May, the Ontario government said that since the numbers had stabilised at around 3,500, it believed the protocol would not have to be used.)

This is but one example of how, since the beginning of the COVID crisis, doctors have found themselves essentially operating on a war footing, something none had “signed up for”, as Dr Michelle Gibson, who teaches in Queen’s University’s department of medicine, put it.

After acknowledging this, Murray told me that he believes the medical humanities training has provided “the current generation of physicians with a much broader basis for managing the COVID crisis than my generation of doctors was given”.

Their training in medical humanities buoys the doctors. “It consoles them that they are not alone,” says Duffin. “This is not the first time this has happened and, sadly, it will not be the last.”

Accordingly, the literature these professors point to as being important at this time is not escapist, but rather deals directly with sickness and death, and shows how people in the past perceived them.

One work Murray points to is Katherine Anne Porter’s (1939) novella, Pale Horse, Pale Rider, which is about the 1918-19 Spanish flu. “What it powerfully shows is the personal impact of the disease that suddenly affects people who are otherwise young and healthy, and how the doctors and others coped with this horror.”

In a course Healey put together quickly last spring after the third- and fourth-year clerks were taken out of the hospital at the start of the pandemic, they read Abraham Verghese’s My Own Country: A Doctor’s Story of a Town and Its People in the Age of Aids (1994). “The conversations were emotional for everyone,” her tone indicating just how emotional the Zoom-enabled class was.

“The students had been removed from the hospital environment, but they were scared because they were going to have to go back in. They were seeing their colleagues around the world dealing with the uncertainty of being on the wards.”

In those early days, among the greatest fears was “not knowing what you were seeing, not really knowing how to treat it. And, of course, seeing doctors dealing with massive death and confusion”, she says.

Healey gave her students the option of writing a traditional research paper or keeping a journal of their readings and responses to the COVID crisis as they were going through them. “It’s our hope that after anonymising the journals they will be donated to Queen’s archives so researchers in the future can look back and see how people coped.”

Many medical humanities programmes include Daniel Defoe’s A Journal of the Plague Year, published in 1722, but ostensibly a memoir of the last outbreak of bubonic plague in London in 1665. Now considered an early example of the historical novel genre, Defoe’s text has a surprisingly modern feel.

“There’s a lot of numbers. He records pages and pages of case numbers. This week in this parish there were this many deaths. It reminded me of the first months of the pandemic when we were all concentrating on the numbers. It’s like an 18th century version of ‘doomscrolling’,” says Healey.

When they read it this year, her students were also struck by reading about people trying to avoid public health measures and the anger people felt about being selected for quarantine.

Gibson credits the medical humanities programmes with providing residents and doctors with the tools to communicate their experiences and feelings. “Very soon after the pandemic began, a full year ago now, a lot of students and residents were writing pieces either for social media or publishing in the Canadian Medical Association Journal, describing what they were experiencing as health professionals in the midst of the pandemic.

As did doctors in other cities, Dr Dawn Lim, an emergency room physician in the University Hospital Network (UHN) of Toronto in Canada and professor at the University of Toronto’s faculty of medicine, returned to the hospitals with a camera in hand to document what it was like for those on the frontlines during the early days of the COVID crisis. Her work is an example of what Gibson calls “processing” what she was going through, using the tools provided by medical humanities.

Lim’s photo essay serves as a counter-narrative to the story of ‘heroes’ then (and now) being told by politicians and much of the media, as she shows the doctors, nurses and cleaning staff struggling with inadequate protective equipment.

In a posting entitled, “Don’t call me a superhero if you expect that to mean I don’t need help,” on the UHN’s website on 23 February 2021, she wrote: “Our underfunded health care system was not prepared. And, that broken system fell on healthcare workers. COVID has seeped into the hospitals with a vice-like grip forcing healthcare workers to make sacrifices in the act of caring. When we go home, the fear of COVID remains. Every sniffle and dry cough remind me that I can easily bring this virus back to my children.”

Riotous behaviour

As the numbers of references to the ancient Greek historian mounted in Duffin’s Thucydides, Healey had her students read the work by the man often called the ‘father of history’. More than once, the 25 centuries between the 5th century BC Plague of Athens and today’s COVID crisis all but vanished, as her students responded to the horrors Thucydides described, she told me.

And there were also moments that surprised her students and even made them laugh. “My students found it funny in the historical context to read descriptions of young people saying, ‘I’m facing certain death. I know I’ve been exposed’, and then reading about their carpe diem (seize the day) riotous behaviour,” she says.