THE CEYLON MEDICAL JOURNAL The humanities and its relevance to the practice of medicine

In 1995 Steven Hsi (pronounced “she”) was diagnosed with Takayasu’s arteritis leading to aortic valvular disease. He was only 40 years old, a successful physician, happily married with two sons, In two years he underwent three surgeries, numerous investigations and prolonged hospital stays with devastating consequences for his mental state, family and practice. In his book Closing the Chart: A Dying Physician Examines Family, Faith, and Medicine, he writes that though his doctors were mostly technically competent they failed to ask what he felt to be the most important questions: “What has this disease done to your life? What has it done to your family? What has it done to your work? What has it done to your spirit?” He goes on to say, “Regardless of the considerable compassion and caring of many of them, no one asked the questions that needed to be asked. I have come to believe this oversight was the single most grievous mistake my doctors made”[1].

The humanities and its relevance to the practice of medicine In 1995 Steven Hsi (pronounced "she") was diagnosed with Takayasu's arteritis leading to aortic valvular disease. He was only 40 years old, a successful physician, happily married with two sons, In two years he underwent three surgeries, numerous investigations and prolonged hospital stays with devastating consequences for his mental state, family and practice. In his book Closing the Chart: A Dying Physician Examines Family, Faith, and Medicine, he writes that though his doctors were mostly technically competent they failed to ask what he felt to be the most important questions: "What has this disease done to your life? What has it done to your family? What has it done to your work? What has it done to your spirit?" He goes on to say, "Regardless of the considerable compassion and caring of many of them, no one asked the questions that needed to be asked. I have come to believe this oversight was the single most grievous mistake my doctors made" [1].
What do we understand by the term "humanities?" The word humanities is derived from the Latin noun humanitas meaning human nature, civilisation and kindness. It corresponds to the Greek concept of philanthropia (loving what makes us human) which first emerged in the fifth century BC Greece. The idea was brought to Rome by Cicero and rediscovered by the Italian Renaissance Poet Petrarch who understood a person who cultivates the humanities as someone knowledgeable in grammar, rhetoric, poetry, history, and moral philosophy. An education in these subjects aimed to form a person with humane feeling, liberal learning, who acts in the world. This threefold ideal is the core of a humanistic education.
Medical science has advanced much in the last 50 years but has it lost something important along the way? Has it lost its humanity? The rise of technology in medicine has diverted attention from the patient to the machine, encouraged the attainment of technological perfection rather than expertise in understanding the emotional needs of patients and emphasised biomedical aspects of disease rather than the psychological and social issues. We have become experts at reducing pain but forgotten the suffering of the patient, focussed on the disease but not the illness, and lost sight of the difference.
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A cohort of 456 medical students from Jefferson Medical College USA was asked to complete the Jefferson Scale of Physician Empathy at five different times. First during entry and then at the end of each academic year. The empathy scores did not change significantly during the first two years, but declined in the third year and persisted until graduation. The decrease in empathy scores was similar for men and women. Other studies have replicated this effect. The reduction in empathy coincides with the time that students shift emphasis from learning basic medical science to clinical care activities [2].
On 1 May 1889, Dr William Osler, the father of modern medicine, delivered his now famous lecture "Aequanimitas." before the graduating medical class of the University of Pennsylvania. In it, he refers to two elements which may make or mar their lives. The first is imperturbability, the "calmness amid storm, clearness of judgment in moments of grave peril," the poker-faced composure, which he claims is essential to instil confidence in frightened patients and the second, equanimity, which some have interpreted to mean as the absence of emotions and others as measured or moderated emotions. Osler tells the young doctors that "a certain measure of insensibility is not only an advantage but a positive necessity in the exercise of calm judgement." [3] Though William Osler advocated equanimity as a virtue in a doctor, he was himself a compassionate physician. This is illustrated in his famous quote, "The good physician treats the disease, but the great physician treats the patient…It is much more important to know what sort of patient has the disease than to know what sort of disease the patient has." Osler was well educated in the liberal arts and knew Latin and Greek. All his lectures have numerous references to ancient mythology and cannot be fully understood without knowledge of the classics. He was a man of science but well grounded in the arts. But medical education was changing, and liberal instruction gave way to teaching in the natural and social sciences.
In the 19th century medical education, even in elite medical schools like Harvard, remained rudimentary. In Harvard, in 1869, all who could pay the admission fee was admitted. Only 20% had a college degree, and over half could not write. The curriculum was two four-month terms of lectures with no examinations, no laboratory or clinical work [4]. But with a series of reforms by the 1920s, American medical education and research reached high standards of excellence. In 1910 Abraham Flexner, an American educator, published the Flexner Report, a detailed analysis of all 155 medical schools functioning at the time in the United States. He found most of them inadequate and advocated closing half of them. He recommended that the medical curriculum be at least four years in duration with two years in the basic sciences and two years of clinical study [5]. This recommendation has been the foundation of the syllabi of most medical schools around the world including Sri Lanka.
In the years following the Flexner Report, the core medical education shifted to science-based subjects. The Flexner model of two years of basic science followed by a minimum of two years of clinical training remained unchallenged for over a 100 year. With the emphasis on scientific knowledge and practice, there was little or no time in the medical curricula for liberal art subjects. Selection of medical undergraduates to medical schools emphasised knowledge of science and on entry had little understanding of liberal art subjects. In 2010 the Carnegie Foundation which had sponsored the Flexner report 100 years before published another major study of medical education based on 14 US medical schools [6]. The report identified four key deficiencies. First, medical training was inflexible and too lengthy and not learner centred. Second, it focussed too much on inpatient clinical experience,. Third, there was lack of holistic learning about patient experiences and absence of teaching about the "broader civic and advocacy roles of physicians." Fourth, the report commented that the "pace and commercial nature of health care often impede the inculcation of fundamental values of the profession." Unlike the Flexner report, it did not find any fundamental differences between medical schools, but there was a deficiency of teaching of humanitarian values. In the UK the first edition of Tomorrow's Doctors published by the General Medical Council recommended that the teaching of communication skills and ethics be a vital component of the medical curriculum.
As the concept of humanities developed in the late 60's and 70's the medical schools distanced themselves from the humanities. Dr Edmund Pellegrino, an American doctor, pioneered bioethics and teaching of humanities in medical schools. In a book published in 1979, he identified three essential goals for humanities in medicine [7]. First, it would clarify ethical issues in clinical decisions. Second, it would inculcate habits of critical self-examination. Third, the humanities would, "confer those attitudes which distinguish the educated from the merely trained." Pellegrino's essential goals reflected the three core ideals of the humanities, to create a person with humane feeling, liberal learning, who acts in the world. Another who was influential in shifting the focus from a purely biomedical model was George Engel, an American psychiatrist. In 1977 he proposed a biopsychosocial model of medicine advocating that health and disease cannot be understood in biological terms only but must take into account a patient's psychological state as well as the social environment [8]. The biopsychosocial model is a humanitarian concept bridging science and a patient's experience. Vol. 62, No. 4, December 2017

Leading article
How have medical schools responded to the challenge of introducing the humanities to the medical curriculum? After the GMC recommendation of 1993 many medical schools in the UK have added teaching in communication skills and ethics. In Sri Lanka too, the Faculty of Medicine Colombo undertook a major curriculum reform and created the behavioural sciences stream with the teaching of communication skills, ethics and changing behaviour skills as its core syllabus. The stream has now undergone a name change to Department of Medical Humanities, the first in Sri Lanka. Are these measures effective? Do they really prevent the erosion of empathy in the third year of medical school? There is some evidence that it does make a difference. In an American medical school study, students who had mandatory training in a Humanism and Professionalism course did not show a decline in sympathy as was seen in previous batches of students who have not undergone the course. The teaching included blogging about clerkship experiences, debriefing after significant events, and discussing journal articles, fiction, and film. There is some hope that even in busy medical curricula students can be effectively taught humanistic values.
Francis Peabody was an academic and physician at Harvard. He was 46 years old and at the peak of his career of but he knew he was suffering from an inoperable malignancy. He died one year later. On the 21 of October 1926, he delivered his now famous lecture to the graduating class of Harvard titled The Care of the Patient. Published in the JAMA, it is one of the most cited articles in medical literature. He ends his lecture with these words, "The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient [9].
All doctors should read his lecture in its entirety and take his words to heart. It will make them better doctors.

Conflicts of interest
There are no conflicts of interest.