Medical humanities: developing into a mainstream discipline

To the editor I read with great interest the article titled ‘Is assessment of medical humanities test needed in the national medical licensing examination of Korea: opinions of medical students and physician writers’ [1]. The author raises a number of issues related to medical humanities learning and assessment and the place of the subject in the medical curriculum. Medical humanities programs are now common in medical schools in many countries [2,3]. The case scenarios mentioned in the article as part of the questionnaire are mainly concerned with medical ethics. Medical ethics, an important area of study in its own right has attracted greater attention and interest than other areas of medical humanities. The relation between medical ethics and medical humanities has been debated in the literature. Kopelman [4] in an article published in 1998 mentioned that bioethics and medical humanities can be regarded as one field. The author mentions six features which unite the two areas ranging from the use of interdisciplinary approaches, dealing with certain important aspects of the human condition, employing cases and practical reasoning and finding morally justifiable solutions. However another author mentions that bioethics in medical schools should not be considered as a part of or substituted for medical humanities within the curriculum [5]. The author mentions that medical humanities has become a hand maiden to bioethics which has gained more acceptance and respectability. Bioethics may be more acceptable because it employs a more scientific method of reasoning while medical humanities employs a more humanistic approach. In a previous book chapter I had mentioned that ethical dilemmas, problems and standards of behavior can be immersed within a medical humanities course [2]. In the module I facilitate clinical scenarios and ethical issues play an important part. I am happy to note that active associations of physician essayists and physician poets exist in Korea. There is a close association between doctoring and writing and many doctors have become famous writers. Doctors deal with human sickness, suffering, cure and foibles which can offer plenty of good writing material [6]. The process of writing also serves to crystallize ideas and concepts and helps in dealing with the stress associated with the profession. Two authors have recently expressed the view that medical humanities can be regarded as expressive of western culture [7]. Medical humanities is culturally limited by a pedagogical and scholarly emphasis on Western cultural artefacts, as well as a tendency to place an uncritical reliance upon foundational concepts (such as 'patient' and 'experience') within Western medicine. The authors also suggest that for medical humanities to grow and be accepted more widely other experiences and systems of medicine should be incorporated within the framework. I have been involved with medical humanities for over eight years and have facilitated modules first in two medical schools in Nepal and now in Aruba in the Caribbean. We have used English as the language of the module in all our courses. Using English has both advantages and disadvantages which we had examined in a previous blog article [8]. The literature excerpts, and paintings we used/use were predominantly from western sources. The scenarios and role plays however dealt with local issues and in KIST Medical College, Nepal the role plays were conducted in Nepali, the local language. In many countries the language of medical instruction continues to be English and English literature exerts a powerful influence. In Korea with medical instruction in Korean I am sure local influences are stronger and Korean literature has a more substantial role. I am happy to note that most medical students and all physician writers agreed that medical humanities should be introduced in the medical school curriculum. In the literature most studies showed a positive opinion towards medical humanities and its inclusion in the school curriculum but the issue of finding place for one more subject in a crowded medical curriculum has also been debated. The issue of possible impact and effectiveness of medical humanities and arts-based interventions has also attracted attention. A recent review concluded that some studies had shown that arts-based interventions could alter attitudes but the methodology and results were not described rigorously to judge these claims [9]. The authors concluded that the evidence base for the effect of these interventions on fostering diagnostic observation skills was stronger. Introducing medical humanities within the national licensing exams which are high stakes exams might bring to the fore the issue of objectivity of assessment. The results of the author’s survey suggests respondents regarded interviews as the most favored assessment method followed by objective structured clinical exam (OSCE), written examination and essay. Licensing exams have traditionally employed multiple choice questions or OSCE because of their objectivity. The drawback may be objective assessment methods can only evaluate certain aspects of medical humanities. Medical humanities is strongly linked to the social sciences and subjective and qualitative paradigms play an important role in the discipline. The assessment scheme we follow at Aruba has been described in a forthcoming article [10]. A mixture of formative assessment during the medical humanities sessions using a structured checklist, grading of a reflective writing assignment and assessment of student interactions with a standardized patient are used. Based on these initiatives and the keen interest in the subject I am sure medical humanities will develop and grow in Korea and the discipline will be rooted in local values and the Korean culture. The Korean experience will be of importance to other Asian countries and non-western cultures to develop medical humanities more rooted in local values and traditions and to grow beyond the western boundaries of the discipline.