Medicine and Compassion, a medical humanities collaboration
Medicine and Compassion
Exploring and teaching the art of medicine in ItalyThe New Physician December 2010
Health care is a rapidly changing and increasingly complex environment, not only for patients but also for professionals. Changes have arisen as the result of significant advances achieved in personalized medicine and from the very real pressures of reducing health care costs while promoting efficiency. As patients are asked to participate more actively in their own care, doctors must find a way to empower them to do so. Economics continue to drive debates over health care reform while quality is defined in terms of coordinated care, timeliness and evidence-based practice. As such, educators are challenged to implement a curriculum that will address the fundamental values embraced by health practitioners. The question of how to best prepare future health care providers for patient-centered and compassionate care must be seriously addressed if the profession is to maintain the respect and trust merited in the past.
The question requires investigation into student formation even prior to medical school. Undergraduate students who pursue premedical curricula do so most commonly through traditional majors in biology or chemistry, priming their minds to repeatedly memorize, recall and associate scientific content. As they move into their medical education, students continue this trend, while learning to rapidly apply clinical diagnostic skills and navigate the idiosyncrasies and tools of various practice settings. Many schools now offer fast-track programs that allow students to complete their undergraduate studies along with medical school in six or seven years, inevitably at the expense of in-depth liberal arts course work and study-abroad opportunities. Learning how to communicate with patients, be culturally sensitive, and understand the psychosocial circumstances of individuals, families and populations are often undervalued by medical students and faculty alike. Increasingly, students give little consideration to these social and cultural determinants of health before entering medical school and are thus poorly prepared to do so thereafter. Perhaps, on the eve of the 100th anniversary of the Flexner Report, we would do well to re-examine how doctors are trained. Modern medical culture often embodies qualities that are in direct opposition to values considered to constitute a good doctor. We train clinicians to manage time constraints, follow clinical pathways, practice evidence-based medicine, and functionally interface with an electronic health record system. However, we do not train them to care. Yet, this is the foundation of the practice of "good" medicine as Dr. Jack Coulehan and Peter C. Williams described in a 2001 Academic Medicine article, "Vanquishing Virtue: the Impact of Medical Education."
Renée Fox, professor emerita of sociology at the University of Pennsylvania, proposed that any student wishing to become a doctor should have the opportunity to study another society in order to gain empathy and understanding outside of her own experience. Responding to this call, we describe a unique course founded at Emory University for pre-health undergraduate students called "Medicine and Compassion," integrated into a summer-abroad Italian cultural studies program. The course aims to provide tools for students to examine their own beliefs and actions, as they work to articulate their own definition of compassion and delineate why compassion is fundamental to the practice of "good" medicine.
"Compassion" literally translates from Latin as "to suffer together." The word "patient," again from Latin, reveals both "bearing and enduring without complaint" and the "suffering or sick person." Linking these two words is the idea of suffering. The person offering compassion is offering to share in the sick person's suffering. This course was designed to provide a foundation for future health care professionals in the importance of compassion for patients, and more generally its importance in everyday life. This challenging concept is best conveyed through experiential learning and introspection, and is promoted by incorporating the course work into the framework and content of a transform-ative study-abroad experience. We present our experience designing and conducting this course, and challenge others to consider opportunities to advance pre-professional pedagogical content that teaches the values essential to our profession.
The Medicine and Compassion Program
For the past seven years, faculty from Emory University's Italian Studies Program and School of Medicine have collaborated to integrate an undergraduate medical humanities course into an undergraduate Italian studies summer-abroad program.
Emory undergraduates enrolled in "Medicine and Compassion" participate in six weeks of scholarly structured travel to 43 Italian towns, exploring how compassion relates to the profession of medicine. Using moral imagination as a tool for inquiry, students examine significant historical works from the humanities: literature, philosophy and the arts, along with numerous cultural and social renditions of complex concepts such as love, care, mercy, pity, sorrow, death, disparities and healing. Through intensive writing and reading assignments, followed by group discussions on the ethics of healing, students are encouraged to contemplate compassion and medicine, both as private individuals and as future professionals. Students engage in cross-disciplinary discussions with faculty from the School of Medicine and the College of Arts and Sciences, surrounded by Italian landscapes, ruins, artwork and other tangible artifacts that require critical thinking in the medical, historical and cultural context.
While learning the science of medicine requires memorizing, understanding and using a vast quantity of facts, learning the art of medicine requires learning the value of a human connection. What does it mean to "suffer with" a patient? How do we build trust or restore it when it is lost? What is real communication? How do we learn to listen and respond to often unspoken and sometimes unrecognized needs of those we aim to help? Teaching the science of medicine is relatively straightforward and predictable. The art of medicine is much more difficult to teach, if it is taught at all, and much more challenging to learn. Why should a pre-health professional student read Boccaccio's introduction to the Decameron? Not necessarily to discuss the impact of this seminal text in literature, but perhaps to experience what it would be like, for both physician and patient, to live in an outbreak of life-threatening illness such as the Black Death.
While grappling with their course content and context, students often realize they lack the academic tools to frame their investigations of compassion. When they say, "Tell me what you want me to learn," they receive a reply that sadly they have rarely heard: "You need to think." This comes instead of a checklist of assignments with due dates. Students are encouraged to draw from their past studies and personal experiences and learn to forge connections with the new material. Stripped of their familiar yet one-dimensional learning tools, they frequently react with confusion, consternation, indignation, belligerence ("I don't have time to think; just tell me what you want me to know") and, finally, acceptance of the challenge. These initial student reactions speak volumes to the state of premedical and pre-health education and to the need for a new approach.
The Importance of Study Abroad
Teaching the course abroad provides cognitive estrangement. Our opinions on what compassion is and is not, as well as our opinions on how we should treat one another, are just that: opinions. Although we can base them on underlying principles, we often formulate assumptions based on what we learn from our families, friends and culture. Examining one¿s own assumptions can be a difficult task, particularly for students still seeking to define themselves and their own beliefs. Cultural immersion in Italy pulls students out of their familiar environment, where they possess an innate understanding of cultural rules, and thrusts them into the unfamiliar, where they must learn to recognize the unspoken rules of another culture. As they learn to identify underlying cultural assumptions, they are better able to examine their own beliefs about how people treat one another. Students examine real-life health and medical issues of today as they learn to articulate the intricacies and complexities of ethical and moral dilemmas that have challenged medical professionals throughout history. Taking advantage of the lenses offered by cross-disciplinary faculty, students are challenged to understand their own biases, and to develop principles that help resolve conflicts between varying points of view and assumptions.
Italy Sets the Stage
The past and present of Italian culture, the cradle of Western civilization, lend themselves to discussions on compassion. Through the study of ancient and modern history of medicine and public health, commissioned art and public buildings, the state and church, popular beliefs and traditions, and integration of regional realities within a national unity, the course offers scenarios that transcend time and context and deal with the universal and human. Students explore diverse paths of inquiry as they explore various geographic regions that reflect differing historical and cultural practices. For example, as students visit sites of ancient Greek and Roman ruins, they discuss past practices regarding disease and epidemics. In medieval towns, discussions include how the Byzantine Christian world viewed relationships between thoughts of bodily sin and the practice of personal hygiene. At the base of the podium where Galileo lectured in Padova, students discuss Renaissance innovations in the sciences and arts coexisting with devastating outbreaks of plague. In the cemetery of Pisa, students read the introduction to the Decameron by Bocaccio and undertake a large classroom unit on how cultural practices relating to death define a society, and how historical lessons from the plague in Italy inform our modern-day approaches to HIV and AIDS, pandemics, and national preparedness.
When navigating rapidly on foot through unfamiliar Italian cities, students look at their feet to keep from stumbling. However, students quickly learn to look up at cathedrals, Greek temples and the general beauty of Italy so as not to become lost. Therein lies a potential lesson for future physicians. The art of medicine requires the ability to avoid the pitfalls and shortsightedness associated with new challenges and daily fatigue. By the end of the program students have changed; they stride briskly without fear of stumbling. This program challenges students entering medicine to look up and navigate with a sense of purpose and orientation. In the cities of Italy and in their future careers, students find themselves not lost, but in the place they intended to be.
Trained to Think
When asked what makes young students become great doctors, Dr. J. Willis Hurst responded, "learning to read, write and think." Students in this course read three novels, numerous newspaper articles, historical texts and current medical literature. They keep an individual scholarly journal and write a group summary thesis, but most importantly, they are forced to think. The fundamental accomplishment achieved by those who respond to the challenge is the capacity to think critically and to articulate their thoughts and values.
Does this exercise in moral imagination teach students to be more compassionate? A quantitative study on efficacy and results has not yet been undertaken, although anecdotal evidence from former students has been overwhelmingly positive. The "Medicine and Compassion" course teaches students not what to feel or think, but more fundamentally the importance of recognizing feeling and intentional thought. Each student will embark on a unique journey and will walk away not necessarily sharing the same fact set memorized by other classmates, but more significantly with a new approach to the collective subconscious of humanity. This course in Italy may well be expanded to target not only undergraduates with aspirations for careers in health care, but to those in graduate training as well.
Interestingly, in a February article in Academic Medicine, Dr. Raymond Curry and Kathryn Montgomery of Northwestern University's Feinberg School of Medicine proposed that critical thinking is achieved through active engagement in a pedagogy that respects students' thinking and allows their involvement in determining the direction of their learning while pushing them to explore how they view the world and why. Arguably, the most detrimental mistakes doctors will make are not errors of competency, but errors of ethics, which we would consider to be decisions made without compassion. The Emory program attempts to address this serious lacking by offering a course that teaches the heart of medicine, embedding in students the value of respecting their oath and always doing what is right, not what is expedient. The reflective nature of the course is not solely about a student¿s feelings and emotions vis-à-vis the challenges of health care practice. Rather, it serves as an ethical compass for future health care providers, thoughtfully guiding their decision-making and reminding them of what doctors should always do, regardless of the conflicting pressures that surround them.
Adam J. Carlisle is a fourth-year at Emory University School of Medicine, where Dr. Ruth M. Parker is a professor of medicine. Dr. Paul Cantey is a medical epidemiologist and clinician at the Centers for Disease Control and Prevention. Michael S. Wolf is associate division chief of research at Feinberg School of Medicine at Northwestern University. Judy Raggi Moore is director of Italian studies in the Department of French and Italian Studies at Emory University.