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Humanities in Undergraduate Medical Education:The gift of understanding suffering

and the development of compassion

Professor Chan Li ChongLKS Faculty of Medicine, HKU

Google Search Aug 8th 2008

• 13,500,000 for humanities and medicine• 3,720,000 for humanities and doctors• 283,000 for humanities and patients

• Deeper understanding of and bringing kindness to patients and doctors: literature studies in medical humanities (stories of/by doctors and patients; narratives)

• Medical humanities in HKU –looking ahead and a wish list

What do sick people worry about?

• Sick person rely on physicians for skilled diagnosis, effective therapy and human recognition of their suffering

• How do they live their lives around their diseases?

• What sense can they make of random events of their illnesses?

• How can doctors help them to find meaning in their experience ofillness and thereby facilitate in participation in treatment or acceptance of the inevitability of death?

• Patients: “I am not treated like a human being”

• Literature and Medicine: Contributions from Clinical Practice: Rita Charon et al 1995 Annals of Int. Medicine

What do doctors worry about ?Need to cope: (beyond diagnosis and treatment)

Punishing hours of workUncertainties in medicineUnreasonable patients’ expectationsAnxiety and guilt over making mistakesHow to face their mistakes (soul searching)Worry over competency and performance

Through tending to the wounded, doctors become “wounded healers”

Doctors: I am only human (“ I am a wounded healer”)

-----------------------------------------------------------------------------------------------------Facing our mistakes: David Hilfiker NEJM 1984

Healing the Wounds: A Physician Looks at Work (David Hilfiker, 1998) :“The Wounded Healer”

Doctors as humans

“It is only the wounds that make doctors human, that bridge the gap between doctors and patients” .

Healing the Wounds: A Physician Looks at Work (David Hilfiker, 1998) :“The Wounded Healer”

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The neglected curriculum in medicine• “What makes us human?”

• “What is the nature of suffering?”

• “What gives our lives meaning?” (patients, doctors)

• “What can we do for when there appears to be no cure or hope for improvement?”

• “How does one face uncertainties and mistakes, and develop appropriate responses?”

Medical humanities and the human condition

Humanities: Reflective endeavours; disciplines which value reason and explore emotion

Medical Humanities: Growing area of engagement and exchange between the humanities and medicine

LawOutcomes of Medical Humanities

DramaMeditative appreciation Environmental improvementHealth promotionArtistic and communicative displaysTherapy and human comfortingInterdisciplinary research and teaching

in health care

(Medicine, the Arts and Humanities :Hurwitz, Clinical Medicine, 2003)

NarrativesSpirituality

The Study of Literature in Medical Education –Hunter, Charon and Coulehan 1995 Acad. Med

Reading and writing poetry, fiction, stories (narratives) enables doctors learn to take better care of patients and better care of themselves

Focus on moral reflection and consideration of the “quality of a lived life” (ethics)

Development of skills of observation and interpretation; and to formulate responses to difficult situations (critical thinking)

Understand experiences and feelings of patients (empathy)

Doctors Stories

• Doctors’ confessions – Williams Carlos Williams

• Doctors’ conflicts – Abraham Verghese

• Doctors’ self awareness – David Hilfiker

• Doctors on medicine – Atul Gawande

• Doctor’s activism – Tracy Kidder

Narrative in Medicine“Human beings are storytelling animals, and narrative is the most compelling form by which we recount reality, understand events and through which we make sense of our experience and ourselves” -Narrative and the Practice of Medicine: 2000. The Lancet: Brian Hurwitz

-------------------------------------------------------------------------------------------------“Only in the telling is the suffering made evident…..fresh means to understand the disease itself….

not only is the diagnosis embedded in the narratives butdeep and therapeutically consequential understandingsof the persons who bear the symptoms…”

Narrative and Medicine Rita Charon NEJM 2004

Stories in the Service of Making a Better Doctor: NYT Oct 23rd 2008

Residency programs - narrative medicine training for their residents

Doctors initiate the workshops, sessions and lectures

“When You Come Into My Room,” by Stephen A. Schmidt (JAMA)

“When you come into my hospital room, you need to know the facts of my lifethat there is information not contained in my hospital chartthat I am 40 years married, with four children and four grandchildren....

that I love earthy sensuous life, beauty, travel, eating, drinking J&B scotch, the theater, opera, the Chicago symphony, movies, all kinds, water skiing, tennis, running, walking, camping...

that I am chronically ill, and am seeking healing, not cure.”

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Advice to doctors: Writing mends broken hearts

“Give sorrow words. The grief that does not speakWhispers the o'er-fraught heart, and bids it break” :(William Shakespeare)

Writing helps to sort out one’s thoughts –

it is private between you and the paper

Get doctors to talk, make sense about stories to improve one’s life and those they share

Why don’t doctors write:

Perfectionist, self critical nature of GPs(Ted Hughes – Progress of a writer is when he outwits his own

police system)------------------------------------------------------------------------------------Writing workshop (Gillie Bolton): Taking Heart: Medical Humanities Workshop 2006 Byron Bay, Australia

Writing is about learning to do right

Medicine – an endeavor that involves risk and responsibility (plus big egos)

Doing Right (moral reflection)

“Write something…..even the angriest rant forces the writer to achieve a degree of thoughtfulness….

by offering your reflections, you make yourself part of a larger world”.

Atul Gawande: A Surgeon’s Notes on Performance

A Physician Looks at Work (David Hilfiker, 1998) :Healing the Wounds

Though imperfect, possibilities for healing involve:

Sharing work

Circle of peers

Respond to patients on their own terms(as a servant not an entrepreneur)

Each doctor brings unique gifts to his/her work – and to discover such gifts

Medical humanities in HKU – the challenges

• Is there a case for the humanities in medicine?

• How do we define the curriculum?

• Who is qualified to teach/facilitate learning?

• What will assessment look like?

• How do we measure outcome?

Medical humanities: getting started…

External assistance

1. Articles, monographs, books

2. Medical humanities conferences

3. Establish links, collaboration (KCL; UVA)

Internal (local) issues

1. Interest group

2. Faculty/institution aims (window)

3. Educational resources

Themes of Byron Bay workshop

• Perspectives in Grief e.g. Teaching about grieving using the visual arts

• Metaphors in Medicine e.g. Metaphors for disease in contemporary media

• Talking Hearts e.g. Making meaning: Doctors as Story Tellers

• Art and Healing e.g. using visual image to explore doctor-patient relationship

• History and Philosophy of Medicine e.g Thinking about reasoning• Creativity workshop e.g. Medicine as Music; Writing to Heal

• Medical Education Workshop : Human response to medical situations; Fall from professional innocence

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Just what the medical humanities ordered

HKU Educational Aims: New undergraduate curriculum from 2012

1. Critical intellectual inquiry and life long learning

2. Tackling novel situations and ill defined problems

3. Critical self reflection, greater understanding of others, personal and professional ethics

4. Intercultural understanding and global citizenship

5. Communication and collaboration

6. Leadership and advocacy for improvement of human condition

Medical humanities in HKU– the way forwardSpecial study modules and pilot common core modules 2010Common core curriculum for 2012

Issues:Curriculum design – alignment of learning outcomes with learning activities and assessment methods

Student and faculty background

Social, Societal, and Cultural issuesDoctor patient relationships“Face” and Openness in Asian cultureConcept of disease, death, bereavement

Partners for collaboration – teaching and research (SOH, HKU; KCL (UK))

(Interdisciplinary disciplines engaging conversations between doctor, poet, philosopher, artist, writer…)

Centre for Medical Humanities would help (WISH)

From humanities to humanitarianism (altruism) journey of HKU students

One planet – different worlds

Fan Lau, Jerome So, Mina Cheng & NG Patil,

Eradicate extreme poverty and hunger

Achieve Universal Primary Education

Promote Gender Equality and empower women

Reduce Child Mortality

Improve Maternal Health

Combat HIV/AIDs, Malaria and other Diseases

Ensure Environmental Sustainability

Develop a Global Partnership for Development

Cameroon elective by Jerome So

Jerome SoE-health elective at Tabubil Health Centre

Papua New Guinea 2006

• Medical humanities through study of literature can bring deeper understanding of the human condition and compassion alike to patients and doctors

• There is a great future for medical humanities in HKU

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Let us start working….come and join our afternoon workshop

• SWOT analysis for Medical Humanities

• Strategies for implementation

ProfessionalismProfessionalism

Ethical and Legal UnderstandingEthical and Legal Understanding

Skills (Communication, Reasoning)Skills (Communication, Reasoning)

Knowledge (Content of Medicine)Knowledge (Content of Medicine)

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Acknowledgments

• Prof. SP Lee• Prof. Mary Ip• Prof. Niv Patil• Dr. Julie Chen

• Ms. Ann Storey• Ms. Lai Kun Chan• Ms. Julia Chan

• Prof. Brian Hurwitz• Prof. Jill Gordon