Humanities and geriatric education: a strategy for recruitment?

Ageing is a common subject in arts and literature as it is a universal experience. The use of the humanities in medical education may have a positive effect on trainees' attitude to caring for seniors and on geriatrics as a career choice. This paper summarizes the role of humanities in medical education and provides some examples and thoughts on how humanities curriculum can be used in geriatric teaching.

INTRODUCTION

“To be educated is not to have arrived; it is to travel with a different view.”

Medical or health-care humanities have been defined as an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theatre, film, and visual arts), and their application to medical education and practice.( Medical humanities attempt to help physicians understand the human condition.

Ageing is a common subject in arts and literature as it is a universal experience. Although positive exposure to an older relative is thought to affect attitudes of medical trainees to geriatrics,( the role of humanities on medical trainees’ attitudes to caring for seniors and the impact on their career choices has not been well studied. In the last decade there has been a greater interest in the role of medical humanities in undergraduate and postgraduate medical education. This paper will briefly discuss the evidence for humanities curriculum in medical education and consider possible roles for humanities in geriatric education and as a strategy to aid recruitment to geriatric-focused fields.

MEDICAL HUMANITIES IN CANADA

In his acceptance speech as President of the British Classical Association in 1919, Sir William Osler commented that, “The Humanities bring the student into contact with the master minds.” Despite Osler’s important influence on medical education in Canada, there was no consistent movement to incorporate humanities content into medical education until the 1970s. A 2008 qualitative survey of key informants described humanities content in Canadian medical schools.( There was a wide variety of content reflecting differing definitions of humanities and only one university had a mandatory course (Table 1). The goals of humanities programs were: (i) to encourage curiosity about the human condition along with skepticism about the nature of medical “truth”; and (ii) to model acceptable moral behaviours. This survey is currently being updated.

TABLE 1.

Sample of humanities content in 2008 survey of curriculum

University of British Columbia	Required course taught over the first 2 years of the medical curriculum whose subject matter includes health care ethics, epidemiology, sexual medicine, clinical anthropology, and domestic violence. History of medicine was dropped from University of British Columbia’s curriculum before the survey. This curriculum is also presented at the University of Northern British Columbia.
University of Calgary	No required medical humanities curriculum, but is well known across Canada for its extra-curricular emphasis on the history of medicine. Student discussions occur over 60 hr outside class time; typically, only first-year students take part; each conducts a research project that is presented and evaluated at the end of the year.
University of Saskatchewan	Required course in first year called “Life Cycles and Humanities,” which includes medical ethics and professionalism. Students are also required to shadow both physicians and non-MD health-care professionals in order to learn about the larger social context of medicine and the health care system generally.
University of Manitoba	A formal, non-elective Medical Humanities Program. The program has grown from a relatively narrow focus on the history of medicine and health care ethics, to include sessions on health law, complementary and alternative medicine, and palliative care.
Western University	Required humanities curriculum that consists of lectures by a clinician during pre-clerkship, and a major independent project in second year. Its subject areas include ethics, law, literature and theatre. Also offered is a fourth-year elective in medicine and film, for which the final assignment is to write a story.
University of Toronto	Required coursework consisting of 52 hr of lectures and case-based seminars in the first 2 years which are devoted to themes of professionalism, ethics and health law. An elective called “The Healer’s Art” is also offered.
Memorial University of Newfoundland	Film, literature, and history are integrated into the required Humanities, Ethics, Law and Medicine course for both first and second year, which is a fully evaluated component of the Clinical Skills course.

Modified with permission of author

Like geriatric medicine, the presence and strength of humanities content in medical curricula often depend on the passion and perseverance of faculty members and clinical teachers.( Advocates of humanities in medical curriculum have generally focused on the premise that exposure to humanities curriculum will produce more holistic physicians with improved communications skills, greater empathy, and better critical thinking skills.( Other proponents suggest that humanities exposure improves physician resilience and helps deal with stressful clinical encounters.( The counter arguments are that medical school curriculum is already overburdened and that “soft” content may decrease available time for students to gain knowledge and skills in clinical care. Critics also express concerns about inclusion of humanities content due to the challenge of measuring its benefit. However, most areas of clinical education have limited evidence of their impact on development of competent physicians.(

As a response to criticisms of humanities content in medical curriculum, Shapiro et al.( have organized critiques into broad responses to three questions:

Is the content irrelevant? A concern is that humanities training is not clinically relevant in comparison with concrete skills, such as learning to start an intravenous. The humanities are a far cry from the ‘traditional’ view of training which focuses on clinical knowledge and the practical ability to get things done. Accordingly, even students with an interest in humanities may advocate for humanities opportunities to be elective rather than mandatory.

Are the teachers and their methods the problem? Similarly to other professionals with long duration of training and high stress roles, physicians may view those from outside the disciplines with skepticism and distrust. Trainees may regard teachers from other disciplines as having limited understanding of clinical realities. Medical trainees may view teaching exercises, such as reflective practices and writings, with suspicion or as threatening, especially if the exercises highlight uncertainty or vulnerability. Finally, students may be skeptical of the objective of humanities content, especially if it appears designed to help with “character formation”, which some students feel is beyond the realm of medical education.

Is the positioning within the curriculum appropriate? The positioning of humanities content within the medical curriculum is challenging and criticisms are inevitable—if placed too early in the curriculum, it is too removed from clinical work; if done later in the syllabus students complain of being overwhelmed; if the content is heavy on reading and assignments, students criticize the workload; and, if it relies on small group processes, it is viewed as too vague or personal. Mandatory experiences tend to generate controversy among faculty and trainees while elective opportunities may be taken by students already interested in the content.(

Published research provides support for proponents of humanities in the medical curriculum.( Students’ pre-med academic performance correlates with medical school success more than the academic field taken before entering medicine.( In addition, students’ previous humanities education has some correlation with higher ratings of clinical judgment and interactions with patients, although this finding was not consistent.(

It has been shown that empathy tends to diminish over the course of medical training, more so in medical school than residency.( Sessions using reflective practice in medical students have improved scores on empathy scales and have increased the depth of students’ understanding of patients’ perspectives.( Critical thinking and observation skills appear to be positively affected by exposure to humanities strategies including arts appreciation.(

The impact on professionalism is hard to evaluate as the term encompasses a wide range of attributes and is itself, hard to define.( Key competencies for professionalism in the CanMEDS framework are ethical practice and physician health.( Little published evidence exists for the impact of humanities curriculum on professionalism. A recent pilot narrative writing project with third-year medical students incorporated an assessment of the CanMEDS roles and suggests that reflective writing helps to encourage personal reflection and reflective thinking in the clinical context, including the development of competencies in professionalism.(

The “ornamental” role of humanities as a source of relaxation for stressed physicians has been criticized as a conciliatory goal that does not effect change to the prevailing medical culture.( However, breaches of professionalism in physicians or students often relate to challenges of “self-care”. Fatigue, stress, poor nutrition, and isolation are commonly associated with episodes of unprofessional behaviours. In addition, little attention is paid in medical training to the nature of life as a physician or to facilitate reflective practice on the stresses and strains of training and careers in health care. Several strategies have shown benefits on self-perceived resiliency of trainees, including lower rates of depression and anxiety and greater sense of connection to classmates. These studies used educational interventions such as reflective writings on the humanities and clinical experiences, lectures and self-directed activities about personal health/self-care, and sessions to help students connect humanism with professional practice.( The effectiveness of these approaches in reducing professionalism problems is unclear.

HUMANITIES AND GERIATRICS

Caring for older people requires skills in communication, critical thinking, comfort with uncertainty or ambiguity, and empathy. Trainees who are comfortable with their own skills in these areas may be more likely to view geriatrics care positively. These attributes are potentially affected by exposure to the humanities, but there have not been studies of the impact of humanities curriculum on interest in caring for seniors or careers in geriatrics. Table 2 provides examples of curriculum that may foster trainees’ interest in geriatric care.

TABLE 2.

Curriculum possibilities to increase interest in caring for elderly

Social Sciences	Training in critical thinking Understanding of ‘cognitive dispositions to respond’ and cognitive aspects of decision-making Ethical issues in geriatric care (capacity, autonomy, etc.)
Narrative medicine	Close reading of patient essays on experiences in health care Reflective exercises on patient narratives Reflective exercises on student experiences in caring for seniors Personal reflections on elderly family members’ experiences with health and healthcare Close reading of poetry or prose related to ageing
History	Historical biography projects to highlight changing perspectives and values of healthcare Projects related to specific aspects of history such as hospitals, hospital architecture, or pharmacy to highlight changing approaches to caring for seniors Historical events through the eyes of the elderly patient Ageism in healthcare
Arts	Projects or sessions discussing portrayal of ageing in the media and the arts Learning the skills of listening to music or interpreting painting to teach skills in observation, tolerance of ambiguity, lateral thinking Book or film clubs related to ageing and healthcare Performance or writing of theatre pieces related to ageing

Social Sciences

Ken Rockwood has suggested that we celebrate the complexity of geriatric care, as it is part of what makes the specialty appealing and interesting.( As with the field of economics, medicine is increasingly aware that our complex decisions and thought processes are influenced by far more than clinical knowledge. The concepts discussed in popular books like “Thinking, Fast and Slow” by Daniel Kahnman are interesting, but also highlight the pleasures of the intellectual challenges and potential pitfalls of geriatric care. The popularization of cognitive aspects of decision-making by physicians like Jerome Groopman is particularly relevant to the care of older patients with multiple co-morbidities and with poorly described histories and atypical presentations. Exposure to finding from social sciences like psychology and sociology, and recognition of cognitive errors such as “premature closure” or “diagnostic momentum” can have a big impact on our success as clinicians working with frail seniors.

Narrative Medicine

When asked why they chose geriatrics as a career, clinicians sometimes say, “I love the stories.”( Narrative medicine may be a mode by which we allow trainees to celebrate the stories we hear and are part of. Although the definitions vary, narrative medicine connotes an emphasis on the stories patients tell us related to their illness and on the practitioner’s understanding of the complexity, context, and content of the patient’s symptoms and illness. As Rita Charon has said, “Sick people need physicians who can understand their diseases, treat their medical problems, and accompany them through their illnesses.”( These skills are crucial in caring for older people and promoting development of narrative skills may increase the appeal of geriatric care.

Narrative medicine is closely linked in some curriculums with reflective practices, where narratives of experiences and patient encounters are used as fodder for reflection and learning.( When practiced to its full depth, narrative medicine attempts to increase practitioners’ skills in attention, representation, and affiliation. Attention refers to the clinician’s efforts to develop a full understanding of the patient’s situation with an emphasis of interpretation of the words used. This skill is clearly needed for picking up nuances in the older person’s history. Charon uses “close reading” of prose and poetry to teach skills of attentiveness for clinical practice. Representation uses narrative writing to help practitioners to elucidate parts of the story that might otherwise have been hidden. Skills to interpret the meaning of narrative writing are taught with techniques used in analysis of other forms of writing. Attention to the writing of clinical notes can be taught as a way to connect the clinician with the sufferer. The goal of attention and representation is affiliation—between doctor and patient, nurse and physician, and inward for the clinician.(

This approach does not imply that the physician must listen to long anecdotes about the past from older patients. However, geriatric care requires patience and skills to gather the necessary information to develop a management plan. This can be very difficult for trainees and lead to frustration with geriatric care. Strategies like role modelling are important, but formal exposure to narrative medicine principles may improve outcomes for patients and trainees’ comfort with caring for seniors.

The life experiences of seniors, especially the very elderly, are quite different from those of most medical trainees and may stand out from the narrative experiences of younger patients. Strategies to expose students to the stories of older patients and allow them to integrate and reflect on the stories may overcome possible ageism encountered in training. As noted above, a pilot study at University of Toronto used narrative strategies to improve reflective writing related to CanMEDS roles and found that the process was viewed positively and seemed to have an impact on understanding of CanMEDS.( A similar approach could be used to allow students to examine their attitudes to working with the elderly and the impact of their attitudes on career choices and focus of practice.

History

The stories many clinicians enjoy hearing often reflect an interest in history; our elders are a glimpse of a life students can only read about. A better understanding of the history of medicine and how social context affects the health care and medical opinions and norms of the day can be a tool for teaching current medical principles and culture. Study of history provides students with insight into how the values of the era influence perceptions of research and clinical practice. This can help foster greater comfort with ambiguity, particularly relevant in a generalist specialty such as geriatric medicine. As an example, the Heroes and Villains course at Queen’s University has first-year students research a noted historical medical figure and decide if they are a ‘hero’ or ‘villain’ (or both). In addition to these benefits, increasing students’ interest in history and the past may increase interest in providing care for those patients who have experienced the history firsthand.

The Arts

As noted, ageing has always been a common theme in the arts. Although the portrayal of ageing in popular culture is not always positive, ageing may be appear in literature and film in ways that increases empathy and understanding, or highlight the complexity of the patient’s experience. The Canadian Geriatric Society (CGS) has developed a reading list and a collection of films related to ageing that can be used to promote interest in ageing (www.canadiangeriatrics.ca). Strategies like “book clubs”, film nights, blogs, and theatre productions have been used to expose students to a variety of topics in interesting and meaningful ways.( Scholarly work, such as the analysis by Hogan and Clarfield of ageing portrayed in The Lord of the Rings,( may spark individual students’ interest in looking at ageing in different ways. Use of arts to understand the experience of dementia from the patient, caregiver, and physician perspective may help students to deal better with the challenges of dementia care.( The photographic works of Mark Nowaczynski may change attitudes and understanding of the challenges older patients face in their homes.( Study of the arts has been shown to improve aspects of critical thinking, analysis, and observation. These skills are very important in outcomes of care, but also affect the satisfaction of the physician providing care.

Strategies to expose students to seniors in non-clinical contexts also have potential to affect attitudes in clinical work. The London Intergenerational Gala has been held for ten years and allows seniors and students to attend a dinner and dance together. The event has been shown to positively affect students’ perceptions of caring for older patients.(

CONCLUSION

There is increasing interest in the use of humanities in medical education and some evidence of positive effects. Little study exists of the role of humanities exposure on geriatric education or trainees’ career choices. Facets of medical humanities, including history, reflection, understanding of decision-making, and representation of ageing in the arts, may be positive factors in students’ perceptions of caring for seniors or their choice of a career with a focus in geriatrics.