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Don't cry for us Argentinians: two decades of teaching medical humanities
  1. Leopoldo E Acuña
  1. National University of La Plata, Argentine Republic

    Abstract

    Medical humanities—history, literature, anthropology, ethics and fine arts applied to medicine—play an important role in medical education. For more than 20 years an effort has been made to obtain an academic identity for such a multidisciplinary approach. A distinction between humanitarianism and humanism is attempted here, the former being associated with medical care and the latter with medical education. In order more precisely to define the relationship between the arts and medicine, an alternative term “medical kalology”, as-yet-unsanctioned, coined after the rules of medical terminology, is proposed.

    The Department of Medical Humanities in the School of Medicine, National University of La Plata, submits the following apologia: Don't cry for us Argentinians, since the teaching of medical humanities has helped our doctors to function more truly humanistically during the past two decades, and we intend to continue with this calling in the future.

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    Introduction

    The University of La Plata in Argentina was founded in 1897, and its school of medicine was created eight years later, in 1905. The contents of the latter's curriculum followed the example of the most prestigious medical schools in Europe and the United States, and in the first years of this century medical education flourished. Sir Arthur Conan Doyle's second most famous character, Professor George Challenger, thought to be based on one of Sir Arthur's own professors, had academic links with various famous universities, among them La Plata.1 In those days La Plata was reputed to be at least the equivalent of similarly prestigious institutions, in the northern hemisphere. Unfortunately this situation deteriorated during the following decades and the university eventually fell below the prevailing international standards for excellence. Moreover, as a consequence of both the enormous development in global technology after the second world war and our educational orientation along those same lines here in Argentina, there was a relative decline in humanistic values during that time, particularly within the area of medical practice. The need to renew teaching methods, and the challenge to rehumanise doctors' personal attitudes towards their patients therefore became priority issues in La Plata.

    During the mid-70s, despite this period's constituting the eye of a national sociopolitical storm, certain initiatives were seriously considered by the medical school, with the aim of addressing the crisis in medical education and gaining a complete and comprehensive understanding of the various aspects of human disorders. In order to achieve these goals, the introduction of medical humanities as an academic discipline, among other projects, was recommended.

    The introduction of medical humanities

    Medical humanities became part of the curriculum as early as 1976 as a non-compulsory element. It included philosophy, anthropology, and the relationship between medicine and the arts. It was not entirely an academic success. Medical students considered such approaches to be theoretical, irrelevant to their training and superfluous, to say the least. This point of view prevailed perhaps because initially those subjects seemed ill defined or overlapped the already existing sociomedical subjects within the medical curriculum. In those days, in fact, the humanitarian behaviour, which a doctor was obliged to practise, was felt to derive directly from the Hippocratic Oath and was thus an obvious, natural consequence of the virtuous technical education that each student was already routinely destined to receive.

    Thus at this point, it was felt that the difference between humanitarian and humanistic behaviour had to be stressed in order to define more clearly the role of medical humanities at the medical school, for medical humanitarianism and medical humanism were not the same thing. In fact a large part of the justification for introducing the humanities into medical education lay in the subtly different nuances of meaning between these two terms. “Humanitarianism” had been traditionally related to the doctor's professional attitude of compassion, charity, and beneficence towards those who suffer. For young doctors to achieve these qualities it had thus far seemed sufficient for those individuals simply to follow the example of the daily practice of their prestigious professors at the medical school. The Oath of Hippocrates clearly states that he who fulfilled the oath would keep patients “from harm and injustice”. Furthermore he would consider that if the one who had taught him the art were in need of money he should give him a share of his own; and that with regard to patients he should work for the benefit of the sick.2 But “humanistic” meant something different. This term referred to the personal level of sensitivity towards, understanding of and involvement with the patient that a prospective doctor could acquire through a humanities-oriented medical education.

    We hastened to define these words. “Sensitivity” referred to a doctor's ability morally to register and assess his/her own behaviour towards the patient. “Understanding” stood for the capacity for sympathising, for seeing from the sufferer's point of view. “Involvement”, finally, stood for the extent of a doctor's self denial in the assistance of someone seeking help. It was intended then to make clear for a young twentieth-century doctor that his/her covenant concerning a humanitarian attitude was still absolutely necessary, but no longer sufficient. A first provisional conclusion read like this: humanitarian physicians looked after their patients, but did not always behave humanistically. The reverse was less likely to be true, and we believed that a doctor whose training was supplemented by a humanistic education would rarely fail to attain a more profound personal involvement in his/her work.

    The unique atmosphere of the doctor-patient relationship appeared to provide a valuable arena for demonstrating medical humanism. To this end, the example of the American usage of “humanities applied to medicine” appeared a reasonable model to adopt. Already by 1965 the United States Congress had created the National Endowment for the Humanities, aimed at a rehumanisation of the use of technology. Among the general principles cited was the statement that

    “… a high civilization must not limit its efforts to science and technology alone but must give full value and support to the other great branches of a man's scholarly and cultural activity, in order to achieve a better understanding of the past, a better analysis of the present, and a better view of the future. Democracy demands wisdom and vision in its citizens and it must therefore foster and support a form of education designed to make men master of their technology and not its unthinking servants.”3

    The introduction of medical humanities into the curriculum was thus justified on the following grounds:

    1. in the developed countries, there had been an innovation that was highly relevant to health care with respect to the teaching of non-technical medical issues;

    2. it was then not only possible but highly desirable in view of our previous three years of experience to introduce those innovations into our curriculum, and

    3. no overlapping or duplicating of subjects would occur: humanitarianism was both socially oriented and directly related to medical training, while humanism was individually oriented in practice and associated, instead, with medical education.

    In 1980 a Department of Medical Humanities was officially created.

    The department of medical humanities

    The activities in the department of medical humanities were originally described as complementary to medical education. Courses and seminars were attended by recently graduated physicians attempting to gain specialty-level academic credits towards some particular fields of medical practise that would be open to successful participants.4 Difficulties with this scheme, however, soon arose. In general, participants had no theoretical background in philosophy, no real interest in anthropology, and were reluctant to consider the arts as a priority in medical education. Axiology and epistemology—understood respectively as a general theory of values and as the findings of scientific knowledge—seemed attractive global paradigms, but proved complicated for an everyday approach towards humanisation of medical practice. These attitudes became especially reinforced by the fact that the non-medical professors who were responsible for teaching in these areas were not held in very high esteem by the undergraduate medical students. Somehow we were experiencing the same difficulties we had faced a few years earlier. Something had to be done. It was then decided to:

    1. encourage a medical humanities education abroad for young members of the faculty;

    2. promote undergraduate participants on the basis of regular course attendance as the only criterion for performance evaluation (there being no formal assessment), and

    3. organise a course, initially, in a single classical humanistic discipline, ideally one which was in some way already familiar to all participants.

    The first of these objectives was initiated in prestigious universities within both the United States and Europe—and there mainly in Spain and Germany. This decision was wise, for apart from providing academic skills for new teachers and professors, such international links represented, both then and now, the basis for domestic acknowledgment of the academic value of medical humanities as a discipline.

    History of medicine

    History of medicine was initially selected for the annual course as the single classical humanistic discipline. Short texts from well-known medical writings—usually no greater than three pages in length—were chosen (for example, The origin of modern anatomy, from Vesalius's De Humani Corporis Fabrica).5 Participants were expected to comment on each selection. Whenever possible, texts were analysed during a single session, thus allowing participants (the majority of whom were young doctors) to finish the work in less than an hour. Although no deep analysis was ever achieved, this approach was nevertheless found to be appropriate: participants contrasted these sessions, and favourably so, with their daily medical activities in the office or at the hospital. The course also seemed to promote extensive voluntary reading of non-technical literature on the part of the students. It was, and still is, well accepted and at that time provided a wide range of teaching and learning possibilities.

    Participants suggested that if the analysis of texts were to be the central activity, another approach was possible. This involved a seminar on the analysis of literary writings (offered during subsequent terms), as well as continuing the original course with its orientation around medical texts.

    Medicine and literature

    Non-technical literature proved to be a useful means of defining more clearly the humanistic as opposed to the humanitarian aspects of our department. A line by the Spanish poet, Antonio Machado, (1875—1939) depicted our academic status in those days: “Caminante no hay camino, se hace camino al andar” (“Wayfarer, there isn't any road; you make the road as you go on”).6

    In 1983, a regular course on medicine and literature was offered to students and young doctors. Again excerpts from well-known books and other works were used rather than complete texts, and were classified according to three categories: first, texts by medical doctors on non-technical medical issues, for example, Sir Arthur Conan Doyle's Doctors, Richard Selzer's Rituals of Surgery, and the Argentinian physician Baldomero Fernández Moreno's On Call in La Plata; second, texts also by medical doctors but on non-medical topics, for example, poetry by John Keats and William Carlos Williams and short stories by Chekhov and by W Somerset Maugham, and finally third, texts by lay authors, but dealing with aspects of medicine, for example, the Italian playwright Luigi Pirandello's one-act pieces such as The Doctor's Duty or Man With a Flower in His Mouth. The analysis of theatre proved particularly effective since participants took the parts of characters in play-reading performances during the sessions. Each class thus turned into a sort of “medicine-drama”, with noteworthy personal involvement on the part of the participants, again considered to represent the sort of involvement we referred to above as being necessary for humanistic behaviour.

    Medical anthropology

    This was the second academic discipline that survived from the original medical humanities curriculum. A good part of the success could be attributed to the participation of a professional anthropologist who addressed the students using language from the natural sciences as well as medical terminology. In Argentina, internal migrations during the previous fifty years had brought native Americans into the cities. These individuals spoke our official language of Spanish but also retained their own languages and dialects. Such ethnographic phenomena had already been widely studied by sociologists and anthropologists; but within the specific field of medicine, the development of medical anthropology ended up working as a sort of bilingual medical dictionary between dialects and Spanish, thereby helping to connect those communities more effectively with Western medical-care systems.7 The regular annual course on medical anthropology was considered by young professionals as the closest one to everyday medical practice. Having taken particular account of this fact, the department proposed a more rigorous method of performance assessment. Multiple-choice exams were designed to test the level of knowledge in these areas.

    In the following years medical anthropology was also incorporated into other departments at the medical school, which have, ever since, participated in its teaching.

    Bioethics

    During the mid-80s previous medical progress in areas such as organ transplantation, prenatal diagnosis of genetic disorders, and in vitro fertilisation began raising new moral issues in the field of medical practice; which questions, in turn, became germane to those interested in the study of medical humanities. Indeed, the introduction of the new discipline of bioethics in medical schools all over the world, in the attempt to address such concerns, provided an original approach to the doctor–patient relationship and also offered the opportunity for novel multidisciplinary ways of dealing with certain emerging health care problems that had thus far been considered only from a purely medical vantage point. Although not present in our original prospectus for the medical humanities curriculum, a course in bioethics based on the guidelines issued by Georgetown University in the US was then established. During the academic terms that followed, this innovative course established its own momentum. Eventually the study of bioethics separated itself from that of medical humanities, as also happened in universities elsewhere.

    At the present time, a course entitled Introduction to Biomedical Ethics is being conducted by the department, but here again the teaching load is shared with other departments at the medical school such as those of legal medicine and social medicine.

    History of medicine, medicine and literature, medical anthropology, and bioethics have thus far constituted the four distinct disciplines subsumed under the overall umbrella of the Department of Medical Humanities. All four were fashioned after corresponding examples from abroad. It was accordingly felt that perhaps a local, ie domestic, initiative would help to motivate prospective participants towards the pursuit of study and research in the field of medical humanities. Once again, the idea of a multidisciplinary approach seemed attractive.

    A proposal from the department of medical humanities in La Plata University: medical kalology

    The relationship between the arts and medicine has been widely addressed in medical humanities, but nevertheless in a rather unclear way. If the art involved were to be music for instance, the relationship with medicine could have been described as rhapsodic (a rhapsody being a musical composition of irregular form having an improvisatory character).

    Under the broad rubric of medical aesthetics, the general features of the fine arts and music have been used in teaching medical humanities.8 At the medical school it soon became clear that, as had been true of the terms “humanitarian” and “humanistic” when the department was founded, the chosen phrase “aesthetics in medicine” was ambiguous for teaching purposes. Students took the term to mean things completely different from what was intended. For instance, they might construe “asethetics in medicine” as referring to classical aesthetic surgery, cosmetic medicine or even body-building, but seldom would they arrive at the desired definition of an educational discipline in the field of medical humanities that relates the arts to the practice of medicine. An attempt was thus made in La Plata to delineate the relationship between the arts and medicine more rigorously and to show how the interaction between them was relevant to medical education.

    It was felt that a good starting point was to try to find an alternative wording that would more accurately, and perhaps more medically, define the relationship between the arts and medicine, including the links beteween music and medicine. (Music therapy is excluded from consideration here: music as a means of therapy does not form a part of the medical humanities' approach to medical education.) Western medicine was born in Greece in the 5th century BCE. Most of the technical names in medicine come from the Greek, as does the neologism, medical kalology, proposed here. (Medical kalology is an as-yet-unsanctioned term coined by the department).9 Kalòs is translated as “beautiful” and refers to beauty in music and in the dance.10 Coined after the traditional manner for most other medical terms, and fully respecting the norms of medical terminology,1112 perhaps “medical kalology” will appear less ambiguous, even more “scientifically” medical as students usually demand, thus supplying a specific name for a hitherto rather vaguely-termed educational discipline. The next step forward was to set out some characteristics of this discipline. Medical kalology, first and foremost, concerns the teaching of all aspects of the relation between music and medicine. “Kaloiatrics” refers to the practical application of this teaching in clinical medicine. Just as “paediatrics” and “geriatrics” refer to the care of children and the elderly respectively, “kaloiatrics” names the so-called medicine of the arts, among them the therapeutic engagement with the performing arts.

    Medical kalology seminars were accordingly held in 1993 both in La Plata and—as a result of an international agreement with the Ruprecht-Karl Universität—at the Naturwissenschaftliche Fakultät in Heidelberg, Germany. For example, a course on music and medicine was offered under the title, The Physician on Stage: Opera, where the roles of medical characters in opera were analysed. Participants read through librettos while listening to the music. Both the German and the Argentinian participants found this use of opera to be a valid and original way of depicting different aspects of medical practice, distinct from that seen in other artistic genres. From that point onwards, the operas selected for teaching purposes were classified according to three categories13: first, those in which doctors are featured, but not as engaging in their medical practice (good examples are Dr Giovanni da Procida in Giuseppe Verdi's Sicilian Vespers and the anonymous Herr Doktor in Alban Berg's Lulu); second, those including in the cast doctors who fail to abide by their medical oaths (such as Dr Malatesta in Gaetano Donizetti's Don Pasquale or the quack physician Dulcamara in L'Elisir d'Amore, also by the same composer), and third, those featuring genuine practitioners on stage (this authenticity of representation is clear in the sensitive attitude of Dr Grenvil in Verdi's La Traviata, and in the understanding exhibited by the nameless doctor in Claude Debussy's Pelléas et Mélisande).

    As Sir William Osler insisted, when referring to bedside reading for medical students and doctors, physicians on stage in such portrayals serve as a valid means of contributing to medical teaching in order to provide “the education, if not of a scholar, at least of a gentleman”.14

    The department of medical humanities today

    More than twenty years have elapsed since the first attempts at teaching medical humanities in La Plata. History of medicine continues as the core course; medicine and literature has been accepted as a valid alternative; bioethics and medical anthropology are offered by more than one department of the medical school; medical kalology is striving for acceptance under that name.

    The overall size of our faculty is very large by international standards: about 500 students are admitted each year. However, a gigantic remora [backlog, very loosely translated] of about 6,000 un-graduated “chronic students” makes teaching troublesome. Under local university regulations students may remain at the university even if they do not fulfil their compulsory obligations, semester after semester. The educational authorities have been working on this issue for years, but nevertheless it remains unsolved at the present time.

    Course attendance in medical humanities has been stable for over two decades and has now gained an additional 50% through volunteer enrolment. The number of students, graduate and undergraduate, who take part in our activities per year is around 50. A major drawback, however, has been the lack of adequate course evaluation. Effective systems of assessment have yet to be designed. Once adapted to the new criteria in medical education, these modes of feedback should both reflect the knowledge acquired by the student and also characterise eventual changes in attitude on the part of these fledgling doctors towards their patients. The monitoring of such changes could be achieved by measuring medical performance as perceived “from the other side of the counter”. In short, patients' opinions on their relationships with their doctors should be included in the reckoning at the time of assessing physicians' changes in attitude, with respect to sensitivity, understanding, and personal involvement.

    Conclusions

    During the past two decades medical humanities has been taught at the school of medicine in La Plata, Argentina with the conviction that it could help to improve the quality of medical education as a whole. Some of the constituent subjects originally gathered under the broad spectrum of medical humanities were abandoned or fell by the wayside. The failures along the way were generally subjects that were perhaps too distant from everyday medical practice and from a physician's immediate professional interest. It is probably true that there is nothing more practical than a good theory, but this notion is something that a young doctor does not always accept.

    Although the availability of and proper training in state-of-the-art medical technology is absolutely necessary in the field of modern-day health care, in the majority of situations this potential and expertise is, unfortunately, insufficient. Indeed an adequate level of humanistic medical education is desirable to counterbalance the impersonal power of scientific development with the intimacy of the doctor's everyday contact with patients.

    The underlying essence of the teaching of medical humanities as an academic discipline has always been aimed at trying to shift the concept of medicine as a healing art towards the more humble, less pompous, yet thoroughly realistic depiction of medicine as an alleviating art.

    For all these reasons, we would submit the following apologia: “Don't cry for us Argentinians”. The teaching of medical humanities has helped our doctors to function more truly humanistically for the last twenty years, and we fully intend to continue with this calling in the future.

    References

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    Footnotes

    • Leopoldo E Acuña, MD, PhD, is Chairman of the Department Medical Humanities, School of Medicine, National University of La Plata, República Argentina, Calle 60 y 120 La Plata (1900). Phone/Fax 54 0221 427 0795; solmayor{at}netverk.com.ar.

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