The alleviation of suffering has been described as a central goal of medicine. A familiarity with this subject may have great practical benefit, while promoting reflection upon medicine more generally. This paper describes a study day for medical students that encourages them to think about suffering. A variety of texts in different media were used as the basis of group discussion. Sources reflected the range of suffering that may be encountered, including suffering from causes not normally considered to be “medical”. An evaluation of the study day was performed, using the nominal group technique, suggesting that the day was both popular and had achieved its goals.
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The Nature of Suffering and the Goals of Medicine by Eric Cassell offers a positive critique of the ongoing preoccupation with “disease” in Western medicine. As Cassell boldly declares in the preface to his book: “The test of a system of medicine should be its adequacy in the face of suffering; this book starts from the premise that modern medicine fails that test”.1 Cassell is keen to encourage understanding of suffering for practical benefit in the alleviation of distress. Furthermore, he sees an engagement with the concept of suffering as encouraging philosophical reflection about purpose of medicine.
This paper describes a “day of suffering” study day to introduce Cassell’s ideas to medical students, both for their practical benefit and to encourage reflection about medicine more widely. Once again the Special Study Module (SSM) prevalent in UK medical schools proved a forum for the inclusion of medical humanities in undergraduate teaching.2 This study day was offered to 3rd year students attending nine week full time SSMs run by the Department of General Practice, at the University of Wales College of Medicine. Eighteen students attended: four who attended a course in philosophy and medicine, and seven each from the other courses with no formal philosophical content (Chronic illness, and Preventive medicine). The medicine and philosophy students had received an introductory course on basic philosophical method, formal argument, and medical ontology, and had read the first four chapters of Cassell’s book (the core text for their course). The other students had received no prior teaching in this area.
One author (WL) provided the teaching and facilitation for the day while the other (AG) provided the lead in evaluation. It was hoped that collaboration between an enthusiastic supporter of humanities teaching in medical education and a more sceptical educationalist would provide a more balanced consideration of the strengths and weaknesses of the day.
GOALS AND OBJECTIVES
Two main educational goals were identified, one practical and the other more philosophical. First, students should understand more about suffering, its various forms, and how it may be alleviated. Second they should consider the alleviation of suffering as a possible goal of medicine. The objectives of the study were more narrowly defined as finding evidence that the students had reflected upon the nature of suffering and the possible goals of medicine.
The study day was prepared for approximately 20 students using teaching methods that included a mixture of whole and small group work. The students were first asked to identify what they considered the goals of medicine to be. This discussion introduced the conventional view that medicine is about “conquering disease”. This was contrasted with Cassell’s alternative goal—the alleviation of suffering. The students were encouraged to reflect upon the goals of medicine throughout the day, and disagreement with Cassell’s view was permitted.
An introduction outlining Cassell’s basic ideas about suffering and medicine’s response was given to the whole group, followed by a brief extract from the Woody Allen film Hannah and her Sisters.3 This depiction of a patient attending his doctor with slight hearing loss, but becoming convinced he has a brain tumour, was used to show how suffering is a whole person concept, occurring when the integrity of that person is under threat, differing between persons and not identical with pain.
The students were then divided into four small groups, each of which discussed a text illustrating a variety of suffering that they may encounter. Extracts used were from Snake Oil by John Diamond4 (iatrogenic suffering in the context of disease); Yosl Rakover Talks to God by Zvi Kolitz5 (spiritual suffering); the painting Guernica by Picasso (suffering due to war), and the song Street Spirit by Radiohead6 (existential suffering). After discussion each group reported back to the main group, where further discussion took place.
The small groups then turned to texts illustrating possible responses to suffering. These extracts were from Withnail and I7 (the challenge of “trivial” suffering); When I consider how my light is spent by John Milton8 (reframing suffering); a drug company advertisement (commodification of suffering), and the adagio from Mahler’s 9th Symphony9 (the witnessing of overwhelming suffering).
Next the whole group discussed A Lie Softly Spoken10 where the suffering of the doctor was highlighted, along with an extract from Plato’s Republic11—suggesting that doctors may benefit from suffering. Finally, Hannah and Her Sisters was revisited, showing how the patient originally encountered escaped from suffering (by watching a Marx Brother’s film).
A questionnaire, even one with space for comments written free hand, might not have explored the students’ own experience of the day and determined whether the aims had been met. For this reason the nominal group technique (NGT) was used.12
One student (from the chronic disease SSM) was unable to attend the evaluation, so two groups of eight and nine students respectively were formed, facilitated by the authors. The division into two groups for evaluation served a practical purpose, in allowing the NGT method to proceed more quickly, and is recommended by Delbecq.12 Groups were formed on the basis of the students’ position within the room, and this inadvertently led to group 2 (WL) containing all of the students studying the philosophy of medicine SSM.
Step one consisted of students writing their comments on a piece of paper. They were asked to do this in complete silence and not to look at what their neighbours were writing. The question they were asked to address was: “What are the strengths and weaknesses of this study day on suffering?” Students were encouraged to write as many comments as they wished.
Step two comprised the “round robin” stage. The purpose of step two is to record all the ideas of group members on a flip chart where they are easily visible. The facilitator goes round the group in turn and asks group members to read out one idea from their list. This continues until all the ideas have been written down. Ideas are taken down verbatim in the group member’s own words and where there is duplication the facilitator asks the two members if the two may be combined.
Step three is the voting stage. Each group member was given five three inch by five inch cards on which they were asked to write the five items from the list they considered most important. They were then asked to put the cards in rank order giving a number five to the one they consider most important down to a one for the idea they considered least important. The numbers are then collected and the votes for each item counted (see tables 1 and 2).
There was a difference in the responses from the two groups. This may reflect the inclusion of all the philosophy of medicine students in group two, but with such small groups it may merely reflect individual variation among the students.
This study day was concerned with two goals: first, students should understand more about suffering, and how it may be alleviated and, second, they should think about alleviation of suffering as a possible goal of medicine. Evidence of reflection upon suffering and the goals of medicine was identified as a specific objective. The responses “Good to make us think why we are doing medicine and the function of medicine” and “insight into different perspectives into role of doctor” both suggest that they did think about the goals of medicine and the place of suffering in them. Although not given many votes, the fact that another strength listed was promoting discussion of “ways of alleviating (the) suffering (of) people” suggests that at least some of this time was spent thinking about practical approaches to suffering, thereby addressing the first goal. Both groups voted strongly in favour of the use of different art forms during the day, and for the benefits of an enthusiastic tutor. Group one voted strongly in favour of having “time to think”. This alone is of major benefit in a busy curriculum. The two groups differed in their opinion of the clinical relevance of the day.
Most of the rest of the comments were about the structure of the day, most of them positive. The two groups gave eight and five votes respectively for the day having been structured well. Comments about the course also included being “pitched at the right level,” the “examples [not being] too scientifically based” and the “relaxed environment [where] everybody’s ideas were welcome”.
A number of the comments about weaknesses related to the length of time the day took and the structure of coffee and lunch breaks. Students said they would have liked a shorter day with fewer or shorter breaks or that they would have liked either a morning or an afternoon session. The content of the course, the small group format, and being given tasks requiring thought on subjects very different from their normal work might have been exhausting for the students without plenty of breaks, but experiments need to be made with this structure.
The comment that the day was “too philosophical” attracted 15 votes from group two. Although it would be easy to dismiss this by saying that students should expect a high philosophical content from such a study day, it would be valuable to ask them to elaborate on this so that this perceived weakness could be addressed in future years. This comment was somewhat tempered by a request from one student that he be allowed to vote negatively for this statement, as he felt that the day could have benefited from more philosophical content! Furthermore, it may also reflect a reaction within the group to the presence of the philosophy of medicine students; as students from other SSMs suggested this response and were the only ones to vote for it.
TUTOR’S PERSONAL REFLECTION UPON TEACHING EXPERIENCE (WL)
Delivering the study day proved to be both enjoyable and exhausting. All students attending the study day had just endured a gruelling series of university examinations; this proved a useful reference point, as there was universal assent that they had all recently been suffering. The small groups varied considerably in their ability to work as groups and in their skills of engaging with texts. The visual material proved particularly effective in stimulating discussion, while Milton’s poem, When I consider how my light is spent, proved particularly difficult for the students to analyse, although it stimulated a great deal of debate. The inclusion of humorous texts dealing with suffering helped prevent the day becoming too sombre.
The identification of the suffering doctor (in A Lie Softly Spoken) proved a particularly effective element in making the students take suffering more seriously. This effectively placated those who, up to that point, had conceded that suffering was important but not within the remit of medical staff (preferring to leave it to some other professional, such as nurses or counsellors), and facilitated discussion of suffering amongst clinical staff already witnessed by the students.
The “day of suffering” appeared to be popular with students and to have achieved its original goals. Shortening the day while achieving the same objectives might be feasible, probably by using fewer texts.
At least two constituencies for the teaching offered on this day became apparent to the tutor during its delivery, perhaps because the majority of students on the day had not enrolled on a humanities course. Firstly, some medical students are hungry for a reflective engagement with their subject. These students merely need a small amount of facilitation along with suitable sources to thrive. For example, one student gave an excellent impromptu seminar to his small group on the political background to Picasso’s Guernica. Others were seeking immediately tangible benefits from any teaching they received, not seeing the utility of reflection in any real sense. Such students approximate to the “practical clinicians” of Cassell’s work who “disdain all theorists and philosophers”.13 This study day encouraged reflection upon the goals of medicine while also offering some tangible clinical benefit, by suggesting practical responses to suffering.
This dual approach to enthusiasts and sceptics in the student body will be increasingly required of humanities teaching if it becomes part of the core curriculum14 and is no longer confined to the optional space of the Special Study Module. A further response to broadening the humanities role in teaching medical students may simply be a contentment to remain unnamed; the students requesting “less philosophy” had been very active and reflective in discussion and might just have been objecting to this activity being termed “philosophy”.
Thanks to Professor Chris Butler for his comments on this paper.
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