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In the first issue of this journal Greaves and Evans1 characterised the medical humanities as a spectrum with an additive view of the relationship between humanities disciplines and medicine at one end and an integrated view at the other. The first part of the paper by Louis-Courvoisier and Wenger2 represents a good example of the integrated view of medical humanities, addressing as it does a theoretical underpinning for the inclusion of the teaching of history and literature in medical education, the practical value of this teaching for medical students and the tools provided by these disciplines to the teaching of medical students. The second part of the paper deals with the difficulties both actual and potential for teachers in delivering such a programme. The discussion of these areas is based on their own experience but may have much wider currency and provide a detailed reflective account of areas of importance to the place of Medical Humanities in medical education.
The main theoretical concept that they claim is common to all the humanities disciplines is that of “distancing”, by which they appear to mean that they are all involved with investigating the gap between an object and how we understand that object. They distinguish two types of gap: the diachronic temporal gap exemplified by historical investigations and the synchronic gap between an idea and the expression of that idea in language as exemplified by literary studies. However, whichever discipline is considered, there are bound to be both diachronic and synchronic aspects to any such gap. What is key is that they all involve achieving an understanding of the object which is “context dependant and culturally shaped”. In other words recognising what Gadamer3 termed the horizons of understanding and eventually achieving a shared understanding where possible. Their claim that “distancing” is common to all humanities disciplines seems reasonable but is it the most important concept in relation to the place of humanities in medical education?
This idea of “distancing” could be seen to have both an “instrumental” and “non-instrumental” value in medical education as described by Macnaughton.4 In her discussion of the non-instrumental value of the humanities in medical education she identifies the notion of education, as opposed to medical training, as being a valued outcome of the humanities in medical education along with personal development and opportunities to experience a counter-culture to medicine. Each of these three could be fostered by “distancing”. However, it is predominantly the instrumental value of the humanities that is the concern of Louis-Courvoisier and Wenger.2 They identify similar instrumental values to Macnaughton; such as providing a reservoir of vicarious experience, improving analytical and communication skills and improving skills in the construction of arguments. However, they also include the development of specific narrative competences. At first glance this emphasis on the skills of literary criticism may seem excessive for teaching medical students in the context of what they describe as a compulsory course but the arguments they put for its importance seem compelling. It is both consistent with the underpinning concept of “distancing” but also with the increasing acknowledgement of the importance of narrative in medicine.5,6
Distance, and bridging it, seem to be the key to the practical difficulties for teachers discussed in the second part of their paper. They identify four important gaps, which may occur when humanities are included in medical education. The first three gaps (for example, differences in the questions, methods, and language of the humanities and medicine; differences in the pedagogical cultures of humanities and medical faculties; and lack of understanding of medical culture by humanities scholars) are problems inherent in humanities scholars teaching within a medical curriculum. The fourth, that of the distance which teaching humanities within the medical environment may put between humanities scholars and their own discipline, is a consequence of the medical humanities project in medical education. The logic of the solutions proposed seem both necessary and pragmatic but somewhat one sided. As an enthusiast for medical humanities with a background in medicine I am conscious that it is easy for the charge of medical imperialism to be brought.
If the distance between the humanities and medicine is to be bridged in medical education then pragmatic solutions must involve mutual respect. Team teaching has much to recommend it as a bridge. But for it to be a strong bridge, educators from both the humanities and medicine need to make the effort to understand each others’ cultures. If the fourth gap is to be overcome it is important that those making appointments to medical humanities posts in medical schools negotiate appropriate joint appointments for scholars from the humanities. If the distance between us can be bridged with respect then Pellagrino’s ideal of “double belonging”7 will be truly possible within medical education.
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