Medical Humanities has been defined as an integrated, interdisciplinary, philosophical approach to recording and interpreting human experiences of illness, disability and medical intervention.¹ Thus, Medical Humanities may variously include the fields of arts, humanities and social science, and is concerned with how they may provide an insight and understanding for medical practice that is qualitatively different to a scientific viewpoint. The inclusion of Medical Humanities in the curriculum for tomorrow’s doctors can therefore be viewed as a vital step towards the development of a compassionate and reflective practitioner who understands and respects patients needs, and who has a desire to relieving suffering and promote well-being.^2,3 Indeed, the role of arts and humanities in the understanding and practice of medicine is widely recognised.⁴ Friedman argues that emotional and cognitive skills achieved by studying humanities within a medical education setting develop the essence of professionalism within medicine.⁵ It aids an awareness of strengths and limitations of modern medicine, enabling students to develop a sense of social responsibility and a responsiveness to the existential dimension within the patient encounter that acknowledges the emotional, spiritual and unconscious.^6,7 So, the inclusion of aspects of the Medical Humanities within the undergraduate curriculum may facilitate a tolerance of ambiguity within knowledge and develop existential, patient-centred aspects of medicine.⁸

However, Medical Humanities as a technical term is still not established in the wider medical, educational and academic communities and there is much confusion as to what comprises Medical Humanities.⁹ Indeed, the term Medical Humanities is intimately (if problematically) intertwined with other domains such as Professionalism, Inter-Professionalism and Communication Skills. In addition, the term itself is little used within core reading of the medical community. In short, the concept of Medical Humanities appears “hidden.” The BMJ and The Lancet,¹⁰ for instance, apart from citing the journal Medical Humanities, only mentions it a few times. If the concept of Medical Humanities is not transparent to experienced practitioners, how will they as clinical teachers successfully encourage students and junior doctors to develop this perspective?

This study explores how clinical teachers involved in the development and delivery of a new medical school, with Medical Humanities as a core curricular theme,¹¹ understood the term Medical Humanities both as a general concept within medicine to be assimilated by medical students, and as a label for that concept. I wish to add to the current debate concerning the development of the field by investigating attitudes and understanding of Medical Humanities in clinical practice, rather than describing the concept from a survey of the Medical Humanities literature.¹² Therefore, this research was approached using an interpretive framework, without formulating a working definition of Medical Humanities, with the intention of reducing (as much as possible) the influence of researcher expectations during the interviews, thus giving free rein to the consultants.

METHODS

The research was conducted across three hospital trusts in the south west of England involved with the delivery and development of a new curriculum. A purposive sample of 45 clinicians was contacted via letter for participation in a study to look at the role of clinical teachers at the new medical school (15 participants from each hospital trust were involved). Clinicians were from diverse specialities all of whom who had expressed an interest in teaching. This systematic non-probabilistic sampling method ensured that specific people with relevant characteristics for the focus of the research were approached.¹³ Details of individuals who had been approached were anonymous to the researcher. Of the 45 contacted, 16 agreed to participate in the study: 13 men, 3 women, mean duration as consultant 12 years (range 2–22 years). At the time of the research, the first cohort of students was in the second year of their studies at the new medical school and was predominately university based. However, due to the structure of the curriculum, some of the students had already come into contact with clinicians via small group work. Of the 16 participants, two had already experienced teaching sessions, six were actively participating in the development of the curriculum and eight had only indirect contact with the school at that time (eg, put their names forward for teaching). As this was a self-selecting sample from clinicians who were registered at the school as being interested in clinical teaching, no claims are made regarding the representative nature of the participants.

The semi-structured interview method was used as this focuses discussion using prepared questions, whilst allowing for flexibility to follow interesting topics. As not all interviews followed the exact same path, frequency counts will only be reported for instances when every participant experienced the same question. Data analysis was conducted concurrently with data collection; interviews were stopped after no new themes emerged.

Interviews, conducted by the author, lasted between 42 and 93 minutes. The interviews began by asking participants about their teaching and learning experiences, then focused on attitudes and values to be acquired by medical students and the role of the clinical teacher in this. Later the interviews explored the understanding of selected terms, including Medical Humanities. This was introduced to all participants as a standard question in the following form: “There has been a lot of talk recently about the Medical Humanities. What does the term Medical Humanities mean to you?”. It is important to note that, at no time during the recruitment or the earlier part of the interview was the term Medical Humanities used by the researcher. A copy of the interview framework is available from the author.

The interviews were recorded and transcribed verbatim. The validity of the information was checked: (1) during the interview, asking interviewees to clarify their statements with examples from their own personal experience; (2) following the interview, participants verifying transcripts before full analysis.

Two researchers (LK and RB, see acknowledgements) were involved in the analysis of the data: listening to the audio files enhanced close reading of the transcripts during this period. The researchers initially worked alone, later coming together to discuss and negotiate their findings. Analysis began by examining reactions to the explicit question asked at the end of the interview “what does the term Medical Humanities mean to you?”. These responses are important as they give an insight into possible reactions that medical students may elicit when discussing Medical Humanities with clinicians.

Next, these answers were coded according to the “approaches” that emerged in their descriptions. This process was intended to elicit evidence of the clinicians’ understandings of the term Medical Humanities.

Subsequently, framework analysis was undertaken,¹⁴ managed and facilitated by Atlas.ti software¹⁵ to examine participants’ spontaneous responses given before any mention of Medical Humanities, in order to elicit evidence of their implicit understanding of the issues frequently associated with Medical Humanities.

RESULTS

Reactions to the question

Immediate responses to the explicit request for a definition of the term Medical Humanities were categorised into four groups; Unsure (7/16), Don’t know (4/16), Confident (3/16), Mistrust/Contempt (2/16), see Box 1.

Mistrust or contempt for the term was expressed by both tone of voice and by dismissing the term as being useful only in academic settings or as a ‘catch-all’ term. While a number of clinicians didn’t know what the term meant, many were unsure, even if they had used it themselves. However, some clinicians confidently produced a definition. Interestingly, these differed greatly in content and approaches.

Explicit definitions of the term Medical Humanities

Twelve clinicians went on to define what Medical Humanities meant to them (those who didn’t know did not attempt this). While diverse, definitions fell into three main approaches to Medical Humanities. We labelled these ‘Humanistic-holistic’ (6/13), ‘Humanities-medicine separate’ (4/13) and ‘Intellectual exercise’ (2/13) approaches, each comprising a number of inter-related topics (Box 2).

The Humanistic-Holistic approach, most common amongst clinicians, considered Medical Humanities to be inextricably entwined with the science of medicine. However, while most felt it natural to link humanities and medicine, others considered them separate, or were aware that they might be perceived as separate by individuals who fail to relate to the interaction between the two (Humanities-medicine separate). Finally, within the ‘Intellectual exercise’ approach, respondents highlighted ethical, moral and philosophical ‘subjects.’ This approach was closest to the Humanistic-holistic approach whereby there was an acknowledgement of the importance of the humanities within medicine, but it appeared to be a more constrained, functional view.

Implicit understanding of Medical Humanities

Before any mention of the Medical Humanities by the researcher, all respondents initially talked about concepts and issues that underlie views and debates within Medical Humanities in the context of everyday practice. We classified these concepts into six main themes, comprising a number of sub-themes identified from the data (see box). From this, we can see how consultants’ spontaneous statements in a general conversation about the role of clinical teachers in medical education cover much of the field studied by Medical Humanities.

Professionalism and professional identity (Theme 1) was a major concern for clinicians (examples in Box 3). While in the US, there has been a trend to merge Medical Humanities into the development of professionalism, the UK field is currently broader. Interviewees discussed personal values within students, helping them to display “honesty and integrity, acceptance of their fallibility” (Interview 11), while recognising that students come with their own values and ethics; a sentiment that is frequently echoed within the Medical Humanities literature.¹⁶

Consultants also stressed the importance of recognising and dealing with Clinical reasoning and uncertainty (Theme 2, examples in Box 4). Literature in the Medical Humanities deals extensively with these issues, critically discussing the relevant merits of different approaches, for example, the usefulness of Chaos theory and how to better prepare medical students for later practice.¹⁷

Approaches to medical care (Theme 3, examples in Box 5), included understanding the role of the doctor, and of medicine in society, were commonly discussed by clinicians. This has long been considered within the history of medicine;¹⁸ one of the original constituents of Medical Humanities. Unsurprisingly, Patients’ experience of illness, communication and death (Theme 4) were discussed. Clinicians frequently talked about empathy. Indeed, “what patients actually experience” (Interview 9) is perhaps the central remit of Medical Humanities (examples in Box 6).^19,20

The nature of medicine and medical humanities (Theme 5, examples in Box 7) considered aspects such as thought collectives; “to get [students] thinking like” whatever speciality they enter (Interview 9) and to learn “what to think about in medicine and what not to do” (Interview 11). The way students are inducted into medicine is discussed within the Medical Humanities.²¹ Moreover, the question of whether medicine “is a sort of art rather than a science” (Interview 10) is another classical issue.²²

Ethical issues came up in most of the interviews and comprised the final theme Values and ethics in practice and education. Respondents appeared to agree “the amount of ethics […] is appropriate for nowadays” (Interview 3) and would consider teaching “issues and ethics” (Interview 12). However, notes of caution were given, for example, “you can teach the theory of [ethics] but actually you can’t teach how to deal ethically with patients except by being with doctors and patients” (Interview 4). Moreover, some interviewees discussed a virtues-based approach to ethics while others discussed a principles-based approach.^23,24

DISCUSSION

Explicit definitions of the term Medical Humanities

Medical Humanities, as a term, was not recognised by many clinicians in this study. When asked for a definition, three approaches to the understanding of Medical Humanities emerged: most clinicians approached it in a holistic, integrated manner within medicine, although some considered it separate to medicine, or as an intellectual exercise. However, prior to any mention of the Medical Humanities, all clinicians freely raised issues within Medical Humanities as being of vital importance for them to get across to medical students during their training. These included patients’ experiences of illness, clinical reasoning and uncertainty, and professional identity.

Strengths and weaknesses of the study

This study has some methodological strengths and limitations that should be considered. Firstly, semi-structured interviews were used. Direct observations of clinician-student interactions would be necessary to verify that the implicit and explicit messages we found are present in the teaching and learning context. Caution must be used when attempting to generalise the results. As this was a qualitative study using a small non-probabilistic sample, for generalisability, quantitative techniques and adequate sampling are needed.¹³ However, the use of semi-structured interviews is of particular importance to the development of themes and topics for further investigation; therefore, one strength of this methodology is that of hypotheses generation. The three approaches to Medical Humanities identified here, and the suggestion that clinicians acknowledge issues central to the Medical Humanities in their day-to-day teaching practices should be viewed in this light. Finally, data was collected from only one medical school, albeit from three hospital trusts. Even so, the results are important for a number of reasons: To our knowledge, this is the first study to investigate clinicians’ attitudes to Medical Humanities, and the further development of the field will depend crucially on the interaction between clinical practice and academic research, not impeded by the lack of shared terminology and concepts.

Meaning of the study: possible explanations and implications for clinicians and policymakers

The term Medical Humanities appeared to be vague or even invisible for many clinicians; giving it a name caused a number of potentially unwanted reactions that could be problematic when students discuss Medical Humanities aspects of their curriculum with clinicians.

The definitions elicited sometimes described the humanities in an additive, disciplinary way and reflect one understanding of Medical Humanities. However, spontaneous references prior to asking the question revealed a far more integrated, if implicit, understanding; raising many important elements of Medical Humanities.¹² All interviewees highlighted the importance of helping medical students develop their humane qualities. Yet there was difficulty in agreeing on the term itself, which some felt to be “silly”, “vague” and “unnecessary.” Attitudes to the Medical Humanities present in the context of clinical teaching therefore remain unknown, although we suspect that more positive than negative attitudes might be present implicitly.

The author suggests that focussing attention on the shared values and attitudes found in this study might offer a way of addressing the mistrust or contempt that some clinicians may hold. As for the term Medical Humanities itself, this study indicates that educators in the area need to either establish the term as shorthand for the implicit artistry of medical practice or develop a new term that better reflects the implicit understanding that physicians have of this concept. Such a shorthand will enable elements of this hidden concept visible and accessible to conscious learning and teaching to facilitate the development of the humane side of healthcare practice in a more efficient, transparent manner.

Whether the Medical Humanities, as the plural suggests, is a collection of individual disciplines, or whether they form an integrated approach to medical education and clinical practice was as controversial an issue for the consultants that were interviewed as it is in the current literature.³⁶ Indeed, several of the existing Medical Humanities programmes do provide formal teaching in individual disciplines from the humanities and human sciences.^37,38 However, a more integrated position seems to be becoming more widespread in the Medical Humanities literature.³⁹

FUTURE RESEARCH

The interviews were conducted before students from the new school were learning in the hospitals to any great extent. We plan to undertake a follow-up study researching clinical teacher-student interaction, with particular attention to the concepts within Medical Humanities.