AAMC Reporter, September 2000: 'Healing as Art: Integrating Humanism in the Medical School Curriculum

VOLUME 9, NUMBER 12

JORDAN J. COHEN, M.D., PRESIDENT

SEPTEMBER 2000

Healing as Art: Integrating Humanism in the Medical School Curriculum

By Barbara Gabriel

First-year students at New Jersey Medical
School mark their entrance into the medical
community by affirming their commitment
to humanity in medicine at their White Coat Ceremony.

"Equally difficult is it to criticize the medical man who brings nothing but pure science to his patient's bedside. He certainly does not lack book or laboratory knowledge of physics, chemistry, bacteriology, biology, physiology, or pathology…Of things material he is easily master. But that is only half the proposition. This materialism reveals itself in the tendency to look on patients as so much flesh and blood; to treat the outer casement rather than the individual within; to forget that 'we are such stuff as dreams are made of'; to take little thought of hereditary impress, prenatal influence, temperament, domestic and commercial status and a host of other nonmaterial factors…If the ultrascientist would realize the full measure of his possibilities, he must possess more or less…a species of telepathy. This faculty of insight - of seeing the unseen - is what distinguishes the artist physician from the materialist."

These words, written by Wendell Reber, M.D., are an eloquent reminder of the elusive qualities of empathy and compassion that separate - regardless of their medical knowledge - the physician who refers to the "cancer case in Room 263" from the doctor who refers to "Mrs. Jones." The fact that the above words were written 100 years ago - in the May 5, 1900 issue of the Journal of the American Medical Association - is a compelling reminder of the timelessness of the issues they raise.

For centuries, it has been the common knowledge of medical educators that many would-be physician artists end up completing their training as materialists. They possess sufficient knowledge of the matter of science, but the ideals with which many of them first entered medical school - to comfort the sick with the power of the healing arts - have given way either to cynicism arising from a highly rigorous and stressful medical training environment or to an over-fascination with medical technology in an atmosphere that can elevate science above patient care.

The current trend in several medical schools to attempt to institute a "humanistic" curriculum is, therefore, hardly new. But the debate over how to effectively produce compassionate physicians is becoming more audible in the halls of academic medicine as curricular reforms are calling into question traditional methods of both the delivery and substance of medical training.

Teaching Humanism at NYU

In January 1996, the AAMC established the Medical School Objectives Project (MSOP) with a goal, among others, of establishing consensus within the academic medical community about the attributes that medical students should possess upon graduation. By January 1999, extensive discussion among medical school leaders resulted in the articulation of four attributes that embody the agreed-upon qualities physicians should strive to exemplify within their practice of medicine. The first of these attributes, altruism, emphasizes the necessity of bringing compassion and empathy to patients' bedsides. Under this rubric fall character traits such as integrity, honesty, and respect for patients' rights.

Steven Abramson, M.D., vice dean for Medical Education at New York University School of Medicine, says the MSOP recommendations called attention to an emerging sense within the academic medicine community that more attention needed to be paid to dovetailing coursework on humanism and altruism with a more traditional mainstream curriculum.

"If we are to teach issues of ethics, humanism, and professionalism, they must be seamlessly integrated into the entire curriculum," says Dr. Abramson. "Teaching these issues as separate activities marginalizes them." Regulating biomedical ethics to a short, one-time course, for example, sends a clear message that humanism is far less valued than molecular biology or gross anatomy, he stresses.

Dr. Abramson's belief in the importance of weaving the tenets of humanism into NYU's medical school curriculum led him to become the principal investigator of a grant that would draw on the multidisciplinary talents of the faculty of the entire university. "By developing ties with the other colleges of the university and encouraging scholarly activity in the areas of humanism and ethics that is rigorous and counts toward a grade, we hope to raise the level of intellectual legitimacy in these areas," he says.

On June 13, Dr. Abramson's vision was realized in the Master Scholar Program. Funded by a $2 million grant from the Pfizer Foundation, the Master Scholar Program aims to gradually initiate substantial reform throughout the medical school curriculum.

The program is built around the leadership of outstanding faculty culled from both the School of Medicine and the university's other colleges. These faculty will develop specific course offerings, including joint coursework and degrees with other schools of the university; provide student mentoring; sponsor regular public colloquia; and create a body of literature arising from the work of the program.

"We want the Master Scholar Program to become a national and international platform for ideas and information in the areas of ethics, professionalism, and humanism," says Sharon K. Krackov, Ed.D., associate dean for Educational Program Development and co-director of the Master Scholar Program.

Beginning in September 2001, all students at NYU's School of Medicine will be required to take a new course titled "The Physician, the Patient, and Society," which will integrate clinical instruction with a range of humanistic issues. Students will also choose among a variety of courses that will develop from the work of five newly created Master Societies, one of which each student will be required to join.

Led by accomplished members of the School of Medicine faculty, the societies are constructed around specific themes, including health policy and public health, bioethics and human rights, and arts and the humanities in medicine.

Merging Medicine With the Humanities

By creating new course offerings that cross previously well-defined boundaries between medicine and "the arts," NYU's Master Scholar Program seeks to forge relationships between schools of thought traditionally treated as discrete. According to Mike Magee, M.D., a senior medical advisor at Pfizer Inc. who played a crucial role in the formation of NYU's Master Scholar Program, it is within these relationships that the strength of the new program lies. "By bridging the gap between the humanities and the pure sciences, you have the potential to transform the curriculum from the inside out," Dr. Magee says.

Edward M. Hundert, M.D., dean of the University of Rochester School of Medicine and Dentistry, agrees that the humanities play an important role in the creation of a humanistic medical curriculum. "Different perspectives add significantly to professional development," he says. "They give students additional lenses through which to view the context of their professional experience."

Dr. Hundert, a recognized leader in the teaching of medical ethics, says that the University of Rochester promotes a humanistic curriculum by combining curricular themes such as ethics, prevention, and diversity with the teaching of hard science.

"The learning objectives of these themes are examined in tests along with their scientific contexts, thus reinforcing their legitimacy," he says. "For example, the case of an elderly woman who has stopped eating can teach students the ethical issues of guardianship and competence as well as the science of metabolism and the Krebs cycle."

The White Coat of Service

Drs. Magee and Hundert both emphasize the importance of faculty mentoring, a core component of the Master Scholar Program Dr. Magee helped create. "Perhaps even more important than teaching the theory and practice of biomedical ethics as it arises in everyday clinical practice, faculty owe students a role modeling of humanism both in the way they treat patients and in the way they treat their students," says Dr. Hundert. "Schools need to reward mentoring behavior, both substantively and symbolically, to create a 'culture of mentoring.'"

In recognition of the importance of mentoring, the AAMC awarded its first Humanism in Medical Education Award last October to Andrew Hsi, M.D. The award, sponsored by Pfizer Inc. and the Pfizer Medical Humanities Initiative, recognizes a medical school faculty physician who is a caring and compassionate mentor for medical students; practices patient-centered care; and teaches ethics, empathy, and service by example.

The power of positive role models also forms the basis of several of the many philanthropic programs supported by the Arnold P. Gold Foundation. In 1989, Arnold P. Gold, M.D., professor of Clinical Neurology and Clinical Pediatrics at Columbia University College of Physicians and Surgeons, joined with his wife, Sandra Gold, Ed.D., to establish a foundation that promotes humanism in medicine.

"After teaching for more than 40 years, Arnold began to sense that the professional priorities of the students and housestaff he was working with were becoming more focused on technology and science and less on the doctor-patient relationship," Sandra Gold says.

With a $50,000 gift from one of Dr. Arnold Gold's patients, he and his wife began what Sandra Gold refers to as "the tiny foundation with a big bite." With its $1.7 million budget, the Arnold P. Gold Foundation supports more than 20 programs for medical students, residents, and faculty that encourage the practice of humanistic medicine.

"We believe that medicine is an apprentice-able profession, and that medical students will teach or practice medicine much as their own teachers do," says Sandra Gold. "We recognize the importance of drawing attention to good role models. So one of our first programs was to establish a commencement award at Columbia University for humanism in medicine. We made it a big prize - $5,000 - so graduates would appreciate the importance of the traits the award recognized."

Although the Gold Foundation supports many programs - from fellowships to essay contests - it is most widely known for its White Coat Ceremony, first held in 1991 at Columbia and now practiced in more than 130 medical schools worldwide, including several in Israel and one in China.

The White Coat Ceremony grew out of Dr. Arnold Gold's belief that medical students should take the Hippocratic Oath at the beginning, rather than the end, of their medical training. During the ceremony, students recite the oath affirming their commitment to the altruistic ideals of medical service, after which they are cloaked in a white coat, symbolizing their entrance into the medical community.

Sandra Gold believes that such symbolic ceremonies can help remind medical students of the altruism required to become a true healer. "Very few medical schools will say, 'Let's change the whole curriculum to focus more on humanism and patient care,'" she says. "We're content with identifying some of the major barriers to these ideals and building small programs that may spark more interest in our message. Hopefully, when there are enough of them, the entire climate of the medical school experience will be affected."

"The fact is that either we or someone we love will get sick at some time in our lives," continues Sandra Gold. "This isn't a remote issue for anybody."