The humanities, which include the wide-ranging fields of art, history, literature, music, philosophy, and other performing arts, are ubiquitous and impact us daily. We remember reading The Good Earth by Pearl S. Buck during English literature class as impressionable youths. It was an opportunity to understand a different culture, and learn about relationships. The narratives helped us connect with emotions like sadness, pity and bewilderment with a consequent desire to get involved – components of what we now define as empathy. The power of literature is all too apparent – to understand lives other than our own.
Filling the gap in medicine
While reminiscing secondary school literature, it is disheartening as clinicians to realise that empathy levels of both medical students and doctors have been decreasing with correspondingly increasing rates of physician burnout. Scientific and technological advances have improved our ability to treat disease and extend life expectancy, but we are paradoxically inundated with complaints about doctors not spending enough time with patients or treating them as a collection of dysfunctional organs. “If we are interested in people’s well-being, we also need to take seriously the implications of characteristics of ‘persons’… their subjectivity and ‘inner life’ including their capacity for suffering; their identities, histories and social contexts, including the way these are embedded in both personal and social relationships and social structures.”1 The framing of medicine within the narrow lens of natural sciences and evidence-based practice has been the shortcoming of many a dissatisfied clinician. Medicine is about caring for people as much as it is about treating disease. “Without an active component of eliciting patient values and preferences, then biomedical reasoning will fall short: it can reasonably aim to make valid judgments about people’s bodies and what might happen to them, but it cannot make valid claims about the course of people’s lives and what should be done.”1
The gap in practice between treating the disease and caring for the person is what the medical humanities can fill. It is an interdisciplinary field where concepts, content and methods from art, history and literature are used to investigate the experience of illness and to understand professional identity.2 Experiences and perspectives depicted through the humanities can help develop observation skills and deep reflective practice. Such transformative change is possible through an appraisal of clinical experiences and examination of both personal and professional values.3 While the science of medicine continues to provide us with answers about facts of nature, it struggles to provide all the answers to the important question of value – what counts as good and what counts as bad. The COVID-19 pandemic has brought this into sharp focus. The vast range of national responses to the same viral pathogen illustrates why there can be no valueneutral health policy based on science. The humanities generate knowledge about value through reflecting on human experience and by sensitively analysing these experiences.
Medical humanities and its application
The medical humanities can be employed in all three areas of academic medicine – medical education, patient care and research. In medical education, the humanities offer a diverse trove of materials to teach topics like communication skills and empathy. Learners can observe realistic patientdoctor interactions depicted in movies to appreciate non-verbal signs of distress and how to respond appropriately. As the scenarios are hypothetical, psychological safety is ensured to facilitate uninhibited sharing between students. Literary works can also be used. For example, at the Division of Supportive and Palliative Care in the National Cancer Centre Singapore, residents have been taught empathy through close reading exercises of the book The Death of Ivan Ilyich. This novel vividly describes the distress of an authoritative lawmaker Ivan, and how he struggles with severe pain on his deathbed, unable to comprehend how a life of personal discipline and material prestige could be ending in such existential misery. As one passage reads:
“It occurred to him that what had appeared perfectly impossible before, namely that he had not spent his life as he should have done, might after all be true. It occurred to him that his scarcely perceptible attempts to struggle against what was considered good by the most highly placed people, those scarcely noticeable impulses which he had immediately suppressed, might have been the real thing, and all the rest false. And his professional duties and the whole arrangement of his life and of his family, and all his social and official interests, might all have been false. He tried to defend all those things to himself and suddenly felt the weakness of what he was defending. There was nothing to defend. ‘But if that is so,’ he said to himself, ‘and I am leaving this life with the consciousness that I have lost all that was given me, and it is impossible to rectify it — what then?’”
Education
The residents rotating through the palliative care posting are asked to share their thoughts and examine their own values in order to strive towards more empathetic patient care. These sessions received positive feedback from the learners4 because the humanities are an excellent means to deliver educational content. The material engages the senses and emotions, facilitating a connection between teacher and learner, and between learner and content. The humanities also provide context and realism so that teaching is not done in the abstract. Besides serving as a modality to deliver medical content effectively, the humanities can operate as the content itself. Philosophy in bioethics, observation skills in art appreciation, listening skills in music and interpretive abilities in narratives are but some of the many examples. It is little wonder that many universities in North America have medical humanities built into the medical curriculum.
Patient care
In clinical practice, healthcare is as much about care as it is about health. Creative therapies such as music and art can be employed as interventions to reduce anxiety and stress. COVID19-related isolation measures have exacerbated the psychological distress of the illness experience. In response, the humanities have also gone digital. For example, at the Singapore General Hospital (SGH), paintings of hope, tips on coping with stress and verses of encouragement from healthcare teams have been provided for patients in some isolation wards via bedside electronic tablets. Patients have expressed that these platforms provide a sense of connection with the outside world and alleviate what can be the cold and sterile environment of an isolation room. A collaborative effort between the SGH art therapist, the SingHealth Duke-NUS Institute for Patient Safety and Quality, and the Care Collection of the National Gallery Singapore and Singapore Art Museum to offer an online art-as-therapy programme through a mobile phone app is also underway.
Communication theory places humanities at the heart of clinical practice through what is affectionately called “bedside manner.” This includes listening skills, non-verbal communication, interpersonal approach and even how we use touch to relate to each other. Appreciating the narrative of a patient’s life provides genuine appreciation for the fact that illness is as much a disruption of biography as it is of biology. Only when we appreciate the depth of this disruption can we as clinicians empower patients to rewrite their biography. Narratives are about appreciating the details of the illness experience and their impact. Narratives also help delineate peripheral concerns from core values.
The practical application of bioethics occurs through discourses on patient’s rights, standards of informed consent, professional accountability, boundaries of medicine and conflicts of interest. Even when philosophical questions yield no definitive answers, healthcare professionals have to live out some answers to these questions through the clinical judgements made in daily practice. The SMA through the Centre for Medical Ethics and Professionalism continues to serve as a beacon of these standards and as a forum to advance such discourses.
The humanities help us tackle physician burnout by facilitating the expression of complex and difficult emotions. We can find comfort in uncertainties through perspective-taking and develop a sense of meaning at work through finding a common purpose. Examples of activities to tackle burnout include group art-making, chalkboard doodling and sharing of music and songs. These activities are not only enjoyable in themselves, but help humanise each other by providing a glimpse of another aspect of our colleagues beyond that of a fellow co-worker. The humanities by being interdisciplinary in nature can fuel interprofessional collaboration through insights on change management, complexity theory, professional boundaries and alternative framing/perspectives.
Research
In research, the humanities can be at the forefront of knowledge generation. As the physics Nobel laureate Carlo Rubbia claimed: “Science for me is very close to art. Scientific discovery is an irrational act. It is an intuition which turns out to be reality at the end of it – and I see no difference between a scientist developing a marvellous discovery and an artist making a painting.” Besides the pioneering research pursued in medical education, humanities research often takes the form of narratives and critiques. Narratives can contribute to the burgeoning range of qualitative analysis that is being done to improve interpretative understanding in medicine. Critiques offer fresh perspective often beyond the confines of the biomedical paradigm. In addition, the clinical effectiveness of creative therapies is being subject to more rigorous analysis.
Concluding thoughts
The medical humanities may be viewed as either a possible elixir to cure some of the maladies of modern medicine, or as something that has always been an integral part of clinical practice but somehow got lost along the way as we focused on binary clinical outcomes and technological advances. Either way, the humanities ought to co-exist with the science of medicine and in doing so, make medicine more whole. That promises to make medicine more meaningful for doctors and for patients.