In this essay I will look at how engagement with the humanities in medical training can increase compassion of future healthcare professionals towards their patients. I will begin by looking at the methods traditionally used in medicine to garner truth and the difficulties in applying this to individual patients. I will then look at the aims of medicine and how these have changed in the light of modern medical advancements. I will then use the notion of compassion as a way to mediate this, before finally looking at potential ways to foster compassion in training healthcare professionals.
Science and the scientific method
Karl Popper attempts to define the boundaries of what science is by defining what it is not. For Popper the difference between science and pseudoscience is neatly encapsulated by the single criterion of falsification. In The Logic of Scientific Discovery (1968) Popper uses some examples to illustrate this. The 1919 solar eclipse that emphatically proved Albert Einstein’s general theory of relativity is used as an example of science. Einstein’s theory went that the large gravitational pull of an object like the sun would bend light from a star behind it, meaning that it would be seen on earth slightly before predicted if it were assumed that light travelled in a straight line. This claim Popper says is falsifiable and testable, and as such is science. Indeed in 1919 it was tested and turned out to be true. He uses the example of Marxist ‘scientific analysis’ history as pseudoscience. Class struggle determined everything and a revolution was inevitable, Marxists say, however when the workers did not revolt the Marxists said that the workers were victims of false consciousness. For Popper this attitude to counter-evidence jarred with his idea of falsification. No possible piece of evidence could counter this statement, for whether the workers revolted or not the Marxists would still claim to be right.
One unifying aspect to the practice of science is its methodology. Of this, Popper says that science makes observations, generates theories, and then sets out to refute these theories using experiments or studies. This theory now takes the form of the hypothetico-deductive method of research where observations are converted to a falsifiable hypothesis. This hypothesis is tested deductively in order to see if it is true or not (Fig. 1). For Popper this concept of falsifiability is the key to what makes science. Popper says that looking for theories that have a high probability of being true is a false goal and ‘certainty fetishisation’ (Popper, 1968). He thinks that science should look for the theories that are highly falsifiable and that all existing attempts to falsify them have failed.
Practically this methodology relies on three key principles: the uniformity of the population studied, repeatability of the experimental conditions, and reproducibility of results. These principles have moved medicine and society forward a huge amount over the last 100 years, however they do have limitations. For me, as a future doctor, the key limitation with it is about the application of this science to the individual. Uniformity, repeatability, and reproducibility are a fantastic means of measuring the impact of a particular drug on liver enzymes, for example, however to measure human consciousness it feels like the wrong set of tools.
The Aims Of Medicine
In his 1871 lecture to that year’s graduates from Glasgow University’s Medical School Dr John Young set out to outline what these aims are before they began to practice. “It seems a truism to tell you” he said, “that the practice of medicine is not the application of rules, but is solely and entirely the exercise of common sense” (Young, 1871). This is in vast contrast with the way medicine is taught and articulated today. In an attempt to generate an acceptable minimum standard for all who enter the NHS the National Institute for Clinical Excellence (NICE) have generated evidence-based diagnostic and treatment flowcharts for every significant disease from chronic fatigue syndrome to cardiac arrest, depression to diabetes (NICE, 2016). To practice (at least at a junior level) all a doctor needs to do is (essentially) follow these rules. This model is based on the best available scientific evidence, and does provide the majority of patients with very good healthcare outcomes. When Young gave his lecture, the average life expectancy was 41.35 for men and 44.62 for women. In 2011 it was 78.97 and 82.8 respectively (Office for National Statistics, 2015). This is undeniably a fantastic success for society, that came out of medicine. What these figures do not tell you though is about quality of life. Through the scientific method, medicine has become exceedingly good at extending life, however it is less good at assessing the role of the individual patient and including their wishes. This push has lead to a culture within the medical field where death, the only certainty in life, is perceived as a failure of medicine (Middlewood and Gardner, 2001). Medicine is not simply a science, and practicing it as so is doomed to failure.
Medicine’s frontier with the world, the point at which it steps from the page and the lab, is with human beings. This encounter is as much with person as it is with flesh. So, good medicine can only ever be partially realised through technical, rational or reductive paradigms. What’s more, authentic encounters with our patients almost drive us to go on and practice medicine well, both technically and ethically. (Guglani, 2014: 60–61)
The science of medicine is a remarkable thing, but to articulate it properly healthcare professionals need common sense, reactivity, and compassion.
Compassion in Medicine
Compassion is defined by Webster’s Dictionary as a “sympathetic consciousness of other’s distress together with a desire to alleviate it” (Merriam-Webster, 2015). This definition contains two aspects: a feeling of/or related to empathy coupled with a will for action. Whereas empathy is simply a feeling, compassion is a drive and one that should be at the heart of good medical practice. The first Principles of Medical Ethics of the American Medical Association echoes this saying “a physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights” (American Medical Association, 2001). In a seminal essay entitled The Nature of Suffering and The Goals of Medicine (Cassell, 1982) from the New England Journal of Medicine from 1982 Eric Cassell (physician, professor of Public Health, and writer) talks about the reasons compassion is so important in medicine. He talks about the concept of suffering, how physicians are obliged to relieve it, and how in the modern era, despite huge advancements in medical science, that suffering in hospitals is common “not only during the course of a disease but also as a result of treatment” (Cassell, 1982). He talks about how this is a result of an innate, unquestioned belief in Cartesian dualism within the medical field. Medicine prioritises what it can quantify objectively and through this it has become a science of the body. This demarcation of what medicine is became more entrenched, Cassell says and therefore began to leave out relieving suffering from its aims:
So long as the mind-body dichotomy is accepted, suffering is either subjective and thus not truly real – not within medicine’s domain – or identified exclusively with bodily pain. (Cassell, 1982)
He concluded by saying that for medicine in the modern era to alleviate suffering it needs to acknowledge the patient as a person as it cannot truly heal their suffering through treating the body as suffering does not only originate from the body.
A Loss Of Compassion?
Samir Guglani (Director of Medicine Unboxed, consultant oncologist at Cheltenham General Hospital, poet and writer) says that disasters such as Mid Staffs come out of the lack of compassion and humanity in medical training. The culture in which that kind of disaster is possible is one “based on a version of medicine that suggests that patients are not human beings” (Pugh, 2013). In the aftermath of the appalling failings of care in the Mid Staffordshire NHS trust in the late 2000s, Robert Francis QC chaired the public inquiry into how this level of poor care and institutional abuse had been allowed to happen, and provided recommendations to stop it happening in the future. Whilst talking about the culture of professionals within the NHS he said that post-Mid Staffs “patients must be the first priority in all of what the NHS does by ensuring that, within available resources, they receive effective care from caring, compassionate and committed staff, working within a common culture, and protected from avoidable harm and any deprivation of their basic rights” (Francis, 2013 p.67). When talking to the House of Commons Treasury Committee, Bob Diamond, Chief Executive of Barclays Bank during the LIBOR fixing scandal, defined culture in institutions as “how people behave when no-one is watching” (House of Commons Treasury Committee, 2012 p.60). Although the committee endorsed Diamond’s comments, they also acknowledged that the culture at Barclays was one that “allowed people to do the wrong thing quite openly over a long period” (House of Commons Treasury Committee, 2012 p.61). For me, this idea of culture is where compassion should be fostered in healthcare.
How Can We Foster Compassion Amongst Healthcare Professionals? – The Medical Humanities
Medical humanities as a field aims to illuminate the ongoing progress in biomedical science by aiming to understand their socio-political and cultural context (Centre for Medical Humanities, 2010). In the same way that language without context is almost meaningless biomedical research without an understanding of the world it exists in can only do so much. What poetry, fine art, fictional narratives etc. do is give insights into peoples’ realities. As a young, male junior doctor I will have a set of experiences that will shape my reality. However I can begin to expand the empathy I can generate towards my future patients by engaging with these accounts.
In an article for The Guardian published just before the 2013 Medicine Unboxed conference on the theme of ‘Voice’, Rachel Pugh wrote an outline of the real world impact of medical humanities. In the article, she cites quotes from Innocent Orora Maranga a practicing gynaecology oncologist in Kenyatta National Hospital, Nairobi who was caught up in the Westgate Mall Massacre in Nairobi on 21st Sept 2013 and by all accounts saved numerous lives through his heroic actions and organization in its aftermath. Maranga did his PhD at Manchester University and cited the most important piece of training he had had for this situation was not any of his medical training but a leadership course that he attended as part of his PhD. “One comes out [of medical school] not knowing how to deal with real-life situations that don’t necessarily require a written prescription. I believe a number of medical schools around the world might be churning out ‘robots’ with few other human skills” he said of the current state of training (Pugh, 2013). Its focus on bioscience, procedure, protocol and quantification means that it does not adequately equip for the uncertainty that is the only certainty in the application of medicine. Moreover, Pugh outlines the other ways in which an engagement with the humanities can aid medicine. She cites one study from 2008 (Naghshineh et al., 2008) as an illustration of this. In the study medical students were taught to interpret paintings at the Museum of Fine Arts in Boston. The students were then observed before and after whilst inspecting patients in an attempt to detect pathology and make diagnoses. The study found that clinical observations were improved by 38% in those who had done the session in the Museum of Fine Arts compared to those who had not (Naghshineh et al., 2008).
Criticism of Medical Humanities
One main issue has been brought up with the field of medical humanities. The first is contained within the name and is the criticism that it is an attempt to medicalize yet another field – “they’re not ours, the humanities, they’re not medical. Not medicine’s.” (Guglani, 2014, pp. 60). In an essay entitled Medicine’s Humanity in a 2014 Wellcome Trust publication on Medical Humanities called Where Does It Hurt? – The New World of the Medical Humanities (Holden et al., 2014) Guglani says that the humanities are the carriers of empathy. The way we comprehend experiences we have never had or can never have, through the aspects of personhood we share such as: fear, envy, passion, love, and so on. “They tell of our common and fragile humanity. They illuminate other perspectives, beyond the ones we have grown settled and accustomed to” (Guglani, 2014, pp. 61) and as such they have everything to offer medicine, but they are not its property.
Beckett On The Wards – an example of a medical humanities pedagogy
“Beckett on the Wards” was a direct collaboration between theatre practitioners and consultant psychiatrists that occurred in 2013, which was briefly written up as a case study in the BMJ’s Journal of Medical Humanities (Heron et al., 2016). The paper talks about an experimental learning workshop that used “Beckett’s depiction of disordered experience [to offer} a stimulating challenge to the categories and narratives used in medicine” (Heron et al., 2016). In particular, providing ways to decode the “fragmented, incomplete and unconventionally structured” (Heron et al., 2016) narratives that often occur as part of dementia, as well as “extend the range and depth of ‘compassionate care’ among clinicians, managers, patients and carers, by engaging imaginatively with different possibilities for human embodiment (in the drama of Samuel Beckett)” (Heron et al., 2016). The workshop used methods adapted from theatrical rehearsal and material from two of Beckett’s pieces (Not I and Footfalls) and was followed by reflective group discussion. Feedback for the sessions was mostly positive and participants noted amongst other observations that “it did allowed [sic.] a breath of discussion beyond our usual experience”, however two participants were critical of the lack of “tangible outcomes” (Heron et al., 2016).
This workshop and the feedback it received is a good example of the role the humanities can play in exploring personhood and the impact it can have on healthcare professionals’ views and practice. The arts explore themes, like narrative fragmentation, the self, and metamorphosis that are key to medicine but are difficult to investigate in a medical context, and this workshop aims to cross-fertilise ideas of topics relevant to both fields garnered in different ways.
The split of science and art into two cultures has lead to much innovation. Superspeciality in both fields has allowed us to further our knowledge of the body, and expand the scope of artistic practice. However this trend has led to practitioners not fully understanding the wider context of their work. For me this divorce of art and science within medical training specifically has led, to some extent, to a dehumanizing of the patient, and a focus on treating the body, not healing the patient. I feel that an engagement with the humanities within medical training is one way to help generate compassion towards the patients who are at the centre of medicine and as such improve their care.
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