A course, ‘The Human in Medicine’, as an example of a preclinical medical humanities program: A summary of 7 years

Abstract

Background: This article is based on the experience with ‘The Human in Medicine’ (HIM) courses that had been a part of the preclinical program of the Marmara Medical School.

Aim: The evaluation of the HIM course in terms of its efficacy and the impressions of the students.

Methods: Three groups of data were collected: (a) Students’ feedbacks about the courses, (b) HIM final scores and (c) a thematic/content analysis of randomly selected students’ reports. Stratified random sampling was used to select student reports for qualitative analysis. Content and thematic analyses were carried out by two researchers independently.

Results: In general, the HIM program was evaluated as moderate or above moderate by 60–80% of the students. Content and thematic analysis of student reports showed that there was a rich variety in individual definitions, descriptions of causal relationships and suggestions for possible solutions about themes medicalization and stigmatization. Student reports on the case were analysed in concordance with psychologic and social parameters.

Conclusion: As a conclusion these results showed that program goals were mainly achieved and the multidisciplinary, preclinical HIM program can be seen as efficient starting point to complement the biologic perspective of medical education with a social and humanistic perspective.

Introduction

Paradigmatic/methodological discussions during the twentieth century have revealed the pitfalls of positivism and reductionism. This paradigm change has led to a number of changes in concepts such as health status, disease modalities, perceptions of illness and health seeking behaviours. Interdisciplinary collaborations of biological sciences with humanities and social sciences have brought about a more holistic approach to medical research and education as well as to health services (Evans 2002). These collaborations have resulted in health and disease being defined as complex phenomena with biological, economic, psychological, social and cultural dimensions. This transformation in the approach to health has also some implications for the desired characteristics and competencies of the physician. This relatively new bio-psychosocial and cultural definition of health has necessitated a complete restructuring of the medical education process including the aims, learning objectives, learning modalities, learning environment and assessment procedures. Reports by the Association of American Medical Colleges (AAMC 1998) and the General Medical Council (GMC 2003) also stress the importance of the bio-psychosocial approach. In these reports a number of desired characteristics and attitudes of a young doctor to be acquired in the process of medical education have been pointed out. These include an awareness of one's personal and professional boundaries; the ability to collaborate with other disciplines with due respect to personal and professional boundaries as well as to autonomy; an attitude of respect towards all patients regardless of differences in lifestyle, culture, beliefs, race, ethnicity, gender, sexuality, disability, age or socioeconomic status; the respect for the patients’ rights to be fully involved in decisions about their care, including the rights to refuse treatment or to refuse being used as subjects in teaching or research.

Table

Practice points

Medical humanities programs have the valuable function of complementing biological perspective of medical education program with humanities and social science perspectives. According to our 7 years experience, the preclinical phase is a good start for these programs, but, it should be followed in clinical year programs as a line. Similar programs are being implemented at different medical schools evaluations of efficacy, however, are not found frequently in the literature. It s important to evaluate effectiveness in order to realize suitable improvements in education programs.

It has also been stated in these reports that physicians must understand the history of medicine, the nature of medicine's social impact, the ethical precepts of the medical profession and the physician's obligations under law. All aspects of a physician's behaviour must rest on integrity, honesty and full respect for the patients’ privacy and dignity as persons. In all of their interactions with their patients, physicians must seek to understand the meaning of the patients’ stories in the context of their beliefs, family and cultural values. As a reflection of all the above-mentioned changes, during the last decades, medical humanities programs have been added to the undergraduate and graduate curricula of a number of medical schools. (Rodenhauser et al. 2004)

Humanities in medicine

During the last 50 years, there has been a growing tendency in medical education to cover metacognitive and affective areas as well as cognitive and psychomotor areas. The felt need for supplying education in a moral, social and cultural context has also contributed to the complex and multidimensional quality of medical curricula. Even though this may appear to be a relatively recent development, it can be traced to the beginning of the twentieth century when Osler reminded the medical community of the ‘wisdom’ in Hypocratic thought, which pointed to a balance between philosophia (the head–thought), philotechnia (the hand–psychomotor skills) and philanthropia (the heart–feelings) (Burns 2003). During the Ottoman empire, a similar meaning had been attributed to some physicians naming them ‘hazık hekim’ which meant that they were practicing medicine with ‘wisdom’. It is important to notice the gradually increasing efforts during recent years to restructure medical education programs taking these three areas into consideration. As a result, in many medical faculties around the world medical humanities programs have become incorporated into medical education either as parts of the curricula or as extracurricular activities. These programs include fields such as literature, philosophy, history, art, music, cinema, theatre, law, economics, politics, theology, ethics, sociology and anthropology. Based on a research survey, it has been reported that a considerable number of the medical schools in United States of America have courses in medical humanities either as part of the curriculum or as extracurricular activities (Rodenhauser et al. 2004). Some schools started community-based educational implementations like ‘Literature and Medicine in the Community’ and ‘Illness and Culture’ (Donohoe & Danielson 2004). Lectures, panels, psychodramas, community-based projects and small group discussions on educational materials like stories, poems, paintings, films are being utilized as educational techniques and materials in ‘Human in Medicine’ (HIM) programs (Donohoe & Danielson 2004; Lee & Ahn 2004).

Medical humanities programs introduce into medical education the perspectives of the humanities and social sciences and help students to understand and express themselves more efficiently and to develop a deeper insight into human nature. Furthermore, these programs enable students to understand the patient as a unique individual embedded in his/her social and cultural environment and endowed with personal experiences and feelings. By means of these programs, the students may develop a capacity for reflective thinking about their own experiences as medical students and future physicians (Bolton 2005; Hilton & Slotnick 2005). They may become more flexible in exploring a patient's world, perceiving not only the black and white tones, but also the spectrum of colours in between and refraining from premature and reductionistic explanations at the first glance (Darbyshire 1994; Wear & Aultman 2005). In the movie Patch Adams, Patch spoke to a patient in the psychiatric clinic. According to the metaphor in this conversation, one should not focus on the finger, but on everything lying behind it. Similarly, HIM programs can be a good way of teaching students how to focus on the person behind the disease, just in accord with the advice of the psychiatric patient to Patch: ‘you will not even be able to get a good start, if you just see an angry and crazy old man but nothing else here’.

Although there has been a worldwide implementation of humanity programs in medical curricula, there is not sufficient literature regarding the efficacy of medical humanities courses. The few articles on the subject conclude that these programs have positive effects on the students’ patient management skills by enhancing empathy, improving understanding and reducing frustration. (Shapiro & Hunt 2003; Shapiro et al. 2005). The aim of this article is to evaluate the HIM program of our faculty with regard to its efficacy and on the basis of the impressions of the students. For this purpose the data of student performances and feedbacks during the last 3 years will be analysed.

Introduction to clinical practice and HIM

Human in Medicine is an integral part of the Introduction to Clinical Practice (ICP) program, which is a 3-year, longitudinal and interdisciplinary program with a primary emphasis on preparing students to care for patients and families in a humanistic, competent and professional manner. ICP accounts for 15% of the first 3 years’ total curriculum of Marmara Medical School. This program was first put into practice in the 1999–2000 academic year. The curricular content and sequence of ICP were primarily provided by the department of family medicine and organized in cooperation with the departments of Medical Education and Public Health.

The goals and objectives of this program are to develop clinical and reasoning skills by exposing students early in their medical career to the skills and knowledge necessary for the practice of medicine in a humanistic and competent manner (Figure 1).

Figure 1. Outline of the ICP Program, Marmara University School of Medicine.

Human in Medicine

As a major part of second year's ICP program, the HIM sub-program consists of three main courses: ‘Social Concepts in Health’, ‘Arts and Humanities’ and ‘Ethics’. A major aim of this sub-program is to enrich medical practice education with societal/cultural, ethical and artistic dimensions in order to create doctors sensible to patients’ social, cultural and psychological background. Consequently, students will be more open to individual stories/experiences of patients and their feelings.

Courses were taught in groups consisting of 20–25 students as 3.5 h interactive sessions. Short tutor presentations, group discussions, small group studies were the main educational techniques used and experiential learning principles applied in all courses. Films, visual art pieces, poems, stories, biographies, novels, essays related to topics are used as educational materials. A social concepts course takes place in three 3.5 h sessions in three consecutive weeks. In the first week, development of the modern scientific paradigm is evaluated from a historical perspective. Biological determinism is discussed specifically as an example of a reductive approach. Pros and cons of a holistic approach to human beings are explored with their impact on medical issues. In the second week, the effects of psychosocial and cultural variables (gender, age, class, etc) on health and disease processes are discussed. The last week, is dedicated to a discussion of the implications of current medicine and medical practices on our social lives. In this regard, medicalization and stigmatization issues are primarily considered. A written exam (multiple choice questions–MCQ and case-based questions–CBQ) and student reports are used for assessment. For assessing to which degree the students have retained course information MCQ are employed. CBQ are used at assessing how well the students are able to apply the concepts and principles in the course information to clinical cases (Appendix, an example of this CBQ). A holistic rubric (Linn & Gronlund 2000) is applied for the assessment of the reports. The holistic rubric consists of a likert type scale with five intervals ranging from 1 to 5 (1: far below adequate, 2: below adequate, 3: adequate, 4: above adequate, 5: outstanding). Students whose reports are rated 1 or 2 do not pass the course. Each student report is evaluated by two different assessors according to above mentioned intervals regarding the following four criteria:

• A detailed comprehension of the concepts and principles related to the course topic and display of this comprehension using examples.

• Defining problem areas and developing one or more solutions for each.

• Internal (among the principles, concepts and solutions) and

• External (consistency with the information in the relevant literature) consistency

An Arts and Humanities course is also taught in 3.5 days (3.5 h) in three consecutive weeks. The aim of this course is to help the students to perceive different aspects of existence on the basis of the abstractive and reflective nature of art and to incorporate these perceptions with the students’ insight of human nature. In the first week, there is a general discussion with an embedded short tutor presentation about the meaning of art in our individual lives and the historical perspective of its function followed by a film session (‘One Flew Over the Cuckoo's Nest’, ‘Philadelphia’, ‘Wound’ are the films shown). In the second week, students find a chance to reflect about their feelings and opinions on different art pieces (poems, paintings, essays, stories and novel chapters). The third week, is dedicated to an artist as a guest lecturer. In this session students have a chance to see an artists’ understanding of the link between arts and medicine. Student attendance and the evaluation of the student reports about the movie shown counts for the assessment. The duration of the ethics course is 2 weeks, 3.5 h sessions each week. The main themes discussed in these sessions are, ‘beginning of life’, ‘right to life’, ‘confidentiality’, ‘informed consent’ and ‘decisions near the end of life’. A report-based assessment is used for this course. The same holistic rubric that is used in the social concepts course is applied to these reports.

In addition to the HIM courses, there are several opportunities for workshops, panels and conferences, or research activities regarding medical humanities during the ICP program. The theme of the students’ second year research activity is ‘community and health’. As a part of the ICP program, students plan and carry out a research project under this theme and present it at the annual student congress. Examples of titles from the ICP conferences and workshops were ‘Health in War’, ‘Medical Terms From Anatolian Mythology to Medicine’, ‘Physicians, Patients and Stories’, ‘Mind-Body Duality’.

Methods

Since 2001, there were several revisions and development regarding the HIM program. Three years ago these developmental efforts reached saturation and the program took its final shape in terms of aims and objectives, materials and methods and assessments. Therefore we will present in this article the data of the 2004–2005, 2005–2006 and 2006–2007 academic years. For each year student feedbacks, academic grades and student reports are evaluated separately.

Collection and analysis of data

Three groups of data were collected: (a) the students’ feedbacks about the courses, (b) HIM final scores as students’ success and (c) thematic/content analysis of randomly selected students’ reports.

1. Student feedbacks: In order to determine students’ opinion about the courses, a standard evaluation form was used. This form consists of three major parts: content, scope and learning outcome of the program (5 items), tutors and educational methods (5 items), planning and organization of the courses (6 items). Each item was scored according to a 5 point Likert scale (1: poor to 5: excellent). Three courses under HIM were evaluated separately by the students.

2. Academic grade: Student success was evaluated by a HIM final score. Contributions to the final score are 50% for social concepts, 35% for ethics, 15% for arts and humanities. Students were split into three groups according to their final score: group 1 below 50/100, group 2 50–75/100, group 3 above 75/100.

3. Thematic/content analysis of randomly selected reports: Stratified random sampling was used to select student reports for qualitative analysis. Stratification was done in two layers: one for the year (30 reports from each year) and the second for the subject:

   • 30 reports about stigmatization and medicalization. Stigmatization and medicalization are both major concepts dealt with in the social concepts course and they have been assigned as topics for the student reports.

   • 30 case reports in which the students have to discuss short cases written by the instructors. In doing this the students have to use the psychosocial and cultural variables related with health. In each case story at least five or six of these variables can be identified. These cases are not used in the written exam, but they are assigned as weekly homeworks.

   • 30 reports about the movie ‘One Flew over the Cuckoo's Nest’ that has been used as a teaching material in arts and humanities course.

In the thematic analysis, two researchers (M.A.G., M.A.) first analysed the student reports independently and manually. Each of them identified coding categories which they then brought together and identified a final categorization scheme. This scheme was discussed afterwards with third investigator (İ.U.) who is a sociologist and has not carried out independent analysis of the reports.

The content analysis was based on the students’ individual differences and misconception or misunderstandings regarding terms and concepts, and also causes, problems and solutions proposed by the students. Common emerging themes were identified by thematic analysis.

Results

Student feedbacks

Student feedbacks are shown separately for three courses of HIM in Table 1. For the first 2 years (2004–2005, 2005–2006), all three courses were evaluated as excellent or good by half of the students for content, methodology and organization, whereas social concepts and arts and humanities courses were evaluated as below moderate by 20–30% and ethics by 15% of the students. However, in the last year's evaluations, HIM courses were scored as moderate by 35% of the students. Ratings below moderate were 30–40% for social concepts and arts and humanities, and 20% for ethics. In general, the HIM program was evaluated as 60–80% moderate and above moderate during last 3 years.

Table 1.  Students' feedback on HIM courses

Academic grade

For the three consecutive years most of the students’ (53–79%) final HIM scores were between 50% and 75%; 5% and 26% of the students’ scores were below 50 whereas 11–42% scored higher than 75 out of 100 (Figure 2). On an average over the 3-year period, 15% of the students scored below 50 out of 100, 69% scored between 50 and 75, and 26% scored 75 and above.

Figure 2. Percent of student grades in three categories over a three year period of the HIM course.

Thematic/Content analysis

During the content analyses definitions, nomenclature and misconceptions or misunderstandings were first identified from the texts and afterwards expressions regarding causes and solutions that had been proposed for each case were detected. Examples and also some of the definitions are shown in Tables 2 and 3, which show that, both concepts (stigma and medicalization) were richly defined and different aspects of reasons and solutions were argued by students. A few students misunderstood the medicalization concept as innovations in medicine. This could be noticed in expressions like ‘medicalization is useful for our lives, but might also be used in favour of ulterior motives’, ‘medicalization could be used beyond its real goals’, ‘we might have an advantage of medicalization by using it for our own purposes’.

Table 2.  Student opinions about stigmatization

Definition/attributed meaning
‘Underestimative behaviour’
‘Considering just the disease, ignoring the patient's personality’
‘Being prejudiced; prejudices that transform into or cause discrimination’
‘Not considering the patient as a human being, living with ignorance’
‘Reduction of an individual from a complete human being to a few features’
‘Not seeing the situation as a disease but placing a label on the ill person’
Causes	Solutions
Religious beliefs and moral values Lack of knowledge about the stigmatized disease Considering the stigmatized disease as irrational or untreatable Fear of a mortal disease Prejudices Unacceptable way of living of the stigmatized patients Irresponsible or biased attitude of the media	Education, sufficient information about the disease Social support and intervention programs Freeing physicians from their prejudices, Accepting the stigmatized disease as just a ‘disease’ and learning to live with that disease

Table 3.  Student opinions about medicalization

Defnition/attributed meaning
‘The tendency to solve every problem by doctor visits and medication’
‘Representing paramedical as medical staff’
‘Creating diseases through questionable symptoms’
‘A bad twosome of a medicalized physician and a somatized patient’
‘Considering human life from a medical perspective only’
‘Not using medicine for medical purposes but for political or economic purposes, or perhaps due to political or economical pressures’
‘Giving the medical authorities a right to decide for the sake and in place of human beings
‘Asking expert help for every simple problem; the reorganization of individual lives by experts’
‘Intervening in the natural course of life, controlling every step’
‘Reorganization of lives in a framework determined by medical authority’
‘Devaluation of ethical and social explanations’
Causes	Solutions
Technological and medical developments Easier access to knowledge with developments in information technologies Exploitation of health by pharmaceutical companies and physicians for their own ends The need of belief in an authority among people The need for personal beauty and vigour throughout life, as promoted by the media	Education Sufficient information through media Face up to the reality instead of ignoring the problems Evidence-based medicine

Content analysis of case reports consisted of five different cases related to psychosocial and cultural variables and proposed solutions. Results of our analyses showed that cases were handled on the basis of 2–3 variables out of 5–6. Accordingly, solution proposals were also based on 1 or 2 social variables. As an example, results of the two case analyses are summarized in Table 4. The first case was a 56-year-old woman who had retired and was widowed with two children. She had somatization symptoms. The second case was a 36-year-old housewife who could not get her masters degree and could not start her career because of gender issues. Later on, she ended up with a depression. In these reports, getting old was expressed as ‘time to be ill’, ‘losing control of one's own life’, ‘being useless’; retirement was expressed as ‘emptiness in social life’, ‘losing the connection with life’ by students.

Table 4.  Two examples of case report analysis: social variables and solution suggestions

Psychosocial and cultural variables	Psychosocial and cultural variables and proposed solutions mentioned in student reports
I. Case: retirement and loss of a spouse
Age; elderly	Getting old, retirement, loss of a spouse and conflicts with children were mentioned by most of the students whereas gender, self accusation, insufficient social support were not mentioned that much. Solutions: Biopsychosocial approach in medical practice, social and psychological support, improvement of family relations.
Sex and gender
Occupation; retirement, restricted social life
Marital status; loss of a spouse, being widowed
Daily hassles; family problems
Insufficient social support
Self accusation
II. Case: sociocultural change and gender
Age; Adulthood	Age, gender and conflicts related with sociocultural change were mentioned by most of the students whereas occupation and insufficient social support were not mentioned that much. Solutions: Social and psychological support. New job and new hobbies. Strengthening relation between spouses.
Sex and gender
Occupation; house wife and economical dependence
Sociocultural change, conflict
Insufficient social support
Low self esteem

For the final thematic analysis, selected reports were coded and common themes were categorized according to these codes. Emerging themes and related statements for these themes are presented in Table 5.

Table 5.  Emerging themes and related statements from the student reports

Themes	Statements
Authority vs. autonomy.	‘There was no interaction between health professionals territory and patients’ territory’
	‘Patients should take a functional part in therapy’
	‘(He) made the patients to be more self confident, he make them feel as human. He had a power of changing patients by giving them responsibility, making them believe that they could take these responsiblities. He make them feel like an individual. His major influence was triggering self esteem and the autonomy of the patients’
	‘Rules determine everything; nobody and no event breaks the system’
Openness to feelings vs. sentimental blindness. Caring in the context of life vs. caring out of real life context.	‘You can have pleasure from life even when you are ill and this pleasure may effect the prognosis positively’
	‘The treatment strategy shown was insulating the patients from the society’ ‘Life conditions of patients in the clinic were very poor’
	‘Instead of static solutions more social and population oriented therapies must play a role in the treatment. Patients must not be seen as just sick people, but also as social and individual beings’
Reductive, (biological) approach vs. holistic (biopsychosocial) approach.	‘To see the patient as someone to be treated’
	‘Only treating with medicine or technical interventions. Choosing the easiest way in treatment’
	‘The therapeutic approach shown was considering patients as machines that needed fixing. Actually the human being is not a mechanical entity’
	‘Three times a day taking pills was thought to be enough for therapy’ ‘Practicing medicine is not just prescribing drugs’
	‘The patient should be treated as a social and psychological entity’
Formalism, reduction of the profession to procedures and technics. Contextual vs. decontextual approach.	‘Health professionals see the patients as apathetic creatures that belong to the system they created’
	‘According to the health professionals excellent working systems of the clinic are much more important than the patients’
	‘I believe that I can do much more than a robot for my patients and I should do so’
	‘Staff having a narrow vision, just seeing the profession as a profession’ ‘Dialogues with patients are very restrictive, not allowing any humanistic interaction, more like a mechanical system’
Openness to individual differences vs. uniformity. Disease vs. patient centredness	‘Health professionals forced the patients till they got the form that they wanted’
	‘Although they (health professionals) realize the differences between the patients, they still use the classical methods. Each patient must be treated separately’
	‘They (health professionals) never look at the issues from the patient's point of view’
	‘Giving the same treatment to everybody regardless of individual needs’
Empathy and open communication	‘(He) had a big influence on the patients because he was empathic, more close to them than the doctors’
	‘Health professionals kept a big distance between themselves and the patients. They do not let the patients express themselves’
	‘Formalism built a thick wall between her and her patients’
Stigmatizing behaviour of medical professionals, their ability and willingness to make patients dependent on them.	‘Nurse behaved in a stigmatizing way to the patients, she did not handle them as human beings. She tried to isolate them from the society’’
	‘There was a perception of incurable disease towards psychiatric illnesses. There was stigma and isolation.’
	‘All patients were labeled as ‘mad’ by working stuff and maybe because of this patients did not have any courage to go out alone.’

Discussion and conclusion

According to student feedbacks, more than 70% of the students rated the HIM program as ‘moderately good’, ‘good’ or ‘excellent’ with regard to (a) contents, (b) methods and (c) organization. Approximately 15% of the students were rated unsuccessful as a final grade. These two findings indicate that the majority of the students have accepted the program and that the program goals have been achieved to a considerable degree.

Another indicator of the fact that the program goals have been achieved is the rich variety in individual definitions, descriptions of causal relationships and suggestions for possible solutions which emerged from the student reports. For example, very important themes and categories such as autonomy and power, being ready to perceive and accept the patient's feelings, the pitfalls of reductionism, considering only the technical requirements of the physician's role, the biological approach, sensitivity to individual differences and patient centred approach were identified by the thematic analysis. This could be interpreted in terms of the students becoming more sensitive to the human-being as a whole and as a gateway being opened to humanistic issues in their personal worlds. Medical humanities programs add a social and humanistic perspective to medical education. Therefore, they may be very valuable in constructing a holistic perspective in medicine. In these programs a student can find an opportunity to view human beings in their own integrity and individuality and to understand the patients through attention to their personal life experiences, feelings and thoughts. A new door may open up in the minds of tomorrow's doctors to humanism and humanistic issues by means of this deepened understanding (Darbyshire 1994; Evans 2002).

Although medical humanities courses are increasing quantitatively in the curricula of medical faculties during last decades, there are not many studies investigating the efficacy of such programs (Rodenhauser et al. 2004). A few studies pointing to efficacy, indicate that medical humanities programs are beneficial for strengthening the students’ empathy, deepening their understanding, enabling them to manage conflict, helping them to express themselves more efficiently, endowing them with a social and humanistic perspective, making them grasp life experiences related to medical practice and develop a new line of insight (Shapiro & Hunt 2003; Shapiro et al. 2005; Lee & Ahn 2004). These programs also function as a tool to open discussions about ‘biological determinism’, ‘technicalism’ and ‘proceduralism’. These concepts support the reductionistic approach, which considers the patient as an object or as an instrument. After this general evaluation of the HIM program, our results also show that, 70% of the students have been moderately successful (50–75 out of 100); there were some misunderstandings or wrong usages of terminology in the student reports; and cases were analysed by using fewer social variables than implied in the case stories (i.e. the students used 2–3 social variables, whereas the cases involved 5–6). These results could be interpreted as a lack of multidimensional problem solving skills in our students. It seems that HIM is a useful program as a starting point during preclinical years, but it has also some limitations. Actually, the HIM programs could have been better planned in relation to the 6-year-medical education process. Some improvements can be proposed to overcome the present limitations. For example, a larger number of clinical or preclinical HIM courses might be implanted in the medical curriculum or provided as extracurricular opportunities. Community-based activities could be planned. In this way medical students may have a greater chance to enrich their social and humanistic perspectives (Donohoe & Danielson 2004; Rodenhauser 2004). For these purposes elective courses could be added to the preclinical curriculum and/or different HIM activities could be added to clinical clerkships as a ‘line’. As an extracurricular activity artist–physician, physician–artist, artist–patient and artist–student meetings, conferences and movie sessions might be organized. With respect to community-based activities NGOs like the ‘Fight against AIDS’ Association, or the associations for street children and children with cerebral palsy as well as schools might become partners of the HIM activities and mini projects could be carried out together. At the same time, students could participate in art therapies in different institutions like hospitals, prisons, nursing homes as a part of their HIM courses. To support all of these efforts and to ensure long lasting effects for such programs, faculty staff (including hospital staff) obviously should also have humanistic attitudes and the standards of care in the university hospitals should be established with respect to social and humanistic perspectives.

On the basis of our findings, we can conclude that the multidisciplinary, preclinical HIM program has been an efficient starting point to complement the biologic perspective of medical education with a social and humanistic perspective. However, it is important to continue the HIM courses with intracurricular and extracurricular activities during clinical years in order to strengthen this perspective. The efficacy of preclinical and clinical programs of medical faculties and various fields of health need to be analysed in a similar manner, in order to reorganize educational programs. The outcomes of such reorganized programs can be evaluated by further research. In any case, we may suggest depending on our 7 years experience that our HIM course can be used as an example in developing curricula of other medical schools.

Acknowledgements

We thank Dr Çağrı Kalaça, Dr Sibel Kalaça, Dr Ahmet Arzık and Dr Pemra Unalan for their efforts in design and coordination of ICP program. We also thank Dr Ray W. Guillery for editing the English language of the article.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

Mehmet Alı Gülpinar

MEHMET ALI GÜLPINAR, MD and PhD, assistant professor, instructional designer in the Department of Medical Education of the Marmara University, School of Medicine, Istanbul, Turkey.

Mehmet Akman

MEHMET AKMAN, MD and MPH, working as instructor of Family Medicine at Family Medicine Department, Marmara Medical School, Istanbul, Turkey. He has experience in teaching communication skills, Medical Humanities and clinical skills.

İncı User

İNCI USER, PhD, associate professor, Faculty of Science and Letters, Department of Sociology, Marmara University, Istanbul, Turkey.

Appendix 1 An Example of CBQ used in assessment of HIM

Case

Zeynep A. is 56-year old and a high school graduate. She has lost her husband 8-year ago. Her sons are 25 and 28. One of the sons is married with a child. Sometimes Zeynep A. stays at her son's and takes care of her grandson. Her other son changes jobs very frequently and does not wish to get married. Zeynep A. is anxious about his situation. For the last 5 years she has been complaining of pains and feelings of unrest. Every now and then she consults doctors about these complaints. She has a small bag filled with pharmaceuticals, which she carries with herself, wherever she goes.

Related questions

(1) List three social factors which you think to influence Zeynep A.'s health status. (2) Chose one of these factors and evaluate its impact on Zeynep A.'s health status