Black, White and Gray: Student Perspectives on Medical Humanities and Medical Education

Abstract

Issue: In recent years, the value and relevance of humanities-based teaching in medical education have become more widely acknowledged. In many medical schools this has prompted additions to curricula that allow students to explore the gray—as opposed to the black and white—areas of medicine through arts, humanities, and social sciences. As curricula have expanded and diversified in this way, both medical educators and students have begun to ask: what is the best way to teach medical humanities?

Evidence: In this article, five current medical students reflect on their experiences of medical humanities teaching through intercalated BSc programmes in the UK. What follows is a broad exploration of how the incorporation of medical humanities into students’ time at university can improve clinical practice where the more rigid, objective-driven, model of medicine falls short.

Implications: This article reinforces the merit of moving beyond a purely biomedical model of medical education. Using the student voice as a vector for critique and discussion, we provide a starting point for uncovering the path toward true integration of humanities-style teaching into medical school curricula.

Keywords:

• Medical humanities
• medical education
• student perspectives

Introduction

It is possible, and easy enough, to view medicine entirely from a scientific, biomedical perspective. A patient presents with a series of symptoms. The doctor takes a history and elicits signs on examination. Investigations may follow; a diagnosis is made. A management plan, based on a scientific understanding of the underlying pathology, is prescribed to the patient. When phrased like this with no nuance, no humanity, and no wider factors considered, medicine is easily framed as a black and white exercise. However, neither the patient’s nor clinician’s experience exist in black and white. In each clinical encounter, the gray areas of humanity are brought to the forefront and shape the complex relationships between patient and doctor. Symptoms, signs, investigations, and management are shrouded in undefined areas of gray.

An increasing focus on humanities within medical education has generated opportunities for students to delve into these gray areas; simultaneously broadening and deepening their knowledge outside of the core curriculum. But how exactly does one delve into the gray? How can we best teach medical humanities (MH) to students?

The value of MH teaching - not only for future clinicians, but also for patients whose demographics and disease experience have so far been neglected by traditional biomedical models - is well documented.^1–3 Arno Kumagai describes how MH assist students in: dismantling assumptions and attitudes upheld in medicine; encouraging reflection on our experiences; broadening perspectives and prompting analysis of medical care through different lenses; providing outlets for expressing and understanding our experiences; and driving empathy in clinical encounters.² Kumagai argues that the arts and humanities “lead us to a knowledge of a thing through the organ of sight instead of through recognition”:^3(p6) in essence, through questioning ideas that are held to be true, we engage more deeply with the information presented to us and as such better our understanding.

Despite their demonstrable value, the optimal approach to teaching MH is less clear cut. In order to elucidate how best to optimize the value of MH teaching, this piece discusses its integration in medical school curricula. Building upon ideas put forth in the Association of American Medical Colleges’ (AAMC) 2020 report The Fundamental Role of the Arts and Humanities in Medical Education, we explore attitudes toward MH from a medical student perspective and the impact of a reluctance to step away from objective, positivist thinking amongst educators and learners alike.⁴

The AAMC proposes a working definition of MH in medical education as “content or pedagogy derived from arts and humanities and integrated into the teaching and learning of medical students, trainees, and practicing physicians.”^4(p.4) Importantly, the AAMC discusses some of the barriers to integrating MH into curricula, including the belief that the syllabus is already “full” and there is no room nor funding available. As such, where MH are included in the curricula, they are often added on for those who are interested, rather than built into the foundations of the course.

This phenomenon demonstrates Alan Bleakley and Robert Marshall’s concept of “weak inclusion:”^5(p.129)

“The weak version of inclusion of the medical humanities in the curriculum appears as optional study, a bolt on, usually advertised as a compensation for science. The strong version, however, involves a core, integrated curriculum component as a complement to science, creating a more nuanced educational culture”.^5(p129)

“Weak inclusion”^5(p129) encompasses many of the approaches to MH we have experienced at our respective medical schools in the UK. However, the teaching we have received through undertaking an optional year of study - a so-called intercalated Bachelors degree⁶ - in MH, has shown that strong inclusion is both possible and desirable. “Strong inclusion” of MH in curricula advocates for the development of an interdisciplinary approach to these interventions whereby medicine and MH are not seen as distinct entities but rather symbiotic approaches to understanding human problems.

Thus far, the student perspective has remained relatively absent in this discussion. There are numerous examples of students contributing to MH literature but explicit acknowledgement of student perspectives on teaching approaches is currently lacking.^7,8 We believe that the barriers to integration can be explored further by showcasing the student perspective. As current medical students who have recently completed intercalated Bachelors of Science (intercalated BSc or iBSc) in MH, the evidence we present is largely anecdotal. Imbuing personal experience into the methodologies of medical education is a relatively new approach that has gained traction in recent years, most particularly within the realms of MH.⁹

To organize our reflections of the gray areas of medicine and medical education, we have isolated five themes relating to specific domains of MH. These include history, narrative medicine, anthropology, and philosophy and ethics. We also comment on a variety of practical considerations to contextualize the delivery of MH teaching in the UK and beyond. Through these reflections, we provide a starting point for a critical discussion of learning experience, aiming to improve the synergy of MH teaching in medical education.

The medical student perspective

Medical education does not end at graduation. Students should be supported and empowered to critique, challenge, and advocate for changes in their experience at medical school in preparation for continued learning as a doctor.

In an earlier installment in this series, Gert Biesta and Marije Van Braak¹⁰ highlight the need for increased engagement in the purposes of medical education, as opposed to just focusing on the processes. In this piece, they discuss socialization (becoming a member of the professional group) and subjectification (becoming a thoughtful, independent, responsible professional) as important goals of medical education. We believe that we can better achieve these purposes by including MH and the student perspective in the discourse surrounding medical education.

Using the medical student perspective in academic research, we can better explore attitudes toward MH teaching amongst current learners. Student perspectives on current curricula provide detailed, nuanced learning points for educators and are often accompanied by practical real-world solutions from current students, for future students. A recent, excellent example of such a paper comes from Liu and colleagues¹¹ discussing shortcomings in medical ethics teaching and assessment. Another recent paper looking at health systems and scientific education was conducted more traditionally by a team of researchers who analyzed student questionnaire responses and did not probe student perspectives directly.¹² Reading these two papers one after another, the power and precision of the student perspective for medical educational research becomes abundantly clear. Educational research using questionnaires or focus groups made up of medical students and then interpreted by academics is, of course, not without merit and the paper in question makes several important conclusions with which we do not disagree. However, in our reading, it becomes weighed down by data collection, methodology, and terminology. Whereas student perspective research papers can be more reflective and critical, resonating with current students and potentially resulting in better, more directed, changes in educational approaches.

Understanding student attitudes toward learning MH is crucial in recognizing the pitfalls of MH teaching. Amongst medical students, there exists a rhetoric that MH are “tick box exercises” that function purely to coax out empathy and soft skills, such as teamwork, leadership, and problem solving. This has been recognized previously as a significant barrier to integration of MH.² Hunter Birden and Tim Usherwood comment on similar attitudes toward professionalism teaching whereby students are able to anticipate the desired outcomes and game the system^13(p408) as opposed to exercising reflective abilities. We have seen this played out in our own experiences, where reluctant students feel MH are being unnecessarily forced onto them by educators. Students resist participating in activities prescribed by the medical school unless they directly ascertain the benefit before engaging in the process. Often, there is a correlation drawn between what students know is examinable content and whether they are motivated to engage with it. Of course, MH educators will promote their subject; they have already demonstrated a degree of passion by choosing to teach it. Students, by contrast, have no such vested interest in promoting MH and therefore positive perspectives on the learning experience are more authentically received by peers. As such, students can play a pivotal role in encouraging MH engagement; by communicating the benefits of MH teaching, their contemporaries are more amenable to participating themselves. Furthermore, learning from student perspectives opens opportunities for peer teaching that allows a longitudinal flow of knowledge beyond a perceived hierarchy of teacher-student relationships.

Not everything of value in medical education is taught through the formal curriculum. Consciously and subconsciously, medical students learn from clinical experiences with patients and other healthcare professionals. With regards to medical education and MH, it is important to create an informal space in which students can autonomously explore and reflect on their experiences. A consideration of this so-called hidden curriculum allows for more well-rounded research in medical education.⁴⁵ In essence, learning within the hidden curriculum is centered in student experience and, as such, exploring these perspectives offers an inlet for understanding. MH must be both accessible and ubiquitous within curricula such that all students are comfortable contributing to the field and the wider discussions it opens up, without fear of making mistakes or getting things wrong. In providing MH opportunities to all medical students, as opposed to the self-selecting few, we broaden the scope for their impact on future practice.

Intercalating in the UK

The AAMC report comprehensively outlines the benefits of MH within the American medical school model, however this differs greatly in structure to the UK system. In the UK, there is an opportunity to undertake an intercalation: students interrupt their five-year undergraduate medical degree to spend an extra year studying a topic related to medicine. These courses need not be taken at a student’s home university and are either crafted specifically for intercalators or allow students to join a cohort of undergraduates from beyond medicine. Intercalated courses are offered in a range of subjects and, from our own experience, popular choices include anatomy, neuroscience, and women’s health. A prevailing misconception that intercalation is reserved for the most academically minded students, combined with the propensity toward electing “traditional” science-based courses mean that the uptake for MH intercalated courses is still relatively low, although this is not well documented aside from university-specific websites. For example, in the 2020/2021 uptake at University College London, just nine internal students undertook an MH intercalation (in either Medical Anthropology or History and Philosophy of Science & Medicine) compared with 37, 34, and 24 students for Cardiovascular Science, Neuroscience, and Pediatrics and Child Health respectively.¹⁴

Intercalators gain an extra degree qualification in the form of a BSc, MSc, MRes, BMedSci, etc. Intercalation in this format is unique to UK medical schools but similar programmes are run in Ireland, Australia, New Zealand, the West Indies, Hong Kong, South Africa, and Canada.¹⁵ Despite the patchy uptake from students and schools alike, MH’s intercalated courses have certainly become more popular. Developing from a tiny minority, we have seen an international interest beginning to rise and an increase in uptake of humanities-based courses in medical schools in the UK and the US.⁴

Our experience that the majority of intercalating students come to value their BSc year and develop skills beyond the scope of the core medical curriculum is confirmed by the literature.¹⁶ Students see this as an opportunity to develop how they think, write, and communicate as well as a chance to work within interdisciplinary teams, contribute to research, and maximize their future career options. A great deal of the literature on motivations to intercalate highlight the benefits in terms of future employability; the transferable skills of critical appraisal, statistical analysis, and in-depth research are highly sought after in students choosing a BSc.¹⁷ In terms of MH, an intercalated degree is arguably a stronger version of inclusion than a one-off assignment or workshop. Reflections on how strong inclusion has been achieved in our experiences of MH intercalation are explored in the Gray Areas section of this piece.

However, we represent a self-selected group of students, brought together by our interest in MH. This highlights one of the pitfalls of intercalation as a stronger form of inclusion: it is voluntary and, as such, attracts only those with prior interest or belief in MH as a facet of becoming a good doctor. Furthermore, despite being a year-long course, intercalation is still condensed and sporadic in terms of its relation to the broader medical curriculum. An isolated one-year engagement with MH has the propensity to perpetuate the goal-oriented, objective success measures of medical education as it facilitates medical students’ belief that the breadth of skills amassed through engagement in the humanities can be reduced down to focused but intermittent study. This is demonstrably untrue: one does not become proficient in history, art, anthropology, or any of the other academic fields encompassed by studying humanities overnight, or over a series of lectures. Similarly, as many students intercalate having undergone two or three years of their medical degree, much of the early part of the course requires an un-learning of the notion that clinical medicine is derived from pure science, devoid of the gray areas MH seeks to understand.¹⁸

An isolated day, or even year, of engagement with MH by no means makes a student an expert. A developed comparison between MH and the more traditional areas of medical education (such as anatomy or physiology) is required in order to manage expectations. One would not expect to gain a wholly comprehensive understanding of neuroscience from one year studying the subject as a BSc – application of this expectation to humanities courses is only accepted among medical educators because the end goal is less well-defined compared with clinical medicine. As students, we can work toward refining this goal.

Gray areas

In this section, we organize our reflections across five domains from within the MH. We focus on how teaching in these areas has allowed for exploration beyond the black and white biomedical model and whether or not learning outcomes were provided by strong or weak inclusion of MH.

History

A great deal of medical education is centered around case studies, illustrated by the global rise in interest of “problem-based-learning”.¹⁹ Encouraging students to build their approach to modern practice around contextual criticism of historical events mirrors this method of learning. Today’s medical schools employ teaching strategies that have been around for centuries. However, the sociological impact of these strategies is rarely explored within medical education. Foucault’s The Birth of the Clinic delineates how dissection, one example of a teaching strategy that has prevailed through the ages, fundamentally changed the practice of medicine through its development of the medical gaze.²⁰ The medical gaze presents a broad lens for understanding the objectification of patients.

More specifically we can consider an item all medical students are familiar with, the stethoscope. The stethoscope made previously inaccessible bodily processes audible to the doctor, through which the doctor came to know more about the patient’s condition than themselves. Slowly, these ‘signs’ began to take precedence over the patient’s symptoms.²¹ As medical students, we can recall being sent by our seniors to examine a patient with an interesting heart murmur or breath sounds, listening to the chest and returning to report our findings: the patients’ internal intonations taking precedence over their personal story. Not dissimilarly, students and doctors alike are often presented with radiographic images, ECGs, or blood results to interpret without ever having seen the patient from whose body they were derived. We have found that understanding how medicine has changed since the advent of dissection, the stethoscope, and other historical developments installs a sensitivity to the ethics and biases of modern practice.

Learning from history allows a greater reflection and awareness of ethical practice, how to act and – perhaps more importantly – how not to act in clinical settings and within research. This is a point of deviation between weak and strong inclusion of history within medical education. In our experiences, weak inclusion tends to be hagiographic focusing on “successes and achievements” of our predecessors, while missing out “follies, omissions, and failures of the past”.^22(p.629) The over-glorification of the past paints medicine as an institution and practice never in the wrong, only doing good. Well-rounded teaching in history shows this to be a false and potentially dangerous idea to present to medical students. Understanding both its successes and failures is essential to the history of medicine.

The Tuskegee syphilis study is a poignant example of the importance of ethics and equipoise in medical research.²³ Without an understanding of where these values come from, it becomes difficult to appreciate their monumental importance in future research. In the Tuskegee study, black male participants who had contracted syphilis were observed over a 40-year period to study the natural history of the disease. Over this time, treatment for syphilis became available but was not given to the participants such that their condition could be researched: this led to a significant number of unnecessary deaths (for more information on this study, see ‘The Tuskegee Timeline’²³). Since this trial, a number of studies have revealed a tangible, lasting impact in the therapeutic relationship between African Americans and medical institutions and research.^24,25 Work from historian Susan Reverby suggests that the reasons for this distrust goes back much further than the trial in Tuskegee.²⁶ There is evidence of slaveholders instilling fears of ‘night riders’ who would steal slaves for medical experimentation and, later in the 19th century grave robbers selling black bodies to medical schools for dissection. The Tuskegee study may have added to the sense of mistrust that we see today, but this is built on centuries of pain and suffering inflicted on black individuals at the hands of the medical community. For us, in the contemporary context, where enduring structural inequalities between ethnic groups have manifested in dire outcomes and significant variation in vaccination uptake throughout the Covid-19 pandemic, an understanding of the racialised history of medicine is ever more pressing.^27,28

The manner in which we look back on and approach historic events in the field is important for the public face of medicine. In 2019, protesters in Central Park, New York demanded the removal of a statue depicting Dr J Marion Simms, a gynecologist who experimented on black female slaves without their consent or analgesia. This brutal manipulation of power eventually culminated in the development of a number of pioneering gynaecological surgical techniques and the eponymous Sims speculum, an instrument still in use today.²⁹ In our experience integration of historical context into curricula is vital to produce healthcare professionals informed about the origins of Western healthcare practice, sensitive to the implications of that history, and therefore have the tools to speak out against the injustices that still exist within medicine.

In an earlier installment, Zareen Zaidi et al. consider the idea of ‘normalization’ within medicine and medical education.³⁰ This links to the examples discussed in this section as we can see how socially constructed ideas bring about an idea of what is normal, and alongside this, what is abnormal. We can see from these examples that the white perspective and experience is dominant and therefore normalized, resulting in the black perspective becoming the abnormal or othered perspective.

A detailed knowledge of the history of medicine, as would be fostered through a stronger inclusion of MH in curricula, trains a critical lens on damaging presentist and hagiographic views of our past, which remain rife through current medical education and healthcare.³¹

Literature

In contrast to the sciences, the humanities utilize qualitative data over quantitative. The investigation and analysis of written, literary evidence allows for nuanced evaluation of gray areas, otherwise missed by scientific methods. That is not to say that MH are without distinct methods or fields of study, nor are its conclusions without concrete evidence. For medical education, these methodologies not only provide valuable academic research; they also provide frameworks for understanding medicine beyond black and white scientific binaries.

In our experience, educators spending time to teach MH methodologies carefully and from the ground up equips students with the vocabulary for understanding not only patient experiences, but our own experiences and wider structural problems with medicine. For example, auto-ethnography, a research methodology based on the reflexivity of the researcher, allows medical students to study and question “the interrelationships between self and culture”, moving beyond commonly used simple reflective exercises.^{32(p 975)} The importance of studying language in order to improve clinical communication is discussed in depth by John Skelton in his paper, ‘Language, Philosophy, and Medical Education.’ In this piece, he argues that there does not exist one singular method of communication which is effective in all patient scenarios, and it is, therefore, only the awareness and knowledge to select from a range of linguist approaches that can lead to success in these scenarios.³³

One such source for qualitative evidence is patient narratives. When considered fully, these stories allow for a richer holistic understanding of the patient experience. Studying literary examples such as Tolstoy’s The Death of Ivan Illych and Wit by Margaet Edson offers medical students an opportunity to develop a diverse set of tools for analyzing and contextualizing patient narratives.^34,35 Case histories and summaries encourage students to condense the complexities of patient experience into a short, often one-minute, summary. In our experience, this results in a specific way of talking and thinking about patients and introduces the opportunity to neglect a holistic appreciation of the many ways in which illness can affect a person’s life. For example, as a medical student reporting the most damaging impact of a patient’s condition as the inability to walk their dog, rather than their chronic pain, could result in a disillusioned response from senior colleagues. This causes significant changes in clinical behavior over time. Students become conditioned to forget their initial enthusiasm for approaching patients as whole people and instead learn, through observing doctors, that clinical signs and symptoms are more important. In our own experience, leading with information about the patient’s life and social factors when presenting a patient to a senior doctor is often met with ‘but did you find out what is actually wrong with them?’. These interactions reinforce the idea that patient stories are unimportant in clinical medicine.

Rita Charon argues that narrative understanding is a key skill for healthcare professionals.³⁶ Medical students should develop “narrative competency”^36(p1897) and learn to “absorb, interpret and respond to stories”.^36(p1897) Narrative belongs to the “intersubjective domains of human knowledge”^36(p1898) and thus require two subjects: “a teller and a listener, a writer and a reader”,^36(p1898) student and teacher, doctor and patient. Hence narrative understanding leads to an enrichment of clinical communication. In contrast is the detached, ‘objective’ observer of “logico scientific knowledge”.^36(p1898) In this way, narrative medicine brings both the experiences of doctor and patient into view, and promotes a medical practice built around “empathy, reflection, professionalism and trustworthiness”.^36(p1897)

Philosophy and ethics

For us, the value of philosophy to medical education lies in the provision of new angles of understanding; examining existing assumptions, leading to answers for “problems no one looked for”^37(p343) and enlightening us to new, better ways to do medicine.³⁷ In the same vein, addressing ontological questions, such as what medicine is, can provide insight and guidance to what medicine ought to be and consequently be used to shape medical education.

Phenomenology is a philosophical methodology that has had a profound effect on our clinical placements. Most recently and thoroughly explored by Havi Carel in Phenomenology of Illness (2016); phenomenology can be used in tandem with other humanities methodologies in its focus on the careful examination of experience as it pertains to the individual.³⁸ Through so doing, phenomenology explores illness as firstly a lived experience, that is distinct biomedicine focus on biological disease. For medical education, phenomenology provides a new perspective onto what illness, healthcare, and medicine mean for individual patients and necessarily promotes a pluralistic approach. We can apply this to our experience to patients with illness that lacks a clearly understood biological pathway. These include psychiatric illnesses and “medically-unexplained” syndromes like fibromyalgia. Phenomenology’s emphasis on patients’ lived-experience a priori to the biological phenomena adds validity to the illness experience of these patients and it aids understanding of these experiences for the healthcare professional. Furthermore, understanding the epistemic bias of biomedicine toward disease over illness as a lived-experience can explain why these groups of patients can be side-lined in modern healthcare and often struggle to receive a diagnosis. The phenomenological approach is discussed in more depth in Veen and Rietmeijer (2021).⁴⁰

In her paper on changing the medical curriculum, Sundeep Mishra explains that it is important to maintain medical students’ orientation with the external environment, that is the one outside the world of medicine, as well as keeping us “grounded to reality”.^41(p187) Philosophy and ethics facilitate the conversations that keep medicine in perspective by questioning concepts that are otherwise taken as assumptions and accepted to be true. As students studying MH, we have explored what is meant by disease, what the purpose of medicine is - reducing pain, prolonging life, curing disease, etc. - and what the reasonable means to achieving these ends are. Even if we never arrive at a definitive answer, we have found value in navigating the grays of difficult arguments, understanding the perspectives of others, and deepening our own reflections on clinical practice.

Asking some of these big questions may seem like the opposite of keeping medicine “grounded to reality”; ^41(p.187) however, this approach provides a wide-angle lens with which to view society and allows us to assess the bigger implications of medical decisions. Medicine is affected by economics, politics, culture, media, and public opinion and in turn it has effects on these sects of society. Yet, as medical students, we can become more and more detached from the outside world as we continue our studies. With different demands than other students, different term times, more years of study, even clubs and societies exclusively for medical students, it is no wonder we risk forgetting to orientate ourselves in the external environment. It is important that we engage medical students with MH to create a group of empathetic and broad-minded future clinicians so that they might engage and propagate this understanding of medicine as inextricably grounded in society.

Two recent popular memoirs from surgeons Henry Marsh and Paul Kalannithi in Do No Harm (2014)⁴² and When Breath Becomes Air (2016)⁴³ respectively offer a powerful insight into the challenges, possible benefits, and effect of patient objectification described by Foucault.^20,44 Resonating with our experiences, in both Marsh’s and Kalanithi’s work, we see patients reduced to objects-containing-disease which enable the surgeons to disconnect and carry out their work. However, this is arguably at the expense of empathy as patients are viewed as less than whole individuals.

David Rothman’s Strangers at the Bedside details the history of medical decision making, and the subsequent rise of bioethics, in the second half of the 20th century.⁴⁵ He expertly draws out how medicine has changed and become disconnected from the world and its patients. Through the medical profession’s quest for ever more knowledge and techniques it became more scientific, more specialized and less personal. Rothman’s work is a poignant example of how factors outside of clinical medicine, that is to say beyond the bedside, can influence medical decision making and the patient-doctor relationship.⁴⁵ For us as medical students, understanding the history of medical ethics, rather than rote learning the principles and laws, shows what is considered to be good, or ethical, medical practice is always situated in history and, to a certain extent, dictated by the historical period. Notably, Rothman goes so far as to suggest that MH may be able to close the gap between doctor and patient that modern biomedical models and specialization opened up.⁴⁵

When teaching and learning aspects of medicine, perhaps especially ethics, we must consider the role and importance of the hidden curriculum. Educators and students must be aware of both the advantages and disadvantages of learning within the hidden curriculum such that its potential benefits are maximized.⁴⁶ MH teaching has been found to mitigate some of these disadvantages. Jack Coulehan and Peter Williams explore how students are immunised^47(p.598) from the negative consequences of the hidden curriculum through teaching on ethics and MH. We can confirm the findings of this paper and know the skills of reflection, critique, and empathy that are cultivated through MH allow students to sift through their experiences on placement, picking out the things they wish to emulate, and others that they hope to avoid.⁴⁸ Furthermore, reflections are enabled and promoted by MH, especially the arts by the process of “making strange”.³ This involves a novel presentation and consequentially new perspectives on our “normal”, automatic, everyday behavior. For example, one can make the process of surgery strange to an experienced surgeon by presenting aspects in artwork, film, and narratives. This forces analysis and reflection upon previously unexamined biases and ideas, leading to new insights and approaches to clinical care.

Anthropology

Posited as both the most social of the sciences and the most scientific of the humanities, anthropology traverses traditional academic disciplines in both content, context, and the competencies it develops. Ethnographic data, the mainstay of research for anthropologists, shares a lot of the principles of medical research in its scope for teasing apart the human experiences of particular cultural phenomena. Ultimately, medicine is a service profession. As clinicians, our work is indelibly influenced by the nuance and variation in the human condition. An anthropological framework with which to think on medicine allows future doctors to understand the origins and implications of western biomedicine. Much unlike the rigid schema of biomedicine would have us believe, it is not the only viable method of treating disease and ill-health. For students who, ultimately, will go on to uphold the hegemony of biomedicine, it is crucial to think critically of its origins and to be open to the possibilities of alternative healing practices.

For medical students and healthcare workers alike, studying anthropology offers an insight into methodologies for better understanding how medicine is contingent on culture, and culture is contingent on medicine. Medical schools attempt to address this interplay through teaching “cultural competence”, a fashionable yet nebulous subject that seeks to equip students with enough knowledge about culture in order to treat patients equitably regardless of the social determinants of health they are impacted by. Much like the manner in which MH education often involves the adoption of techniques from different fields and ill-fittingly superimposes them onto a biologically focused model of teaching, cultural competence teaching inadvertently assumes that culture is a static phenomenon that can be digested and acted upon accordingly. Clearly, as Arthur Kleinman argues in Anthropology in the Clinic, this is not the case.⁴⁹

Workshops and teaching in cultural competence, in our experience, seek to highlight patients’ protected characteristics yet do little to dismantle the structures through which these characteristics prevent access to appropriate care. For example, it is important to consider that the transgender male patient may have the same contraceptive requirements as a cisgender female: it is even more important to consider how this may be a dysphoric experience for our patient and devise solutions through which our healthcare systems can mitigate this harm. In our experiences, students who are members of, or allies for, the transgender community are more likely to take the time to learn about the clinical impact of being transgender. In the absence of teaching on transgender health in the curriculum, these students perform better in exams. We strongly advocate for more teaching on the barriers to healthcare that marginalized groups face, such as contraception for transgender patients. However, going beyond and teaching students the clinical guidelines and adding anthropological understandings of the structural and political barriers to healthcare. We believe this adds poignancy and an importance to these topics. On reflection, we find this results in better student engagement with this material and better student advocacy for marginalized groups.

What studying anthropology, and MH more generally, provides is a methodology through which to think on the social and cultural pressures faced by patients and clinicians alike. Anthropology has a critical role in the clinic, in its capacity to develop empathy, understanding, and humanism beyond the boundaries of traditional clinical competence.

Practical considerations

The value of a strong inclusion of MH is well demonstrated by teaching that seeks to conceptualize and promote holistic approaches. However, there are significant barriers to integration of MH which we will discuss here.

As well as the sheer breadth of content to cover, financial pressures encourage students to prioritize what they perceive to be important outcomes (for example, building a clinically-focused resume). Given that intercalation adds an additional year of study, financial planning is certainly important when considering the “worth” of exploring a new subject, particularly for students from widening participation backgrounds. The economic constraints of intercalation, by extension, impact engagement in MH. Addressing misapprehensions about the employability of students that have intercalated in MH is vital, such that students, who are capable of and want to invest their money in intercalation, know they are getting value in terms of research and clinical competency.

Another such area is the matter of assessment. Rather than assessments which encourage flexibility and creativity, UK medical students are repeatedly presented with multiple-choice, single-best-answer examinations in which marks are broadly reduced to correct vs. incorrect. Furthermore, theoretical frameworks from humanities and the arts can provide critiques and insights into assessment itself for medical education to improve itself.⁵⁰

MH are more difficult to mold to a proforma through which medical schools traditionally mark their students. Written work is useful to educators in determining the accreditation of a student’s degree, yet students often interpret these tasks as an extension of “tick-box exercise” medical education, whereby one must demonstrate proficiency in a particular skill in order to move onto the next phase. Students will perform what is expected of them, rather than truly engaging with the task, if the benefit is unclear or assessment unimportant.⁵¹ This teaching model often fails to captivate potential students and, once again, demonstrates how MH teaching is often shoehorned into the predetermined methodologies and administrative structures of current medical schools. Engaging with MH teaching, and the conversations one has with peers in order to consolidate new areas or patterns of thought have been shown, through our experience, to offer equally tangible learning outcomes.

At one UK medical school, all second year students were offered a day dedicated to small group teaching around interpreting Katsushika Hokusai’s woodblock print The Great Wave off Kanagawa (circa 1829 − 1833). These workshops were spread over two days for the entire cohort of students to receive teaching. On the second day, workshop attendance was low; having heard from peers that there was no register or formal assessment, many decided it was not worth their time. This particular approach - a day long workshop - falls short of captivating the interests of those who cannot immediately see the value. When MH is added on top of, rather than built into the foundations to the curriculum, students are able, and willing, to disengage provided it does not affect their grade.

In our opinion, to encourage engagement, formal assessment must embrace the gray areas of medicine without separation from the core curriculum. As such, we must avoid the urge to quantify the value of MH teaching and embrace its epistemological origins. Educators might better engage students with the process by adopting techniques nascent to the academic field they are exploring; in fully integrating the strategies of academic humanities, students are offered a more authentic experience. Furthermore, adopting these techniques through strong inclusion best demonstrates the financial worth of MH to students and institutions.

Further work

There are of course considerations we have not covered; for example, is it better to join other medical students in a learning space, or do students learn more effectively when they join courses outside of the medical department? In positing our own relatively narrow range of experiences as evidence, it is important to recognize their limitations. Each of us studies at UK universities and as such cannot account for a global student perspective on how MH are weakly or strongly integrated in curricula: we invite further reflections on this topic, particularly from those which incorporate the student voice. The student perspective provides a novel lens for considering issues in medical education as we believe students are invaluable, not just as research participants but as researchers and authors themselves. This is significantly important in issues where we see a generation gap such as racism, LGBTQ+, climate change, and technology and innovation.

Similarly, as we represent a self-selected few who have reflected on and advocated for the value of MH in our curricula, our position is biased toward its benefits. Those who have poor experiences with MH or aspersions that present a counter-argument to what we have said; those who have witnessed particularly weak or strong inclusion, those with further reflections on the academic fields we have discussed, and those within realms of study we have missed are, too, invited to submit their observations. In order to best interweave MH into curricula and begin to make sense of the gray areas of medicine we must cultivate a well-rounded debate.

Conclusion

In this piece we have provided a broad overview of just some of the domains of MH and their value in medicine and medical education from the student perspective. As former intercalators in MH, our introduction to learning from within these disciplines has given us a renewed and nuanced way of viewing every aspect of medicine.

We have discussed the strengths and shortcomings of intercalation as a stronger method of inclusion for MH. While our discussion does not aim to define a single best method for integration, we have demonstrated how MH ought to be viewed as far more than optional extras which may invoke a better bedside manner. Rather, the existence of the gray demands global MH education.

Even the most hardened humanities-sceptic medical educators cannot argue in good faith that medicine exists in a vacuum of objective, black and white, facts, separated from the grays of society, its people and their problems. For us, MH provide an opportunity to look at these gray areas, and a framework for studying them carefully. Medicine can be changed for the better by the people within it, especially when they are given the tools to analyze its shortcomings. Utilizing the student perspective allows a deeper dive not just into what works well in MH, but why it works well and how we might develop education moving forwards. Students offer novel insights which contribute meaningfully to pedagogical discussions that ultimately help to shape medical education and practice. For an institution so consistently in flux, who better to envisage its future than the students at its core?

Previous Philosophy in Medical Education Installments

Mario Veen & Anna T. Cianciolo (2020) Problems No One Looked For: Philosophical Expeditions into Medical Education, Teaching and Learning in Medicine, 32:3, 337-344, DOI: 10.1080/10401334.2020.1748634

Gert J. J. Biesta & Marije van Braak (2020) Beyond the Medical Model: Thinking Differently about Medical Education and Medical Education Research, Teaching and Learning in Medicine, 32:4, 449-456, DOI: 10.1080/10401334.2020.1798240

Mark R. Tonelli & Robyn Bluhm (2021) Teaching Medical Epistemology within an Evidence-Based Medicine Curriculum, Teaching and Learning in Medicine, 33:1, 98-105, DOI: 10.1080/10401334.2020.​1835666

John R. Skelton (2021) Language, Philosophy, and Medical Education, Teaching and Learning in Medicine, 33:2, 210-216, DOI: 10.1080/10401334.2021.1877712

Zareen Zaidi, Ian M. Partman, Cynthia R. Whitehead, Ayelet Kuper & Tasha R. Wyatt (2021) Contending with Our Racial Past in Medical Education: A Foucauldian Perspective, Teaching and Learning in Medicine, DOI: 10.1080/10401334.2021.1945929

Chris Rietmeijer & Mario Veen (2021) Phenomenological Research in Health Professions Education: Tunneling from Both Ends, Teaching and Learning in Medicine, DOI: 10.1080/10401334.2021.1971989

Associated Podcast

Let Me Ask You Something (iTunes, Spotify, Google Podcasts and https://marioveen.com/letmeaskyousomething/)

Funding

The author(s) reported there is no funding associated with the work featured in this article.