Humanities and GP training: the perception of GP trainers towards using medical humanities to teach GP trainees primary care

ABSTRACT

Purpose

The benefits of medical humanities in medical education have been extensively cited. The aim of this research was to explore the perspectives of UK GP trainers towards using medical humanities to teach GP trainees in primary care.

Method

Phenomenological, qualitative research designed was used. Semi-structured interviews were conducted with eight GP trainers from across the UK, between April and May 2020. Poems were used as discussion prompts for those participants who lacked experience using medical humanities to teach GP trainees.

Results

Emerging themes were that all participating GP trainers recognised the benefit of medical humanities to GP training, yet only 50% of them were actually using medical humanities in their teaching. An overburdened GP curriculum, a lack of funding and a lack of clinically relevant art and literature resources were identified as barriers for the inclusion of medical humanities into GP training. Furthermore, GP trainers identified the need for peer networks and medical humanities conferences to encourage the use of medical humanities in GP training.

Conclusion

This study provides the perspective of UK GP trainers towards using medical humanities in teaching GP trainees in primary care. GP trainers identified sustainable funding to develop a resource bank of art and literature, peer network events and medical humanities conferences as key interventions to facilitate medical humanities teaching in GP training. Recommendations for future research include robust studies focusing on the effectiveness of various techniques used to integrate medical humanities into GP training, such as poetry.

KEYWORDS:

• Medical humanities
• GP training
• GP trainer
• GP trainee
• medical education
• general practice
• primary care

Introduction

Medical humanities can be defined as ‘an integrated, interdisciplinary, philosophical approach to recording and interpreting human experiences of illness, disability and medical intervention’ [1,2]. Combining humanities with medicine has a myriad of potential benefits, yet the potential for learning through humanities in medicine, especially general practice, has not been fully realised [3]. The argument for including humanities teaching in medical training is two-fold. Firstly, humanistic study contributes to doctors becoming better clinicians whereby they understand the patient condition in the context of their life [4]. Secondly, humanities can support doctor wellbeing and resilience. Humanities can preserve clinicians’ wellbeing by increasing practitioner compassion and empathy [5,6]. This is especially important in general practice where evidence shows the level of stress and burnout among GP trainees and GPs is increasing and can pose risks to patient safety [7–8,9]. Art, literature and music promote a work-life balance and prevent burnout by sustaining the humanity of doctors in conditions of dehumanising pressure [3]. Foster [10] suggested that poetry should be included in the GP training curriculum. Encouraging trainees to read, reflect and write poetry may enhance reflective practice and empathy through the use of language, metaphors and ambiguity. GP trainees may relate this to the patients ‘hidden agenda’, in other words, what is not directly spoken by the patient in GP consultations. This deeper understanding can help GP trainees to foster empathy where compassion fatigue is a real risk [11].

The RCGP curriculum states that GP trainees should learn in a variety of ways such as ‘exploring medical humanities literature as this provides an essential opportunity for reflective practice’ [12]. However, detailed guidance in how this can be achieved is absent. Forde et al (2020) reported how a six month mandatory medical humanities teaching programme was well received by GP trainees and concluded that their research might encourage more GP training schemes to adopt a similar approach [13]. However, before this can happen, the knowledge gap about what GP trainer perceptions are towards using medical humanities to teach GP trainees in primary care, needs to be bridged.

Methods

This qualitative study was based on the constructivist paradigm. A phenomenological approach was utilised to understand the subjective ‘lived in experience’ and perception of GP trainers towards the use of medical humanities in teaching GP trainees in primary care. Semi-structured interviews provided in-depth perceptions of GP trainers towards the use of medical humanities in GP training. Poems were used discussion prompts for those participants who were unfamiliar with medical humanities. The research was conducted during the Covid-19 pandemic. The online video conferencing platform Zoom™ was used

Purposive, convenience sampling was used to recruit participants. Eight participants were recruited to this study. This was determined by data saturation. Participants were Health Education England approved GP trainers who were involved in GP training and their characteristics can be found in Table 1. Participant ages ranged from 36 to 63 years old. Four out of the eight participants were Training Programme Directors. They were recruited from different geographical locations within the UK which was advantageous because they will have varied experience and interests that will lead to a slightly different GP training experience for trainees.

Table 1. Participant characteristics.

Participant Unique code	Age	Gender M/F	Country where undergraduate medical education completed	Duration as GPT (Years)	Number of Current GPTrs supervised	TPD (Yes/No)	Additional Educator Role
001	43	M	India	5	66	Yes	Appraiser Medical Students
002	49	F	UK	10	70	Yes	Foundation Years
003	43	F	UK	6	2	No	None
004	51	F	UK	9	78	Yes	GP Appraiser
005	41	F	UK	9	77	Yes	Medical Students
006	52	M	UK	10	1	No	Foundation Years Medical Students Minor Surgery course Respiratory Lead
007	63	F	UK	5	10	No	Researcher Artist Medical Students
008	36	M	UK	3	4	No	Medical Students

Ethical approval was obtained from the University of Bedfordshire.

Two poems served as discussion prompts to stimulate discussion for trainers who lacked understanding of what was meant by medical humanities. These poems were written by Laing [14]. They were chosen because one of the poems highlighted Johari’s window [15] and the other poem was about lack of insight. These are both familiar concepts to GP trainers and relevant to GP training. One advantage of using poems was that the interviewees shared their perspectives without fear of judgment, because poetry depersonalises the discussion.

Verbatim transcription of the interviews was analysed. Transcripts were assigned unique codes to preserve anonymity. The data was subjected to open coding and classified into categories to allow systematic comparisons between the data sets. For each participant, a table presenting the codes, quotations and researcher comments was created. To avoid taking comments out of context or misinterpreting them, whole quotations from the interviews were used in the Framework analysis Gale et al [16].

Results

The major themes are shown in table 2, along with illustrative quotes from the interviews. GP trainers recognised the usefulness of medical humanities in maintaining wellbeing of GP trainees, how it helps doctor-patient communication and relationship. Some GP trainers commented that medical humanities could be used to support the wellbeing of GP trainees during the Covid-19 pandemic. Most participants felt that medical humanities could be used to help GP trainees develop reflective skills. Furthermore, if GP trainers experienced the use of medical humanities in their own career, they were more likely to use medical humanities to teach GP trainees. Therefore, suggesting that role models using medical humanities can inspire GP trainers to use medical humanities in their own teaching and learning. Also, if a GP trainer has a personal interest in medical humanities, this positively influences them to incorporate medical humanities into GP training. Those who lacked experience in the use of medical humanities supported the use of medical humanities but were uncertain about how to integrate it into GP training. The discussion prompts were helpful in stimulating discussion in these cases. Training Programme Directors had a degree of autonomy to decide how the GP curriculum was delivered if they enjoyed arts and humanities, they were able to integrate it into their GP training programmes. The GP trainers identified an impressive long list of topics suitable to be explored using medical humanities. Topics which emerged more than once were communication skills, chronic illness and mental health.

Table 2. Major themes.

Theme	Participant	Quote
Wellbeing	006	‘Arts and humanities is [sic] like a tool box that help frame and reframe situations and how you deal with them’.
		‘Art and humanities help wellbeing, reduce stress, reduce burnout, help us build relationships with our patients’.
	002	‘One of the things we tried to put across to the GP trainees is that this is good for you and your wellbeing’.
	004	‘Day release is called that as mental and psychological release and there is a role for drawing and theatre in day release’.
	005	‘ … and I think one of the things is it again provides a really safe space for talking about emotion … ’
Doctor patient relationship	007	‘Humanities can help build doctor patient relationship, makes it personal which can aid diagnosis and treatment as well as help the doctor to relax and enjoy their work. Relate to the person on different levels. Humanities can help doctor-patient communication’.
Reflection & Empathy	007	“ … creating space for quite deep reflection and different sets of languages and different age groups and different cultures, different knowledge. Accessing my feelings about how I treated someone or how they reacted to me just by having that awareness of how patients are feeling or how they put that on paper or make a sculpture it makes me think about my own feelings better. It”s a new way to tap into reflecting”.
	005	‘ … a GP trainee who was really struggling and we did some Elizabeth Jennings poetry … and then this guy produced this learning log entry that his trainer screenshot and sent to me … what was this, what was this magic that you did to this man because he seems to have learned how to reflect and from then on, his portfolio was incredible’.
	002	‘This will give you an insight into people’s experience of life and of illnesses and about situations that you personally may never experience yourself but you’ve got to understand if you’re going to help them.”
GP Trainer Interest	005	‘ … 3 sessions on average a year to teach humanities. I run a GP film club’. ‘ … I have an English A-level … tend often to use poetry … ’ ‘ … whereas actually for me, this is about me. I would be lost if I couldn’t do this stuff and this is what makes me live and breathe this is what I love the most and I’m so glad I can combine my life together when I’m doing this stuff’. ‘I’ve got a lot of more literary friends who have read more than I have, so I’m aware that because some of my friends know that I do this stuff every so often I will get a WhatsApp with this poem, I think your junior doctors need this one and others put something on Facebook that I will use’.
	002	‘I learnt about the value of the humanities and people can tell the patients stories through poetry and stories and visual performances’. ‘I think the desire that trainees don’t see the arts a bolt on but they see it as a very integral way in which they can learn … ’ ‘ … and always to give the patient story whatever we’re doing … ’
Lack of funding & resources	004	‘Money, investment for instance using actors’.
	007	‘Art isn’t free’. ‘ … there won’t be sustainable funding’.
	001	‘ … I am not a creative thinker and can’t come up with examples myself’.
	003	‘ … it be great if there were some online resources for a tutorial’.
Peer Network and Medical Humanities conferences	005	‘ … that’s why I love the Humanities in Medical Education Facebook group because you know really positive ideas in there and people who go I’m looking for a thing about whatever sometimes it is that you just happen to be reading about’. ‘I set up that Facebook group to try and gain a little bit of some kind of a community. So I just feel that dialogue and a real world network would make a huge difference’.
	005	‘I went to medicine unboxed a couple of years ago, again you meet all these people that love this stuff and you kind of bounce out feeling totally you know excited and energised’.
	002	‘I find by going to conferences like that Medicine unboxed opened my world to lots of different resources … and I met a few people there’. ‘There was one in particular who has been a bit of a mentor to me and she’s giving me lots of ideas and introduced me to people and resources’. ‘ … and I’ve been to the global health Film Festival a couple of times and that’s given access to lots of ideas for films’. ‘A medical humanities day /conference with different workshops’. ‘ … Medicine unboxed. There’s pain in my heart that it’s not being held this year’.
	007	‘.things are brought to our attention that we would not consider … Sharing different thinking and experiences’.
Poems	008	‘We have Johari’s window in medicine and that is like this’.
	003	‘I was actually reading a war poem this morning with my daughter … and it evoked some strong emotions in me about the COVID pandemic. Perhaps there’ll be some strange behaviours or anxieties or health seeking behaviour from our patients at the moment might be the same as the people had during war. We could discuss a war poem and then use it for the basis for tutorial to discuss this further’.
	005	‘ … tend often to use poetry because it’s short’.

Barriers

All of the GP trainers in this study supported the use of medical humanities to teach GP trainees, yet only half of them were using them to teach GP trainees. Barriers that GP trainers identified included: a lack of resources such as an online database of clinically relevant art or literature to use in GP training, and a lack of sustainable funding to invite external artists or facilitate theatre trips. GP trainers wanted peer networks and medical humanities conferences to meet likeminded individuals, so they could share resources and discuss ideas how to combine humanities with medicine.

Conclusion

The RCGP curriculum states that GP trainees should learn in a variety of ways such as ‘exploring medical humanities literature as this provides an essential opportunity for reflective practice’ [12]. However, detailed guidance in how this can be achieved is absent. Medical humanities can be used to teach holistic patient care, communication skills, reflection, empathy as well as a myriad of other topics [1]. This study demonstrates that experience and personal interest in medical humanities can give GP trainers the confidence to use it. Individual GP trainer preference determines the modality (i.e. art, music, film or literature) by which humanities is included in GP training. The use of medical humanities can help the wellbeing of GPs and GP trainees. It can help build doctor-patient relationship by advancing communication skills, reflection and empathy.

Barriers to the inclusion of humanities in GP training have been identified as lack of time and space in an overburdened curriculum, the type of humanities content, who should teach it and what are the most effective teaching methods. GP trainers would like peer networks and medical humanities conferences as opportunities to energise and share ideas. They would like access to sustainable funding to secure clinically relevant medical humanities resources for GP training. All of the GP trainers in the study support the use of medical humanities in GP training but some trainers fear that GP trainees are too exam focused and would not appreciate the relevance of medical humanities in GP training. They also found it challenging how to integrate humanities into their curricula, the content, methods and the type of integration [3]. Wear [17] states that science and humanities should sit side by side, harmoniously in the medical curriculum. Whilst science explains the anatomy, physiology and pathology of human experience, the humanities explore the meaning individuals and groups of people assign to events within their lives [1]. Pellegrino [18] and Charon and Williams [5] suggest that humanities should be taught by faculty experts in subjects such as philosophy, history, literature, theology and ethics, visual arts, so that the intellectual value of each field is not compromised. Yet, there is a risk that combining too many areas of study, may subsequently diminish the relevance and pedagogical depth of each subject [19]. In addition, at postgraduate level, it can be challenging to identify subject matter experts to deliver interdisciplinary learning.

Recommendations

Involvement of the arts and humanities in general practice appears to be dependent on the individual GP trainer’s interest and discretion [1]. One suggestion is that formal written guidance for training programmes to include theatre, drama, poetry and visual arts might improve the integration of medical humanities into GP training [11]. Finn et al [1] assert that framing engagement with medical humanities as an opportunity for professional development for GP trainers might be a step in the right direction. Forde et al [13] suggest that a longitudinal curriculum integrating medical humanities into GP training, taught jointly by GPs who bring clinical relevance and artists who bring the expertise is a way forward. This research demonstrates that before all of the above can happen on a wider scale, GP trainers need sustainable funding to access clinically relevant arts and literature resources, including medical humanities conferences and peer networks to share ideas. Placing this research into the current context of the Covid-19 pandemic, it can be argued, that now, more than ever before, GP trainers should use medical humanities in GP training to show GP Trainees, how they can call upon the humanities to support their own wellbeing and that of their patients.

Limitations of this research include a lack of triangulation and a single researcher conducting the interviews and analysing the data, increases risk of researcher bias. The lead researcher is also a GP TPD and trainer which may have led to insider bias. Efforts to minimise this were made by keeping reflective and reflexive notes. Furthermore, poems that were used as discussion prompts had the potential to obtain in depth information from participants about their perceptions about the role of poetry, however, this was outside the scope of this research project, but may be a focus for future project.

In conclusion, this qualitative study has provided greater understanding about the perspective of GP trainers towards using medical humanities to teach GP trainees in primary care. The majority of the evidence supporting the use of medical humanities in healthcare training consists of opinion and editorials. Future research should provide high-quality evidence, focusing on the effectiveness of using poetry in GP training and explore how GP trainers may incorporate interdisciplinary approach to integrating medical humanities into the GP curriculum. Finally, studies investigating how using medical humanities in GP training reduces stress, burnout and improves trainer and trainee wellbeing may also be beneficial.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

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