Medical Humanities & Medical Education: How the Medical Humanities can Shape Better Doctors
by Alan Bleakley. Published by Routledge, 2015.
Reviewed by Dr Claire Elliott
How can medical education be changed to produce better, kinder medical students? How can they develop more astute clinical skills and improved awareness of the ethical and professional aspects of caring for and treating patients? In this book, Alan Bleakley argues for the democratisation of medical education – with integration of medical humanities as a core discipline – to help effect this change. He argues powerfully for a ‘critical medical humanities’ to be integrated into the medical curriculum in order to challenge the existing culture of medicine, which he feels breeds what he calls ‘insensibility’ and ‘insensitivity’.
Bleakley describes insensibility as the dullness to perception or blunting of close observation by clinicians. He feels that, for example, the decrease in physical observation and clinical examination in the consultation causes the loss of sensibility. He notes that there is a trend for medical students and doctors to request more investigations such as laboratory tests, x-rays and scans and subsequently their skills for ‘hands on’ examination of patients decrease. Indeed, the longer you are at medical school, the greater the lack of sensibility. He distinguishes this from insensitivity, which he describes as a way in which medicine (as currently taught and practiced) can lead to a lack of awareness or ability to be open to the experiences of peers and patients. Clinicians witness suffering all the time, but Bleakley notices that our current practice of medicine enables or encourages us not to see it.
Bleakley gives us a comprehensive view of the origins and growth of medical humanities in North America, UK and internationally. He observes that we have moved on from the exciting first wave of a new discipline to a more discerning and sophisticated second wave. He provides a full and detailed discussion of the choice of the name ‘medical humanities’, suggesting perhaps that it should be called ‘health humanities’. He argues for a critical medical humanities to reshape clinical thinking and practice to help students improve their tolerance of ambiguity. Bleakley argues persuasively that we need a new approach to medical education to help lessen the burnout, cynicism and high suicide rates that are prevalent amongst doctors. He believes that medical humanities helps stop medical students becoming inured to their patients and can help redistribute the power of noticing by experts to all of those involved in patient care. A key part of his argument is his suggestion that medical educators can challenge existing ways of teaching and practice by seeing the work of radical performance artists such as Bob Flanagan. Flanagan, who had cystic fibrosis, made a film, Sick: The Life and Death of Bob Flanagan, Supermasochist, in which he mixed his relationship with terminal illness and his sexual pleasure from being dominated by his partner.
The need for empathy in medicine is frequently encouraged, yet Bleakley discusses some of the problems with teaching it, as it can be superficial or even disingenuous. It may be that reading fiction can help with this. However, by taking us back to Homer’s Iliad, he (with Dr Robert Marshall who co-authored this section) explores how the powerful emotions of this epic story with its tales of war and killing, the heroic and the temporary nature of life on earth, can engage us emotionally in a more genuine way than teaching empathy through communication skills.
In focussing towards goals and making diagnoses, clinicians often do not see or hear what does not fit with their models of disease. In this way, we cannot see the individuality of the patient or where he or she does not fit in with our expected patterns. This tunnel vision approach is limiting for both doctors and patients. Bleakley suggests that creativity can be gleaned from learning to experience (in contrast to learning from, or through experience). This can allow the flourishing of imagination and new ways of experiencing medicine. Bleakley explores and describes a variety of types of creativity, including collaborations between jazz musicians and surgeons to matching volunteers with chronic illness in the community with second year medical students. Bleakley (who plays the saxophone) illustrates that improvisation and creativity, as used in playing jazz, can directly contrast with the reductive, pragmatic and minimalist approach to learning medicine.
Bleakley tells us about ways in which artists and doctors can work together to enhance observational skills. This can improve the noticing that is needed for clinical acumen and for sensitivity to patients’ needs. He emphasizes the need for awareness of all the senses to improve clinical acumen and decision-making. He describes examples of where clinicians are encouraged to observe, listen, smell, and touch (skills encouraged by William Osler), and this have been shown to improve their abilities. Bleakley also examines the role of close listening to the patients’ story in his exploration of narrative in medicine. He challenges the term ‘history taking’ and suggests that ‘receiving’ would be a better term as it suggests less of a power imbalance between patient and doctor. He explores the ways in which studying narrative can help clinicians, yet also suggests ways in which it can limit expression or cause harm.
Within the context of the medicalisation of normal life, Bleakley considers the ‘normality’ of taking prescription drugs. He investigates how the powerful (such as pharmaceutical companies) create an ‘insensibility’ in the general population of the potential dangers of taking medication for conditions that could be considered within the range of normal behaviour (such as ADHD, psychological problems). He cites a variety of novels where this medicine-taking activity is integral to the life of the characters.
Finally, Bleakley considers one of the common questions from within and outside medical humanities. He asks if the impact can or should be evaluated. He proposes that there are more important issues than measurement of impact: to be a critical contrast to the science based curriculum, to help clinicians be more humane and socially aware, to reconsider the meaning of wellbeing and health, and to educate for the tolerance of ambiguity.
This book is not an anti-doctor polemic, though it does challenge the existing structures and methods in medical education and clinical practice. By proposing a new and critical medical humanities, it suggests ways in which we can subvert the status quo and produce a more observant, imaginative, kinder and resilient medical student who works within an environment where the power is more equally distributed amongst the patients, and all of those who work within health care.