It’s been said that according to TV, there are only two interesting professions: law enforcement and medicine. Police dramas, mysteries, procedurals, and courtroom shows are nearly limitless. On the other hand, medical shows ranging from melodrama to comedy to documentary are easy to come by. The commercial success and wide range of even fictional stories about medicine points to an important discussion about the intersection of patient care and the humanities.
In the Journal of the Royal College of Physicians of Edinburgh, Robert Downie writes a synopsis of experiences working in the medical humanities since the early 1990s. The article is not only a good-faith effort to improve the practice of healthcare through the humanities, it’s a call to engagement. Anyone, whether patient or provider, can appreciate that
readers may wish to disagree with some or all of [these arguments], but in disagreeing they will themselves be engaged in the philosophical enterprise. … A philosophical critique of some aspects of medical practice is not exclusive to professional philosophers.
Downie names three “functions” of the medical humanities:
the supplementary function, something that contributes to current medical education or practice;
the critical function, a way to offer “detached scrutiny” or put medicine into a
wider perspective; and
personal and professional development, or ways that the humanities can contribute to the individual lives of practitioners
The author spends a good amount of time discussing at least some examples of each. Ethics is a prime example when discussing the supplementary function. Medical or Biomedical Ethics is a huge field by itself. Downie’s overarching point is that any attempt to systematize ethics into a framework or categories — while not wrong or misguided — will always be lacking. Every healthcare interaction is a human interaction, and the ethical skills needed to navigate those interactions are as varied as the skills it takes to be a human being.
For example, sometimes a doctor may need to stand up to a manager, or an angry relative. Qualities such as courage, equanimity, tact, honesty or patience may be needed — even humility when things go wrong. The general point is that hospitals or general practices are microcosms of society as a whole — with heightened tensions — and it is therefore necessary to have the entire range of moral concepts to understand their problems.1
Several points stand out to a storyteller. Not the least of these is that Downie refers to ethics and morality as being the way to understand problems (and every story starts with a problem).
Beyond that is the idea that a clinical setting is a
microcosm of society. Moments in a healthcare environment are sometimes life-and-death, sometimes humdrum; the emotions range from boredom to fury; a clinic has its own hierarchy and decision-making processes. This may go a long way to explaining why medicine makes for good TV stories:
heightened tensions come and go quickly, new characters are easy to come by, and a resolution to conflict may be immediate, may take several seasons to tease out, or may never come at all.
Downie’s point is that the relationship goes both ways. The humanities, above all the dramatic, performing, and literary arts
can provide condensed versions of the problems of life (or of the clinic!)
and confront us with the question: What would you have done? The crescendo to this discussion of ethics is this:
Stories can sharpen judgement.
Human interactions are messy and complex. Stories are messy and complex, but in a contained, useful way. The need for ethics to go beyond a systematized approach also applies to communication. The teaching of communication skills is not wrong or misguided, but
the attempt to have a complete reduction of communication to a set of discrete skills is bound to fail. Just like with ethics, the skills necessary to communicate effectively are the skills necessary to be human:
Good communication is not a manipulative technique but is inherently creative.2
The clinic is a microcosm of society and working in healthcare takes many varied and deep skills. The line between personal and professional development for the healthcare profession is blurred in ways that it’s not for other occupations. Whatever helps us become more human will necessarily improve ethics and communication.
The identity of being a doctor can consume all other aspects of personality. This is certainly true in other areas of healthcare, but particularly with physicians. This is something like a career in the arts: the creative impulse is so personal to artists that it seems like the dominant personality trait, at least to others. The humanities are not only important for the development of skills in the clinic, they produce well-rounded individuals outside of it, as well.
Early in the article, Downie seeks to give a definition broad enough to allow for all examples of “humanities”. One of the problems with the humanities in general, and “medical humanities” specifically, is that they are not all created equal. It’s
worth issuing the warning that the humanities themselves are not necessarily humanistic or educative. The entire point of medical humanities (and some would expand this to all humanities) is to make healthcare better by making it more human. If the medical humanities become an academic discipline for study, they become an area closed off from everyone who could benefit, aloof and isolated in jargon. The human part of the medical humanities is directly related to its teaching.
Throughout, Downie acknowledges and even invites disagreement, and one of the touchiest of subjects may come at the article’s end. The author correctly identifies that literature has been given a kind of preferential treatment.
One consequence, Downie notes,
of this narrowing of the medical humanities to literature has been an obsession with certain words, especially ‘narrative’.
There are benefits and downsides to this, and Downie gives a brief but accurate summary of them. The literary emphasis on narrative is certainly a good reminder to look beyond the “laboratory tests” to the human patient. On the other hand, good clinicians are surprised, if not annoyed, at the insinuation they haven’t been paying attention to narrative in the first place. A purely literary understanding of the medical humanities focuses on “reading” a patient like a text. This is not wrong, but it misses the fact that the human practice of medicine does not only read narratives in this sense. It absorbs them, analyzes them, places the provider in the middle of them, rearranges them, and then demands that the provider be able to continue them, communicating back to the patient in meaningful ways. If that wasn’t enough of a challenge, the demands of modern healthcare require this happens faster than the speed of literature:
Clinicians of course have always listened to the patient’s story. It was called ‘taking a case history’… In any case, in contemporary healthcare there is not enough time to listen to anything so grand as a ‘narrative’.
The article reviewed: Downie, Robert. 2016. “Medical Humanities: Some Uses And Problems”. Journal Of The Royal College Of Physicians Of Edinburgh 46 (4): 288–294. https://doi.org/10.4997/JRCPE.2016.416.
1 Downie, R. S., and Jane Macnaughton. 2007. Bioethics and the Humanities. Abingdon: Routledge-Cavendish. ↑
2 Salmon, Peter, and Bridget Young. 2011. “Creativity In Clinical Communication: From Communication Skills To Skilled Communication”. Medical Education 45 (3): 217–226. https://doi.org/10.1111/j.1365-2923.2010.03801.x. ↑