Evaluating the Impact of the Humanities in Medical Education

MOUNT SINAI JOURNAL OF MEDICINE 76:372–380, 2009 372

Evaluating the Impact ofthe Humanities in Medical Education

Andrea Wershof Schwartz, MA,1 Jeremy S. Abramson, MD, M.M.Sc,2

Israel Wojnowich, BA,1 Robert Accordino, MSc,1 Edward J. Ronan, PhD,1

and Mary R. Rifkin, PhD1

1Mount Sinai School of Medicine, New York, NY2Harvard School of Medicine, Cambridge, MA

ABSTRACT

The inclusion of the humanities in medical educationmay offer significant potential benefits to individualfuture physicians and to the medical communityas a whole. Debate remains, however, about thedefinition and precise role of the humanities inmedical education, whether at the premedical,medical school, or postgraduate level. Recent trendshave revealed an increasing presence of thehumanities in medical training. This article reviewsthe literature on the impact of humanities educationon the performance of medical students and residentsand the challenges posed by the evaluation ofthe impact of humanities in medical education.Students who major in the humanities as collegestudents perform just as well, if not better, thantheir peers with science backgrounds during medicalschool and in residency on objective measures ofachievement such as National Board of MedicalExaminers scores and academic grades. Althoughmany humanities electives and courses are offered inpremedical and medical school curricula, measuringand quantifying their impact has proven challengingbecause the courses are diverse in content andgoals. Many of the published studies involve self-selected groups of students and seek to measuresubjective outcomes which are difficult to measure,such as increases in empathy, professionalism, andself-care. Further research is needed to define theoptimal role for humanities education in medicaltraining; in particular, more quantitative studies areneeded to examine the impact that it may have

Address Correspondence to:

Andrea Wershof SchwartzMount Sinai School of Medicine

New York, NYEmail: [email protected]

on physician performance beyond medical schooland residency. Medical educators must considerwhat potential benefits humanities education cancontribute to medical education, how its impactcan be measured, and what ultimate outcomes wehope to achieve. Mt Sinai J Med 76:372–380,2009. 2009 Mount Sinai School of Medicine

Key Words: empathy, evaluation, humanities, lit-erature, medical education, medical student per-formance, premedical, professionalism, residentperformance, self-care.

Medical educators have long recognized that physi-cians in training require more than just an under-standing of scientific principles to become successfuldoctors.1 As early as the 1920s, Dr. Francis Peabodyof Harvard Medical School lamented that ‘‘younggraduates have been taught a great deal about themechanism of disease, but very little about the prac-tice of medicine or, to put it more bluntly, they aretoo ‘scientific’ and do not know how to take careof patients.’’2 Inclusion of the humanities in medi-cal education may offer significant potential benefitsto individual future physicians and to the medicalcommunity as a whole and may provide an avenueto address the concerns that Dr. Peabody raised solong ago. Some of these benefits may include creat-ing a more diverse medical profession with studentswho bring various backgrounds and talents the manychallenges of medicine3 and perhaps creating moreopen-minded doctors who are able to better relateto their patients or understand their points of view.Studying humanities may enhance medical students’ability to communicate with patients or improve theircomfort level in the clinical setting,4 and it mayincrease their ability to listen to and observe diag-nostic findings from patients.5,6 Additionally, medicalschool communities may be enriched by the pres-ence of humanities; at our own institution, SinaiArts,

Published online in Wiley InterScience (www.interscience.wiley.com).DOI:10.1002/msj.20126

2009 Mount Sinai School of Medicine

MOUNT SINAI JOURNAL OF MEDICINE 373

which coordinates student music and dance per-formances and art exhibits, and the Mount SinaiMosaic, a student literary publication,7 are 2 examplesof ways in which the humanities can be incorpo-rated into student life and provide opportunitiesfor reflection about the process of becoming aphysician.

Debate remains about the definition and preciserole of the humanities in medical education,whether at the premedical, medical school, orpostgraduate level.8 Consensus is lacking in themedical community about which subjects fall underthe rubric of humanities education and what thegoal of their inclusion in medical education maybe. For the purpose of our review, we havedefined humanities education broadly as non-medical subjects that may enhance the training ofphysicians including literature, visual arts, performingarts, ethics, philosophy, anthropology, history, andsociology.

Even as the discussion continues, the humanitiesare occupy an increasingly important role in medicalschool admissions and curricula. Calls for reformof the premedical curriculum seek to encouragestudents to study more than basic science andincrease their appreciation of the humanities,9 andsome colleges offer courses or majors in the medicalhumanities in addition to the traditional premedicalpreparation.10 Undergraduate humanities and socialscience majors make up close to 15% of successfulmedical school applicants.11 Medical schools aroundthe country offer electives and required coursesin the humanities,12 and the field of narrativemedicine, which uses literature and writing asa vehicle for increasing physician self-reflectionand empathy, is gaining increasing prominencein both the medical literature13,14 and the laypress.15

Driving this trend is the recognition thatthe study of humanities may provide a uniqueavenue to positively affect physicians in training.Medical educators must consider what specificcontributions humanities education can make, howits impact can be measured, and what ultimateoutcomes we hope to achieve. These questions areparticularly challenging because they require medicaleducators to reflect on how to define a successfulphysician and how to measure that success. Thisarticle reviews the literature on the impact ofhumanities education on the performance of medicalstudents and residents and the difficulties posedby the evaluation of the outcomes of a humanitieseducation.

MEDICAL SCHOOL AND RESIDENCYPERFORMANCE OF UNDERGRADUATE

HUMANITIES MAJORS

A frequently studied concern is that students whomajored in the humanities prior to medical schoolmight be inadequately equipped to perform academ-ically at the level of their science-focused peers.At our own institution, the Mount Sinai Schoolof Medicine (MSSM), the Humanities and Medicine(H&M) early admissions program has for 20 yearsaccepted humanities majors to the medical schooland tracked their academic progress in comparisonwith their peers with traditional premedical back-grounds. These students apply to medical schoolas college sophomores majoring in a humanitiesdiscipline and, if accepted, complete only minimalpremedical requirements and do not take the Med-ical College Admission Test (MCAT); this providesthem with maximal flexibility during their premed-ical years to focus on their humanities studies. Toensure adequate exposure to premedical science,these students spend a summer prior to matriculationat the medical school, studying abridged curriculain organic chemistry and physics and participatingin medical ethics courses and clinical activities. In2000, we conducted a study of the first cohort ofH&M students, who matriculated at MSSM between1991 and 1997, and compared them to 2 matchedcohorts of students accepted through the standardadmission process.16 We found that H&M studentswere more likely to have academic difficulties duringthe preclinical years, but by the third year, they were,as a group, indistinguishable academically from theirclassmates with traditional premedical backgroundson the basis of clerkship performance. In fact, theH&M students were overrepresented among studentswho earned membership in the Alpha Omega AlphaNational Medical Honor Society, honors in clinicalclerkships, and other academic awards. These datasuggest that although medical students with majors inthe humanities may not succeed as well in the preclin-ical curriculum in comparison with peers with moreextensive science backgrounds, they do excel in theirclinical clerkships, where textbooks and Petri dishesgive way to real patients and clinical problem solving.

Several studies have compared humanitiesmajors to science majors in their undergraduate med-ical curriculum accomplishments. Zeleznik et al.17

and Herman and Veloski18 studied the medicalschool performance of students with science andnonscience bachelor’s degrees. Data were collectedfor students entering over a 4- or 7-year period atthe same medical school. No difference was found

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374 A. WERSHOF SCHWARTZ ET AL.: EVALUATING IMPACT OF HUMANITIES IN MEDICAL EDUCATION

in yearly grade point averages, in parts I and IIof the United States Medical Licensing Examination(USMLE) examinations, and in ratings in 6 requiredclinical clerkships between the science and non-science majors. Yens and Stimmel,19 in a study of9 classes at 1 medical school, compared a num-ber of variables (scores on parts I and II of theUSMLE examinations, course grades for all 4 years,and membership in Alpha Omega Alpha) for stu-dents with various undergraduate majors and foundthat nonscience majors performed as well, or some-times better, than their science major cohort. Studyafter study supports this finding that there is no signif-icant difference in medical school performance whenscience and nonscience majors are compared.20–23

Table 1 summarizes the findings of these studies,which in aggregate suggest that students who studythe humanities in college perform at least as well inmedical school and residency as their colleagues whostudied sciences, and perhaps have an advantage incertain settings.

The single best predictor of academic achieve-ment in medical school and residency is previousacademic performance, regardless of the discipline ofstudy. Previous success in school most closely pre-dicts academic achievements in medical school24,25

and residency ranking,26 although this has not beenas well validated for postgraduate performance.27

Students who majored in the humanities may in factperform better as interns when rated by supervisorson criteria ranging from clinical judgment to rela-tionships with patients and peers,28 although somestudies found no difference in residency perfor-mance in comparison with science undergraduatemajors.23,29

Beyond medical school, predictors of perfor-mance include scores on the National Board ofMedical Examiners (NBME) Step 1 and 2 examina-tions and clinical clerkship grades; the latter havebeen shown to correlate closely with success inresidency programs30 and are reliable predictors ofintern-year knowledge and professionalism ratings,31

particularly at the extremes of performance.32 Thestrength of the relationship between medical schooland residency performance varies by specialty; there-fore, interpreting the data across medical specialtiesshould be performed with caution.33 In addition,humanities background and academic performancein medical school do not have a significant influ-ence on whether a student chooses a primary carefield,34–36 although students who studied humani-ties as undergraduates may be more likely to selectpsychiatry as a specialty.37

INCREASING PRESENCE OFHUMANITIES IN PREMEDICAL AND

MEDICAL EDUCATION

Premedical education has for decades centeredaround the principle that applicants to medical schoolrequire preparation in the sciences and a rigorousapproach to learning.38 Beginning with the 1984Association of American Medical Colleges report onthe general professional education of the physicianand college preparation for medicine,39 calls forreform of premedical curricula have stressed thevalue of studying humanities in addition to traditionalscientific and mathematical courses. Certain courses,such as calculus and organic chemistry, are largelyirrelevant to medical practice and are used primarilyto distinguish students from one another academicallyin the premedical setting,40,41 often creating acompetitive learning environment antithetical to theteam-based approach so central to the practice ofmedicine.42– 44 In place of these often unnecessarycourses, some experts suggest that premedicalcurricula should include studies in the humanities,which may better prepare students for the complexrealities of medicine9 and emphasize the moral andpersonal development of physicians in training.45

At the medical school level, many curriculacurrently offer humanities electives or requiredcourses, including writing, literature, music, arts,and ethics,46– 48 and this trend appears to beincreasing.12 As of 2004, 88 of 125 American medicalschools required humanities courses, and 55 offeredelective courses.49 Some medical schools also offera concentration or minor in medical humanities formedical students.50,51 An entire issue of AcademicMedicine was devoted to highlighting examples ofthese various programs, indicating the increasingdegree to which these programs are becomingcommonplace within medical education.52 At MSSM,humanities-focused courses include electives onwriting about medicine,53 literature and medicine,and music and medicine, and a required componentof the internal medicine/geriatrics clerkship includesguided visits to an art museum with exercises in theart of observation; this program has been favorablyreviewed by students at our institution and is gainingpopularity at other medical schools.54

POSITIVE IMPACT OF HUMANITIESEDUCATION ON MEDICAL TRAINING

The increasing presence of the humanities at thepremedical and medical school levels does not

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Table 1. Predictors of Success in Medical School and in Residency.

Medical School

Study Group Finding Reference

190 medicalstudents

Despite lower uGPAs, humanities majors more likely to earn AOAmembership and formal commendations.

Stratton et al.81 (2003)

808 medicalstudents

Previous academic performance is the best predictor of medical schoolperformance.

Bastias et al.25 (2000)

255 medicalstudents

Compared to matched traditional premed humanities and science majors,humanities and medicine students had more NBME Step 1 failures butearned more graduation awards and honors and were more likely toearn AOA membership.

Rifkin et al.16 (2000)

406 medicalstudents

No difference in medical school performance between humanities/socialscience majors and science/math majors.

Smith22 (1998)

200 medicalstudents

No correlation between the quantity of undergraduate science and averagepreclinical performance. uGPA and MCAT scores predict NBMEperformance.

Hall and Stocks21 (1995)

782 medicalstudents

No difference in medical school performance based on the quantity ofprevious science study.

Neame et al.24 (1992)

812 medicalstudents

Undergraduate science majors had higher MCAT scores than humanitiesmajors, but no statistically significant difference in performance in thefirst 2 years of medical school.

Ashikawa et al.20 (1991)

200 medicalstudents

No difference in uGPAs or NBME performance between degree types;humanities majors consider leaving medical school more frequently, andhumanities/social science majors are more likely to choose psychiatry.

Zeleznik et al.17 (1983)

735 medicalstudents

Nonscience majors do just as well or better than science majors. Yens and Stimmel19

(1982)1077 medical

studentsNo relationship between premedical training and clinical competence. Herman and Veloski18

(1981)

Residency

Study Group Finding Reference

1069 residents Low third-year grades predict low ratings in knowledge andprofessionalism; NBME Step 1 scores predict knowledge.

Greenburg et al.31

(2007)645 residents Cognitive and noncognitive factors are important in predicting future

success and residency ranking.Peskun et al.26 (2007)

5701 psychiatryresidents

Psychiatrists scored higher on measures of verbal ability but lower onNBME.

Sierles et al.37 (2004)

1659 medicalstudents

NBME scores, grades, and AOA membership led to no difference inchoosing generalist fields.

Stimmel and Serber34

(1999)104 residents Students who study the humanities in addition to science as

undergraduates perform better as interns.Rolfe et al.28 (1995)

581 residents No difference in NBME Step 2 scores, but science majors scored higher onNBME Step 1. The same residency performance was found.

Elam et al.23 (1993)

277 residents Higher NBME scores correlate with outstanding resident evaluations. NBMEscores provide reliable predictions only at extremes of performance.

Yindra et al.30 (1988)

185 residents uGPA and medical school achievement are not the best predictors ofresidency performance; NBME II is.

Gunzburger et al.32

(1987)636 medical

studentsUndergraduate academic background makes no difference in career plans

or residency selection.Ferrier and Woodward35

(1983)441 residents The strength of the relationship between medical school performance and

residency performance varies by specialty.Gonnella and Hojat33

(1983)185 residents Intern-year performance is similar, regardless of the undergraduate major. Woodward and

Mcauley29 (1983)135 students Similar NBME scores and residency selection were found, and there was no

adverse effect of humanities education.Dickman et al.36 (1980)

NOTE: The studies are presented in reverse chronological order.Abbreviations: AOA, Alpha Omega Alpha Medical Honor Society; MCAT, Medical College Admission Test; NBME,National Board of Medical Examiners; uGPA, undergraduate grade point average.

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correlate with the measuring of its impact onphysicians in training. This lack of research is partiallydue to the diverse reasons why medical educatorsturn to study of the humanities.55 Humanitiescourses are used in a variety of settings at thepremedical and medical school levels, with noconsensus in the medical community about thedesired outcomes or benefits from participation inthese courses, which are often more qualitative thanquantitative. Humanities education may be usedas a vehicle to incorporate nonscientific aspectsof medical education,43 such as professionalism,communication,56 cultural sensitivity, and ethics.49

Studying the humanities may also be used tocombat a perceived loss of empathy that may occurover the course of medical training.57 In someinstitutions, humanities education is used, togetherwith rituals such as White Coat Ceremonies, toformalize a commitment to the values of humanismin medicine.58,59

Robust interdisciplinary programs have beendeveloped to bring faculty and students fromhumanities departments together with medical facultyand students.60,61 In some cases, more limitedprograms introduce literature or poetry to focusdiscussion of clinical cases in an attempt to highlighthumanistic aspects of patient care.62 However, thediverse goals of and outcomes anticipated fromprograms at medical schools thus make it challengingto measure what students gain from such courses.The data available fall into 3 main categories: theability of humanities education to promote empathy,professionalism, and medical student self-care.

Levels of empathy have been noted to declineover the course of medical school, with youngerstudents and students earlier in their training scor-ing higher on validated measurements of empathysuch as the Jefferson Scale of Physician Empathy(JSPE).63,64 A prospective longitudinal study mea-sured empathy among 125 medical students at thebeginning and end of the third year of medical schoolusing the JSPE and found statistically significantdeclines when comparing the 2 tests.65 Accordingto one study, students with higher empathy scoreson the JSPE tend to earn higher ratings of clini-cal competence on clerkships, although scores didnot correlate with performance on NBME or MCATexaminations.66

Debate exists about whether empathy levelschange during residency. A study that administeredthe JSPE to 98 internal medicine residents foundthat empathy scores remained stable throughoutresidency,67 whereas a separate prospective, longitu-dinal study that measured residents’ empathy usingthe Interpersonal Reactivity Index found that empathy

decreased slightly during residency. This latter studyfound that residents’ knowledge, as measured by theInternal Medicine In-Training Examination, increasedduring the same time period and concluded that,because knowledge and empathy are not necessarilylinked, residency programs should focus on culti-vating each competency separately within trainingcurricula.68 Even if a decline in empathy as mea-sured by the JSPE or Interpersonal Reactivity Indexdoes occur during medical training, it may not beclinically significant. However, the downward trendssuggest that empathy may indeed decrease duringthis critical period in a physician’s development, rais-ing the question of which aspects of medical trainingcontribute to this decline and, in turn, which inter-ventions could be effective in minimizing or evenreversing this trend.

Humanities education may play an importantrole in cultivating or maintaining empathy duringmedical training. A qualitative survey by DasGuptaand Charon69 found that among 16 medical studentswho participated in a reflective writing workshop,several reported increases in empathy on a 7-question survey administered after the course. Aquantitative/qualitative study by Shapiro et al.70

examined the impact of an elective course discussingliterature and medicine. The 22 students whovolunteered to participate in the course were foundto have improved levels of empathy after theintervention, as measured by the Empathy ConstructRating Scale. Qualitative evaluations found that thestudents’ understanding of the patient’s perspectiveincreased in complexity, and students also noteda role for the humanities in dealing with thestress of medical training. Another study found thatparticipation in sessions on empathy and spiritualitycorrelated with higher scores on the JSPE.64 Empathyand humanism ratings are highly correlated67 and aresometimes used interchangeably when physician ormedical student performance is being rated.

The second dimension of medical training thatmay be positively affected by humanities educationis professionalism. Reliable, evidence-based meth-ods for assessing professionalism are notably lack-ing, particularly because professionalism is oftendefined by one of its subcomponents, such ashumanism, ethics, or cultural competency.71 Study-ing the humanities may lead to improvements inphysicians’ cultural competence and enhance theirability to care for diverse patient populations.72 Pre-vious areas of study do not predict professionalbehavior: a retrospective cohort study found thatprofessional behavior among medical students onclerkships could be predicted by student perfor-mance on standardized patient examinations and

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adherence to required immunizations but not frommedical school admissions materials.73 A comparativestudy of 148 first-year internal medicine residentsfound that professionalism could be assessed withpeer and supervisor observation-based assessments,which in turn were associated with knowledge andclinical performance.74 Thus, few data are availableto support the hypothesis that humanities educationaffects professional behavior, unless one considersprofessionalism and humanism to be linked, andthus changing one affects the other. Some argue thathumanism and professionalism are not necessarilyintertwined and in fact may be at odds with oneanother. One author defines humanism as ‘‘a univer-sal, egalitarian ideology,’’ whereas professionalismrepresents ‘‘the parochial, culturally determined prac-tices of a particular professional group’’, arguing thatblurring the distinction between the two may actu-ally decrease humanistic behavior by asking medicalstudents to leave behind humanistic values in favorof professional behavior.75

The third area in which medical trainees maybenefit from humanities education is student orphysician self-care and well-being. Studying thehumanities may provide much needed opportunitiesfor self-reflection about the intensive process ofbecoming a physician and may ease feelings ofisolation or burnout.61 Educational interventions havebeen shown to have a positive impact on the healthhabits and self-care practices of medical students,which may in turn increase their ability to beresilient to the challenges of medical school.76 Forinstance, a randomized controlled trial involving64 medical students suggested that writing aboutemotional topics could decrease the incidence ofself-reported depressive symptoms and healthcarevisits in a 3-month follow-up period.77 Additionally, acourse on humanism and professionalism for medicalstudents that used reading and discussion to provideopportunities for self-reflection found that 73% ofthe students reported an increase in connectednesswith their classmates, suggesting a role for improvingcommunication and creating positive change in theway in which medical students interact with theirpatients.78

THE CHALLENGE OF MEASURING THEIMPACT OF HUMANITIES EDUCATION

Despite these data suggesting that humanities educa-tion may positively affect empathy, professionalism,and self-care among medical trainees, exactly howexposure to the humanities engenders these attitudes

and skills and, therefore, the most effective typeof humanities education, remains to be determined.One attempt at offering a conceptual basis for usingnarrative in medical education discussed particularpedagogical methods, such as creating a cognitivedisequilibrium and using transformative learning, aspossible mechanisms for creating a positive impacton medical students through humanities education.79

Another problem with analyzing the impact ofhumanities education, whether at the premedicalor medical school level, is that there are manyconfounders, such as gender, age, years spentpursuing other careers or degrees prior to medicaltraining, and different types of coursework withinthe humanities. These different factors may affectstudents’ interests in the humanities as well as thetalents and abilities that they bring to their medicaleducation experience. For instance, female medicalstudents have repeatedly been shown to score higheron measurements of empathy.63,66 Another weaknessof the few studies that have attempted to analyzethe impact of humanities education is that manyof these courses are electives, and so studentsparticipating are, by definition, a self-selected group.In such a setting, any observed increase in empathyor improvement in communication may be due tothe possibility that students who already possessgreater empathy or communication skills may bedrawn to enroll in humanities courses in the firstplace. Furthermore, most of the studies are drawnfrom cohorts at individual institutions, which mayhave their own particular biases and values in theadmissions process and criteria used to determineclinical and academic awards. Certain nonquantitativemeasures, such as patient satisfaction, may be entirelytoo subjective to be helpful markers of physiciansuccess and competence. Although it is much easierto compare objective findings such as grades andNBME scores, these more subjective qualities play anequal if not more significant role in determining thekind of physician that a given medical student willultimately become.80

CONCLUSION

Recent trends indicate an increasing appreciationof, and role for, humanities education in medicaltraining. There is ample evidence that collegehumanities majors perform ably in medical schooland residency and that medical schools can recruitstudents from nonscience backgrounds withouthesitation with respect to their potential for academicsuccess. Further research is needed to track the

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performance of these students beyond residency todetermine what impact, if any, humanities educationcan have on a physician’s subsequent career choicesand success as a doctor.

At MSSM, we are currently conducting a follow-up study of the cohort in our initial comparison ofH&M students to students with traditional premedicalbackgrounds.16 We are gathering data about thesame cohort of MSSM graduates, now 3 to 13 yearsout of medical school, and will quantify certainmeasures of their success as physicians, includingawards, elections to prestigious societies, andpublications. We will also assess choices of specialtyand career paths, including academic medicine orprivate practice. Our study will assess the impactof humanities studies during college on medicalprofessionals who have completed their postgraduatetraining. By matching the H&M cohort with studentswith traditional premedical backgrounds as well asstudents who majored in the humanities but did notparticipate in the early admissions program, we hopeto compare performances of similar students whodiffer only by undergraduate major.

Future studies should better characterize thephysician behaviors and competencies that medi-cal educators can encourage in students throughhumanities education. Humanities courses in medi-cal schools should set specific, measurable goals fortheir curricula and determine methods to evaluatewhether those goals are met. Possible markers forthese goals include academic achievements, fulfillingcurricular competencies, performance on validatedmeasures of empathy, and inclusion in the GoldHumanism Honor Society. Systematically evaluatingthe impact of different types of humanities education,within a definition of what it means to create suc-cessful physicians, could ultimately help determinethe most important and effective types of humanitieseducation in medical school. If such studies do pro-vide evidence that students who study the humanitiesperform better in certain measurable areas than theirtraditional pre-medical counterparts, it would furtherlegitimize the place of humanities education withinmedical education and create new ways in which toprepare students for the privilege and responsibilitiesof physicianhood.

DISCLOSURES

Potential conflict of interest: Mary Rifkin and EdwardRonan are Director and Associate Director, respec-tively, of the Humanities and Medicine Program atThe Mount Sinai School of Medicine. Andrea Wershof

Schwartz, Jeremy Abramson, Robert Accordino andIsrael Wojnowich were participants in the Humanitiesand Medicine Program at The Mount Sinai School ofMedicine.

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Evaluating the Impact of the Humanities in Medical Education