Medical Humanities

Medical Humanities and Their Discontents:Definitions, Critiques, and ImplicationsJohanna Shapiro, PhD, Jack Coulehan, MD, MPH, Delese Wear, PhD,and Martha Montello, PhD

Abstract

The humanities offer great potential forenhancing professional and humanisticdevelopment in medical education. Yet,although many students report benefitfrom exposure to the humanities in theirmedical education, they also offerconsistent complaints and skepticism.The authors offer a pedagogicaldefinition of the medical humanities,linking it to medicine as a practiceprofession. They then explore threestudent critiques of medical humanitiescurricula: (1) the content critique,examining issues of perceived relevanceand intellectual bait-and-switch, (2) theteaching critique, which examinesinstructor trustworthiness and perceived

personal intrusiveness, and (3) thestructural/placement critique, or how andwhen medical humanities appear in thecurriculum. Next, ways are suggested totailor medical humanities to betteracknowledge and reframe the needs ofmedical students. These include ongoingcross-disciplinary reflective practices inwhich intellectual tools of the humanitiesare incorporated into educationalactivities to help students examine and,at times, contest the process, values, andgoals of medical practice. This systematic,pervasive reflection will organically leadto meaningful contributions from themedical humanities in three specific areasof great interest to medical educators:

professionalism, “narrativity,” andeducational competencies. Regardingpedagogy, the implications of thisapproach are an integrated requiredcurriculum and innovative concepts suchas “applied humanities scholars.” In turn,systematic integration of humanitiesperspectives and ways of thinking intoclinical training will usefully expand therange of metaphors and narrativesavailable to reflect on medical practiceand offer possibilities for deepening andstrengthening professional education.

Acad Med. 2009; 84:192–198.

As any medical educator will tell you,it is in the nature of medical students tocomplain about their curriculum.1–3 Themedical humanities receive more thantheir fair share of students’ critiques interms of both quantity and virulence.Although the majority of students’comments are supportive and positive,many refer to humanities teaching aspointless, boring, worthless, or just plainstupid.4 Even otherwise favorablydisposed students are sometimesadamant about not making medical

humanities required coursework. Thissituation leads us to ask, Why doeshumanities teaching regularly engendernot just legitimate criticism, butoutpourings of anger and contempt?

In this article, we offer a pedagogicaldefinition of medical humanities,describe their potential contributions tothe medical education enterprise, identifymajor critiques of the medical humanitiesfrom learners’ perspectives, and offersuggestions for systemic pedagogicalresponses to address these critiques.

A Pedagogical Definition ofMedical Humanities

Despite ongoing lack of clarity on whatexactly the medical humanities comprise,and how they should be integrated intomedical education,5 medical humanitiesteaching activities share severalcharacteristics:

1. They use methods, concepts, andcontent from one or more of thehumanities disciplines to investigateillness, pain, disability, suffering,healing, therapeutic relationships, andother aspects of medicine and healthcare practice.

2. They employ these methods, concepts,and content in teaching healthprofessions students how to betterunderstand and critically reflect ontheir professions with the intention ofbecoming more self-aware andhumane practitioners.

3. Their activities are interdisciplinary intheory and practice and necessarilynurture collaboration among scholars,healers, and patients.

Conditions 1 and 2 imply that medicalhumanities have a significant moralfunction.6 –9* That is, an importantgoal of medical humanities is toreconceptualize health care, throughinfluencing students and practitioners toquery their own attitudes and behaviors,while offering a nuanced and integratedperspective on the fundamental aspectsof illness, suffering, and healing. InAristotelian terms,11 medical humanitiesaim to improve health care (praxis) byinfluencing its practitioners to refine andcomplexify their judgments (phronesis) inclinical situations, based on a deep and

Dr. Shapiro is professor of family medicine anddirector, Program in Medical Humanities and Arts,University of California, Irvine School of Medicine,Irvine, California.

Dr. Coulehan is senior fellow, Center for MedicalHumanities, Compassionate Care, and Bioethics,Stony Brook University Health Sciences CenterSchool of Medicine, Stony Brook, New York.

Dr. Wear is professor of behavioral sciences,Northeastern Ohio Universities College of Medicine,Rootstown, Ohio.

Dr. Montello is associate professor, History andPhilosophy of Medicine, University of Kansas Schoolof Medicine, Kansas City, Kansas.

Correspondence should be addressed to Dr. Shapiro,Department of Family Medicine, Route 81, Bldg.200, 101 City Dr. South, Orange, CA 92868;telephone: (949) 824-3748; fax: (714) 456-7982;e-mail: (jfshapir@uci.edu).

* Following Friedman,10 we see medical humanitiesand bioethics having equally valuable but essentiallydifferent ways of analyzing information, viewing theworld, confronting dilemmas, and teaching students.

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complex understanding (sophia) ofillness, suffering, personhood, and relatedissues. In this respect, medical humanitieshave a more applied function than thehumanities as they are traditionallydefined in the academy.

Nevertheless, despite the substantialpromise of the medical humanitiesduring the past 35 years and compellingevidence of their significance for medicaleducation,12–14 the incorporation ofmedical humanities in medical traininghas not proceeded smoothly. By andlarge, medical humanities remain anintriguing sideline in the main project ofmedical education.15 Below, we considermajor critiques of medical humanitiescurricula that we have heard fromlearners and those critiques’ implicationsfor the relationship between thehumanities and medical education.

Learners’ Critiques of MedicalHumanities Curricula

Critiques of medical humanities may begrouped as responses to three broadquestions: (1) Is the content irrelevant?(2) Are humanities teachers and theirmethods the problem? (3) Is thepositioning of humanities courseworkwithin the curriculum inappropriate?

Is it the content?

The relevance critique. This critiqueacknowledges that the humanities may beimportant to future physicians in someindirect way, but it asserts that thematerial is impractical. The humanitiescan’t provide student physicians withconcrete skills (such as learning how tostart an IV) that are useful in clinicalpractice. How does reading a poem helpthe student measurably improve thetreatment of patients? When one of us(J.C.) first introduced topics such asinterviewing, clinical ethics, and medicalhumanities, some students found thematerial simplistic, commonsense,uninteresting, and—worst ofall—irrelevant.16

At the medical school of another one ofus (M.M.), first- and second-yearstudents were polled after their courses toassess, among other things, whether thehumanities material presented in lecture,readings, and small-group discussion was“clinically relevant.” Results showed thatalmost half of the students gave thehumanities material moderately low

ratings for “clinical relevance”; theremainder of the students gave thematerial more positive ratings. A studyexamining possible outcomes of students’exposure to poetry reading during aninterstation break of a third-year OSCEindicated little or no effect in up toone third of respondents in terms ofinfluencing treatment, increasingempathy, or improving stress.17 A kinder,gentler version of the relevance critiqueaffirms the “niceness” of the humanities,as in “It’s a nice change of pace frompathophysiology” or “It’s very relaxing.”This modification assumes that themedical humanities are enjoyable but notcrucial to the education of physicians.In either case, both anecdotal andinvestigational data suggest that medicalhumanities faculty have failed toadequately convince students that themedical humanities really matter to themas future physicians.

Intellectual bait-and-switch. Moststudents enter medical school havinginternalized the view that medicine is anobjective, scientific pursuit based almostexclusively on factual knowledge andtechnical skills. This perspective isunderstandable because it reflects theprevalent image of medicine in Americanculture18 and is reinforced by the narrowprerequisites of premedical majors andentry requirements for medical schoolthat prioritize quantitative and scientificperformance. In medical training, it isreinforced by basic science courses and,later, a hospital culture that often eschewspatient-centered or relationship-basedmedicine in favor of technicalexpertise.19,20 One of us (M.M.) recalls astudent complaining bitterly about anarrative writing assignment aboutpatients. Why should he be “forced towrite a story?” He “didn’t come tomedical school to be a writer.” Thisyoung man and students like him feel asense of grievance: it’s unfair to beevaluated in an area they hadn’t expectedto be part of their curriculum.

The preference for “elective”humanities. One of the symbolicmanifestations of “irrelevance” and“intellectual bait-and-switch” complaintsis the persistent resistance to requiredcurriculum in the humanities. One of us(D.W.) recounts a typical incident:

A student and I were talking about arequired Reflections on Doctoring class

that focuses on topics most oftenilluminated by a short story, poem, oressay. The young man told me how muchhe liked the class, that is, really liked it,but that “a lot” of students did not andwondered if it wouldn’t be better as anelective. “Of course, I’d take the course ifit were elective and I know a lot ofstudents would, but it would relieve thosewho aren’t interested or who are too busyto come to class. . . . We’re all so busy.”

Because medical humanities are a domainoutside the basic and clinical sciences,some students believe that one must havean interest in or affinity for them, a bitlike the elective system in the final yearof medical school. This assumptionguarantees a peripheral role for thehumanities in the curriculum.

Is it the teachers and their methods?

The trustworthiness critique. In medicaleducation, the current process ofsocialization encourages a reliance oninsiders (physicians) and distrustof outsiders (nonphysicians). Thereis a widespread perception thatnonphysicians do not comprehendclinical realities. Students object thathumanities instructors lack professionaltraining or experience in medicine. Theyaren’t doctors, and only doctors can trainmedical students in clinical skills. Thus,to many students, medical humanitiesteachers seem to talk the talk withoutwalking the walk.

The therapeutic critique. Humanities-based exercises frequently ask students toreflect on their own values, attitudes,and behavior, as well as on issues ofsubjectivity, multiple truths, andambiguity through the filters of poems,stories, artwork, or music.21–25 Studentsoften resist this personal engagement asexcessively intimate and intrusive.Indeed, the very “softness” of thehumanities can pose a threat to studentsby forcing them to examine their ownvulnerability and uncertainty. Beingasked to write, either about their ownexperiences or about those of patients, oreven being asked to offer opinions abouta poem or painting, can generate anxietybecause no universally agreed-upon rightanswer exists. Instead, they must usetheir own powers of observation, insight,and intellectual and emotionalconnections as the bases for theirresponses. Equally disconcerting,humanities instructors often say, “I don’tknow, what do you think?” thus

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questioning the foundational expertisethat medical students have learned toexpect from their teachers. Perhaps mostalarming, “real” teachers, such as basicscience faculty, overworked residents,and multitasking attending physiciansseem to studiously avoid such subjectivityand lack of uncertainty.

Along these lines, some students perceivethat humanities courses attemptcharacter formation, and they believetheir own characters not to be in need offurther formation. One of us recentlycarried out a study26 in which a quarter ofparticipating fourth-year studentsbelieved that their medical education hadlittle or no effect on their conceptions ofand capacity for compassion, altruism,and respect for patients. Such studentsfeel pressured by humanities courses tosomehow become more humanisticwhen, in fact, they believe qualities ofhumanism are already formed andunchangeable.

Is it the placement in the curriculum?

The structural critique. Medicalhumanities are often criticized forinefficiency and improper placementin the curriculum. With regard toinefficiency, students seem to adopt theRule of Halves: however many hours orseminars are assigned to the humanities,they say the program would be moreeffective (and more highly rated bystudents) if it were taught in half thetime. Students make a compellingargument that the less humanitiesteaching they are exposed to, the morethey would learn. Another version of thestructural critique is the Content Catch22. In this case, if the humanitiescurriculum includes high content (denselectures, lots of reading), it is criticizedfor overwhelming students. On the otherhand, if it includes low content (smallgroups, process oriented), it is criticizedfor being vague, open ended, and toopersonal.

A related argument is that the humanitiesare not properly positioned in thecurriculum. Appearing in the first year,they are too far removed from the clinicalsetting. In the second year, they competewith preparation for the boards (onwhich they are not represented). In thethird year, students are overwhelmedtrying to master basic clinic medicineand, therefore, are less responsive tohumanities teaching. In the fourth year,

students frequently disappear to away-rotations. It may seem that the best placeto introduce medical humanities isnowhere.

A Meaningful ConceptualResponse

Underlying all of these specific studentcriticisms is the larger problem of howcertain biomedical narratives areprivileged,27 which in turn influenceswhat can be legitimately incorporated inthe curriculum and what can beexcluded. The prevailing metaphors ofmedical education continue to be heavilymechanistic (the body is a machine),linear (find the cause, create an effect),and hierarchical (doctor as expert),28,29

while its dominant narrative tends to be astory of restitution (patient becomes ill;patient is cured by physician expert;patient is restored to preillness state).30

Exclusive reliance on these metaphorsand narratives, with little space toacknowledge or explore others,31,32

marginalizes the humanities, which don’tneatly conform to this cultural model. So,how can we work to change such elusiveabstractions as metaphor and narrative?

Training cross-disciplinary reflectionabout medicine

Surprisingly, little curricular timecurrently is devoted to training studentsto think about the practice of medicine,to help them examine the process ofdoctoring as well as its outcomes. What isit that doctors do? What should doctorsdo? How do different people experiencethe same illness? How do doctors learn tocare for patients as persons? How dodoctors interface with the larger society?10

Doctors—and students—tend not to asksuch meta-questions, as if by and largethey consider medicine a-theoretical, apermanent “Truth” with a capital T, aconstant reality that simply is. Of course,this is not to say that medicine has notbeen extensively and insightfullytheorized, from biopsychosocial,33

phenomenological,34 postmodern,14,35

feminist,36,37 and narrative38 – 40

perspectives. Nonetheless, such theorizingseems to bear little relationship to day-to-day medical education or clinicalpractice. We believe that this needs tochange.

Despite the dominance of technical,rational, and efficiency-based priorities incontemporary medicine and medical

education, the culture of medicine is nota monolithic entity and no longer speakswith a single voice. For example, a recentstudy41 concluded that although manyphysicians responded to the term“medical humanities” with reactions ofuncertainty or even contempt, in fact thegoals of medical humanities—particularlythose involving increased personal andprofessional awareness andself-critique—and the goals of thephysicians interviewed in terms offostering professionalism andprofessional identity, were very similar.This suggests an underlying commonalityof interest uniting medical humanitiesand medicine. Within our own and otherinstitutions of medical learning, manyreflective physicians and other medicaleducators are eager, and indeed havealready been working, to engage inactivities to promote an expanded visionof medicine and medical educationbeyond the instrumental. These nascentchanges in conceptualizing andcontextualizing medicine, if embraced byeducational structures, should benurtured and enlarged.

What we hope future educationalinitiatives will acknowledge in asubstantive, systematic way is just howclose to the heart of medicine thehumanities lie. Essentially, thehumanities focus on the study ofthose subjects that lead to a betterunderstanding of the human condition.42

Medicine necessarily engages with almostevery aspect of the human condition. Inthis respect, the humanities are notadditive to medicine, which implies thatmedicine has become somehow deficient.43

Rather, as Bishop44 suggests, we shouldbe working toward abandoning theinstrumental thinking that humanitiesinquiry is compensatory to the “biologismof the scientists.” It may be more accurateto say that the humanities can offermedical students additional intellectualtools to help recontextualize theirprofession in a way that more fullyhonors its complexity, nuance,ambiguity, and possibility.

In the past decade or so, the concept ofreflective practice has penetrated themedical school curriculum throughsessions in which humanities scholars,physicians, and medical students interactto more critically understand their ownand patients’ experiences in healthcare.45– 47 Reflective writing and

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journaling further supplement discussionas a reflective exercise.48 Engenderingself-reflection in students will likelylegitimate multiple ways of identifyingand evaluating medical knowledge andskills beyond the purely technical.49,50 Inparticular, it can help medical humanitieseducators focus their efforts on threecrucial aspects of medical education,namely developing medicalprofessionalism, understanding thenarrative dimension of doctoring, andcritically questioning the currentemphasis on competency-basededucation.

Professionalism. The humanities haveimportant implications for the concept ofmedical professionalism or, in lay terms,what matters in the making of a physicianor, to return to an earlier point, whatconstitutes authentic relevance topraxis. Epstein and Hundert51 offer acomprehensive definition ofprofessionalism that extends far beyondconventional competency checklists.They include criteria identified moreclosely with the humanities than withbiomedical sciences, such as tolerance ofambiguity and anxiety, observations ofone’s own thinking, emotions, andtechniques, recognition of and responseto cognitive and emotional biases, andintegrating judgment from multiplesources including the scientific, theclinical, and the humanistic. Of specialinterest is their inclusion of relational,affective, and moral components,including attentiveness, critical curiosity,self-awareness, and presence, dimensionsthat legitimize introspective, emotionallabor as well as instrumental work52 andthat increasingly are recognized asvaluable by other scholars.53,54 Thehumanities’ recognition of multipleperspectives, priorities, and truthsrequiring “practice in the negotiation ofmeanings”55 as well as the moralimplications accompanying thisrecognition can provide valuableapproaches—for example, throughsupplemental monthly reflection sessionsthat accompany required clerkships tofurther develop such habits of mind.

“Narrativity.” Medical humanitiesshould play an even larger role inteaching narrativity, which Charon56

defines as “the ability to acknowledge,absorb, interpret, and act on the storiesand plights of others.” The narrativemedicine movement reframes many core

doctoring skills under the aegis oflanguage, culture, and story.56,57 Infurthering comprehension of thenarrative component of medicine,literary and cultural scholars couldcontribute to case conferences and otherexercises in which students present verbalnarratives that explore their developingprofessional identities. Likewise, theymight help design and facilitate curricularopportunities for medical students towrite their patients’ stories and/or theirpersonal reactions to patients, families,colleagues, and teachers. Medicalhumanities faculty could also coordinatecurricula in which students enhance theirnarrative understanding throughexposure to memoirs, essays, fiction,poetry, and film. Stories about physiciansmay also contribute to developingprofessional identity by expanding thestudent’s repertoire of positive andnegative physician role models.58

“Humanistic” competencies? Lookingbeyond the narrow instrumental focus ofmedicine would also lead to natural andorganic ways of addressing certainrecognized clinical competencies thathave common sensical links to themedical humanities. Because much ofmedical education is currently framed interms of competencies,59 there is noreason for medical humanities toreflexively resist examining what theprofession is trying to achieve throughthis system of outcomes andmeasurement. However, such curiositydoes not imply that the humanitiesshould unquestioningly further theagenda of the current medical culture.Rather, serious inclusion of medicalhumanities in conceptualizing theeducational process can help theprofession think more broadly andcreatively about what exactly it ispursuing through its competencyorientation.

For example, until now, competenciesin areas such as empathy andcommunication have been definedalmost exclusively in checklist-, product-oriented ways (i.e., measurable,observable, and quantifiable behaviors).One contribution to emerge from amutually respectful dialogue betweenhumanities and medicine would bepossibilities for enlarging how to moremeaningfully investigate the goals andpursuits that “humanistic” competenciessymbolize. Specifically, the humanities

can contribute an understanding ofattitudes, knowledge, and behaviors asdialogical, things that come aboutbetween human beings in ways that arealways incomplete, partial, and inevitablybiased. The humanities’ tradition ofcritical inquiry and intellectualskepticism can help medicine movebeyond checklists and algorithms toadvance analytical and reflective habits ofmind in students so that they are betterable to think from the perspectives ofothers, move toward a greater humility,and focus on the values and vision thatthey brought to medicine in thefirst place.60,61 This approach couldincorporate the building of studentportfolios62 to provide textured, depthexploration, and demonstration ofhumanistic values through methodssuch as critical incident reports63 andcreative projects,64 as well as the use of“humanistic connoisseurs”65 to mentorand formatively evaluate learners.

Pedagogical and StructuralImplications

Integrated, required curriculum. Abroader context within which tounderstand medicine, to conceptualizeand develop professionalism, toappreciate the narrative, story-makingcomponent of illness and its treatment,and to revisit the concept of humanisticcompetencies would also logically lead toan integrated curricular role for thehumanities. This approach already hasbeen tried successfully with largenumbers of cross-cutting areas, such asbehavioral health, communication skills,cultural awareness, palliative care, andgeriatrics.66 Disciplinary divisions stillform the underpinnings of the academiccommunity, and this is especially true inmedical schools. Nevertheless, at thehigher echelons of administration, deansof schools of medicine and schools ofhumanities and the arts might profitablyopen dialogues that eventually could leadto shared and funded positions thatbridge the arts/science divide.

Locations abound throughout thefour-year medical curriculum wherehumanities-based learning can occuralongside the basic and clinical sciences.Moving away from purely electiveformats would be a huge step indiminishing the perception that medicalhumanities are an add-on, separate fromthe “real” curriculum. For a significant

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systemic change in the culture ofacademic medicine, faculty allies ofthe medical humanities must takeadvantage of the ample and substantiveopportunities for meaningful integrationin the basic sciences (e.g., end-of-lifeinquiry in anatomy; film, art, andliterary representations of depression,schizophrenia, or autism inneuroscience) and in each of the clinicalclerkships (e.g., arts-based sessions tohone observational skills; narrativemedicine seminars integrating poetry andprose stories of illness; popular mediarepresentations of physicians andpatients; relevant historical perspectivesin each required specialty; ethical issuesfrom the perspectives of patients as wellas physicians and bioethicists).

To some extent, these opportunitiesalready exist in lecture, small-group, andelectronic formats. The key emphasis,however, should be on systemicapplication: all these suggestions requirebuy-in from the leadership on basicscience and clinical curriculumcommittees to prevent the sporadic, in-the-margins enactment of humanitiesinquiry, which often gives such inquiryits irrelevant, frivolous, why-are-you-wasting-my-time feel for so manystudents. If humanities analysis cangenuinely become part of theeverydayness of learning medicine,endorsed by well-positioned, respectedfaculty, little by little the ubiquitousdivide between scientific/clinicalmedicine and all other domains may belessened. In such a changed culture,students may begin to recognize andappreciate how meaning making is a lush,complex, and often contradictoryundertaking rarely tied to evidence andefficiency in scientific ways, one thathonors rather than dismisses subjectivity.

Integrated role modeling. It is wellestablished in the research literature thatrole modeling is among the strongestinfluences on medical students’learning.67 Medical humanities facultycan play a key role in helping interestedphysicians become more effective inmanifesting humanistic skills and valuesin their teaching.68 Humanities educatorscan accomplish this informally byserving as role models for clinicalfaculty, especially in large, requiredmultidisciplinary “patient– doctor”courses, where we coteach or cofacilitategroup sessions, and more formally

through medical humanities workshopsand retreats for physician faculty. Wecould consider developing mini-fellowships that focus not only onpedagogy but also on selected knowledgeand skills in medical humanities. Evenfurther, we can promote the concept thatmedical humanities teachers themselvesserve as role models for students in termsof listening, thinking, resonatingemotionally, and being fully present.

Applied humanities? It is beyond thescope of this article to address the debateas to whether the humanities shouldproperly focus only on training modes ofcritical thinking and analysis or whetherthey should also aim to encourage certain“narrow behaviors or mental attitudes,”such as compassion or empathy.69

However, wading into the shallows ofthese waters, we offer the concept of theapplied humanities scholar as a furtherextension of curricular integration.Evans70 has usefully distinguished variousfunctions of the medical humanities,including the analysis of the practice ofmedicine, the moral suasion of medicine,and medical education. Certainly, not allmedical humanities educators need todevelop applied skills, but like theircounterparts in anthropology,71 somemight consider becoming more deeplyimmersed in the world of illness and itstreatment that they study. An appliedhumanities scholar conceivably could bepart of a ward team, whose role would beto ask questions, for example, about thestories being told (or not told), theexercise of power, the way the interactionbetween doctor and patient might beunderstood as a kind of dramaticperformance, or the aesthetic aspects ofthe encounter.

Concluding Thoughts

Our approach to medical humanitiesteaching addresses students’ critiques in anumber of ways. First, our call for across-disciplinary, collaborativerecontextualization of medicine placesmedical humanities close to the corerather than on the periphery of theprofession, and it makes perceptionsof irrelevance much more difficultto sustain. Similarly, becauseprofessionalism, narrativity, andcompetencies are concepts currentlyacknowledged as critical in medicaleducation, focused attention in thesedomains from the medical humanities

will help these disciplines be seen notonly as “nice” but also as essential.Taking seriously the scholarly traditionsof the humanities will quicklydemonstrate their intellectual challenge,toughness, and rigor and would makestudents less likely to succumb tointellectual bait-and-switch grievances.

In addition, regular collaboration inteaching, clinical correlates, grandrounds, and other pedagogical exercises,such as those suggested here, need notentail major curricular battles or changesin time allocation. It would also reducethe prevailing insider– outsiderdistinction that exists between physicianand nonphysician faculty and wouldimprove the perceived fidelity andcredibility of medical humanitieseducators. Further, rather than somehowattempting to “produce” humanisticattributes widget-fashion, the kind ofmechanical attempts at characterformation that students so resent, thisapproach would instead stimulatethoughtful and disciplined investigationof and dialogue about these concepts andvalues and perhaps help to stem themoral stagnation and erosion that canoccur over the course of training.72

Required medical humanities curriculawould reinforce all these dimensions ofrelevance, intellectual rigor and value,pedagogical trustworthiness, and moralinquiry.

New metaphors and storylines about thenature of doctoring would also emerge inconjunction with this proposed teachingmodel. For example, we would likely seeinclusion of more types of narratives asacceptable,73 even desirable, in thepractice of medicine. Rather thanexclusive reliance on restitutionnarratives (always welcome when you canget them), with all other narratives seenas synonymous with failure, curiosityabout other narrative typologies mightbegin to surface. Doctors and patientsmight explore and, in the rightcircumstances, even welcome journeynarratives, in which they embark on a riteof passage together. They might becomecurious about witnessing narratives,where the physician accepts that bearingwitness to a patient’s suffering or finaldays is a valuable contribution to healing,or even about transformational narratives,in which the encounter between doctorand patient changes both of them inmultiple ways. Instead of metaphors that

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revolve only around mechanical functionand its repair, we will begin to hear healthprofessionals—and their ever-attentivestudents—also using metaphors ofgrowth, organicity, and healing (andother metaphors not yet imagined). Inshort, we will be able to use thehumanities’ intricate and sympatheticknowledge about the human condition(sophia) as well as its ability to examineparticularistic, experiential knowledge(phronesis) to help ensure a morallysensitive, narratively sound, and deeplyprofessional clinical practice (praxis).

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Teaching and Learning MomentsHana No Hana: Artist’s Statement

As assistant director of the Center forBiologic Imaging at the University ofPittsburgh, I am often asked by variousclinicians to assist in projects usingmicroscopy to augment their clinicalresearch. B. J. Ferguson, MD, asurgeon in otolaryngology at theUniversity of Pittsburgh MedicalCenter, invited me to collaborate on aproject to identify bacterial biofilms inpatients with chronic rhinosinusitis,especially those cases refractory toantibiotic treatment. I was givenmyriad sinus biopsies from a variety ofpatients and, after the usual time-consuming processing, I set aboutlooking for bacteria and/or biofilmsusing transmission electronmicroscopy. During the many hours Ispent at the electron microscopesearching for the microbes and biofilmcommunities, I often came acrossspectacular scenery through the

oculars. One such frame caught myeye and reminded me of a field offlowers. Sinus epithelium is veryspecialized and, in its normal state, hasboth microvilli and cilia decorating theapical plasma membrane surface. Thisspecific section had a nice combinationof cilia in cross section and microvilli inlongitudinal format, resemblingflowers and tall grass, respectively.After taking the frame, the black andwhite image was pseudocolored torepresent the field of flowers I hadenvisioned, with the cross-sectionedcilia as flowers and the microvilli asgrass, all against a blue sky.

My observation of the resemblancebetween the cilia and microvilli andflowers and grass has been influencedby, of all things, my study of theJapanese language. The Japanesewords for flower and nose are

homonyms: hana. However, thecharacters the Japanese use in writingthese words are different. Thecharacters written in the lower right-hand corner of the image read “noseflowers” to reflect that the depicted“field of flowers” was derived from aparanasal sinus mucosal biopsy. Thefinal product was meant to looselyrepresent a Japanese watercolor orwoodcut with a title written inJapanese on the print.

Donna Beer Stolz, PhD

Dr. Stolz is associate professor, cell biology andphysiology, and assistant director, Center for BiologicImaging, University of Pittsburgh Medical School,Pittsburgh, Pennsylvania.

Editor’s Note: This Teaching and Learning Momentsessay was contributed as a companion to thismonth’s AM Cover Art selection, which appears onthe cover.

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