The Humanities in Medical Education Ways of Knowing,

8/12/2019 The Humanities in Medical Education Ways of Knowing,

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The Humanities in Medical Education: Ways of Knowing,

Doing and Being

J. Donald Boudreau &Abraham Fuks

# Springer Science+Business Media New York 2014

Abstract The personhood of the physician is a crucial element in accomplishing the goals of

medicine. We review claims made on behalf of the humanities in guiding professional identity

formation. We explore the dichotomy that has evolved, since the Renaissance, between the

humanities and the natural sciences. The result of this evolution is an historic misconstrual,

preoccupying educators and diverting them from the moral development of physicians. We

propose a curricular framework based on the recovery of Aristotelian concepts that bridge

identity and activity. The humanities and the natural sciences, jointly and severally, can fulfill

developmental, characterological and instrumental purposes.

Keywords Medical humanities . Humanism . Aristotle . Phronesis . Professional identity .

Character development

The language of human science is irreducibly equivocal and continually adapts itself to

particulars.

Mary Hesse

Models and Analogies in Science

Background

A series of inquiries into professional education in the United States was recently published

(Cooke et al. 2010; Foster et al. 2006). These reports signaled professional identity formation

as a primary concern. The process was described as a commitment to professional values and

behaviors, accompanied by the human sensibilities and dispositions necessary to specific

practices. The recommendations pointed to an education aimed at character development

and the nurturing of virtues. While this may come as no surprise with respect to pastoral,priestly and rabbinic practices, it articulates a dimension that has been insufficiently developed

in medicine, a profession that is nonetheless also concerned with a form ofministry.

J Med Humanit

DOI 10.1007/s10912-014-9285-5

J. D. Boudreau (*) :A. Fuks

Faculty of Medicine, McGill University, Montreal, Canada

e-mail: [email protected]


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The blossoming of the medical humanities as a self-identified field is in large part a

response to perceived failings in the contemporary practice of medicine. There are widespread

complaints that physicians treat patients as cases or bearers of diseases rather than as

individuals who are ill. While the advent of technological interventions is seen as beneficial,

they can also become barriers to interchange between caregivers and patients. Diagnostics andtherapeutics often represent a series of interventions with little thought to the physician-patient

dyad through which they are effected. This discourse reflects in part the strong influence of

biomedical sciences whose nomothetic perspective is necessary to medicines successes. The

search for an idiosyncratic and individualized view of the patient has prompted a turn in

medical education in which the humanities, understood as contemporary academic disciplines,

provide a counterbalance to a modern medicine, thoroughly cloaked in, if not choked by, a

scientistic understanding.

Scientism is generally thought to depend on neutral detachment while humanism is

expected to foster inter-subjectivity. The former suggests harshness and intellectual rigor while

the latter connotes warm-heartedness and social engagement. However, such basic presump-

tions have been characterized by conceptual fuzziness. How is it that we started to believe

there was something in the humanities that made us more humane, i.e., more benevolent,

sympathetic and concerned for human welfare? Why do we often encounter, stripped of any

hint of irony, the admonition humanism must be promoted within medicineas if one could

contemplate a medicine dissociated from humanity? What assumptions underlie the following

statement by philosopher William Stempsey, .our introduction of philosophical studies into

the medical school curricula is at least partly an attempt atremedial humanization(1999, 7)

Why, indeed, do we presume that the humanities are the route to humane practice?

Proposals to

humanize

medicine generate a series of questions we consider in thispaper. We postulate that attempts to introduce the humanities are bound to fail, based as

they are on perceptions that construe medicine a priori as antithetical to humanism.

However, it was not always so. We propose a return to a venerable developmental

framework within which the humanities can assume an appropriate and productive

place in medical school curricula.

The humanist turn and the academic divide

Humanismis a polysemous term whose meaning has evolved since its ancient origins. Froma contemporary perspective, the term refers to a framework that places humans, or humanity as

a whole, at its centre. It stresses the inherent value and potential of human life. This differs

from notions thought to have prevailed in antiquity. While classical humanism referred to

human naturewith reason representing the supreme force of that natureit did not consider

itself isolated from theistic beliefs (Jaeger 1943).

The word humanities derives from humanus, which in classical Latin held various

meanings: proper to man, benevolent, refined and polite, learned or erudite. Humanitas

entered Latin in the second century BCE. As with the ancient Greeks, the term referred to those

qualities that distinguished the human from the bestial and was tied to human reason

thecapacity to deliberate and choose and express these choices through language. It also signified

a virtue, i.e., good feelings towards mankind. Humanism has been seen as constitutive

of medical practice for over 2,000 years. Between 44 and 48 A.D. Scribonius Largus,

writing a commentary on medicine, considered that medical practice has three char-

acteristic features: humanitatis (love of mankind), misericordiae (mercy), and professionis

voluntatem(the purpose of the profession) (Hamilton 1986).

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Humanist originates from humanista and referred to a teacher of classic literature.

The 16th century humanista studied pagan (Latin and Greek) literature rather than

divinity or theology. A humanist, then as now, was not necessarily a courteous or

compassionate individual.

The termstudia humanitatisis thought to originate from Cicero who used it to imply all thatpertains to humanity. It made reference to all the disciplines that shape a person: oratory,

music, sports, poetry, dialectics and philosophy (Proctor 1988). A curricular exemplar bearing

the label studia humanitatis emerged, adumbrated by Petrarch, in the first half of the 15th

century. Paul Oskar Kristeller (1961) has traced the evolution of strains of learning, the

humanist as well as classic and scholastic, during the Renaissance. He believes that the studia

humanitatisevolved into a limited area of study; it came to exclude logic, natural philosophy,

theology, mathematics, astronomy, medicine and law. This left a narrowly framed program of

studies comprised of classic literature, poetry, history and moral philosophy, along with the

grammatical and rhetorical traditions of the Middle Ages. This division segregated medicine

into a category with the natural sciences of the time and cleaved it from the study of moral

philosophy, literature and history. It foreshadowed the dichotomy we describe below and

constrained the intellectual basis for medicine.

Robert Proctor (1988) suggests that the goals of learning in antiquity had been to under-

stand humans in relationship to a greater wholeto nature, the eternal, the divine and the

infinity of all things. The ancient Greeks and Romans were bound to contemplate their

relationship to a universe conceived as unified, cohesive, complete and perfect; they gazed

outwards to (and with) a universal organizing principle. In the Renaissance, the focus of

interest changed; scholars became intent on looking inwards. The notion of a personal self

emerged

a self that is unique, autonomous and rational. Furthermore, it was assumed that thisentity could be perfected. Pica della Mirandola (quoted in Proctor 1988) suggests that a

personal self is created: We have made thee neither of heaven nor of earth, neither mortal

nor immortal, so that with freedom of choice and with honor, as though the maker and molder

of thyself, thou mayest fashion thyself in whatever shape thou shalt prefer (13). Petrarch,

often described as thefather of humanism, championed philosophy as dialogues which aim

to heal the soul(Saarinen 2011, 44). This notion of the therapeutic utility of learning was a

contrast to the scholastic philosophy prevalent earlier. Proctor refers to this shift from the

eternal to the personal (and perhaps from the transcendent to the therapeutic) as the humanist

transformation.Disciplines considered to have minimal impact on the shaping of the personal

self (e.g. geometry and arithmetic) and thus irrelevant to philosophical therapywere cleavedfrom the educational roster. Proctor argues that conditions were thus set in motion for the great

academic divide between the sciences and the humanities. This split, which achieved its zenith

under positivist philosophy, has been influential in forging the character of modern medicine.

One result is a clinical medicine enthralled by the positivist framing of the natural sciences

with a consequent loss of the idiographic perspective so necessary to clinical practice.

The Renaissance also witnessed a gradual decrease in the influence of Aristotelian

philosophy in deference to a renewed Platonism. A bellwether of this waning of

Aristotles influence was the uses made of the Nichomachean Ethics, previously

considered a guide to life, and the Eudemian Ethics in universities during the ItalianRenaissance. David Lines (2002) finds that Aristotles philosophy remained an impor-

tant curricular component but concludes that the Ethics came to be used for different

purposes. These texts came to be valued as objects for philological analysis rather than

philosophical vade mecums. By the end of the Renaissance, propelled by the progress

of mathematics, astronomy and the experimental methods of Galileo and Malpighi,

Aristotle was displaced as an ideal guide for the right way of life.

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The scientific revolution is generally thought to have been heralded by Copernicus 1543

book on astronomy. The following description of Copernicus by the historian Jacob

Bronowski (1973) is emblematic of the evolution in thought catalyzed by the humanist

transformation: A central thrust of humanism is the revolt against Aristotle.. an attack on

the syllogistic logic of Aristotle.What Bronowski refers to here is Aristotles logic and, morespecifically, the grounding of physics (or natural philosophy) on that logic. While this

enlightenment critique is not an indictment of Aristotles moral philosophy, it paved the way

for a post-enlightenment interpretation of intellectual history that diminished Aristotles ideas

on the nature of intellectual and moral virtues. It undercut his telic view, i.e., one that expresses

purposes or ends. This veering away from an Aristotelian understanding of a virtue-based

moral life and a fundamental ethos of praxis may have been reflected in a diminished presence

of these concepts in magistral medical lectures and clinical instruction in Western Europe.

Knowledge, which had previously been communally contextualized and integrated, was,

during the Renaissance and beyond, discoverable in and by the individual, not tethered to any

divine kinship. Knowledge became fractured and distributed. In the Enlightenment, theoretical

abstraction, with its assumption that discoverable universal truths exist for both autonomous

individuals and for humanity as a whole, came to prevail. Though not antithetical to a scientific

medicine, such concepts are poorly aligned with medicine as a human activity that is

prudential, practical and personal. Stephen Toulmin (1988) has described the advent of an

exclusively scientific worldview as a harbinger of an incomplete medicine.

We thus inherit the following legacies: i) A split between the natural sciences and

humanities such that these domains are now viewed as irreconcilable dichotomiesopposite

and antithetical. This has led inevitably to a recurring preoccupation with integration accom-

panied by a yearning to see the bridging of a perceived gap leading, in turn, to sophisticatedattempts at intercalation, interdigitation and correlation of curricular content (Boudreau

and Cassell 2010); ii) a solipsistic turn with increasing attention to development of the

self rather than to an other-directed virtue-based, moral framework and; iii) a dimin-

ished sense that medicine is, to cite Sir William Oslers (1913) famous essay A Way

of Life, a product of a continuing process of personal development and maturation.

This is amplified by educational outcome measures that reward the acquisition of

knowledge and skills and pay little attention to the holistic and human attributes

inscribed in the mission statements of most medical schools.

Bridging the divide

The impetus for introducing the humanities in medicine stems from the intellectual legacies

described previously coupled to a burgeoning awareness of shortcomings of the positivist

influence on medical practice. Indeed, the term medical humanities is of recent origin,

following on the heels of the growth of medicine as a science in the 19th century. The first

allusion that we could find to it dates to less than a century ago when in an oration the

physician Charles Dana (1922) posited culture as the unifying thread for medicine and the

humanities. Within a few years, the historian George Sarton (1936) was writing about

medicalhumanism, invoking a practice of medicine that went beyond facts, theories and techniques to

include immortal ideals of justice, beauty and truth. Definitions of the medical humanities

were subsequently proposed. Martyn Evans (2002) described the field as: studies concerned

with the specific experiences of health, disease, illness, medicine and health care, with the

practitioner-patient relationship and, above all, with the clinical consultation as a focal arena

for such experiences.

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The first department of humanities in an American medical school was inaugurated at

Pennsylvania State University in 1967. The American Society of Bioethics and Humanities

was founded in 1998 through the consolidation of associations from the fields of bioethics, and

health and human values. The U.K Association of Medical Humanities was founded in 2002.

The humanities have been welcomed as prerequisites to medical education. The body that setsstandards for medical schools in the U.S., the Liaison Committee on Medical Education, states:

Through its requirements for admission, a medical education program should encourage

potential applicants to acquire a broad undergraduate education, including studies of the

humanities, the natural sciences and the social sciences(LCME 2012). The standards make

no further pronouncements that might elucidate a role for the humanities within the medical

program itself.

Involvement of humanities disciplines in medical education has unfolded in phases. The

1960s to 1980s featured literature and philosophy. Studies in philosophy gravitated away from

epistemology and metaphysics towards axiology and deontology; some have decried that

philosophy in medicine is in danger of being totally engulfed by bioethics (Stempsey 2007).

Of late, the nature of literature in medicine has taken on a new dimensionthat of narrative

competence (Charon 2011; Holmgren et al. 2011). Initiated by sociologists and anthropolo-

gists, professionalism has emerged as a particularly influential movement (R.L. Cruess and

S.R. Cruess 1997). Other disciplines, including psychology, history, gender studies and

religious studies have made important contributions. The visual and performing arts are

increasingly popular, particularly in elective-type offerings. A measure of the insurgence of

the humanities in medical education is the voluminous literature devoted to the topic. Several

journals are dedicated primarily to this domain. One of the first compendia to review the topic,

The Role of the Humanities in Medical Education, was published by Donnie Self (1978)30 years ago. The education journalAcademic Medicineissued special thematic issues in 1995

and 2003.

The roles attributed to the humanities in education may be seen to fall into two

camps. In one, such studies represent a catalyst for the formation of compassionate

healers by serving as morally contagious art forms. In the other, they equip nascent

medical practitioners with useful cognitive capabilities. This duality is reflected in the

debate on clinical empathy. Some argue that it is a receptive and affective experience;

others claim that empathy is projective, subordinate to and dependent on cognition

(Verducci 2000; Goetz et al. 2010).

At the developmental pole, the humanities are seen to contribute to the formation of acultivated and insightful person and, by extrapolation, a holistically-inclined and enlightened

physician. They are purported to promote empathy and compassion, evoking the Bildung

tradition of self-cultivation and cultural identity. In discussions situated at this pole, metaphors

such as shaping, nourishing, developing, forming and transforming abound. At the instrumen-

talist pole, the medical humanities are valued for their potential in honing clinical skills. This

idea is based on the precept that the mind is composed of specific, independent, albeit

interconnected, complex and malleable abilities, sometimes referred to as faculties of the

mind (Proctor 1988, 100). What the faculties comprise is arguable but the following are

commonly mentioned: attention, perception, reason, judgment, memory, emotion, imagination,insight and intuition. Many disciplines are considered useful in training these faculties. In this

discourse, action-based descriptors are often encountered. For example, the performing arts

can stretch perception; ethics can exercise reason; philosophy can fine-tune critical

analysis; literature can trigger perspective taking. The belief is that the humanities can

challenge, stimulate and refine the faculties. Lastly, a commonly cited benefit is disciplining

the mind to be critical, curious, creative and at ease with uncertainty.

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Contributions of the medical humanities: a panoply of metaphors

The incorporation of the study of the humanities into medical curricula has been described and

defended by a variety of goals and constructs. The most common are noted below.

a) Balancing

An oft cited rationale for teaching the humanities is that they serve as a counter-weight to

science. Using the balance metaphor, the following image is evoked: on one scale sit the

marmoreal natural sciencesuni-dimensional, rational, value-neutral, computational, hierar-

chical and rigorous. On the opposite scale are the soft humanities and liberal artsmulti-

dimensional, imaginative, tolerant, relational, affective and intuitive. This counterpoint is

grounded in the belief that science and humanities are incommensurable and immiscible

entities. This is a reflection of the old dialectic between the Geistes- and Naturwissenschaften

with the unfortunate consequences of polar opposites, of winners and losers. This model

sustains the notion that while both are considered requisite ingredients to medical practice,

they are not compatible, with a constant risk of one being overwhelmed by the other, i.e., the

weightier one. For example, according to Catherine Belling (2010), .the humanities are so

valuable to medicine, for [they] offer a counterpart to the necessary reductions of the natural

sciences.In a similar vein, Jane Macnaughton (2011) speaks of a calibration of the humanities

with the scientific. A recent expression of the quest for balance is the American initiative

entitled PRIME (Project to Rebalance and Integrate Medical Education). PRIME places itself

squarely in the instrumentalist camp as it aims to build skill sets in visual observation, textual

reading and interpretation, oral reasoning and writing

(Doukas et al. 2012).

b) Assuaging and healing

The humanities have also been characterized as balms, and rescue or healing agents. This is

based on the assumption that biomedicine is sick at its core and that the humanities are

endowed with curative potency. These tropes can be powerful. Edmund Pellegrino (1987) has

stated:Medical humanism has achieved the status of a salvation theme, which can absolve the

perceived sins of modern medicine.The following statement is particularly graphic: One of

the aims of recent curriculum reform has been to release medical education from its scientific

straitjacket(Jackson 2002). The healing potential of the humanities is intimated when theyare seen as agents of remediation or compensation. Howard Brody (2011) has described the

medical humanities as having three personalities, one of which is the supportive friend. They

offer relief from the stress and turmoil of the daily lives of physicians. Characterized by

Johanna Shapiro (2012) as the ornamentaldimension of humanities education, the intent of

literary and artistic education is to provide a means of regeneration and an antidote to burn-out.

c) Compassion boosters

It is often claimed that the humanities can invigorate medicine by potentiating compassion,based on a belief that the physical sciences are inherently corrosive. It has been suggested that

the humanities may combat a perceived loss of empathy over the course of medical training,

and make medicine more holistic (Schwartz et al. 2009) A historian has claimed that [the

study of medical history] is the best antidote we know against egotism, error and desponden-

cyit teaches our students to venerate what is good(Cordell 1904). A startling illustration of

this attitude is a paper entitled, Humanities in medicine: treatment of a deficiency disorder

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(Hook 1997). In it, the author cites one of Oslers last lectures, in which he likened the

humanities to the thyroid hormone. As well as an invigorating agent, the humanities are

advertised as endocrine modulators, leading some commentators to speculate on what might

constitute the optimal dose of medical humanities (Gordon 2008).

d) Aesthetic learning and democratization

An exemplar of a humanities-based medical curriculum can be found at the Peninsula

Medical School recently opened in Exeter, U.K. It has promised a radical integration of

disciplines. The school reports that it has incorporated the humanities seamlessly throughout

the educational blueprint by reformulating them as process and perspective rather than content

(Bleakley et al. 2006). It aims for theoretical unity by accentuating intuitive learning (the

process) and foregrounding of artistry (the perspective). The program envisages an educational

experience in a context where there has been ademocratizationof the physician/patient and

teacher/student relationships and where scienceis viewed as qualitative, imaginative, discur-

sive and aesthetic as well as quantitative, evidence-based, value-neutral and analytical. Aes-

thetics are considered as pertinent and valuable to the natural sciences as they are to the

humanities and clinical work.

Critiques of the humanities in medical education

A recent review of the medical literature on the humanities in undergraduate education found

few reports of empirical findings on educational impact and even fewer articles expressingreservations about the value of the humanities in medical training (Ousager and Johannessen

2010). In their discussion on the paucity of evaluation data, the authors studiously avoid being

construed as having a narrow focus on objective results and argue that interventions of a

subjective or values-based nature are not amenable to standard assessment protocols. While

this methodological limitation is incontestable, the absence of sustained efforts at program

evaluation should prompt critical reflection. Crucial questions become apparent. Can the

rationales for the humanities in medicine and the models for teaching them respond to

perceived needs? What benefits might such programs provide and how can they be

documented?

An interesting critique of the role of the humanities in medical education comes fromoutside the frame, so to speak. Scholars in the arts and humanities are wary of developments in

these fields. The instrumental use of the humanities in medicine strikes some critics as fraught

with the risk of their medicalization and abduction by a powerful biomedical system, a

system that sees the humanities as a utilitarian means to a misconstrued end. Shapiro (2012)

has described this as a model of acquiescence. As a counter-point, she posits a model of

resistance in which the humanities serve a subversive, fifth-columnist role committed to

questioning the foundations of contemporary biomedical thinking. The goal in this

resistive mode is to unearth the presuppositions of scientific medicine and open a

space for debate. In this way, the humanities are seen as injecting a healthy dose ofskepticism and providing a mirror for introspection. Although Shapiro considers that

the humanities can catalyze emancipatory insights, she concludes that neither benign

acquiescence nor radical resistance captures the complexity of humanities teaching

experiences. While this picture may be apt for a scholarly critique, viewing the

humanities as subversive runs the risk of once again inadvertently supporting an

oppositional dialectic of Geistes- and Naturwissenschaften.

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The vision of the humanities as a sort of miracle worker, rescuing medicine from the allure

of scientism and mitigating the damage done through the objectifying tendencies of biomed-

icine, has been subject to increasing criticism. A single-minded focus on the integration of

epistemologies is diversionary because of its reliance on artefactual distinctions between them.

Efforts at balancing have done a disservice to both the natural sciences and the humanities bycaricaturing the former as emotionally desiccated and hailing the latter as inspired revelation.

Attempts at reorienting the medical humanities have taken diverse forms. At one extreme is

the Manifesto for Medical Studies (Chambers 2009). It argues that the medical humanities

should cease being subservient and assume hegemonic status by affirming themselves as the

ideological lenses through which medicine must be studied. In the process of making medicine

the object of scrutiny, the humanities will supposedly be vivified. In some sense, critical social

theorists such as Michel Foucault, notably with his Birth of the Clinic: An Archeology of

Medical Perception, may have served that purpose.

Solutions of a less radical nature have been proposed. Several decades ago, the ethicist

Diego Gracia (1985) advocated for a new medical humanities, referring to the emerging

social sciences. Another insightful publication from the same period provides a helpful

launching platform for a way forward. Michael Schwartz and Osborne Wiggins (1985), after

analyzing attempts at integrating medical science and humanism, stated that such efforts may

..prove inadequate because they merely graft a kind of remedial humanism onto a

fundamentally technological and biomedical practice(332). They condemned initiatives that

treated the humanities as if they were a flavoring ingredient and argued that the biomedical

model is a myth and medical practice needs to be reconceptualized:Medical practice becomes

intelligible only when its moorings in a fundamental domain of human experience are clarified

and delineated

(Schwartz and Wiggins 1985, 333). They suggested that effective renewalmight emerge out of a phenomenological approach and a belief that there is no such thing as

interpretation-free understanding. Such ideologies are now discernible in a few health sciences

programs, for example, the human science-human care theory of nursing (Watson 1985).

To conceive of the humanities as simply a counterpoint to the natural sciences diminishes

both disciplinary traditions. These dual domains share assumptions and expectations and are

mutually reinforcing. They require a fundamental re-alignment in the context of medical

education. A new mindset must transcend the attachment to dichotomies (or trichotomies, if

one sunders the social from the human sciences). Continuing to regard the humanitiesas the

flag bearer ofhumanismpositions them falsely in competition with the natural sciences, and

paradoxically disempowers them. The humanities are inseparable from medical practice ascognate disciplines and not specifically because they may inculcate humaneness.

Curricular conceptualization with an Aristotelian armature

As illustrated in many of the commentaries already cited, perhaps most persuasively by the

psychiatrist Michael Schwartz and the philosopher Osborne Wiggins (1985), too many efforts

to introduce the humanities into medical curricula have been based on the presumption that the

current armature is basically sound and that the humanities can be an additive thereto. Forexample, traditional attempts to provide students with a basic overview of the history of

medicine have relied on a series of lectures plugged in to the curriculum or as electives. The

result is that faculty and students understand these add-ons as peripheral to core objectives and

of marginal relevance. It would be more effective to define specifically what the medical

humanities are designed to accomplish within a reframed curriculum and then proceed with the

requisite restructuring to achieve those goals. We suggest that the following three elements

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must be addressed: the guiding ethos for medical practice; the desired character of the

physician; and, the frames that help accomplish these outcomes. We propose that the human-

ities can help us address each of these foundational issues by providing essential philosophic,

developmental and pedagogical concepts necessary to the task.

Medical practice requires a blend of intellectual pursuits: theoretical, practical, productiveand performative. In its quotidian practices, it relies on trustworthy, often normative general-

izations, and their application to individual cases. Its practitioners are engaged in an intellec-

tual, physical and emotional performance those who are superb execute it with poise and

grace. Notwithstanding the multifaceted nature of medicine, the physician is primarily engaged

in a practical activity. Medicine aims to promote health and to relieve suffering, and its ultimate

aim is the well-being of the patient. A threat to well-being is perceived when persons suffer

impairments of function that interfere with the attainment of their purposes and goals in life.

Thus, well-being, as lived and understood by the patient, is the touchstone of medicine and

must also serve as the fulcrum upon which a medical education program is constructed.

Over the past three decades there has been a resurgence of interest in Aristotelian philos-

ophy as an approach to understanding human conduct. In his extraordinarily influential book,

After Virtue, Alasdair MacIntyre (1981) rejects the ethos of liberal individualism and subjec-

tivism (which he refers to as emotivism) and reaffirms Aristotles core concept of the virtues.

Aristotles idea of moral selfhood has been described by the educational philosopher Kristjn

Kristjnsson (2007) as essentially other-entwined and other-dependent for its formation and

sustenance(177). This orientation is grounded in the idea that moral thinking is derived from

a profound sense of respect and obligation to others. Intentionality is directed towards the

other and actualized in a community of social beings (apolis); it stands in contrast with a

focus on self-actualization which, as we have seen, was catalyzed and promoted by the originalstudia humanitatis. It is noteworthy that Aristotles moral philosophy has recently been

promoted as the conceptual framework for moral education at the primary and secondary

levels of schooling (Carr 2011). Such insights offer a critical opportunity for medical educa-

tion. The role that the medical humanities can assume in the preparation of new generations of

physicians should be reoriented against this backdrop.

Aristotles categorizations of practical knowledge, techn and phronsis, can shed light on

the unique nature of clinical medicine. Techn is often construed as technical thinking,i.e., a

mode of reasoning in which a plan or design is applied towards the production of a particular

state of affairs. In colloquial usage it may have deprecatory overtones invoking notions such as

by roteortheory-averse. These descriptors are misleading. Techn is initiated by finding thefirst principles of things, considering the complexity of individual concrete cases while not

losing sight of general rules or norms, and taking into account opportunity, chance and luck.

Through a process of deliberation, it ultimately converges on a particular course of action.

Aristotle considered several human activities, notably navigation and medicine, as paradig-

matic of techn. This activity is not to be confused with theory (theoria) which, as understood

by Aristotle, was knowledge as a necessary, universal and invariable thing. Medicine, an

activity marked by contingencies and unavoidable indeterminacy, is more aligned with techn

than theoria. Toulmin (1988) underlines this basic but critical point when he says: The patient

is not merely an individual who happens to instantiate a universal law. His clinical state islocal, timely and particular, and universal theories at best throw only partial light on it(345).

To consider medicine purely as techn is, however, an incomplete characterization. The

concept of phronsis is also required. Making a clear distinction between phronsis and techn

is a difficult proposition. Joseph Dunne (1993), who has tried to unpack what Aristotle left as

implicit and fragmented in his written corpus, suggests that the differences reside largely in the

relationship of actor to activity and can be understood through the application of an ends/

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means framework. The actor in techn, a doer or maker, produces outcomes (e.g. a safe

journey for the navigator or health in the case of a doctor). These outcomes are external to and

exist beyond the self. In contrast, in phronsis, the end is in the self. Phronsis is not about

making; it is about being and becoming. Dispositions to choose in a certain manner, through

repeated use, become embedded and embodied. The actors moral compass is revealed andaltered in the process of making particular decisions. A unique, reflective moral being emerges

through the cumulative effects of having made specific choices. The process unfolds most

effectively when the actor is faced with circumstances and dilemmas that are increasingly

complex. Phronsis thus combines disposition, reasoning and action. A person endowed with

phronesis, the phronimos, changes personal attributes through habitual action and practice. In

short, techn can be considered to encapsulate the performative dimensions of medicine (the

doing of the physician) while phronsis describes the emergence of settled character states

appropriate to the medical persona (the beingof the physician).

These concepts can be applied directly to the domain of medical education, particularly if

one accepts the supposition that the educational process must result in formation of a unique

professional identityphysicianhoodor physicianship. We have previously described the first

iterations of an undergraduate medical program focused on identity formation that revolves

around the concept of physicianship (Boudreau et al. 2007; Boudreau et al. 2011).

Physicianship refers to the desired personal qualities and behaviours of the medical practi-

tioner. It is grounded in the notion that the physician fulfills two complementary roles, that of

healer and professional. Healing is considered the doctors primary obligation while profes-

sionalism describes the manner in which the profession has organized itself to deliver healing

services. Physicianship is inescapably moral in natureits philosophical pedigree has been

described elsewhere (Fuks et al. 2012).A physicianship-based curriculum illustrates the relevance of Aristotelian conceptual

anchors. Techn is oriented towards instruction; the teacher qua teacher has an external

endthe students acquisition of new knowledge or skills. Phronsis has an internal end,

namely, the assimilation of values and excellence in ethical decision-making. Phronsis is

accommodated through guided and habitual practice within a particular community, i.e., a

medical apprenticeship. We are hardly the first to emphasize the importance of phronsis. It

has been described as an avenue for moral formation through concrete mentorship (Kinghorn

2010). It constitutes an approach to ethical reasoning and represents a method for understand-

ing critical reflection (Kaldjian 2010; Birmingham 2004). While these applications are con-

cordant with our proposal, we extend the concept of phronsis to the entirety of medicaleducation. Given that phronsis must, by its very nature, respond to a moral aim or intention,

ultimately translated into a specific course of action, the explicit and unambiguous specifica-

tion of the perceived goal of clinical action is a critical first step. As previously noted, the goal

relevant to this discussion is a patients well-being, i.e., requiring help in overcoming the

impairments of function that interfere with the pursuit of achievable goals. A phronimos will

attempt to accomplish this task in the right way, to the right extent and at the right time. A

medical school, in fulfilling responsibilities for selecting appropriate candidates, transmitting

desired values, equipping and guiding their students will necessarily marshal all academic

disciplines, the medical humanities and the natural sciences, in service of that aim.Salient issues in todays medical schools tend to be of the following type: What are genetic

footprints of malignant transformation; the immunological pathways in asthma; the evidence for

use of insulin replacement in steroid-induced hyperglycemia? These are not to be gainsaid as

targets of medical instruction, but, they need to be complemented by questions such as: What is a

lived body, an embodied self, and an embedded moral person? What do we mean by function

and functioning? What is impairment and how does it differ from disease, illness and sickness?

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What are suffering and healing? The array of questions is not currently a central preoccupation of

medical teachers. If only the first set is seen as germane, the so called basic sciences recruited to

the task will include histology and embryology but exclude hermeneutics and ethnography. In a

curriculum which foregrounds identity formation, where external ends such as the discovery of

disease and the mending of altered physiology are not the sole concern of education, the cadre ofdisciplines relevant to its mission is more inclusive. All intellectual traditionswe think of them

asfoundational framesthat can address these issues become germane.

Specific foundational frames of a physicianship-based curriculum

We have developed a series of examples that illustrate the curricular frames entailed by an

instrumental and utilitarian view of the humanities and social sciences, seen not as antithetical

to the natural sciences but with their own defined curricular aims and objectives. These

concepts are further inflected by the Aristotelian developmental perspective introduced above.

It is important to note that we view these new elements as synergistic, not competitive, with

those in traditional undergraduate medical programs. Finally, these are intended to serve as

exemplars, not as exhaustive lists.

a) conceptual frame

The contemporary medical perspective is nomothetic. Spurred by the success of clinical trials

over the past half century and the influence of massive societal investments in science and

technology, research has dramatically reconfigured clinical medicine. This has also incorporatedthe perspectives of the bench scientist and epidemiologist, emblematized by the advent of

evidence-based medicine. These disciplines aim to produce verified and reliable information

from large samples and multiple replicatestheir immediate relevance is necessarily to the

population studied and its cognates. Yet, having such data is only half the journey. A translation

or transposition of such findings to the individual patient visiting a specific clinician is required

and for that, an idiographic framing is necessary. The concept of personalized medicine may help

towards that end, yet to date it operates by splitting populations into smaller and better

characterized subsets. The point of view remains top-down. What we need to learn and teach

is the view from the dyad. This is perhaps best exemplified by paraphrasing the clinicians

question as to why is this personwith his or her particular genetic individuality, developmentalexperience, psychological shape and life in a particular biological and social environmentin

my clinic today (Childs et al. 2005)? It follows that the clinician must apprehend and compre-

hend the particular narrative that shapes the search for the answer sought jointly by patient and

caregiver. This viewpoint, focused on the individual, can perhaps be taught in medical schools by

anthropologists, skilled in ethnography and the collection of stories, in concert with develop-

mental biologists, who can demonstrate the sensitivity of an organisms development to local

experiential conditions. Though the overall framing of the curricular problem is moral engage-

ment, the particular impetus to this intellectual reframing is the recognition of a different model

of the patient, not as broken machine, but as ailing human. The impetus is genetic, epigenetic anddevelopmental, in their broadest perspectives, and implanted in a world of relations.

b) Nature of knowledge

Jerome Bruner (1986) has described the distinction between paradigmatic modes of

knowing and those that are narrative. The former construes reality using rules and deductive

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reasoning while the latter extracts meaning through stories, figurative language, hermeneutics

and abduction. Rather than the imperative of diagnosis whose telos is far short of the clinical

goal and whose demand for simplicity and parsimony flattens identity and erases individuality,

we turn to understanding the patients story as the first step towards comprehension and a

crucial step towards healing. Thus, the professor of literature, criticism and rhetoric can workwith internists, pediatricians and family physicians to teach the elements of stories, their

construction and modes of exemplification. We should consider abandoning the typical case

which eliminates both person and story and move towards stories in all their personalized and

detailed richness. In some real sense, this is what personalized medicine should beincorpo-

rating personal idiosyncrasies as well as genetic mutations. It is in this richness of exemplars,

that the novel offers its greatest heuristic value in medical education. The novelist is able to

capture and describe persons in all their complexities and shades of meanings. By studying

classic descriptions of ailing characters and their relationship to the worlds they inhabit,

students will learn to appreciate human details generally absent in the traditional medical case

record. Not only is the hospital or clinic record a second or third hand abstraction of the

patients actual concerns, it is completely defoliated of any details of the individuals persona

and life world. The novelists eye and facility for language can bring into view nuances that

escape our medicalized attention. Thus, literature should be studied not to familiarize students

with narratology but rather to teach clinical medicine. After all, medical students yearn to

become good physicians, not literary critics.

c) Model of health and illness

The old and hackneyed machine model gained a new injection of energy with the develop-ments in organ transplantation, cardiac implantable devices and the increasing use of artificial

joints by an aging population. At the same time, the burgeoning of chronic illnesses that require

longitudinal care and an emphasis on quality of life and functional capacities, undermine the

machine metaphor with its implicit promise of return to a pristine state with serial replacements

unto the scrapheap. Perhaps the medical historian in concert with the physiologist can remind us

of Walter Cannons (1932) homeostasis as an alternate and more accurate model for describing

and understanding the ill patient and the aims of therapy. Thus, illness becomes dystasisand

modifications of the patient and his lived environment are the means of restoration to a new state

of equilibrium. The clinical commitment (and goal) is a return to a state of balance at any stage of

illness, not a facile promise to cure all ills. The philosopher and theologian can help studentsexplore how the good life can vary in meaning and import for different persons and their

families. Cannons homeostasis is physiological kin to Aristotles eudaemoniathe patterns of

life that lead to wise and good decisions enabling individuals and their communities to flourish.

d) Living persons

Traditional medical curricula often launch the course of study with dead, rather than living,

persons. It would appear to us more appropriate to begin with the subject of actual medical

attention, namely, the person in life, whether ill or well. Thus, we may start with the study ofpersonhood and engage the disciplines of psychology, human development and anthropology

in concert with biologists, geneticists and embryologists. The nature of personhood has

evolved in time, and we can align ourselves with historians and philosophers to understand

the contingent nature of the individual and necessary engagement with and definition by

family and extended network of relationships. It might seem more appropriate to start

holistically and later delve into the details of organs, tissues, cells and nucleic acids. Many

J Med Humanit


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curricula are structured in the converse fashion, starting with the structure of DNA and never

quite arriving at the fully developed whole person until late in the preclinical training when the

studentsattention has already been engaged by the study of diseases.

e) Society

It is evident that persons, patients and diseases are contextualized in their bodies, families

and societies. Yet, we seem to have reduced each to its apparent elemental state and prefer to

deal with reified diseases and rootless patients. Paradoxically, we then teach students about the

socio-economic gradient and health. There is a need to develop a nuanced and contextualized

understanding of illness, and we must recruit colleagues in economics, sociology and envi-

ronmental engineering to teach collaboratively with faculty from public health, infectious

diseases and epigenomics. Given that the problems our students will need to address in their

own careers will be multifaceted and require interventions by teams of care-givers, we must

teach using examples that are complex, complicated and uncertain in their outcomes. Our

simulations must come closer to the studentsfuture realities and we cannot do so in academic

silos. Parenthetically, such initiatives will serve to develop links between medical schools and

their host universities, to mutual benefit.

f) Relationship of physician and patient

Given that the care of the patient is the defining act of the physician, then the doctor-patient

dyad and the bond formed between these persons must be a recurrent theme in medical

curricula. The fields of anthropology, sociology and psychology have long traditions ofscholarship that can enlarge the perspectives of the internist and psychiatrist in teaching

medical students to engage with their patients and also become mindful of their own

behaviours, thoughts and affects in the clinical relationship. The phenomenologist can provide

frameworks from the lifeworlds and horizons of philosopher Hans-Georg Gadamer (Ramberg

and Gjesdal 2013). The neuroscientist can teach the clinical power of placebos. Once again,

the narratologist and novelist can offer finely wrought literary case descriptions of the

connexional dimension of healing and explain how metaphors must be shared and private

ones unearthed to facilitate the explication of meanings (Suchman and Matthews 1988).

Conclusion

Aristotles concept of thephronimosand that of human nature and conduct as described by the

philosopher John Dewey provide roadmaps that can help the teacher understand the process of

character development which medical students experience on their trajectory towards

physicianship. Dewey (1938, 47) argues that ones habit-forming proclivities are reinforced

and sedimented in particular directions through experiences; he points out: In a certain sense

every experience should do something to prepare a person for later experiences of a deeper and

more expansive quality. That is the very meaning of growth, continuity, reconstruction ofexperience. He adds, Collateral learning in the way of formation of enduring attitudes, of

likes and dislikes, may be and often is more important that the spelling lesson or lesson in

geography or history that is learned(Dewey 1938, 49). For Dewey, peoples habits embody

their character. This proposition implies that the pedagogic focus should be more on the means

and path to learning than on narrowly defined intended outcomes. The learning of new skills

and knowledge, without losing sight of preexisting habit and/or tradition, is conceived as a

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means to personal growth. There is aproduct beyond the activity,i.e., the learner acquires a

new skill or expanded data base. And, there is also a productinherent to the activity,i.e., the

learners character development. The conditions favorable to such maturation require a

relational space between teacher and learner that is characterized by emotional support and

unrelenting guided reflection. The relationship must be nurturing and non-judgmental, and thelearner must be encouraged to challenge received truths. It is often qualified as asafe space

i.e., a space where one can develop resilience and a sense of fearlessness. The teacher as

mentor serves in loco parentis. Also, the process of acquiring prudence and wisdom unfolds

most effectively when the actor(in this case, the nascent medical professional) is faced with

circumstances and dilemmas that are incrementally ambiguous and multilayeredexperiences

that are deeper and more expansive(Dewey 1938, 47).

Those planning medical curricula would be wise to engage their colleagues from philos-

ophy and educational psychology to help elucidate these ideas and to learn how to construct

longitudinal mentorship programs. The conceptual basis of these programs need to acknowl-

edge that the boundary between being and doing is porous and that, through a maieutic

process, mentors can catalyze and guide personal transformations in learners.

It should be noted that in all these examples, the engagement with specialists from the

humanities and social sciences involves joint efforts and often, team teaching. This is

procedurally a far cry from simply assigning some curricular time to the teaching of humanities

as elements set apart from the mainstream. Second, these subjects are all viewed as founda-

tional and instrumental, no less than the traditional offerings in biochemistry and pathology.

Finally, there is an implicithidden curriculumfor medical faculty members themselves who

may learn from their colleagues in other enriching disciplines.

The mandate of medicine and our touchstone is the patients well-being. We have outlined a

pedagogical and clinical practice in which all disciplines that contribute to the resumption of a

patients capacity to pursue achievable goals and purposes are enlisted in the task. This mindset

has the potential to leapfrog over futile preoccupations with the integration of the basic and

clinicalsciences. The humanistic and scientific aspects of medicine, married with an eye to

patientswell-being, merge into one coherent, stereoscopic image. We view the humanities and

social sciences as incorporating elements of both character development and instrumentality. The

concept of phronsis is particularly apt in representing the characterological and behavioural

outcomes of guided intellectual activity and growth in ethical virtues and moral development.

Osler (1899) cautioned physicians to care more particularly for the individual patient than for

the special features of the disease.This entreaty requires the medical practitioner to appreciate,to the extent possible, the peculiarities, preferences, perspectives and peccadillos of an individual

patient. The physician must be educated to see, hear and understand the person who is the patient.

This demands a fusion of the practical and particular to the abstract and generalizable. It calls into

question, not the pertinence, but the sufficiency of the natural sciences. Medical practice must rest

on knowledge that is idiographic as well as nomothetic and is enriched by the language of the

human sciences. Knowledge of persons as well as personhood is needed for the medical student

and the practicing physician to develop optimally his or her persona as a phronimos. The

humanities hold promise in revealing an idiographic understanding of patients. We submit that

they will thereby provide an entry to caring

more particularly for the individual patient.

Acknowledgments Dr. Boudreau is an Arnold P. Gold Foundation Associate Professor of Medicine, and he

wishes to recognize the foundations financial support during the period that the manuscript was conceived. We

thank Professors Al Miller, Maria Miller, Irene Gammel and Faith Wallis for their critical review of early drafts of

the manuscript. We are deeply appreciative of the thoughtful editorial advice provided so frequently and offered

so graciously by Sylvia Fuks Fried of Brandeis University.

J Med Humanit


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