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Knowledge and wisdom

Article by Dr. Jock Murray

Dr. TJ (Jock) Murray, 
professor emeritus medical humanities, 
professor of neurology

In the Gilman Lecture to Johns Hopkins Medical School in November 18, 1984, Canadian novelist Robertson Davies called his talk "Can a Doctor Be a Humanist?" but said the title should have been, "Can a Doctor Possibly Be a Humanist in a Society That Increasingly Tempts Him To Be a Scientist?" He spoke of the caduceus, the symbol with the two serpents entwined on the staff, Knowledge and Wisdom. The legend says that the warring serpents were writhing on the ground but were pacified by Hermes when he passed a staff between them. Davies said Knowledge and Wisdom aren't necessarily opponents, but they are opposites, and they must be reconciled and made to support each other. For the physician, Knowledge comes from without, and from education and study, enabling him to help patients. Wisdom, on the other hand, is an introverted element of the doctor's psyche, coming from within.

Wisdom is what makes him look not at the disease, but at the bearer of the disease. It is what creates the link that unites the healer with his patient, and the exercise of which makes him a true physician, a true healer, a true child of Hermes. It is Wisdom that tells the physician how to make the patient a partner in his own cure. Instead of calling them Knowledge and Wisdom, let us call them Science and Humanism.

Medical Humanities at Dalhousie

We agree with Robertson Davies and believe that there has to be a balance between the sciences and humanities in medicine.

Both aspects are integral to medicine and we must strive to bind them and integrate them, not suggest one is important to the exclusion of the other, or that they operate separately.

Over the last decade, there was increasing recognition of the importance of the humanities at Dalhousie, which was focused by the Humanities in Medicine Symposium in 1991, drawing 268 physicians and students for a weekend of discussion and presentations. The Humanities Program at Dalhousie, which was founded in 1992, recognized that many of the activities in the humanities, such as history, ethics, philosophy, literature and art were already going on with the enthusiastic support of many individual faculty members. The Dalhousie Society for the History of Medicine, for instance, has been active for two decades.

The Humanities Program endeavors to foster the humanities in the medical school and hopes to fully incorporate it within the fabric of the medical school curriculum, clinical teaching and the lives of the students and faculty. We feel this is happening as there are increasing activities going on, planned and carried out by the students and the faculty. It was never planned that the Humanities Program would do all these things and it is exciting to see the many activities of the students this year, and the planning for next year. Success would be a future educational system at Dalhousie when the humanities were fully incorporated in the curriculum, taught and modeled by all clinical teachers.

Some of the activities of the Humanities Program this year have been the elective student activities, summer research studentships, humanities evenings for student presentations at the faculty club, discussion groups, regular brown bag lunch presentations, the reading weekend at various sites in Nova Scotia, public lectures, the Dalhousie Society for the History of Medicine, the Artist in Residence Program, visiting professors, student presentations at Dalhousie, the University of Calgary and the Royal College of Physicians and Surgeons of Canada.

The New Paradigm - Balance

The many exciting and important advances in science, technology and therapy over the last 150 years lead to an increasing biomedical view of illness, the continual specialization of medicine and a technological approach to diagnosis and treatment. It has fostered an emphasis on knowledge and technical skills in medical students and physicians with a neglect of the traditional humane and interpersonal aspects of the practice of medicine.

This revolution in science and technology was coupled with an expectation that this direction would continue to advance the goals of medicine and medical care, but the public and repeated reports on medical education suggest the neglect of the medical humanities is causing increasing concern over the imbalance in the two integral components of medicine, humanities and bioscience, and this imbalance is being reflected in the attitudes, approaches and effectiveness of our physicians. The call to pay attention to the medical humanities in medical education is not a call to de-emphasize science—it is to achieve a balance, and it is necessary for our science to be informed by the concepts and lessons of the humanities.

We often use the term "medical science", referring to the scientific knowledge used by medicine. Medicine is not a science. It is a caring profession that uses science. Although it can be argued that the humanities were always an integral part of medicine, in this century science and biomedicine have dominated the educational curriculum, and the philosophy and approach to patient care.

To move away from science would be to return to an unreasoned belief system where anyone's belief in the nature of life and disease is equal to anyone else's, a return to magic and superstition as equal to an informed, critical and evidence based knowledge. The public is already moving in this direction, partly because of larger changes in society, but also because the public is increasingly viewing science as disappointing, sometimes untrustworthy and devoid of the values and humanistic elements that would have science and medicine serve their interests best, not science's interest only. This rejection of medical science has resulted in an increasing move to alternative answers and is also a rejection of what they see as an arrogant medical profession that fails to address their needs and the needs of society.

Historical Perspective on the Medical Humanities

In the middle ages, when medical education moved into the universities, leaving the barber surgeons, midwives, tooth pullers and wise women back in the villages, the physician's education was in the philosophies, mathematics, astronomy (and astrology) and languages. These trained the mind, assisted in ways of thinking and understanding.

Descartes enunciated mind-body dualism; Harvey, Willis, Sydenham, Bell and the Hunter brothers showed a way to correlate symptoms with pathology; Bichet convincingly showed that diseases involved tissues; Virchow later demonstrated they could be explained at a cellular level; Pasteur advanced germ theory; and in our generation explanations increasingly come from explorations in the DNA and cell wall proteins and mitochondria and cytokines and neurotransmitters, and prions, and it seems that more answers would come if we could just look deeper, into more focused areas, deeper and deeper into the molecules and their function. If we just had a bigger electron microscope, a higher Tesla MRI, better genetic probes.

This method, called the reductionist method, has served us well. It has explained many of the illnesses that have plagued mankind, it has allowed us to understand what happens when disorder afflicts our bodies, it has helped us find specific treatments for these disorders, and in some instances, to eliminate many diseases from our communities. We may think of the dramatic instances, of Pasteur developing vaccines, of Lister using Pasteur's concepts of bacterial sepsis to develop antiseptic techniques for surgery, of Fleming discovering penicillin and Salk developing the polio vaccine. Even more important, with greater impact on the health of populations but with less drama and excitement have been the public health measures that have come from understanding the nature of disease processes. These are triumphs of science.

But just as the sciences were achieving such triumphs, there was an increasing debate over the balance of the education of medical students in the humanities and in the sciences. Sir William Olser argued and demonstrated that the ideal physician would be broadly educated and widely read, as well as educated in laboratory and clinical medicine.

Because medical education was in such a sorry state in the USA by the end of the 19th century, the American Medical Association, aided by the Carnegie Foundation, instructed schoolteacher Abraham Flexner to survey and report on medical schools in Canada and the United States. His report had a major effect on supporting the widespread feeling that reform of medical education was urgently needed. But for our discussion it is important to see the direction he set for the educational process of future physicians. He was influenced by the German laboratory sciences and the approaches Johns Hopkins medical school had taken towards a pathological and laboratory basis for clinical medicine and surgery. His report in 1910 would have a great effect on directing medical education heavily to science, with medical schools emphasizing preadmission education in the sciences, and science as a basis for medicine in medical education. It is interesting to reflect that Flexner might have been concerned how far this has been taken almost a century later, as he primarily meant to emphasize a way of scientific thinking, not that the education of physicians would primarily be sciences.

By the middle of this century most medical schools in North America had a similar educational pattern. The first two years were all basic sciences, with an increasing smattering of clinical experience as the years went on, but the clinical was not to apply the basic sciences but to learn another technique, the clinical diagnostic skills. As the years moved towards internship there was greater contact with people suffering from illness, and our challenge was to remember the basic sciences from years before as we tried to apply the newer skills of taking histories and doing thorough physical examinations.

I had a good medical education, and have always been proud of my school and my professors at Dalhousie. We were told repeatedly that Dalhousie Medical School was classed as an A school since 1922, clearly a defensive comment, as Flexner had called the school "feeble" 12 years before that. But as I reflect on my medical education, I note that there was no course (everything was divided into courses) on medical ethics, community needs or values, literature (except the journals), philosophy of medicine, or the nature of the profession and its role in society. There was a brief few hours when an elderly physician gave a survey course on the history of medicine, but as he droned on about Cos and Paracelsus and Queen Victoria's childbirth, we stared at each other and wondered why he was there. Never did I hear a discussion of suffering, hope, patient rights or societal values. The humanities were not part of my medical education. But the lessons and understanding that would come from study in the medical humanities and the values and principles and ways of questioning and thinking were not rejected—they were taken for granted. They naturally followed from your medical education. And if there was any hesitancy or slowness in adapting these aspects of a medical life, just watch the professors and the skilled physicians, and you will learn these things.

Interest in incorporating the humanities fully within medical education resurfaced again in the 1960's, led by physician educators such as Edmund Pelligrino in the United States. The first humanities program with departmental status was at Pennsylvania State University at Hershey in 1967, with five funded positions, and a full role within the medical school organization. Students had two compulsory courses from a selection of death and dying; medicine and ethics; major medical novels; religion and medicine; philosophy of medicine; history; philosophy of genetics and a number of others.

By 1973, there were 40 humanities "programs" in American medical schools. It is interesting that even in the height of interest in the USA, no identifiable program arose in Canada, and there was little discussion here about the concept. However, the elements of humanities were developing, especially with the Hannah Chairs in the History of Medicine in Ontario, and the broadening of educational experiences to include community teaching, communication skills, selection procedures that emphasized humanistic qualities and broad education and community experience in the entering students.

By 1984, Cassell, in an overview for the Hastings Center, was able to report that there were four full departments of humanities in American medical schools (Pennsylvania State University College of Medicine, Wright State University School of Medicine, Southern Illinois University School of Medicine and the University of Nebraska School of Medicine) but "innumerable" humanities programs based in departments or in dean's offices, and a few free standing institutes. Cassell reported that the movement back to the humanities was increasing, at least in interest, if not funding. However, he was aware that there was little consistency in the nature of these programs, with variable personnel, resources and role in the medical schools. They shared one characteristic—some of the faculty felt the medical humanities should be recognized in the curriculum, and the dean agreed.

Every major report on undergraduate education over the last three decades emphasized the importance of addressing the imbalances in medical education. The under emphasis of the medical humanities is only one of the imbalances to be addressed (community based clinical experience, ethics, community needs assessment). Most medical schools are struggling to understand how a humanities program could be incorporated within their curriculum, especially as they all move towards a problem-based approach.

Why the Medical Humanities?

The humanities are an integral and central aspect of medicine and always were. They are just more neglected in an age dominated by science and technology, accepted as important, but taken for granted.

Those who would argue for science as the basis of learning and decision- making in medicine must reflect that those same decisions must be guided by a broader understanding of the person who is exhibiting the disease and the family and society in which they live. A study of persons and values, ethics and historical context requires study in the medical humanities. For example, if it is important that physicians understand the way illness affects the person, their lives and the lives around them, this is much better done through great literature. It is hard to find such discussion revealed in traditional textbooks that center on disease.

Interest in medical humanities in recent years also came from the feeling we are increasingly treating patients as impersonal cases and diseases, not persons. There is a sense of fragmentation of life, medicine and patients that makes us want to reorient towards a sense of "wholeness". Wholeness of person is wider than his or her person, as it includes social, historical and communal aspects of their broader life.

The recognition that one person cannot command all the resources, background and expertise to address all aspects of a complex person and their problems led initially to the development of teams of people with different backgrounds and training, in hopes that wholeness could be approached by fragmented expertise. This clearly fails on many counts, one of the most obvious being the lack of understanding of the concept of wholeness, if each of the players is a focused specialist.

Finally, medicine and a life in medical practice will be fuller and more enjoyable if it is coupled with an understanding of medical culture, the history of the profession, and a fuller understanding of the persons we treat and the society in which we function. Joy in medicine is not to be minimized as one of the roles of the medical humanities.

One Culture

C.P. Snow suggested that there were two cultures, the sciences and the humanities. I would argue strenuously that there is only one culture in medicine, a melding of the humanistic and the scientific that cannot be separated. The issue now is to address an imbalance that has occurred with most of the educational process and the emphasis and evaluation in medicine being heavily weighted towards the biomedical and scientific aspects of medicine to the neglect of the humanities; the values and the attitudes of future physicians; the understanding of persons, cultures and community; and the role and responsibility of physicians and medicine in society.

Some might say they work out these issues without the humanities. However, they are likely to do so without studying the humanities or recognizing the value systems affected by their decisions. Is it too much to ask that we have some more structured discussion on these values, so we know how to think them through, and even recognize when they are involved in our decisions?

Many of the judgments of physicians cannot be reduced to anatomy, pharmacology, or clinical signs and symptoms, but are questions of fundamental human values. These are aspects of the physician-patient interaction, the value of human life, the nature of relationships, family and society, personal and societal rights, as well as the rights of physicians, and finally, the nature of a "good and just" society. Are these not worthy of a recognized place for discussion and study within the medical curriculum?

The Elements of the Medical Humanities

So what are the elements of the medical humanities? The traditional humanities do not cover all aspects, such as a study of values and the nature of humanistic medicine, but there are components we can identify. The wide variety of fields include philosophy, ethics, theology, history, literature, art, music, language and the social sciences as they relate to medicine, health and the human condition. It is interesting that as far back as the middle ages, when medicine first became a university study, medicine itself was regarded as a philosophy, with preparatory studies in the arts and mathematics, philosophy and often theology. Medicine was also regarded as a natural art and one that assisted nature with healing, just as agriculture assisted nature in growing foods and teaching assisted people to learn. Healing, growth and learning all occur in nature, but the natural arts assisted nature.

Humanities in Medical School

Up until this century, the curriculum of study was strong in the wide fields of arts, as well as sciences, in the belief that mathematics, languages, literature and philosophy all aided in training the mind for the difficult field of medicine and broadened the understanding of the human condition. The medical humanities in its broadest concept are an essential part of medicine and it was always so. The humanities and the humanistic aspect of the profession were an integral part of practice thousands of years before medicine learned to use science as a new approach to acquire knowledge and understanding. And the humanities are not just another subject in a complex medical curriculum, no matter how little place it currently finds itself in most medical schools. Even schools that say they have no place in the curriculum for medical humanities actually take it for granted that it is already there.

Humanities Are About Values

Pelligrino says that the humanities in medicine are distinguished by their focus on human values, and focusing on human values is essential for medicine to avoid being swallowed by its own technology or dehumanized by its complex organization. Those who argue you cannot teach values hope for the serendipity effect—if you study medicine, you will learn by association. Many think that teaching about values, on the other hand, smacks of dogmatism. Also, we are often uncertain about our values, so how could we teach them?

Values can be studied, but are difficult to teach. We can become aware of values and can decide which should be reaffirmed. We can understand what it is to be a human person. We can learn what people believe in.

The faculty teacher should focus on values and not try to "out-science" the scientist. We should help the students and others to become aware of their values. Working with the sciences, humanistic studies can help enlarge perspectives, lessen dogmatism, provide a philosophical framework and enhance critical openness.

Conclusions

My conclusions are simple:
medicine is a caring profession, which strives to foster health, prevent illness and assist the unhealthy, and this is a humanistic struggle that uses science to inform and advance that effort. The medical humanities are an integral part of medicine and always have been, thousands of years before science helped medicine advance.

The central importance of the humanities in medical education must be addressed consciously and not just taken for granted as something that will be there, or will necessarily follow from a science-based biomedical curriculum.

The humanities help us understand the nature and values of science through ways of exploring and thinking and learning that are appropriate to the humanities. The humanities should not be overly responsive to the demands of science to use science's rules, language and learning methods. The challenge is to create an educational system and atmosphere where these flow and work together, each stimulating and informing the other.

Science and technology are not the enemy and not to be devalued. We need science, but science also needs the humanities to understand the human values and the human questions and the human decisions that must guide our use of science.

If we don't get this right, (I apologize for making this in the form of a warning, but it concerns me so much that I find it necessary), we will see a continuing move by the public away from medicine and science towards a more caring magical system, and an increasing control and definition of what the medical profession is by corporations and governments who recognize that the profession seems to be uncertain about its own definition, values and directions. And when that happens we may not be able to think clearly about what is being eroded as we haven't seriously examined or valued it. We lived in a world that believed that science would answer the questions about life, death, suffering and the values of a person, a society and even the medical profession lie in the realm of the humanities.

The seamless blending of the humanities and the sciences of medicine is occurring at Dalhousie Medical School, and we are excited about the enthusiasm of the students who are doing so much to make this an important part of their education and their lives in medicine and society.

References

  1. Davies, R. Can a Doctor be a Humanist. The David Coit Gillman Lecture, Johns Hopkins Medical School, November 18, 1984. (Republished in The Merry Heart, by Robertson Davies, 1990, 110.)
  2. Cassell, EJ. The Place of the Humanities in Medicine. New York, The Hastings Centre, 1984.
  3. Snow, CP. The Two Cultures. London; Cambridge University Press, 1964.
  4. Pelligrino, E. The Humanities in Medical Education, Mobius 1982; 2:133-141.

Other Readings in the Medical Humanities

  1. Brody H, Connolly J, et al. Physicians Pursuing the Humanities: Benefits and Barriers. J Med Humanities 1994; 4: 163-169.
  2. Charon R, Banks JT, Connelly JE, Hawkins AH, Hunter KM, Jones AH, et al. Literature and Medicine: Contributions to Clinical Practice. Ann Int Med. 1995; 122: 599-606.
  3. Gevitz, N. The Value of History in Medical Education. Bull of Dept of Med Ed, Univ of Illinois at Chicago, 1995; 2: 1-2
  4. On-line Resources for Medical Humanities: Literature, Arts and Medicine Database; New York University of Medicine.

  5. The Humanities and Medicine. Editors, Chester R. Burns and H. Tristram Engelhardt Jr. in Texas Reports on Biology and Medicine, 32:1, Spring 1974.
  6. Rogers J, Being Sceptical About the Medical Humanities. J Med Humanities, 1995: 16; 265-277.
  7. Schneiderman H. Literature, Humanities and the Internist. Ann Int Med, 1995; 122: 618-619.
  8. Swales J. Culture and Medicine. J R Soc Med, 1998; 91: 118-126.
  9. Thomas L. Notes of a Biology Watcher: How to Fix the Medical Curriculum. N Engl J Med, 1978; 298: 1180-1181.
  10. Wear D. The Colonization of the Medical Humanities: a Confessional Critique. J Med Humanities, 1992; 13: 199-209.
  11. Zaner RM. The Unanchored Leaf: Humanities and the Discipline of Care. in The Humanities and Medicine (above) pages 1-18.
  12. Nourishing the Humanistic in Medicine: Interaction with the Social Sciences. Editors, Rogers WR, Barnard D. Contemporary Community Health Studies. Pittsburgh, University of Pittsburgh Press, 1979.