“16 is too young to sell yourself.
You’re old enough to feel like a child
When you cry.
You’re father died in 2005, you said
(by way of explanation)
To the undercover cop.
He said your small arms raged
Against his chest, he said
He wasn’t fast enough:
You drove a blade into your belly.
What is your name?
The gauze dressing oozes blood, and
We howl through red lights with sirens.
At least give me a name to put down –
Not for billing purposes, just
So I don’t have to write ‘Denied.’
I’ll be holding pressure by your side,
And the ETA is 5, 10 min.
We have a little while.”1
Sarah Buckley’s poem “Denied” skillfully highlights the intersecting roles of healthcare, politics, and socioeconomic iniquities in the context of medical practice. A personal and informative look at the causal roles of poverty and prostitution to produce self-harm, “Denied” is a gripping example of the creativity within the medical humanities. As part of a growing appreciation for human-centered medicine, the medical humanities aim to place what has become a biologically dominated practice into a broader context, while raising important questions about the role of the doctor, curing versus caring, the value of empathy, and an accompanying host of provocative issues that arise partially from increasing distrust in the U.S. medical system.2
While media reports of the healthcare debates tend to focus on insurance coverage, payment and distribution, the quality of healthcare offered is essential to healthcare reform. Contemporary issues such as public distrust in medicine and “overspecialization; technicism; over-professionalism; [as well as] insensitivity to personal and sociocultural values” should be equally alarming and call for critical attention.3 One way to analyze the current healthcare situation is to look at its historical context. It is widely held that many current realities in medicine can be traced to their origins in the Flexner report, which revolutionalized medical training more than a century ago.
In 1910, Abraham Flexner, a former schoolmaster, was commissioned by the American Medical Association’s Council on Medical Education (CME) to assess US medical education. After visiting all 155 existing North American medical schools at the time, he was struck by the enormous variations in scientific understanding and the slack standards of these predominantly for-profit trade schools. In an attempt to increase rigor and specialization, Flexner suggested four years of medical education, incorporation of medical schools into existing universities, and that admissions to medical school require on minimum, a high school diploma and two years of college education devoted to basic science. CME’s enforcement of the report’s recommendations resulted in the closure of over half of the existing medical schools that did not comply with its standards.
The Flexner Report greatly increased standardization of the scientific method, physician quality, income and prestige conferred upon doctors.4 However, Flexner also conflated humans with their biology, arguing that “clinicians must, in short, be impregnated with the fundamental truths of biology” because “the human body belongs to the animal world”.3 While a debatable assertion at the time, the biological foundation of illness has been made a touchstone of modern medicine, and Flexner’s criteria has largely determined today’s scientifically focused pre-medical track and medical school curriculum.
The problem with the Flexner Report for scholars in the medical humanities is its biological centrality. Recognizing that biology as a basis for the treatment of disease is important, Bradley Lewis, professor of cultural studies at NYU, argues that humans are more than biological animals, and therefore require care during illness above and beyond treating biological symptoms.3 Because humans center their lives around meaning, social, emotional, and biological realities work in synchrony to influence our health.
In the 1970s, the scientific notion of medicine was re-examined, which commenced the inauguration of various “human values teaching programs” in medical schools across the US.5 The curriculums of these interdisciplinary courses and their administration were locally decided and remain extremely inconsistent across schools. Although some faculties believe a core curriculum for the medical humanities would create clearer standards, others support localized control. No real consensus on the medical humanities curriculum exists. Still, healthcare began to resist Flexner’s exclusively biological approach. Some proposed that the goals of medicine should be redefined as tending to human suffering instead of treating disease, while others conceptualized the doctor-patient encounter as a “moral relationship”.3 These human-centered ideas would later become the unifying theme of the medical humanities.
Edmund Pellegrino, medical philosopher, summarized the plight of medicine seventy years after the Flexner report was published, criticizing its “too narrow a construal of the doctor’s role; too much “curing” rather than “caring”; not enough emphasis on prevention, patient participation, and patient education; too much economic incentive; a “trade school” mentality; over-medicalization of everyday life; inhumane treatment of medical students; over-work by house staff; and deficiencies in verbal and nonverbal communication”.3
The emphasis on objectivity following the Flexner Report ignored the subjective experience and created a way of life out of touch with human needs, human goals, human desires, and human suffering. In order to address these issues, Pellegrino suggested that “illness is an altered state of existence arising out of an ontological assault on the humanity of the person who is ill”.6 In short, the ill person loses freedom of physical movement, lack of knowledge to heal oneself and autonomy over the self, and consequently must redefine his or her self-image to match this newfound vulnerability. The question for medical practitioners then becomes how to heal both biologically and psychologically.
The 1970s, 80s, and 90s witnessed an upsurge of interest in the medical humanities and “narrative medicine”, the current umbrella term for “a range of contemporary efforts to humanize medicine and counterbalance the many problems of Flexner’s model”.3 Narratives in medicine encourage empathy, allow for the construction of meaning, encourage a holistic approach to management, and are grounded in experience and self-reflection, thereby validating the patient while challenging the physician to be more of an empathetic healer than a technocrat.7
The range of contemporary topics covered in the medical humanities is impressive. A skim through The Journal of Medical Humanities yields an analysis of doctor-patient encounters, a discourse on the constraints of medical ethics, and other captivating titles such as “Psychopathology and Literature”, “Dissecting Dad”, “The Medical-Industrial Complex”, and “Chess & Schizophrenia”. The past forty years have also witnessed the rise of a slew of journals dedicated to the medical humanities, as well as centers in universities dedicated to the teaching of the medical humanities. Notable initiatives include a master’s degree program in Narrative Medicine at Columbia University targeted towards established doctors, nurses, social workers, and therapists, as well as a comprehensive database and directory for the medical humanities established by New York University.
While many medical schools have already integrated the medical humanities into their medical school curriculum, the future of the field looks more promising than ever as increasing numbers of healthcare professionals recognize the need for less impersonal interactions in the hospital setting. Thanks to the medical humanities, future medical students have the chance of becoming well-rounded and well-read, just as enthusiastic about Nabokov as about nucleophilic substitution reactions.
- Buckley S. For There is Work to be Done: Poetry and Commentary. J Med Humanit. 2011; 32(3): 245-250.
- Armstrong K. Distrust of the Health Care System and Self-Reported Health in the United States. J Gen Intern Med. 2006 April; 21(4): 292–297.
- Lewis B. Narrative Medicine and Healthcare Reform. J Med Humanit. 2011; 32 (1): 9-20.
- Beck, AH. “The Flexner Report and the Standardization of American Medical Education”, JAMA. 2004; 291 (17): 2139–2140,
- Wear D. The Medical Humanities: Toward a Renewed Praxis, J Med Humanit. 2009; 30(4):209-20.
- Pellegrino E. Being Ill and Being Healed: Some Reflections on the Grounding of Medical Morality. Bull N Y Acad Med. 1981; 57(1): 70–79.
- Greenhalgh T, Hurwitz B. Narrative based medicine: Why study narrative? BMJ. 1999; 318:48-50.
- Image: Westfall, Greg. Happy. Flickr. JPG, http://www.flickr.com/photos/imagesbywestfall/4311832482/in/photostream/ (accessed 3/1/2012)
- Image: vaXzine. Pain-map. Flickr. JPG, http://www.flickr.com/photos/vaxzine/2642346629/in/photostream/ (accessed 3/1/2012)