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Remember that the purpose of our pre-clinical medical humanities series of lectures
is to support your professional formation and your personal reflective practice toward
improved resiliency and, ultimately, more effective patient care.

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Karen Kim:
“As pre-clinical students, we never have any forums in which we can learn about each
other and the incredible wealth of experiences and accomplishments that we
collectively bring to medical school. We have virtually no class time devoted to
discussing the whole slew of motivations that brought us into medicine:
• Belief (at least to some degree) in the biomedical model
• A desire to combat poverty, disease, and racial disparities in care
• A search for prestige or financial stability
• Personal experiences of prejudice and discrimination
• Commitment to our communities
With thirty hours a week of class time spent sitting in a lecture hall looking at
PowerPoint slides, who has the time? As the workload and stress mount, discussion
of anything outside the required basics becomes superfluous, unimportant, and an
added headache. Virtually no one wants to attend a voluntary two-hour symposium
on the ethics of transplanting embryonic tissue into the brains of Parkinson’s patients
– after all, who wants to spend extra time and energy caring about stuff we aren’t
tested on?”

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The purpose of studying medical humanities is to provide an opportunity to reflect on
personal and professional formation in a deliberate and conscious fashion, toward
cultivating physician qualities, skills and habits that improve patient care outcomes,
physician satisfaction and resiliency.

You will be examined on your ability to recognize patient-centered communication

and care in a clinical vignette, both within the RUSM curriculum and also on USMLE
assessments. These skills will be assessed during USMLE Step 2 CS and in local
Clinical Skills practical examinations.

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These pedagogical tensions have long played and continue to play a role in medical
education. As medical education history unfolds in the following slides, think about
and note this conflict.

What do you think? How would you prefer to learn to take care of patients?

How much have you learned to date at RUSM about care of unique individuals?

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Ayurveda is the name of the traditional health and healing practices of India; a
patient’s physical, mental and spiritual states are inseparable.

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Imagine living with your teachers, 24-7.
‘
Today, would this be a more positive experience or a more negative experience?

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Secular traumatology, the care of wounds, injuries, and broken bones, was delivered
by a kind of craftsman, either a resident of a community or one who wandered from
one community to another. This medical knowledge was imparted orally, usually
from father to son or to an apprentice. The second kind of practitioner was a sort of
priest physician, and he imparted religious wisdom to his initiates.
Hippocrates changed all of this with his “corpus”, his body of texts that separated
medical from religious explanations for disease, symptoms and suffering, making the
study and practice of medicine a profession. Still pedagogical tensions persisted.
Aristotle decried: “Clearly you do not become a physician by books…”

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Ideas about health, disease and healing have influenced medical education, as have
prevailing social hierarchies.

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Remember in first semester, the movie “The Physician (Der Medicus)” was presented
as an example of middle ages medicine. The protagonist, Rob Cole, was apprenticed
to a barber surgeon, when he learned that he might be able to attend
medical/surgical training in Persia. He traveled for a year and on the way, he
circumcised himself in order to pass as a Jew, knowing that he would not be accepted
into the medical school of Ibn Sina and would be likely killed if he arrived in Persia as
a Christian.

Note the illustration here. Across from the Duomo (cathedral) in Sienna, Italy, is one
of the oldest hospitals in Europe, Santa Maria della Scalla. This is “bedside rounds”
on a patient in the hospital, presumably with some students observing. Notice the
large wound on the patient’s right thigh. Knowing that this was a time in history
when patient care in Europe was being dispersed among many paraprofessionals, this
illustration may make you wonder about how care might have been different in the
Italian city of Siena, considering the presence of a large and famous hospital near the
very center of town.

Note the last bullet point in the slide. Where in the RUSM curriculum have you been
“taught” about professional behavior and deportment for a physician in training?

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*The most advanced medial education available in the West at the time was
considered to be available at these starred institutions.

By the end of the 1100s medical education consisted of learning set doctrines in
unquestioned traditional texts. Surgery was disparaged by physicians and church
officials as a “lower”, less refined art.

However, surgeons who practiced daily accumulated a lot of practical “hands on”
experience with patients and were more likely to be more effective than those whose
teaching and learning were mostly confined to books.

Think about the RUSM “state of the art” anatomy lab and your anatomy training.
Compare and contrast with the “state of the art” anatomy lab created in 1637 at the
University of Bologna, above.

Note: Dr. Mario Babbini, one of our professors in the RUSM Pharmacology
Department, taught at the University of Bologna Medical School!

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You learned about Dr. Andreas Vesalius, physician and anatomist, who created the
anatomy text “De humani corporis fabrica”, based upon his extensive anatomical
dissections.

Textbook knowledge alone is not enough.

Thomas Sydenham (1624-1689) wrote Observationes Medicae, a textbook of

medicine that was used for 2 centuries to educate physicians. He became known as
“the English Hippocrates”.

Experience with patients and disease, combined with reflection on these

experiences, advance medical knowledge and a skilled, effective approach to
treatment. Think about how this philosophy affects physician patient relationships.
Would close observation of the patient and his/her condition create a closer or more
distant relationship between doctor and patient?

In Semester 1, you learned that Paracelcus adamantly and sometimes aggressively

promoted this idea.

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Where do you stand on this point right now? Are you finding yourself desiring more
patient contact at this point in your education?

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Many of the Edinburgh trained North American physicians returned to establish
medical schools in Canada and the U.S.

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There was no regulation for medical education, practice and licensure and no way to
ensure the quality and efficacy of practitioners, nor the consistency of training and
skills.

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Harriet Kezia Hunt, denied admission to Harvard in 1847 (100 years after the opening
of the medical school) and admitted in 1850, but rejected by the student body, ended
up as an apprentice to a practicing male physician and his female non-physician
assistant and augmenting her education and skills with extensive reading and self-
study. She practiced for 40 years in New England, providing care mostly for women
and children.

Elizabeth Blackwell was the first women to receive a medical degree in the United
States from Geneva Medical College in 1849, graduating first in her class after
receiving an acceptance letter that was intended as a practical joke. Her success and
deliberate activism for women’s rights opened doors for women to enter medical
training and practice.

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The Knick, a Cinemax series, dramatizes this period.

A key theme in the series, is the domination of the U.S. medical profession by white
males. Despite Elizabeth Blackwell paving the way and deliberately working to create
opportunities for more women to train as physicians, access to medical education
and certain prestigious specialties and practices were blocked to women and
minorities.

Posted here is a link to a recent article from The Atlantic about the history of African
American physicians in America.

http://www.theatlantic.com/health/archive/2016/12/black-
doctors/510017/?utm_source=eb

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This statement was made in the late 19th century. Is the argument about what it takes
to educate a medical student familiar?

Where do students of medicine learn how to apply the knowledge and skills they
have learned?

What is the BEST way to teach or help medical students to be excellent and accurate
observers, excellent and creative problem solvers, good judges of situations, needs,
the character of others?

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Reflect on these two statements and the time in history they were made, again the
late 19th century.

Based on your life experience AND your experience of medical education so far, are
these statements relevant/true today?

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This report changed the face of medical education in the United States significantly.

Creating standards, pre-requisites and criteria for any profession is generally seen as
favorable. What negative impact might this change incur?

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Do you think the impact on representation of women in the profession was
anticipated or foreseen?

What might be the impact on patient care by excluding women from the profession?
The impact on society?

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Again, what might you anticipate would be the impact of restricting medical
education in this way?

Note when Dr. Townsend lived. He was a graduate of Meharry Medical College and
practiced medicine in Nashville, TN. What challenges do you think he faced during
this time.

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These are major problems facing modern physicians and physicians in training today.

Have your notions about the “best” way to learn medicine changed?
What is the best, fairest, most efficient and effective way to fund health care?
Is health care a privilege (restricted access based upon social status or ability to pay)
or a basic human and societal right (universal access)?
Can any physician know everything he/she needs to know to optimally care for
patients?
Is information technology a blessing or a curse to doctoring and patient care? How?

Burn out is a pervasive problem amongst modern physicians and it is not a foreign
experience for medical students. What contributes to burn-out for students? What
do you imagine, creates burn-out for practicing physicians?

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At RUSM, we have deliberately addressed some aspects of the “hidden curriculum”
to bring them into the open.

What have you learned here so far about being a physician? What ideas or beliefs did
you bring to RUSM that have been reinforced? Ideas that have been challenged?

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Which of the positive values in the left hand column have already been
communicated to you as qualities you should possess and practice as a physician?

Note the potential negative consequences. How can striving for excellence (and
achieving it) lead to a feeling of invincibility? How can the ability to save lives and
cure serious diseases lead to a feeling of omnipotence? Compassion comes from the
Latin word compati which means “suffer with”. How can compassion lead to a sense
of isolation? How can providing service to others lead to a sense of deprivation?

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“House of God” was a popular book written and published by Samuel Shem (pen
name), a psychiatrist, in 1978. It is a satire, describing in a poignant and humorous
way the clinical training of physicians at the time.

Most of the actors in this movie are considered comedians, based on their previous
work. If you have a chance to view the entire film (available from multiple sources,
including You Tube), note the juxtaposition of completely absurd scenes and dialogs
with some of the most poignant themes in modern medicine. Also note the
stereotypes of women and minority physicians.

How has clinical training changed (or not) since this book was written? Because you
are still in the pre-clinical phase of your training, the answer to this may be “I don’t
know” or your answer may change as your training progresses.

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Scrubs is a popular and more recent media depiction of clinical training presented
through the narrative reflections of the character, J.D., a physician in his residency
training.

J.D.’s reflections on his training, relationships with attending physicians, nurses, peers
and patients provide insights on physician formation, despite a humorous bent.

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Gregory House, MD, has a team of physicians in training, both residents and fellows,
for whom he offers teaching and influence as they work with him to manage patients
and solve difficult diagnostic problems.

You may be familiar with these quotes from the television series and we have seen
them before in the Reflective Practice presentation earlier this semester. Here is
another opportunity to reflect on these particular House aphorisms. What do you
think about these, based on your own life (and medical) experiences?

Both television series and movies about physicians depict physician work, attitude
and behaviors AND may both represent and influence evolving social norms and
physician formation. How have your ideas about physician demeanor, lifestyle,
communication, and even dress been influenced by media representations of
physicians?

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Questions for reflection.

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100 years later, what do we know about the best ways to educate physicians for
optimum patient care in today’s world?

What, in modern medical education, is not working well toward this goal?

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Do you agree with these named deficiencies?

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Which of these recommendations resonates most with you at this point in your
medical education?

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This paper “lit up a national debate about social mission in medical education. The
study, conducted by researchers at the George Washington University (GW) and the
Robert Graham Center and funded by the Josiah Macy Jr. Foundation, measured the
“outcome” of the nation’s allopathic and osteopathic medical schools. It ranked the
schools on three core indicators of social mission – 1) what percent of graduates
were practicing primary care, 2) what percent were practicing in shortage areas, and
3) what percent were underrepresented minorities. The results indicated that the
nation’s three African American schools as well as many rural and public schools far
outperformed more research oriented schools – schools which are often ranked
highly by the US News and World Report – in social mission. That debate catalyzed
the concerns of many educators, students, and policymakers about the lack of
attention given to social mission in the programs of medical schools and residency
programs.”

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