Despite the obvious value, as indicated above, of taking critiques of the medical humanities at face value, discussions at a less-than-systemic, paradigmatic level about the role of the humanities in medical education themselves risk irrelevance. Whether faculty solicit feedback or don’t care what students think; whether students are self-protective and resent personaq l exploration or value self-awareness; whether bodies of knowledge outside of medicine and teaching modalities other than those traditionally used in medicine are given a place within the curriculum; whether the humanities are relegated to the outskirts of the curriculum or whether they are integrated across four years of training do depend in part on individual instructors’ commitment, skill and effort ; but more importantly, they depend on systemic values, priorities, and assumptions within the culture of medicine.
Cultures colliding. From the perspective of the students’ lived experience, much of their criticisms are right on target. They cannot embrace the medical humanities because they are not able to “see” how those disciplines fit into health care practice. Everything in their environment convinces them that without an intimate knowledge of say anatomy or biochemistry, they will founder as physicians. But they can easily imagine being doctors without reading poetry or picking up communication skills on their own. This is because, underlying all of these specific issues, is a larger systemic problem. This is not fundamentally a situation so much of how to teach better, what content to introduce, or how to respond to student concerns, although all of these are important, but about what the narrative of medicine will incorporate and what it will exclude. Today, the world of medicine and medical education is unquestionably diverse and heterogeneous in many respects. Nevertheless modern medicine is still rooted in certain positivist, objectivist assumptions that ineluctably lead to, and justify, the above critiques.
Epistemology of medicine. Epistemology asks the question, “How do we know what we know?” and probes the assumptions and foundations of knowledge. In the epistemology of medicine, only knowledge that is empirically provable and replicable by scientific standards really counts. Other knowledge, perhaps derived from the wisdom of elders, or particular cultural stories, or the truth of a poem, is less valuable. Measurable, generalizable, and content knowledge (such as how to diagnose and what to prescribe for a given medical condition) counts. Emotional intelligence, reflection on the attitudes and values of self and others, appreciation for divergent and even contradictory priorities and perspectives are not considered nearly as important or useful. From the predominant assumptions of medicine, the humanities comprise non-essential knowledge taught in formats that seem inefficient and inconclusive. In a system that prioritizes empirical knowledge and is suspicious of inner exploration or appreciation of subjectivity, it is not surprising that students in that system will feel self-protective, even angry and threatened by other approaches to learning.
Additionally, medicine relies heavily on a vertical hierarchy of experts to convey learning, and the criteria for approving these experts are narrow. From this epistemological perspective, not just anyone can possess expertise – and those who don’t qualify (in this case, possess medical or basic science degrees) are regarded with suspicion, are “untrustworthy.” Experts, having expertise, naturally will not be too interested in eliciting input and concerns from those who do not. Therefore, despite personally friendly relationships, in the training current model, the contributions of non-M.D.s to the education of future physicians will always remain secondary.
The epistemology of the medical humanities. The humanities offer fundamentally different foundations from those of the sciences and develop essentially different forms of knowledge, such as narrative knowledge. The epistemology of the humanities is at odds the logico-scientific assumptions that govern modern medicine, particularly for its reliance on the intersubjectivity of knowing, necessarily involves unique individuals who are unavoidably embedded in a particularistic context of culture, gender, biography, intellect, and emotion. The humanities’ recognition of multiple perspectives, priorities, and truths requiring “practice in the negotiation of meanings” (Belling, 2006, p. 5) and the moral implications accompanying this recognition challenge the governing assumptions of modern-day medicine as it is presently taught.
In particular, the epistemology of the humanities has important implications for the concept of professional competence, in lay terms, what matters in the making of a physician or, to return to an earlier point, what constitutes authentic relevance to praxis. In a 2002 article in JAMA, Epstein and Hundert offer a comprehensive definition that extends far beyond conventional competency checklists. They include criteria that are the outgrowth of epistemological assumptions closer to the humanities than to the basic sciences such as tolerance of ambiguity and anxiety; observations of one’s own thinking, emotions, and techniques; recognition of and response to cognitive and emotional biases; and integrating judgment from multiple sources including the scientific, the clinical, and the humanistic. Of special interest is their inclusion of relational, affective, and moral components, as well as what they refer to as “habits of mind,” including attentiveness, critical curiosity, self-awareness, and presence. It is these hard-to-teach, and often unacknowledged or trivialized, elements of professional competence that can be successfully addressed through both the epistemology and the methods of medical humanities.
A complementary paradigm? A paradigm of medical education that, in the classic vision of cognitive psychologist Jerome Bruner, accepted various forms of knowing would take such criteria of professional competence seriously, as well as the bodies of knowledge and the methods to achieve them. A different system would recognize the enormous practical relevance of insights from narrative knowledge for addressing the day-to-day human aspects of doctoring, including its inevitably moral dimension that the knowledge of science has such difficulty tackling. Medical education emerging from the full acceptance of both traditions could comfortably recognize the value of an interdisciplinary clinical enterprise relying equally (although not necessarily in identically equal portions at all points of training) on the basic sciences, the clinical sciences, the social sciences, and the humanities. It could legitimate multiple ways of identifying “knowledge” and demonstrating its utility, i.e., through qualitative as well as quantitative evaluation, assessment of educational portfolios, use of humanistic connoisseurs etc. It could broaden the scope of who is trustworthy, as well as what kinds of learning experiences are valuable and legitimize introspective as well as instrumental work. In such a model, both the knowledge and the methods of the medical humanities would be viewed as having something essential to contribute to the education of physicians and would be seamlessly incorporated into traditional courses such as anatomy and the clinical clerkships.
In a different kind of medical curriculum reflective of a different set of assumptions, the medical humanities would be viewed as an appropriate and worthy use of one’s time and energy on the road to becoming a doctor, as a source of insight, illumination, even revelation