Transforming Healthcare

Medical humanities as tools for the teaching of patient‐centered care

Abstract

Abstract

The Institute of Medicine, in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, highlighted patient‐centered care as an area for the development of quality measures. Since then, medical centers across the country have incorporated patient‐centered modalities in their healthcare delivery systems. In academic medical centers, interest in patient‐centered care has raised the awareness of the interactions between the humanities and medicine. This work aims to define the roles of patient‐centered medicine and the medical humanities in the academic medical environment, to establish the shared values between the medical humanities and patient‐centered care, and to demonstrate how the medical humanities can be a tool for the teaching of patient‐centered care. Journal of Hospital Medicine 2009;4:512–514. © 2009 Society of Hospital Medicine.

Copyright © 2009 Society of Hospital Medicine

In recent years, medical educators have recognized the importance of the inclusion of patient‐centered care in the medical school curriculum.1 There is an increased awareness of the importance of patient involvement in medical decision‐making, as well as a realization that patient‐centered care positively affects patient satisfaction and outcomes measures.2 The Institute of Medicine, in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, included patient‐centered care as one of the areas for the development of quality measures, defining it as providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.3 Several organizations, such as the Institute for Healthcare Improvement,4 have initiatives related to achieving the goals of patient‐centered care. While not a new phenomenon, patient‐centered care is permeating many areas of the healthcare delivery system.5 The recognition of patient‐centered care as both a desirable and measurable outcome of the healthcare enterprise has also renewed interest in the field of medical humanities as a valid tool for the advancement of patient‐centered initiatives and goals.

The Basis for Patient‐centered Care

Stewart et al.,6 in their book Patient‐Centered Medicine: Transforming the Clinical Method, identify 6 essential components of the patient‐centered clinical method: exploration of the disease and illness experience; understanding of the whole person; finding common ground; incorporating prevention and health promotion; enhancing the patient‐doctor relationship; and being realistic. These recommendations seek to improve the patient‐physician relationship by empowering the patient to be an active participant in his/her own health care.

The American Academy of Pediatrics recently released a policy statement7 outlining the benefits of family‐centered care in patient‐family outcomes, as well as in staff satisfaction. The statement also highlights the importance of bedside rounding by the attending physician and the healthcare team. Bedside rounding involves the patient in management discussions and decision making, while allowing for the unfiltered exchange of information. Nurses, therapists, and ancillary staff involved in the care of the patient also participate in the presentation. After the presentation, goals for the hospitalization are established, and the patient and family are asked for permission to implement the plan of care. Educational discussions regarding the patient's diagnosis usually take place outside the room, unless the patient's physical exam warrants a bedside teaching moment. Regardless of the format, patient‐involvement in the decision process is the central objective.

The Basis for the Medical Humanities

At the same time, there is renewed interest in the inclusion of the humanities in medicine. There is a perceived gap between the technological emphasis of the current medical school curriculum and the human values integral to the patient‐physician relationship.8 Namely, there is a growing concern that medical technology has suffused medical education with a sort of trade mentality in which doctors are trained in the latest scientific medical breakthroughs without the proper contextualization of the patient as the center of the healthcare enterprise.9 The National Endowment for the Humanities, the Association of American Medical Colleges, the Accreditation Council on Graduate Medical Education, and the Society for Health and Human Values have all called for increased emphasis of the humanities in medical education.10

What are the medical humanities? There is no clear‐cut definition. Felice Aull11 correlates the term with various so‐called liberal arts disciplines and their application to medical education and practice. She develops the notion that the medical humanities contribute to medical education in areas pertinent to patient‐centered care: insight into the human condition, development of observational and analytical skills, development of empathy and self‐reflection, and intercultural understanding.

In general, the medical humanities provide broad educational perspectives, and allow learners to develop skills critical to the development of a humane approach to patients.12 The paradigm relies on the assumption that exposure to the humanities in medical schoolin the form of formal lectures dealing with topics such as philosophy and literature, or through the role‐modeling interactions of teaching physicians and their perceived empathy to their patientswill allow the students to become more humane, and therefore, better doctors.13 The medical humanities seek to equip doctors with the critical thinking incumbent to the conversation about human values in a scientific field, and to explore questions of value and purpose critical in the medical setting.14

Shared Values

What are the values associated with the medical humanities that make them ideal for the teaching of patient‐centered care? Lester Friedman15 delineates 2 domains pertaining to the intrinsic values of the medical humanities. He identifies an affective domain, corresponding to a loose interpretation of the traditional affective perspective identified in the patient‐physician relationship; and a cognitive domain, a refocusing of medicine to its so‐called traditional professional roots, contrasted with the trade mentality of some in the profession today. Donnie Self16 identifies 2 currents of thought regarding the medical humanities: the affective approach, related to the development of compassion, sensitivity, empathy between the patients and their care providers; and the cognitive approach, which pertains to the development of logical and critical thinking required by medical education. These correspond to the integral attributes of patient‐centered care: incorporating the patients' ideas and affective responses to their illness; and establishing common ground and goals agreed upon by both patient and physician.17

The medical humanities are used to address such patient‐centered issues as end‐of‐life care in children,18 the physician‐patient narrative interaction,19 and the patients' role in their own health care.20 Medical humanities courses are also used in the training of cultural competence.21 Of course, the best‐known contribution of the medical humanities to patient‐centered care is the continuing importance of bioethics programs and their interrelation with other humanities fields.22

One of the goals of patient‐centered care is the elimination of perceived barriers of communication between patient and healthcare providers, in order to create a partnership aimed at improving healthcare outcomes.2 Since one of the fundamental aspects of medical training is learning the language of medicine,23 enhancing the communication skills of future physicians is part of the educational goals pursued by medical humanities programs.24 Language and its applicationsfor example, courses on medical interviewing or narrative medicineserve as the link between patient care and the medical humanities. Effective communication with patients is a measurable predictor of patient satisfaction, patient outcomes, and occurrences of malpractice litigation.17 For example, a study examining communication behaviors between physicians and the occurrence of malpractice claims25 found that doctors who were not sued spent more time with patients, educating patients about what to expect, and asking patients their understanding and opinion of the situation. Another study26 demonstrated that a patient‐focused approach improved the management of asthma, decreasing emergency room visits and hospitalizations. Therefore, it is not surprising that the Institute of Medicine's Committee on Behavioral and Social Sciences in Medical School Curricula identified basic and complex communications skills as priorities for inclusion in the medical curriculum.27

Doubts About the Process

There are doubts as to whether the medical humanities can really instill humanistic qualities in doctors. There are also questions about the physician‐centric focus of the medical humanities.28 This physician‐centric attitude runs counter to the intent of the medical humanities. Edmund Pellegrino and David Thomasma29 define the patient‐physician interaction as a human relationship where 1 person in need of healing seeks out another who professes to heal, or to assist in healing. The act of medicine ties these 2 persons together. While acknowledging the basic imbalance of the physician‐patient relationship, Pellegrino and Thomasma29 strive to close the gap by establishing medicine as a relation of mutual consent to effect individualized well‐being by working in, with, and through the body. The individualized exercise of well‐being, framed in, with, and through the body of the patient is similar to the description used by Stewart et al.6 of the patient as the unit of analysis delineating patient‐centered care, as it incorporates the interactive components proposed for a successful patient‐centered interaction.

There is also confusion between the teaching of humanities in medical schoolfor example, courses in history of medicine, narrative medicine, and medicine and the artsand the attempt to train humanistic physicians.30 Although an examination of humanities texts is certainly useful, the focus of the teaching of the medical humanities should evolve beyond a simple lucubration based on liberal studies, to a focused interaction between patient and physician, and a recentralization of the patient as the focus of that relationship.31

Conclusions

There is general agreement that a humane doctor is a better doctor. There is less agreement on how to measure the impact of a humanities education, as a qualitative assessment of satisfactory health care.19, 22, 25 There has been great growth in the teaching of medical humanities in medical schools. Most of the focus has been on the inclusion of humanities textssuch as literary, philosophical, and historical documentsas tools to establish a correlation between the arts and medicine, in hopes that the clarification of such association will provide medical students a broad‐based assessment, a so‐called world‐view, from which they can become introspective and humanistic when faced with their patients.32 Although this is a desirable goal, the driving force behind the medical humanities should shift to a quantifiable, evidence‐based assessment of its goals. A tool to achieve this verification is through the process of patient‐centered care. There is evidence to suggest patient‐centered care improves satisfaction and outcomes measures. It also refocuses care on the patient, which is the same goal of the medical humanities. By focusing on the patient, instead of the physician, the medical humanities will gain verification and validation within the academic healthcare environment.

References

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