For Your Health
For Your Health

News from the University of North Dakota School of Medicine & Health Sciences

The art of medicine

North Dakota’s only medical school explores how and where to embed more arts and humanities education into its medical curriculum

In 2020, the Association of American Medical Colleges (AAMC) published “The Fundamental Role of the Arts and Humanities in Medical Education,” a report that reiterated the organization’s belief that “integration of the arts and humanities into medicine and medical education may be essential to educating a physician workforce that can effectively contribute to optimal health care outcomes for patients and communities.”

The report came just as UND’s own School of Medicine & Health Sciences (SMHS) put the finishing touches on what it was calling “Curriculum 2.0” – a new medical education curriculum designed not only to give students more elective courses during their first- and second-years, more active learning options in the classroom, and more clinical training sooner, but to better embed the arts and humanities into the curriculum.

Three years following both the AAMC report and UND’s unveiling of its new medical curriculum, however, the SMHS, like many schools, is grappling with the best way to integrate the arts and humanities into the student experience.

Why does this lift feel so heavy for American medical schools nearly 25 years into the twenty-first century?

“In American medical colleges, the trend has been to incorporate more philosophy, literature, and history into the pre-clerkship curriculum as a way to provide context to the standard of practice and to balance the emphasis on the sciences,” explains Patrick Carr, Ph.D., associate dean for medical curriculum at the SMHS, admitting that “more” isn’t saying much when the baseline has been little-to-nothing in many schools. “There exist, however, tremendous time constraints. A typical four-year curriculum is already full of content. This means that the addition of new subject matter requires removal of existing content.”

For Carr, an afterhours musician who has been forthright in his support of engaging medical students in what are often called the “medical humanities,” the arts and humanities are an obvious and necessary component of healthcare education.

“Understanding what people think, why they think that way, and what individuals enjoy in their lives allows the patient and physician to relate to each other better,” he says. “This is all part of being an effective care provider. When millions of humans over hundreds of years have been moved by the same painting, play, or musical piece, that provides insight into a human connection that transcends time and place and allows providers to understand what’s underlying each individual patient’s goals, values, or preferences.”

Improved performance

On this point, most faculty and researchers seem to agree. Referencing a raft of previous studies comparing the medical college performance of students who begin their medical training having studied the arts and humanities to those who did not, one study from 2009 notes that “previous academic performance” – rather than any specific undergraduate major – remains the single best predictor of success in medical school and residency. Even more, the report’s authors suggest, students “who majored in the humanities may in fact perform better as interns when rated by supervisors on criteria ranging from clinical judgment to relationships with patients and peers.”

This is because, suggests Dr. Andrew McLean, the School’s associate dean for wellness and chair of the SMHS Department of Psychiatry & Behavioral Science, both students and residents with arts and/or humanities backgrounds tend to have stronger skillsets in a variety of “soft” skills – from empathy, communication, and situational awareness to “visual literacy” and an understanding of the historical and cultural customs that help them better communicate with, relate to, and maybe treat a diverse panel of patients.

“The humanities allow for a different opportunity to hone one’s skills in observation and critical thinking, enhance one’s curiosity, imagination, and creativity apart from the ‘traditional’ medical model,” says McLean, a prolific writer who published a book of his own poetry and wants to see more arts and humanities “throughout” the medical curriculum. “I specifically teach two didactic classes per year to psychiatry residents related to this topic – one hour per week for three months. One class is on the humanities and personal wellness, and the other is on film, literature, and art in medicine.”

In developing such courses, McLean is following the lead of the instructors of one Harvard Medical School course – “Training the Eye: Improving the Art of Physical Diagnosis” – who noted, in a 2008 analysis of their own efforts to improve visual literacy among medical students, that art can be utilized to teach students to see their patients’ symptoms, bodies, and health needs better.

Thirty-eight percent better in fact.

“Our qualitative and quantitative findings suggest that observation skills, including those directly relevant to clinical medicine, can be successfully acquired through active, structured study of works of art and medical imagery,” the researchers concluded. “Participants demonstrated improved ability to make accurate observations and were more likely to incorporate fine arts concepts relevant to physical diagnosis (e.g., color and symmetry) into their written descriptions.”

Step 1 and the student experience

Such figures are hard to ignore. But despite years of similar reports from multiple research journals, convincing many medical students to enroll in art- or humanities-based electives while in medical school has been a tougher sell, adds Carr, largely for structural reasons.

“Our School has discussed electives focused on visual arts, music, and other aspects of the humanities, but these have not been utilized to this point – no one took the electives we offered,” explains Carr, adding that most students simply couldn’t fit such courses into their schedules. “Students expressed interest, but felt forced to focus on courses that more directly contributed to what seems to be the focus of residency programs and hospitals or clinics, such as research or getting a publication under their belt.”

Part of the challenge recently, Carr says, is that when the “Step 1” exam – the first of three required United States Medical Licensing Examination (USMLE) exams that students must pass to get licensed – converted to pass/fail in early 2022, students lost one important means of quantifying their learning for residency program directors and future employers. In other words, a shift in the exam design wherein students no longer received a specific score on a major test of biomedical and clinical content has prompted many students to look for additional concrete ways of demonstrating their knowledge and achievement in the clinical sciences. Fitting that bill have been activities like additional laboratory research, journal publications, and electives dedicated to one or more clinical specialty – not the medical humanities.

Reflecting on all of this, second-year medical students Madison Seifert and Kate Tomczik, both of whom trained in the arts and humanities as undergrads, nonetheless continue to believe that their training outside the sciences will make them more effective clinicians.

Having double majored in microbiology and English, Seifert wouldn’t trade her practice in the reading and interpretation of complex texts for anything. Indeed, such training helped prepare her to read and better interpret complex people with often complex physical and emotional concerns.

Years of reading and writing “have really helped me not only understand better the medical literature but also with writing and communicating with others,” says the Bismarck native, whose undergrad thesis explored the discourse on science in nineteenth century literature. “I’ve learned, when I interact with people, not to take anything at a surface level, but to dig in and look for nuances or undertones in what a patient is trying to say.”

A Minnesota native who double majored in biochemistry and studio art, Tomczik agreed, calling her proficiency in the humanities “a great tool” for helping her communicate with patients who may be uncomfortable in the clinic.

“I remember working in the clinic during COVID, and one of our patients had to have this procedure done,” Tomczik recalls. “She was afraid of needles but had mentioned earlier that she had just gotten back from a trip where she went to an art gallery. So I was able to hold her hand and say, ‘Tell me about that,’ and talk with her about art – to take her mind off the needle. There’s definitely a patient care side to arts training that has been valuable for me. Even if patients aren’t artists, they like art and I can talk about the arts with them.”

Solutions: electives, badging, and interest groups

SMHS faculty have noted similar benefits of the arts and humanities in their work with other students as well.

“One of the best students I worked with as a facilitator in our Patient-Centered Learning curriculum was an anthropology major,” says Rick Van Eck, the School’s associate dean for Teaching and Learning. “She was able to pick up the science content that was not part of her undergraduate education, but she was already an expert when it came social determinants of health, empathy, and patient-centeredness, which are things that students with undergraduate science majors sometimes struggle with.”

The question thus remains: if the research literature and student experience suggest that the arts and humanities can help produce more thoughtful and observant physicians, how can medical colleges better embed such training into their curricula beyond the standard course in bioethics?

Targeting extracurricular programs – student interest groups or the tried-and-true lecture series, perhaps a humanities-based Grand Rounds series complete with food – is one strategy.

Another novel pathway that UND and other schools are exploring, says Van Eck, is micro-credentialing or “badging.”

According to Van Eck, badges are a way of measuring competencies as part of optional or required curricula that can otherwise be hard to teach and assess through more traditional teaching modes.

“Badges allow students to demonstrate and document diverse skills, attitudes, and knowledge,” says Van Eck, who has championed the School’s badging efforts. “Students can seek optional badges, which can help them communicate their diverse skills, interests, and abilities to residency directors, who may be better able to evaluate how well the student will fit within the culture of the residency.”

Badges can also be required, says Van Eck, like the recently added interprofessional collaboration badge and the telehealth badge, both of which comprise didactic, traditional teaching as well as student-driven learning activities.

“We don’t just want to tell students to be interprofessional and then give them test questions like ‘Is it important to be interprofessional,’ he says. “We want to know whether they choose to behave interprofessionally during the clinical practice and teach them how to do so better. Badges are ideally suited to measuring these kinds of outcomes.”

And although the SMHS has no formal medical humanities badge to date, such a badge has been discussed insofar as it might encourage medical students to take on training in the arts and humanities in a more compact and tiered way that doesn’t require taking a full elective course.

One example of this type of learning might be granting students one or more badges in something like the philosophy of medicine and what French philosopher Michel Foucault called “biopower” as an historical concept. Defined as the collection of techniques, policies, and ideological beliefs that institutions from hospital systems to governments implement that affect the health and lives of individuals and populations, biopower (or biopolitics) can involve everything from vaccination schedules and public health campaigns to healthcare access, the inclusion (or not) of certain medications on insurance formularies, and reproductive rulings in the courts.

Understanding historical and philosophical concepts better can help students understand the challenges they will face as physicians in a particular political or socioeconomic system.

This is also content that remains difficult to incorporate into a traditional medical education.

Even so, says Mick Beltz, associate professor in UND’s Department of Philosophy and Ethics, this sort of training will produce more thoughtful and better health providers.

“The medical humanities are a recognition that some medical issues are not scientific problems,” adds the philosopher who helped the SMHS develop Curriculum 2.0. “If a significant part of medicine is not simple science, then we cannot expect that a strict scientific education will properly prepare future doctors. Literature, history, economics, ethics, and philosophy, all have a track record of significantly helping people become better members of their community and better citizens. If this is true of ordinary citizens, it is also true of doctors.”

Describing how the exponential growth in scientific knowledge and technical precision in medicine has outpaced educators’ ability to improve students’ interpersonal, analytic, and interpretive skills, Beltz adds that even as technology changes the diagnosis and treatment of disease, the world still needs physicians with an exceptional understanding of oral and written communication, history, literature, and philosophy.

Indeed, patient-centered care – the human side of medicine – all but requires such understanding.

“We may not be able to fully predict how artificial intelligence or other medical advances we’ve not yet imagined will change the practices of our students,” he concludes. “However, we can expect that the professional skills needed in the future will be the same skills that are needed today. This is where the strengths of the medical humanities are important. If medical schools build a strong foundation in the medical humanities, future doctors and researchers will be prepared to face whatever practice landscape emerges in the future.”

By Brian James Schill