11 No. 3
December 2008/January 2009
Unraveling healthcare's knottiest problems
Researcher’s alleged transgressions lead to more ethics oversight
“Is it reasonable for [a patient] to be able to demand everything be done regardless of what that does to the healthcare system financially, or to its ability to serve a wider population?”
“I don’t think the main role of the ethicist is to tell people what’s right and wrong. One who does that in my opinion abdicates one’s responsibility.”
Medicine and Compassion
Reaching across the silos to teach the "art" of healing
Things I've learned while I couldn't do my research
Egypt and Emory
Small collection, large footprint
In academia we sometimes forget that medicine is both an art and a science, I could even say an art embedded in science,” Bill Eley, executive associate dean for medical education and student affairs, once said of what it means to teach compassion. Most of us, whether we live within the medical world or not, would agree that competence and compassion are cornerstones of excellence in healthcare.
About 40 percent of Emory’s undergraduate students pursue pre-medical curricula, most commonly through majors in neuroscience and behavioral biology, biology, or chemistry. Their majors and medical school admissions recommendations dictate 70 percent of their graduation requirements. Indeed, our students’ brains are primed to apply memory and recall to scientific content. Their minds are further challenged through studies in social science, some required by Emory and others highly recommended for medical school admission. But what about our students’ hearts? In this essay, we offer our insight on teaching medicine and compassion to undergraduates based on our experiences developing and teaching Medicine and Compassion, an undergraduate medical humanities course that is part of the cultural studies in Italy summer curriculum.
The word “compassion” literally translates from Latin as “to suffer together.” The word “patient,” again from the Latin, reveals both “bearing and enduring without complaint” and the “suffering or sick person.” Linking these two words is the idea of suffering. The person offering compassion is offering to share in the sick person’s suffering. Do heathcare professionals need to be reminded, or perhaps even taught, that compassion reflects true listening and speaking with our brains, our minds, and our hearts? Most importantly, can we teach these concepts to students considering careers in healthcare?
These questions took on an immediacy six years ago when Judy Raggi Moore of the Emory College faculty asked Ruth Parker of the School of Medicine faculty to design a course that would integrate an undergraduate medical humanities course with the cultural studies in Italy summer curriculum. In other words, propose a class that would both help prepare future healthcare professionals and engage the cultural immersion they would experience. Parker surveyed colleagues and leading medical faculty around the country: if they could offer one course taught in Italy to pre-medical students today, what would it be? The sense that Emory’s popular pre-medical curricula lacked “education of the heart” led them to try to create one essential pre-health career course.
For the past five summers, Emory undergraduates enrolled in Medicine and Compassion have spent six weeks asking, “What is compassion?” The main goal of the course is for each student to understand how compassion relates to the profession of medicine. Using moral imagination as a tool for inquiry, students examine historical and recent work from the humanities: literature, philosophy, the arts, and numerous cultural and social renditions of complex concepts such as love, care, mercy, pity, sorrow, death, and healing. They are asked to explore compassion and medicine both as private individuals and as professionals called to the work of healing. Faculty from the School of Medicine (Parker) and the CDC (Cantey), along with Raggi Moore and faculty from the humanities, social sciences, and sciences provide cross-disciplinary insights.
Why Italy? Paul Cantey feels that first and foremost, teaching the course abroad provides cognitive estrangement. Our opinions on what compassion is and is not, as well as our opinions on how we should treat one another, are just that—opinions. Although we can base them on underlying principles, we often base them on assumptions we learn from our families, friends, and culture. Examining one’s own assumptions can be a difficult task, particularly for students still seeking to define themselves and their own beliefs. Italy pulls students out of their familiar environment, where they possess an innate understanding of cultural rules, and thrusts them into an unfamiliar environment, where they must learn to recognize the unspoken rules of another culture. As they learn to recognize the new rules and identify the underlying cultural assumptions they represent, they are better able to examine their own underlying assumptions about how people treat one another. A key component of the course is developing their ability to examine all sides of an issue, recognize their own biases and assumptions, and identify principles that help resolve conflicts between varying points of view and assumptions.
The past and present of Italian culture, the cradle of Western civilization, lend themselves to discussions on compassion. Through the study of ancient and modern history of medicine and public healthcare, commissioned art and public buildings, the state and church, popular beliefs and traditions, and integration of regional realities within a national unity (just to name some of the avenues of inquiry), the course offers scenarios that transcend time and context and deal with the universal and human. Discussion of how a society observes and experiences disease and epidemics, ancient Greek and Roman thought and practices, medieval Christian world relationships between thoughts of bodily sin and the practice of personal hygiene, Renaissance innovations in the sciences and arts coexisting with devastating outbreaks of plague, the stimulation yet dangers of trade and travel—all these scenarios provide introductions to current discussions of AIDS or SARS and social reactions and responsibilities.
Further, for more than two thousand years, Italian culture has been tied to the ideals of Christianity: Christian culture and the Catholic Church in their essence focus on the care of others. In Christian thought, illness reflects the sufferings of Christ who is portrayed in his dual role as both sufferer and healer. The first Council of Nicea, held in 325 AD, formally linked the Church with the care of the poor, orphaned, sick, and widowed, and it recommended the construction of a hospital in the shadow of every city cathedral. The message of compassion is expressed, for example, through the parable of the Good Samaritan, the poetry of Saint Francis, or the writings of Christian philosophers such as St. Augustine and St. Thomas Aquinas. Such works become more meaningful read in situ and offer the opportunity for challenging discussions for students of all creeds and heritage. Civic texts also offer excellent class opportunities. Students are not surprised to learn that the first state to abolish the death penalty was the Granduchy of Tuscany, with its new penal code promoted by
granduke Pietro Leopoldo in 1786.
While learning the science of medicine requires students to memorize, understand, and use vast numbers of facts, learning the art of medicine requires them to make a human connection, build trust, and respond to the often unspoken and sometimes unrecognized needs of patients. Teaching the science of medicine is relatively straightforward and predictable. The art of medicine is much more difficult to teach, if it is taught at all, and much more difficult to learn. Why should a pre-health professional student read Boccaccio’s introduction to the Decameron? Not necessarily to learn the nuances of the Black Death, but perhaps to experience what it would be like, for both physician and patient, to live in an outbreak of life-threatening illness.
In the course, students often realize they lack the academic tools to frame their investigations of compassion. When they say, “Tell me what you want me to learn,” we give them a reply they have, sadly, rarely heard: “You need to think.” Stripped of their familiar yet one-dimensional learning tools, students react with confusion, consternation, indignation, even belligerence (“I don’t have time to think; just tell me what you want me to know so I can learn it and move on”), and finally acceptance of the challenge. What these initial reactions say about the health of our liberal arts ambitions is an important question.
But does this exercise in moral imagination teach students to be more compassionate? Though a quantitative study on efficacy and results has not yet been undertaken, the anecdotal evidence is powerful. As current medical student and former undergraduate in the program, Arian Hatefi said, “In today’s climate, students are often taught practical facts helpful in solving current problems like malaria or HIV, but there is little thought given to the human experience of suffering attributable to such burdens. The course, therefore, teaches students how to feel, rather than what to think, recognizing that each student will embark on a unique journey and will walk away without sharing the same fact set memorized by other classmates, but with a new approach to the collective subconscious of humanity. . . . One can stand in front of Michelangelo’s Pietá and in a moment learn more about compassion than he or she might in four years of college.”
Administrative barriers have challenged the continued life of this course. Differences in pay scales, curricular schedules, and job expectations complicate medical faculty involvement in the course. Additionally, they have had to develop expertise in areas not traditionally taught in medical schools, requiring a significant investment of time and money. Compensation for teaching the course does not even cover the cost of participation, much less additional costs. In fact, one faculty member has taken one to two weeks’ vacation time to cover the days not covered by salary support each year. It is encouraging, on the other hand, that college administrators such as Philip Wainwright of the Center for International Programs Abroad opened the doors to cross-silo teaching by providing support for further developing the curriculum and by partnering with the medical school and physician assistant program to help enable healthcare graduate students to participate as teaching assistants, thus giving undergraduates the unique opportunity to work with medical professional students. The authors hope to continue to explore innovative concepts for bridging the administrative and cultural gaps among the arts and sciences and the health sciences. We are convinced that our students are the true beneficiaries of faculty navigating the hurdles encountered when we truly collaborate to teach across our silos.