A study of acceptability & feasibility of integrating humanities based study modules in undergraduate curriculum

In clinical practice doctors are required to understand patient's emotional and psychological needs while applying scientific knowledge and skills to the patients1. Learning medical humanities will help medical students and doctors to understand patient's emotional and psychological needs. With the help of art and literature, medical students and doctors can further develop their observational skills, analytical reasoning and power of imagination2.

The traditional training of medical students gives very little emphasis on this important aspect. The importance of teaching medical humanities has not been realized yet3. Its integration in undergraduate curriculum still faces criticism as consensus is still required to be developed regarding the content of curriculum, process of teaching and its assessment45. Though there is no agreed definition of medical humanities, the General Medical Council of United Kingdom defines medical humanities as an international endeavour that draws on creative and intellectual strengths of diverse disciplines, including literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology and history in pursuit of medical educational goals6.

Humanities related courses have already been integrated in the undergraduate curriculum in various forms in many medical schools of Europe, USA and Australia.7 It is yet to be developed and introduced in India that has around 310 medical schools with a yearly intake of more than 36,000 students in undergraduate courses8. With worldwide experience, where introduction of humanities based study modules have improved students knowledge, attitudes towards patients and self-directed learning9, we undertook this study to develop, introduce and evaluate the acceptability of medical humanities based study module in our undergraduate (UG) teaching curriculum. The study was designed around three core objectives. First, to develop humanities based study module (HSM) as an educational instrument in UG curriculum; second, to introduce the module as a part of bedside learning experience to the undergraduate medical students attending rotatory clinical posting in a medical college in north India, third, to study the acceptability of study module on the basis of students’ feedback.

Material & Methods

The study was conducted from August 1, 2010 to January 31, 2011 in the Department of Medicine of Lady Hardinge Medical College affiliated to Delhi University. Lady Hardinge Medical College is one of the oldest medical colleges of India with annual intake of 130 students in the undergraduate course. The undergraduate students of 6^th and 8^th semester during their compulsory rotatory ward postings were enrolled on a voluntary basis and introduced to humanities based study module (HSM). Written informed consent was taken from all participants.

HSM was weaved within the clinical matrix of the routine biomedical case presentations done by medical students. The HSM was operationalized during the first 40 min of the clinical case presentation. The HSM unfolded in three sequential stages (Fig.).

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Fig

Framework design of humanity based study module (HSM) used in the study.

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(i) Stage of induction: Each new batch was briefed about the HSM by the investigators. In the first session, usually of 40 min, they were made aware of the medical humanities - its scope, necessity and nature of the study module followed by the enrolment that was on voluntary basis. The students were informed that participation in HSM carried no credit points or marks. This was done to eliminate any scope of bias while giving their feedback in the response sheet meant for evaluation of study module.

(ii) Stage of expression and creative work: Subsequently, of the two hours of daily ward posting, initial 40 minutes were devoted for HSM. In the first 15 min, one student narrated the socio-economic, familial, cultural and biographical aspects of the patient's life and deciphered the impact of patient's disease on his/her life. Over the next 25 min all students were asked to participate in the group-discussion centred on the presentation. Special emphasis was made to discuss the impact of patient's illness on his/her personal and social domains. During the discussion, students were asked to express their feelings about patient's suffering through their own creations by making use of short narratives, stories, poems, sketches, painting and posters. Depending on the level of participation, students were divided into 3 groups: group 1: active performers who volunteered in the study by developing their own creations in the form of poem, short story, poster, sketches and cartoons; group 2 - active participants who participated actively in the group discussion apart from active listening; and group 3 - passive listeners who remained silent during the group discussions and remained listeners only.

(iii) Stage of feedback and evaluation: Evaluation was done at two levels. During each session, students were observed by the investigators and their group behaviour such as the number of students active in each group, nature of activities, level of participation, core issues raised, etc. was noted. At the end of each session, students were given an anonymized questionnaire for feedback. The questionnaire-cum-student Feed back sheet was designed in three parts. Part A assessed their group behaviour and the mode of participation. Part B had questions to get their feedback on HSM, and Part C was meant to get their suggestions relevant to this topic. The correlation between the three groups of participants and their feedback regarding the effect of HSM on their affective- motivational domain was studied by reviewing their response sheet at the end of the study. The consistency between different batches of students attending this module was maintained by ensuring that the same core team of teacher-facilitator anchored various sessions. They tried to maintain uniform frame of the discussions in the various sessions.

Results

The total number of students of 6^th and 8^th semester who attended clinical classes during the study period was 235 and HSM was offered to all of them. Of them, 223 (95%) initially enrolled themselves in the study. 210 (94%) completed the study module and 13 (6%) left the study in between. Of the 210 students who completed the study, 100 (48%) were from 6^th semester and 110 (52%) from 8^th semester. Of the 210 students who completed humanities based study module (HSM), 138 (66%) expressed their views in group discussions only; 55 (26%) students remained as passive listeners while 7 (8%) expressed their views and emotions by means of their own active creations.

The students’ acceptability and feasibility of HSM was assessed by a set of three questions. While 73 per cent of the students perceived a definite positive change in their affective behaviour towards their patients, 82 per cent found themselves more motivated to do in-depth reading focussed on the concerned patient's disease and 85 per cent of the students wanted the HSM to be continued in the future teaching- learning activities (Table I). It was observed that among the three groups structured around the level of participation in the HSM activities, the groups displaying a more active participation displayed a greater magnitude of improvement in their affective-motivational and learning behaviours towards their patients.

Table I Students feedback about HSM

The students’ assessment of the design and the working of the HSM measured on a subjective rating scale of 0-3 is summarized in Table II. Broadly, two-third of the students have found the HSM effective (moderate or greater) in improving their affective-motivational performance.

Table II Students’ rating about humanities based study module (HSM)

Discussion

Medical humanities based programmes are common in the medical schools of United States, Australia and Europe either as a part of the curriculum or as a voluntary module710. However, the concept of medical humanities is relatively new to Asia. Humanities based study sessions have been conducted at Manipal College of Medical Sciences, Pokhara and KIST Medical College, Lalitpur in Nepal where efforts are being made to develop it slowly11. Medical humanities based programmes are largely unknown in most of the medical schools and institutions in India10.

In India, its importance is now being recognized and several authors have highlighted its role in medical education has been highlighted1012. A medical humanities group has been formed in the University College of Medical Sci-ences, Delhi, with the aim to develop this discipline and practice it amongst health care providers by means of lectures and street plays101314.

In our study module, students were encouraged to use various forms of art (sketching and painting) and literature (stories, poems and short narratives) to reflect on socio-economic, familial and cultural aspects of the patient's life. HSM was offered to 235 students of 6^th and 8^th semester. Of the, 223 students enrolled in the study, 94 per cent completed the total duration of study module. Overall, nearly three-fourth of them perceived a significant improvement across all the three domains. The design and the working of the HSM was also rated by nearly two-thirds of the students as being effective in enhancing their affective-motivational performance. The affective-motivational state refers to a complex of affective state which embodies response parameters such as empathy and sympathy towards the patient's human condition and the motivational state which encompasses the behavioural response directed towards the increased desire focussed on learning and patient care. As in other parts of the world15, our study module was readily accepted by the students. In this teaching programme, which was mostly based upon interactive sessions, students mostly opted to take part in group discussions.

It has been found that the medical students read widely beyond their course including fiction and biography16. Literature in all its forms has got the ability to affect human emotions and behaviours and help in developing empathy and imaginative power1718. Through vivid descriptions of illness, death and human suffering it provides a virtual experience of the patient's affective state and thus helps in achieving the goal of making more humane doctors1920. Besides, this literature can be used to inculcate ethical values21. Paintings and sketches enhance one's power of perception and imagination2223. Besides, it has a role in developing medical student's observational and pattern recognition skills24. In a study at KIST Medical college, Nepal, first year medical students were introduced to medical humanities with the use of paintings which evoked positive responses25. Study modules used in medical schools of Greece have incorporated philosophy, ethics, theology, social sciences and history apart from art and literature6. Centre for Medical Humanities, England, used drama, film and creative writing apart from practical arts and literatures in their study module for teaching medical humanities to undergraduate students620.

Medical students are always under immense pressure to attain biomedical knowledge and skill in core subjects within given time but neglecting the importance of medical humanities increases the likelihood of a dehumanized technical approach with concomitant loss of sensitivity to the human condition in medical practice26–28.

This study has several limitations. Firstly, the study was primarily designed to determine the feasibility and acceptability of humanities based study module (HSM) and it was not adequately structured to measure its effectiveness in improving health care delivery outcome. Studies with case-control design measuring perception and outcome assessment of all the three actors viz. the students, the teachers and the patients will be required. Employing structured measurement scales for parameters such as empathy, sympathy, patient satisfaction and above all the qualitative change in the doctor-patient relationship as a consequence would be an integral part of such studies. Secondly, the study population was restricted to the volunteers. So, the possibility of volunteer bias compromising its “external validity” cannot be ruled out. However, the value of this study lies in it being a pilot study with a descriptive observational design which mapped the affective-motivational domains of the medical students. More robustly designed, multi-centric study would form next logical step to enhance the external validity of the humanities based study module.

In conclusion, some broad conclusions were drawn on this important domain of the student's subjective assessment of this module's effectiveness. Firstly, a positive change in their affective behaviour towards the patients was observed in 73 per cent students. Secondly, an improvement in the motivation for enhanced learning focussed on their patient's illness was reported by 82 per cent students. Thirdly, an indirect surrogate hint at the positive motivational change induced by HSM was located in their response to the question whether they wanted the module to be continued in future. Fourthly, an important finding was an improvement in affective motivational performance among those who had displayed a higher level of participation. This suggests the need to design and develop newer teaching methods that would motivate students to be active participants rather than remain passive listeners. Thus, the introduction of humanities based study module integrated with bedside clinical teaching in the undergraduate curriculum may be both feasible and acceptable to the students. Further studies need to be done with robust design in different parts of the country to confirm these findings.