Nicole Piemonte reflects on the role of the humanities in US medical curricula.
When it comes to humanists working in medical schools, I am among the very few and very fortunate. Unlike many of my medical humanities colleagues across the globe, I have never—at my own institution—had to prove to administrators why the humanities matter to medicine and medical education. The leadership at my medical school have asked for the medical humanities. In fact, we’ve started a department of medical humanities within the medical school and have developed over a dozen required humanities sessions in the first and second years of our newly revised medical curriculum. These sessions occur in small groups, require reflective writing, and engage students in content about existential suffering, embodiment, death and dying, narratives of medicine, issues of power and structural racism, and generational trauma and how all this affects the lived experience of health and illness.
We have collaborated with our colleagues in the humanities and social sciences and secured secondary appointments in the School of Medicine so they can create five-week seminar-style humanities courses for all medical students. These courses cover topics like death, dying and grief, the medicalization of deviance, narratives of neurodiversity, Spanish language and culture, the art of observation, and the philosophy of medicine, to name a few. Such courses help to unearth the epistemological assumptions of medicine and deepen and broaden the way students see healthcare and patients and themselves.
Overtly and explicitly, we have made the medical humanities a priority in our curriculum. While I do believe our medical humanities program has had an effect (some preliminary research that includes interviews with our medical students suggests as much), I learned recently that there is still much to do. For instance, a second-year medical student recently asked if we could meet to discuss the usefulness of the medical humanities curriculum. He said he was feeling discouraged because some of his classmates weren’t taking the curriculum serious enough and that there were times that he and his friends felt embarrassed to talk about things like compassion and empathy. For his classmates, expressing these things felt too vulnerable at times because such expressions seemed strange and out of place in a medical school setting. It felt to him that instead of talking about compassion and empathy and suffering and death, he and his friends should be talking to their classmates about tests and grades and studying and choosing a career path in medicine.
So, how is it that even in a medical school that embraces and espouses the value of the medical humanities, students who want to talk about compassion still feel like they are in the minority? Why do they feel that exploring the social and affective dimensions of the medical profession is weird or even risky? How is it that the hidden curriculum (Inui 2003)—the implicit experiences and messages students receive about what it means to be ‘successful’ or ‘professional’— is still more powerful than what we’ve been teaching and discussing? How is it that vulnerability is still silenced?
There are a host of reasons that contribute to this reality—including factors that extend far beyond pedagogy and might, indeed, be related more to what it means to be human than what it means to be a medical student. Talking about death and suffering and injustice is hard for most of us. The humanities force us to face uncertainty and ambiguity. For instructors, students and professionals, those things are uncomfortable. Memorizing scientific, biological, and physiological processes feels safer. Selecting the “right” answer on a multiple-choice exam feels good.
In the United States, medical school curricula have a preoccupation—some might say an obsession—with standardized tests, specifically board certification exams. Students have to take two out of three “steps” of their United States Medical Licensing Exam (USMLE), and medical school curricula are designed around these high-stakes tests, despite the fact that these tests were never intended to shape curricula. They were intended—rightfully so—to ensure that students have the baseline medical knowledge required to be a competent and safe doctor.
Nevertheless, for decades, the three-digit scores students receive have determined their fate when it comes to their lives in medicine. If students get a 250 or above, for instance, they can match into a competitive residency in a well-paid specialty—like dermatology, orthopedic surgery, or ophthalmology. If they get a 210 or below, they will likely find themselves in a less competitive residency in a primary care field like family medicine or pediatrics where doctors are paid much less – though the work in these areas is often both intellectually demanding and intrinsically rewarding. This is despite the fact that there is no evidence that performance on exams like Step 1 predict a student’s future success in residency training (see Cohen et al. 2020).
How has this test come to determine the fate of medical students’ residency training and lifelong careers, if there is no real correlation between standardized test performance and clinical ability as a resident? Why have medical school curricula focused so much on the content of this test, rather than the cultivation of the student as a healer and social practitioner with intangible skills that can’t be captured on a test?
These standardized exams are here to stay in part because they are borne of, and also perpetuate, the epistemological assumptions guiding medical education—assumptions about what kind of knowledge is most important for the practice of medicine. The kind of knowledge valued (and taught) most in medical school is technical knowledge, knowledge about the workings of the physical and passive body-object, knowledge that—perhaps unsurprisingly—is what shows up on board exams. As a result, students and many faculty see the type of knowledge offered through engagement with the humanities as extraneous. This kind of knowledge is ‘not essential’ for getting a high score on board exams. It’s not essential for getting into a competitive residency. It’s not essential for becoming a doctor. The hidden curriculum of medical education is powerful. Regardless of oaths about altruism or compassion, students learn to discern what matters most—which is to become a good test-taker.
So, to me it seems that incorporating the humanities into medical education happens too late in the game. Students enter medical school with pre-formed assumptions about what matters, and premedical pathways during undergraduate years (primarily focused on the sciences and preparation for the MCAT) only reinforce these assumptions. By the time they are in medical school, students see humanities content superfluous or merely tacked-on to the ‘real curriculum’ because they’ve already discerned the true measure of success: if it’s not on a board exam, it doesn’t matter.
We should not, however, blame students for being savvy and attempting to succeed in a flawed system sustained by medical educators. Why blame students for their hyper-focus on standardized exams in medical school and their potentially narrow decisions in their undergraduate years when they are simply abiding by the rules we are complicit in creating?
Even at my own institution, students and faculty tend to see the required humanities sessions as floating somewhere outside the ‘real’ curriculum. If there are topics important to students that don’t have to do with the organ systems they are studying—like content on gender and sexuality or healthcare inequalities based on race or culture or LGBTQ+ communities or poverty—they come to the medical humanities staff to see if such content can be incorporated into small group work. And while I would love to add all of this content, the space and time allotted in the curriculum for the humanities is lamentably finite.
What I am realizing evermore clearly is that what we need is not more humanities sessions. What we need is to seriously and intentionally consider how the rest of medicine is taught. We need to dismantle the artificial bifurcation of the art and the science of medicine. We cannot have humanities content that doesn’t intentionally intersect with the science content. The humanities should inform and shape all content. Those of us in the humanities need to engage with the rest of the curriculum and collaborate with our colleagues who teach the basic and clinical sciences. For example, rather than learning about the lived experience of illness only in a humanities session, medical students learning neuroscience should discuss—or even learn from a patient—how a devastating stroke can shatter a person’s identity, roles, and worldview. Rather than learning about racism in medicine only in their humanities sessions, students—when learning endocrinology, for instance—should hear how Type 2 Diabetes disproportionally affects some minority groups because of structural racism and policies and power that lead to unstable housing and lack of access to healthy foods or healthcare. Rather than discussing the need for better care for patients in LGTBQ+ communities only in a humanities session, students should no longer be taught the physiology, anatomy, and biology of heteronormative cis-gendered white bodies. They should learn about all bodies.
Those of us who care about things like the humanities in medicine will never succeed in cultivating compassionate, deep thinking healers if the transformative work of the humanities only happens in sporadic small group sessions while the rest of medicine is still taught as if it is an ‘objective science’ or that all learning can be objectively measured via multiple choice exams.
We will have succeeded only when thinking critically about unjust systems that lead to poor health is simply the way medicine is taught. We will have succeeded when students who want to talk about vulnerability and suffering and compassion will feel that doing so is normal because that is just what medical students do. We will have succeeded when people who have jobs like my own render ourselves obsolete because medicine and the humanities become inseparable. That is because they are inseparable.
We will have succeeded when medical education relinquishes its grip on certainty and test performance and loudly and courageously acknowledges that it is not in the business of training technicians, but rather whole people who are called to confront vulnerability and extend care to others when they need it most.
Nicole Piemonte received her PhD in Medical Humanities from the University of Texas Medical Branch. She is currently the Assistant Dean for Student Affairs, a faculty member in the Department of Medical Humanities, and holds the Peekie Nash Carpenter Endowed Chair in Medicine at the Creighton University School of Medicine Phoenix Regional Campus in Arizona.
References
Cohen, Elaine R., Joshua L. Goldstein, Clara J. Schroedl, Nancy Parlapiano, William C. McGaghie, and Diane B. Wayne. (2020). “Are USMLE Scores Valid Measures for Chief Resident Selection?” Journal of Graduate Medical Education 12 (4), pp. 441–446.
Inui, Thomas S. (2003). A Flag in the Wind: Educating for Medical Professionalism. Washington, DC: Association of American Medical Colleges.
