Humanities in Medical Education [2 ed.] 9789354666506

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Second Edition

Humanities in Medical Education



iii

Second Edition

Humanities in Medical Education Editors

Rajiv Mahajan MD (Pharmacology), PhD (Health Professions Education), Dip Clin Res, FIMSA, ACME, CMCL-FAIMER Fellow-2016

Professor Department of Pharmacology Principal Adesh Institute of Medical Sciences and Research Adesh University Bathinda, Punjab

Tejinder Singh MD (Pediatrics), MSc (HPE: Maastricht Univ), MA (Distance Educ), FIAP, FIMSA, FAIMER Fellow (USA), IFME, FAMS

Emeritus Professor Department of Pediatrics Chair Centre for Health Professions Education Adesh University, Bathinda, Punjab

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Disclaimer Science and technology are constantly changing fields. New research and experience broaden the scope of information and knowledge. The authors have tried their best in giving information available to them while preparing the material for this book. Although, all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected. The publisher, the printer and the authors will not be held responsible for any inadvertent errors, omissions or inaccuracies. eISBN: xxxx Copyright © Authors and Publisher Second eBook Edition: 2023 All rights reserved. No part of this eBook may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission, in writing, from the authors and the publisher. Published by Satish Kumar Jain and produced by Varun Jain for CBS Publishers & Distributors Pvt. Ltd. Corporate Office: 204 FIE, Industrial Area, Patparganj, New Delhi-110092 Ph: +91-11-49344934; Fax: +91-11-49344935; Website: www.cbspd.com; www.eduport-global.com; E-mail: [email protected]; [email protected] Head Office: CBS PLAZA, 4819/XI Prahlad Street, 24 Ansari Road, Daryaganj, New Delhi-110002, India. Ph: +91-11-23289259, 23266861, 23266867; Fax: 011-23243014; Website: www.cbspd.com; E-mail: [email protected]; [email protected].

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Representatives Hyderabad Pune Nagpur Manipal Vijayawada Patna

List of Contributors Aditya Samitinjay

Juhi Kalra

MBBS, MD (Medicine)

MD (Pharmacology), ACME, CMCL-FAIMER Fellow-2015

Senior Resident Government General and Chest Hospital Erragadda, Hyderabad, Telangana [email protected]

Amrit Virk MD (Community Medicine), PGCCHM, ACME, PSG-FAIMER Fellow-2016

Professor and Head Department of Community Medicine Dr BR Ambedkar State Institute of Medical Sciences, Mohali, Punjab [email protected]

Anil Kapoor

Professor and Head Department of Pharmacology Himalayan Institute of Medical Sciences Jolly Grant, Dehradun, Uttarakhand [email protected]

Jyoti Nath Modi MD (ObGyn), FICOG, CMCL-FAIMER Fellow-2011

Associate Professor Department of Obstetrics and Gynecology All India Institute of Medical Sciences Bhopal, Madhya Pradesh [email protected]

Kapil Gupta

MD (General Medicine), CMCL-FAIMER Fellow-2010

MSc (Medical Biochemistry), PhD, ACME, CMCL-FAIMER Fellow-2019

Professor Department of Medicine People’s College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh [email protected]

Professor Department of Biochemistry Adesh Institute of Medical Sciences and Research, Adesh University Bathinda, Punjab [email protected]

Anshu

Medha Anant Joshi

MD (Pathology), DNB, MNAMS, MHPE, FAIMER Fellow

MD (Pharmacology), MHPE, IFME Fellow-2011

Director-Professor Department of Pathology Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra [email protected]

Anuradha Joshi MSc (Medical Pharmacology), PhD, Dip Cre Ped, ACME, CMCL-FAIMER Fellow-2016, Stanford Fellow Design Thinking-2021

Professor Department of Pharmacology Parul Institute of Medical Sciences and Research, Vadodara, Gujarat [email protected]

Jugesh Chhatwal MD (Pediatrics), DCH, FAIMER (Phil) Fellow

Professor and Head Department of Pediatrics Kalpana Chawla Govt Medical College Karnal, Haryana [email protected]

Consultant Health Professions Education Former Director, MEU International Medical School MSU Bangalore Campus Bengaluru, Karnataka [email protected]

Narendra Nath Laha MD (Medicine), PhD (Medicine), MAMS

Consultant Physician 27, Lalitpur Colony Dr PN Laha Marg Gwalior, Madhya Pradesh [email protected]

Navjeevan Singh MD (Pathology)

Emeritus Director-Professor Department of Pathology Founding member Health Humanities Group University College of Medical Sciences and GTB Hospital, Delhi [email protected]

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Humanities in Medical Education

Neloy Sinha

Shaista Saiyad

MD (Dermatology), DVD, ACME

MD (Physiology), PhD, ACME, CMCL-FAIMER Fellow-2016

Professor and Head Department of Dermatology College of Medicine and JNM Hospital Kalyani, Nadia (West Bengal) [email protected]

Piyush Gupta MD (Pediatrics), FAMS, ACME

Principal and Professor Department of Pediatrics University College of Medical Sciences, Delhi [email protected]

Rajiv Mahajan MD (Pharmacology), PhD (Health Professions Education), Dip Clin Res, FIMSA, ACME, CMCL-FAIMER Fellow-2016

Professor Department of Pharmacology Principal Adesh Institute of Medical Sciences and Research Adesh University Bathinda, Punjab [email protected]

Rakesh Biswas MBBS, MD (Medicine)

Professor Department of Medicine Kamineni Institute of Medical Sciences Narketpally, Nalgonda, Telangana [email protected]

Sahiba Kukreja MD (Biochemistry), Dip Hospt Mgmt, ACME, CMCL-FAIMER Fellow-2016, Dip Clin Res

Dean Academics (UG) Professor and Head Department of Biochemistry Sri Guru Ram Das Institute of Medical Sciences and Research Amritsar, Punjab [email protected]

Sanjoy Das MD (Forensic Medicine and Toxicology), Dip Hospt Mgmt, ACME, FIAFM, CMCL-FAIMER Fellow-2015

Professor and Head Department of Forensic Medicine and Toxicology, Himalayan Institute of Medical Sciences Jolly Grant, Dehradun, Uttarakhand [email protected]

Associate Professor Department of Physiology Smt NHL Municipal Medical College Ahmedabad, Gujarat [email protected]

Sonam Sharma MD (Pathology), MAMS, PGDHM

Associate Professor Department of Pathology Kalpana Chawla Govt Medical College Karnal, Haryana [email protected]

Sunita Y Patil MD (Pathology), PGDHPE, ACME, PSG-FAIMER Fellow-2011

Professor Department of Pathology Jawaharlal Nehru Medical College Director University Department of Education for Health Professionals KLE Academy of Higher Education and Research, Belagavi Karnataka [email protected]

Tejinder Singh MD (Pediatrics), MSc (HPE: Maastricht Univ), MA (Distance Educ), FIAP, FIMSA, FAIMER Fellow (USA), IFME, FAMS

Emeritus Professor Department of Pediatrics Chair Centre for Health Professions Education Adesh University, Bathinda, Punjab [email protected]

Upreet Dhaliwal MS (Ophthalmology), CMCL-FAIMER Fellow-2015

Emeritus Director-Professor Department of Ophthalmology Founding member Health Humanities Group University College of Medical Sciences and GTB Hospital, Delhi [email protected]

Vivek Podder MBBS

Visiting Lecturer School of Public Health University of Adelaide, Australia [email protected]

Foreword

E

ducating the next generation of physicians is task with many layers. At a minimum, the practice of medicine requires retention of a large amount of knowledge and the ability to use it. It also requires communication skill to acquire information from the patient and provide advice. Layered on top of that, however, is the ability to connect with patients and their families, develop a trusting relationship, and place all of this in the context and social milieu of their lives. Educating our trainees must encompass all these layers. The education system needed to achieve this layered ability is complex. The cognitive component, while not simple, is relatively straightforward. Using active learning design, educators can present resources in the form of readings, lectures, demonstrations, then engage learners to understand their existing mental models and build on them or amend them as necessary, provide opportunities for application, and create aligned assessments. The cognitive component, however, is necessary but not sufficient. Social, emotional, relational components are more challenging to teach. Appreciation and recognition of the complexity of the human experience is an essential element of doctoring. Medical education needs to embrace this complexity and use of the arts is one way to do this. Through plays, movies, novels, poems, and visual arts, the subtleties of the human condition may become available to neophytes and experts. Nuances of human behavior discovered through these media can facilitate reflection of how social context, family, personality, values, and culture strongly influence the practice of medicine. As this book points out incorporation of the humanities and the arts into medical education is a valuable tool in this endeavor. The fundamentals of education will always be fundamental. Objectives, clearly written, achievable, and measurable are the starting point. From there, we design an educational methodology that builds on what learners know and encourages them to apply and evaluate what they know. Finally and critically, we assess in formative and summative frameworks what learners know in a manner consistent with objectives. These fundamentals of education apply equally to cognitive components of doctoring and to the social, emotional and relational aspects. Objectives, educational design and assessment should be as well constructed for these components as they are for the cognitive ones. Embracing concepts described in this book of narrative medicine, reflective practice, communication, and the social determinants of health may help teachers and students provide better care for patients. As Dr Francis Peabody famously wrote in “The Care of the Patient”, the secret is “caring for the patient.” The next generation of physicians and their patients deserve no less.

William Burdick MD, MSEd Vice Secretary General The Network: Towards Unity for Health Professor of Emergency Medicine Thomas Jefferson University Sidney Kimmel College of Medicine Philadelphia, USA

Preface to the Second Edition

I

t is with a sense of pride and joy that we present the second edition of Humanities in Medical Education. The first edition sold out very quickly and as it was going for a reprint, we caught the opportunity to revise the book. Many chapters have gone through major changes and many new chapters relevant to the theme have been added. We have improved the layout and visual appeal of the book, while retaining its earlier appeal to capture readers' attention. We do hope that this book will serve as a useful tool with greater emphasis being laid on ethics, professionalism and humane medicine. We are grateful to Dr William Burdick for contributing Foreword to the second edition. We have also retained the earlier contribution of Dr Stewart Mennin for its academic brilliance. All the contributors deserve our gratitude for their contributions as do the readers for showing interest in the book. We are open to any comments, criticism and bouquet to make the book even better.

Rajiv Mahajan Tejinder Singh

Preface to the First Edition Patients don’t care how much we know, unless they know, how much we care. The practice of medicine is a complex interaction of art and science and remains incomplete without either of the components. It is often said that it is not the pill that works but the entire atmosphere and the way it is given and taken which matters. Technological advances seem to have pushed the humane aspect of medicine to the background but fortunately, the educational fraternity has become alive to its need. Humanities help the physician to understand, diagnose and treat the patient as a complete human being rather than being a body with a disease. Humanities provide the opportunities to the healthcare professionals to visualize the social and cultural aspects of disease and health; and incorporate ways and means for tackling the issues like burn-out of patients with chronic disease and their caregivers, improving interpersonal relationships with patients and for addressing the issue of traumatic deidealization among students. The concept of attitudes, ethics and communication (AETCOM) module by Medical Council of India as part of the recently introduced competency-based curricula is a welcome step to give humanities their due in medical education and practice. We are happy to present this compendium on Humanities in Medical Education to the teachers and students of medicine. Various experts with experience in teaching humanities have shared their expertise and we hope that this will provide a food for thought to the readers. We thankfully acknowledge their efforts. We are also grateful to Prof. VP Mishra and Prof. Stewart Mennin for very kindly agreeing to write the Foreword and Curtain Raiser respectively, for this book. We will be happy to receive suggestions to improve the value of this compendium.

Rajiv Mahajan Tejinder Singh

Curtain Raiser ‘It seems paradoxical that with practically unlimited access to data, information, high-speed connectivity, and advanced technology that the challenges of contemporary medicine and society are fundamentally about understanding complex human relationships; how to live together in peace and harmony, how to work together for the common good, and how to preserve and prosper in, and with, the environment’. (Mennin, Eoyang, Nations, 2020)

To paraphrase Hillel the Elder, If not now, when? If not me, who? Medicine/health and the humanities are deeply interwoven. It is as if they were born as fraternal twins, inseparable in their beginnings. Over time they seem to have drifted apart on a sea of scientific and technological progress becoming estranged from one another. The present work reunites them. It shows us how health professions education can shift from the dominant emphasis of a single teacher speaking in front of a large group of learners to the richness and complexity of learning in small groups. Self-directed and small-group learning surfaced the essential social nature of learning and better focused our attention on how people work and thrive together. At the same time, the flames that illuminated the interdependence of learning, teaching, ethics, professionalism, communication and humanism in medical education were lit. As we come to understand learning as a predominantly a social activity, respectful, thoughtful and inquiry-based communication can take its rightful place in the valuing and preparation of tomorrow's health workforce. Now more than ever in this time of global pandemic and local suffering, we recognize the challenges of caring for and about each other, of behaving in ways that create patterns of respect and humanity. It is self-evident that students look to their teachers as role models for thoughtful consideration and behavior in both known and unknown situations. While students look to their teachers, to whom do the teachers look if not to themselves and their colleagues? Thus, it becomes imperative that the experience, work and knowledge brought forth within the pages of the present work about the medical humanities gain wide and sustained readership and action. Medical humanities bring the words of William Doll, Jr to life, “… no one owns the truth, and everyone has the right to be understood” (Doll, 1993). We are challenged to enhance and sustain the humanities in medical education even and to be understood as we shift more toward online learning. How we choose to do this will form and inform the workforce of the future and that health workforce will guide and shape the health system and social wellbeing. Section I of the present work presents the history of the medical humanities together with its needs and purposes. History is understood and remembered through the present context and serves a critical purpose in placing current context in perspective. It is in this way, we find and develop the attributes and qualities of effective and humane physicians. Without sensitive and refined communication skills, professionalism and ethics, informed attitudes, empathy and altruism, the science of medicine cannot truly care for those in need. Section II addresses this essential area in the life of medical students and educators.

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The primary role of medical educators is to guide, question, listen, teach and learn. It is here that the art of teaching comes into play. Section III is a deep dive into forms of teaching and learning that are enriched by the arts. It is the interdependence of art and science that creates the humane and capable practitioners that we need most in society, especially in this time of multiple global crises. Section IV focuses on the beginning of this journey, how we plan, develop, and implement a humanistic curriculum in which our unique cultural perspectives are embedded. The design and conduct of medical education demand nothing less than the humanities and our very humanness be interwoven with artful science. How we serve society requires an exquisite sensitivity to the wellbeing of the lives of the people we touch in so many ways. This journey is found within the pages that follow.

Prof Stewart Mennin Professor Emeritus, Cell Biology and Physiology University of New Mexico School of Medicine Albuquerque, New Mexico, US Adjunct Professor, Department of Medicine Uniformed Services University of the Health Sciences, Bethesda, Maryland Consulting Associate, Human Systems Dynamics Institute, Sao Paulo (SP), Brazil

• Doll WE Jr. (1993). A Post-Modern Perspective on Curriculum. Teachers College, Colombia University; New York. pp 168.

• Mennin S, Eoyang G, Nations M (2020). Health, Health Care, and Health Education: Problems, Paradigms, and Patterns. In: The Routledge Handbook of the Medical Humanities, Alan Bleakley (Ed.). Routledge: London, pp 55–71.

Contents List of Contributors Foreword by William Burdick Preface to the Second Edition Preface to the First Edition Curtain Raiser by Prof Stewart Mennin



v vii ix x xi

Section 1: Introduction

1. Medical Humanities: History and Concepts Juhi Kalra

3

2. Medical Humanities: Need and Purpose Sahiba Kukreja

10

3. What Makes a Good Doctor? Sahiba Kukreja

16

4. Stress and Burnout Syndrome Medha Anant Joshi

25

5. Human Touch in Doctors Narendra Nath Laha

41



Section 2: Focus Areas

6. Communication and Interpersonal Skills

49

Jyoti Nath Modi, Anshu, Jugesh Chhatwal, Piyush Gupta, Tejinder Singh, Rajiv Mahajan

7. Professionalism and Ethics Rajiv Mahajan, Tejinder Singh

62

8. Attitudes, Empathy and Altruism Shaista Saiyad

70

9. Confidentiality and Privacy Sunita Y Patil 10. End of Life Care Jugesh Chhatwal, Sonam Sharma

78

11. Medical Sociology Amrit Virk

89 101

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Section 3: Teaching and Learning Methodologies



12. Role of Cinemeducation in Humanities Anuradha Joshi

117

13. Role Plays Kapil Gupta

126

14. Theatre and Forum Theatre Upreet Dhaliwal, Navjeevan Singh

136

15. Role Modeling Neloy Sinha

142

16. Case Studies Juhi Kalra

150

17. Creative Writing (From Scalpel to Pen: Chaos, Process and Value) Anuradha Joshi

157

18. Role of Poetry in Medical Humanities Juhi Kalra

167

19. Artwork, Comics and Cartoons Sanjoy Das

175

20. Reflections Anil Kapoor

185

21. Teaching Medical Humanities: Global Learning Toward Local Caring Rakesh Biswas, Vivek Podder, Aditya Samitinjay

200

Section 4: Implementation and Assessment



22. Medical Humanities and CBME Curriculum: Opportunities and Challenges Shaista Saiyad

217

23. An Outline of Structured Curriculum of Medical Humanities in Indian Context Rajiv Mahajan, Tejinder Singh

226

24. Assessment in Medical Humanities Rajiv Mahajan

232

Index 243

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Introduction

1. Medical Humanities: History and Concepts 2. Medical Humanities: Need and Purpose 3. What Makes a Good Doctor? 4. Stress and Burnout Syndrome 5. Human Touch in Doctors

1 Medical Humanities: History and Concepts Juhi Kalra Key Points q The

concept of medical humanities is ages old, when it was considered that medicine was an artful practice of science of health for the welfare of masses. q Medical humanities is a multidisciplinary field, consisting of humanities, social sciences and arts, integrated in the undergraduate curriculum of medical schools. q Though still in infancy, efforts are on the way in several medical colleges across India to introduce it formally.

INTRODUCTION Cooper (2003) has quoted Sir William Osler’s golden words that are a source of inspiration for the medical fraternity, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head”. In the old times, there was no clear demarcation between science and art. The Greek philosopher Aristotle believed that medicine was an artful practice of science of health for the welfare of masses (The Works of Aristotle, 1908). A mention of terminologies like ‘humanitas’—a love for humanity and ‘misericordia’—full of mercy have been quoted as early as in the first century AD, by Scribonius Largus who was physician to Emperor Claudius. The Greeks also used the term ‘philanthropia’ to describe an attitude of kindness towards patients that can win a good reputation for the physician (Pelligrino, 2006). Evans (2002) refers to medical humanities as human experience of illness and disability. But as times progressed, the middle ages saw the emergence of ‘mechanical’ and ‘liberal’ arts. Medicine fell into the category of mechanical arts. The word ‘art’, however, continued to be used in the context of science. With emergence of laboratory research from 1870s to 1910, the practitioners of medicine got an additional label of ‘scientist’. Sciences were divided into ‘normative’, ‘analytical’ and ‘humanities’. Normative sciences had a regulatory approach and relied on ethics and jurisprudence to prove things right and wrong. Analytical sciences involved observation and experimentation with both natural sciences and the social sciences. They were governed by rules and dealt chiefly with cognitive component. The natural sciences included physics, chemistry and biology while economics and sociology were 3

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grouped under social sciences. Much in contrast to analytical sciences which were oriented around techniques, cognitive observations and conclusions; humanities was a rather subjective comprehension of human actions and relied on value-based system. As analytical sciences were gaining momentum in the era of industrialization, sciences were becoming synonymous with all that is ‘observable’ and ‘quantifiable’. They were becoming boastful while offering causal explanations through their objective and reductionist approach. In the historic mention of Wassersurg (1987), we find a semblance of mechanicality of science and the enormous power it wields when he mentions that the inanimate scalpels, culture plates and instruments have superseded the humanitarian doctor, thus snatching away the credit of medical progress from him. This thought process led to the most obvious contradiction and an imminent need to humanize medicine. It began to be proposed that arts can tone down the pompousness that arise from “I know it all”, “I can prove it” of the science. The opponents of reductionist approach of science felt that illness can create an inexhaustible set of situations which need an artful critical analysis of patient narratives. It was being realized that non-scientific needs cannot be treated with mere scientific tools. It was evident that the practitioners of medicine must venture out from analytical labs and feel the microcosm of a hospital setting to look, read and hear beyond the confines of the books. There was a time when physicians were the most revered and considered as the most learned people of the society. People looked up at them for their wisdom. The undeniable existence of a psychosomatic component in most diseases needed the amalgamation of arts with science because it was believed that this unique alloy of medical humanities will not only cajole expectations and emotions but also perhaps shall aid finding solutions to those left unattended in the ever deepening sorrow and pain of the disease and the infirmity. Since all that which goes on in the human mind cannot be comprehended from facts, figures, diagnostic scanners and cognitive probes, it was expected that ‘arts and humanities’ can complement science. It was further projected that this admixture will keep the practitioners grounded and help them look beyond the anatomy of cognitive facts. John Stuart Mill (2020) feels “it is important not only what men do, but also what manner of men they are who do it”, and thus pointing that the inherently creative and artful communication in a doctor–patient relationship must retain its finesse to complete the technical jigsaw of symbols, facts, and figures. It was anticipated that arts, literature, poetry, philosophy and myriad components of humanities can infuse finesse in technical sciences.

WHAT IS MEDICAL HUMANITIES? A lot of terminologies (Box 1.1) and definitions (Box 1.2) have floated in the context of medical humanities. Several attempts to define humanities were made in the past (Box 1.2). These elaborate descriptions have differed from the simplified version mentioned in the Oxford Dictionary.

Medical Humanities: History and Concepts

5

BOX 1.1: Some terminologies in context of medical humanities from the Oxford English Dictionary • Humanities: Learning or literature concerned with human culture • Humanism: The quality of being human; devotion to human interests or welfare • Humane: Characterized by sympathy with or consideration for others; compassionate; benevolent • Humaneness: Humane quality or condition; compassionateness • Humanize: Make human; give a human character to • Humanitarian: A person concerned with human welfare BOX 1.2: Definitions purported to describe medical humanities • “An integrated, interdisciplinary, philosophical approach to recording and interpreting human experiences of illness, disability, and medical intervention…”—Evans 2002 • Medical humanities has been defined as “an interdisciplinary and increasingly international endeavor that draws on the 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 goals”—Kirklin 2003 • “An interdisciplinary field concerned with understanding the human condition of health and illness in order to create knowledgeable and sensitive healthcare providers, patients, and family caregivers”—Klugman 2017

Once such elaborate description of medical humanities came to the fore, the individual components like bioethics, narratives, art, poetry, music, sketching, sculpturing and theatre began to be explored in the context of medical sciences. Adrian Hill is acknowledged as the founder of art therapy in the UK. Hill introduced artistic work to his fellow patients, while he was receiving treatment for tuberculosis which is chronicled in ‘Art Versus Illness’. Taking all these facts into consideration, for all operational purposes in this book, medical humanities is described as an amalgamation of medical sciences with arts, viz. philosophy, sociology, psychology, history, literature, theatre and arts, empathy, culture, and more importantly with ethics, communication, and professionalism in medical context, with interdisciplinary interaction and application of clinical skills with soft skills for patient care.

BIOETHICS AND THE MEDICAL HUMANITIES The work of Edmund Pellegrino has emphasized that abstract ethical issues can be high­lighted and discussed through narrative medicine. In his “ethics– humanities–medicine trialogue”, he talked about narratives as an aid to ‘humane approach’ during diagnosis and treatment. In North America, bioethics and medical humanities were more coherently together; while in the United Kingdom, the medical humanities developed as a separate stream. Miles (1989) mentioned the need to incorporate medical ethics in the undergraduate and graduate training

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programs and this finds a mention in reports of McElhinney and Pellegrino. But ethics continued to be part of the hidden curriculum. They were a part of some doctor–patient relationship courses and offered as electives until mid-1970s. But as the importance of ethics in medical education was recognized; they gained a greater footage and were offered as separate courses by early 1980s in the US. In the midst of the debate and of the great felt need to humanize medicine, the term ‘medical humanities’ was first coined in 1948 by George Sarton. He first used the term ‘medical humanities’ in the pages of ISIS, a journal devoted to the history of science, medicine and civilization in the USA.

HISTORY OF MEDICAL HUMANITIES Religion, history and philosophy, as these applied to medicine, were integral to the Department of Humanities at Pennsylvania State University (Penn State) College of Medicine, Hershey in 1967. Literature was added later in 1969. In the same year, ‘The Society for Health and Human Values’ was officially launched. This was the first international organization that offered professional membership for those who believed that inculcating human values in medicine is paramount. Medical humanities was gradually but steadily gaining momentum, crossing geographical boundaries. The University of La Plata medical school, in Argentina designed an optional medical humanities provision in 1976 while in the very same year Moore (1976) described the term ‘medical humanities’. He also developed a short course, using literary extracts. This course enabled him to discuss issues like cultural sensitivities, philosophy and personal issues, as relevant to medical practice. In 1973, the Institute of Medical Humanities was founded at the University of Texas, Galveston and in 1979 Anne Hudson Jones became the first literature professor to join as faculty in a medical school. The year 1993 witnessed the historic inclusion of the medical humanities in undergraduate medical curricula by the General Medical Council (GMC). It brought a ray of hope for educationists, philosophers and physicians who had been keen at developing the discipline of Medical Humanities in the United Kingdom (Kirklin, 2003). Collaborative relationships developed between UK and Australia for carrying medical humanities forward. Later, in 2003, medical humanities was introduced even into the postgraduate program at the University of Sydney and by 2005, it could be integrated into the medical curriculum of Australia (Gordon, 2005).

HISTORY OF MEDICAL HUMANITIES IN INDIA AND ASIA Medical humanities programs are well established in many universities of the United States (US), the United Kingdom, and some parts of Western Europe, New Zealand, Israel and Canada. Medical humanity has a shorter history in Asia where it is claimed to be introduced in Nepal in 2009 (Gupta et al, 2011). Shankar (2009) used a medical humanities model module at a medical college of Nepal.

Medical Humanities: History and Concepts

7

Between the year 2010 and 2012, ‘Theatre of the Oppressed’ workshops began to be organized across four Indian and Nepalese cities. Such workshops were later actively pursued by the medical humanities group at University College of Medical Sciences, Delhi and later by KEM Mumbai and many others. Though ‘Journal of Medical Ethics’ and ‘Medical Humanities’ have been supporting and promoting publications in field of medical humanities and ethics for long; in Asian context the journal—‘Research and Humanities in Medical Education’ was introduced in India in 2014 and the ‘Formosan Journal of Medical Humanities’ from Taiwan. Medical humanities programs have been initiated in many developing countries like Turkey, the Middle East, and South East Asia. A need to evolve modules that address the local challenges, based on the socioeconomic challenges and cultural diversity in India is the need of the hour (Ramaswamy, 2012). Online discussions on humanities in India at several forums have emphasized the need to harness humanities in our interactions with patients (Kalra et al, 2016). In India, faculty members from UCMS, Delhi, have been making consistent effort to explore possibilities in field of medical humanities (Shankar, 2016). A number of initiatives at various medical colleges across India are indicative of the willingness to harness the much-needed change (Singh et al, 2015; Singh et al, 2012). The Centre for Community Dialogue and Change has conducted workshops on theatre of the oppressed (TO) in various institutions and has done pioneering work in popularizing TO among educators in India (Gupta et al, 2013). In the recent years, a number of states across India have taken active initiatives to include medical humanities in their teaching program (Singh et al, 2017; Saiyad, 2017). The need to establish ‘Medical Humanities Cell’ in medical colleges has been identified (Supe and Burdick, 2006). Many other authors have expressed the need and ways and means of establishing medical humanities in medical colleges (Kalra and Singh, 2017; Joshi et al, 2018). Though still in infancy, a beginning has been made in India and some reports of encouraging its use have appeared.

CONCLUSION Though still not a part of formal curriculum, the need for medical humanities is being discussed at various forums in India, small workshops being organized at various medical colleges across India. Efforts are on the way in several medical colleges where formal medical humanities department have been established. The AETCOM module is an effort to introduce the concept in Medical School Curriculum in India (MCI, 2018).

BIBLIOGRAPHY • Batistatou A Doulis EA, Tiniakos D, Anogiannaki A, Charalabopoulos K. The introduction

of medical humanities in the undergraduate curriculum of Greek medical schools: Challenge and necessity. Hippocratia 2010;14:241–43.

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• Cooper SM. The Quotable Osler. Journal of the Royal Society of Medicine 2003;96(8):419. • Evans M. Reflections on the humanities in medical education. Medical Education

2002;36(6):508–13. • Gordon J. Medical humanities: To cure sometimes, to relieve often, to comfort always. Medical Journal of Australia 2005;182(1):5–8. • Gupta R, Singh S, Kotru M. Reaching people through medical humanities: An initiative. Journal of Educational Evaluation for Health Professions 2011;8:5. Accessed on 20.04.2022. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110875/ • Gupta S, Agrawal A, Singh S, Singh NS. Theatre of the oppressed in medical humanities education: The road less travelled. Indian Journal of Medical Ethics 2013;103:200–03. • Joshi A, Singhal A, Loomba P, Grover S, Badyal D, Singh T. Humanities in medical education. Journal of Research in Medical Education and Ethics 2018;8(SI):3–9. • Kalra J, Singh T. Commentary on “Conversations”. Research and Humanities in Medical Education 2017;4:72–76. • Kalra J, Singh S, Badyal D, Barua P, Sharma T, Dhasmana D, Singh T. Poetry in teaching pharmacology: Exploring the possibilities. Indian Journal of Pharmacology 2016;48(7):61–64. • Kirklin D. The centre for medical humanities, Royal Free and University College Medical School, London, England. Academic Medicine 2003;78(10):1048–53. • Klugman CM, Peel J, Beckmann-Mendez D. Art Rounds: Teaching Interprofessional Students Visual Thinking Strategies at One School. Academic Medicine 2011;86:1266–71. • Medical Council of India (2018). Attitude, ethics and communication (AETCOM) competencies for the Indian medical graduate. Accessed on 21.12.2022. Available from: https://www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf • Miles SH, Lane LW, Bickel J, Walker RM, Cassel CK. Medical ethics education: Coming of age. Academic Medicine 1989;64(12):705–14. • Mill J (2020). The Collected Works of John Stuart Mill, edited by John M. Robson (1963–91), in 33 volumes,. Toronto: University of Toronto Press, London: Routledge and Kegan Paul. • Moore A. Medical humanities: A new medical adventure. New England Journal of Medicine 1976;295(26):1479–80. • Pellegrino E. Toward a reconstruction of medical morality. The American Journal of Bioethics 2006; 6(2):65–71. • Ramaswamy R. “Medical humanities” for India. Indian Journal of Medical Ethics 2012; 9 (3). Accessed on 22.04.2022. Available from: https://doi.org/10.20529/ijme.2012.048 • Saiyad SM, Paralikar SJ, Verma AP. Introduction of medical humanities in MBBS 1st year. International Journal of Applied and Basic Medical Research 2017;7(Suppl S1):23–26. • Shankar PR. Medical humanities in medical schools in India. Archives of Medicine and Health Sciences 2016;4(2):166–68. • Shankar P, Piryani R. Using paintings to explore the medical humanities in a Nepalese medical school. Medical Humanities 2009;35(2):121–22. • Singh S, Barua P, Dhaliwal U, Singh N. Harnessing the medical humanities for experiential learning. Indian Journal of Medical Ethics 2017;2[3 (NS)]:147. Accessed on 20.04.2022. Available from: https://ijme.in/articles/harnessing-the-medical-humanities-forexperiential-learning/ • Singh S, Khosla J, Sridhar, S. Exploring medical humanities through theatre of the oppressed. Indian Journal of Psychiatry 2012;54(3):296–97.

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• Singh S, Singh N, Dhaliwal U. Promoting competence in undergraduate medical students through the humanities: The ABCDE Paradigm. Research and Humanities in Medical Education 2015;2:28–36. • Supe A, Burdick W. Challenges and issues in medical education in India. Academic Medicine 2006; 81(12):1076–80. • The Works of Aristotle. Translated into English under the editorship of JA Smith, WD Ross, Vol. VIII. Metaphysica, by WD Ross. Oxford: Clarendon Press, 1908. • Wassersug J. Teach humanities to doctors? Says who? Postgraduate Medicine 1987;82(5):317–18.

2 Medical Humanities: Need and Purpose Sahiba Kukreja Key Points q Lack

of empathy in current healthcare workers is a challenging aspect in patient care.

q Medical

humanities is the amalgamation of arts and science. q Introduction of medical humanities curriculum in health professional courses will result in better patient care.

INTRODUCTION It was the summer of 1990, exams had ended, and it was time to leave school behind and enter a new period of our lives. I can never forget the two words of wisdom my biology teacher wrote for me as a school leaving message—“Be humane”. Thereafter, the years spent in medical school and all the years of training that followed, never was there any mention of anything regarding this. It took a lot of trial and error to learn what the meaning of those two words was. What is the meaning of these words? According to the Oxford English Dictionary, the word humane means to be compassionate and benevolent. In no other profession is humaneness and humanities more applicable. The history of medicine from the time of Hippocrates shows how societies have changed in their approach to illness and disease (Batistatou et al, 2010). Modern medicine which relies on facts, figures, and tests has lost the humanitarian touch. It is the loss of this humaneness which has made us realize the need for medical humanities. Medical humanities is an interdisciplinary field of science that helps in drawing intellectual and creative strength from different fields such as history, literature, ethical decision making, etc. related to the field of medical education. The core strength of medical humanities is the imaginative non-conformist qualities and practices. According to Hall et al (2014), ‘Through humanities-based perspective, learners can reflect on the impact of their personal and professional relationships with patients and their families’.

EMPATHY: THE BASE OF MEDICAL HUMANITIES The humanities, therefore, offers a more holistic and person-centered approach to care. While searching literature, I came across a statement ‘some clinicians have 10

Medical Humanities: Need and Purpose

11

empathy of a cadaver’. Medical education has done very little to ingrain empathy in the minds of young aspiring doctors (Shiand Du, 2020), while empathy is the base of medical humanities. Empathy is a construct which falls in two domains, i.e. cognitive and affective domain.Under a cognitive domain, it has been defined as ‘the imaginative transposing of oneself into the thinking and acting of another and so structuring the world as he does’ (Dymond, 1949). Considering affective domain, it has been defined as ‘experiencing the emotional state of another’. Empathy is very critical in building doctor–patient relationship, it has been an important link to positive patient outcomes, i.e. improvement in patient satisfaction, better compliance of the patient to doctors’ advice, lesser relapse rates and autonomy of patient is also respected. Empathy has been discussed in detail in Chapter 8 of this book. Since it is the vehicle transporting medical humanities into medical students, the same has been touched here.

TRAUMATIC DEIDEALIZATION The gradual development of negative qualities in the medical professionals has been the primary reason for an increase in the patient–doctor conflict and the resultant litigations against the doctors. This has been blamed on ‘burn out’ and/or traumatic deidealization which leads to an attitudinal change causing deflation, pessimism, emotional exhaustion, depersonalization and low sense of accomplishment among medical graduates (Fig. 2.1) (Jerald Kay 1990). Research states that ‘compassion’ and ‘empathy’ can be induced and the students may be trained for becoming more responsible towards their patients (Jeffrey and Downie, 2016). They may even begin considering their patients as a whole human being rather than a complex group of diseases. The primary way of achieving this is through ethical education to the medical students. Plethora of documented evidence has also stated that a student often feels morally challenged during the tensed hospital environment (Parkes, 1985; Hellsten, 2015). An enriching survey conducted by Feudtner et al (1994) in final year medical students of six medical colleges in USA has stated that more than 50% of the students have agreed that their ethical principles have been eroded or lost and they have done something unethical during their medical practice.

Fig. 2.1: Transformation from idealization to traumatic deidealization

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Humanities in Medical Education

Another study has documented that the medical students who are exposed to unethical situations often feel encouraged to have a dual code of ethics. One ethical code is used in personal life, while the other ethical code is developed as a physician (Genuis, 2006). Most of the students in this study felt that their ethics will eventually degrade with advancement in their profession. In another study, the majority of doctors felt that the teaching of medical ethics was highly unsatisfactory during their medical course (Mashayekhi et al, 2021). Most of the students reported that their senior doctors followed unethical practice. Most of the junior doctors suffered due to this unethical practice of their seniors. Experiencing unethical practice by the seniors resulted in the gradual erosion of morals and ethics of the junior doctors. This unfortunate disillusionment with the medical culture necessitates the inclusion of humanities and bioethics into medical curricula as an attempt to stop this decay and restore the sanctity of this profession.The main aim of teaching bioethics to the medical graduates is to allow the inculcation of required reasoning skills in them. These skills are necessary to help them overcome the dilemmas that they might experience during their practice in the near future. It also gives them the opportunity to amicably resolve these dilemmas using the knowledge attained through the course and by the experience that they would obtain during their practice.

PURPOSE OF TRAINING IN MEDICAL HUMANITIES The claim that introduction of medical humanities in the curriculum will help our students to become better doctors has another interesting aspect to it. The term ‘better’ suggests that our young physicians will be able to take care of their patients more effectively, if they study medical humanities. Difference in overall personality of a medical graduate with and without medical humanities depicted in Fig. 2.2. (Birkeland et al, 2013). Learning to become a good doctor is not something which

Fig. 2.2: Difference in overall personality of a medical graduate with (left) and without (right) medical humanities

Medical Humanities: Need and Purpose

13

happens overnight. It involves a process of character formation that requires years and years of role modeling and guided practice. Medical humanity is based on the fundamentals of good communication skills, empathy, professionalism, as well as self-awareness related to the social and cultural aspect of healthcare (Dobie, 2007). However, given a thought, it conveys the message that earlier physicians did not attend any associated course and grasped these skills through years of experience. Thus, healthcare professionals may learn all these skills during their years of practice. Despite all this, ‘medical humanities’ feels right and medical educators worldwide are talking enthusiastically about it and I think that these educators are doing this selflessly to preserve and cater to the essence of the medical profession. The main objective of medical humanities is to integrate the field of humanities in medical curriculum (Eichbaum, 2014). This would help the budding healthcare professionals to become kinder to the patients and will help them understand the difference between life and death. It allows medical professionals to adapt empathy during their practice. It inculcates the important principle of morality and ethics in medical students and prevents the reinforcement of negative aspects of the medical profession, viz. cynicism, feeling of entitlement, and vanity.

WAYS AND MEANS OF INTRODUCING HUMANITIES Humanities education is both an active as well as passive mode of teaching morals, ethics, and professionalism to the budding medical graduates. This passive education has to be implemented with the help of some formal tools such as didactic lectures, ethics rounds, standardized patients, etc. Another important method for this purpose is the use of realistic care-based discussions. These formal tools can only be implemented with the help of the available resources and manpower. Since the success of any education is based on the strength of its roots, therefore, this education can be made useful, only if it is implemented during the beginning of a medical course. This course can be made successful, only if it is integrated in the medical curriculum. This would ensure that medical ethics is considered as the main course instead of a series of boring lectures. Medical humanities need to be integrated both horizontally and vertically during the five and half years of medical course. Though philosophers might be considered as an ideal choice, but the medical ethicists with years of experience and knowledge are best suited for teaching medical graduates and postgraduates. These ethicists are considered as an expert of medical techniques, problems, and associated ethics. It is important to understand that the aim of teaching a medical graduate surgery or obstetrics is not to create a specialist surgeon or obstetrician, but it is done for ensuring that each medical graduate has at least a basic knowledge regarding these fields and the ability to recognize the diseases associated with it. This would allow them to provide the treatment for the disease within the limits of their abilities and refer the patients who are beyond their capacity of intervention to a specialist or a well-equipped healthcare facility. In a similar manner, medical bioethics allows the creation of medical bioethicists who are able to identify ethical dilemmas during

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Humanities in Medical Education

their practice and apply the appropriate reasoning skills for overcoming these dilemmas (MacRae et al, 2005). This would involve the use of appropriate reasoning skills attained using the gained knowledge, and experience obtained during years of practice. It is important to regularly evaluate the progress of ethical education and to resolve any and every problem faced, related to medical ethics. Countries like the US, where training of bioethics was made compulsory several years ago are still facing several issues such as—identifying the curriculum of medical ethics to be followed, teaching pattern, and the eligibility requirements of the teachers who would be designated for teaching these skills. All these issues have to be carefully assessed and individually resolved.

CONCLUSION Much wider variations in the curriculum are usually observed between the institutions of different countries. The driving factor behind these variations is the difference in values and cultures. Medical humanities are a combination of science with arts, which allows an insight into the human illness, suffering, perceptions of professionalism; and responsibilities to themselves, patients, and colleagues. This field enhances analytical and observational skills. It imparts the basic requirements of empathy as well as self-reflection. This course is essential for helping the medical students in overcoming the negative aspects of healthcare studies by improving their perception of empathy, respect, self-awareness, and genuineness.

BIBLIOGRAPHY • Batistatou A, Doulis EA, Tiniakos D, Anogiannaki A, Charalabopoulos K. The

introduction of medical humanities in the undergraduate curriculum of Greek medical schools: Challenge and necessity. Hippokratia 2010;14(4):241.

• Birkeland S, Christensen DR, Damsbo N, Kragstrup J. Characteristics of complaints

resulting in disciplinary actions against Danish GPs. Scandinavian J Primary Healthcare 2013;31(3):153–57.

• Dobie S. Reflections on a well-traveled path: Self-awareness, mindful practice, and relationship-centered care as foundations for medical education. Acad Med 2007; 82(4): 422–27.

• Dymond RF. A scale for the measurement of empathic ability. J Consulting Psychology 1949;13(2):127.

• Eichbaum QG. Thinking about thinking and emotion: The metacognitive approach to the

medical humanities that integrates the humanities with the basic and clinical sciences. The Permanente J, 2014;18(4):64.

• Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med 1994;69(8):670–79.

• Genuis SJ. Dismembering the ethical physician. Postgraduate Med J 2006;82(966):233–38. • Hall P, Brajtman S, Weaver L, Grassau PA, Varpio L. Learning collaborative teamwork: An argument for incorporating the humanities. Journal of Interprofessional Care 2014;28(6):519–25.

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• Hellsten SK. Ethics: Universal or global? The trends in studies of ethics in the context of

globalization. Journal of Global Ethics 2015;11(1):80–89. • Jeffrey D, Downie R. Empathy—can it be taught? J of Royal College of Physicians of Edinburgh 2016;46(2):107–12. • Jerald Kay. Traumatic deidealization and the future of medicine. JAMA 1990;263(4): 572–73. • Mashayekhi J, Mafinejad MK, Changiz T, Moosapour H, Salari P, Nedjat S, Larijani B. Exploring medical ethics’ implementation challenges: A qualitative study. Journal of Education and Health Promotion 2021;10. DOI: 10.4103/jehp.jehp_766_20. • MacRae S, Chidwick P, Berry S, Secker B, Hébert P, Shaul RZ, Faith K, Singer PA. Clinical bioethics integration, sustainability, and accountability: the Hub and Spokes Strategy. Journal of Medical Ethics 2005;31(5):256–61. • Parkes KR. Stressful episodes reported by first-year student nurses: A descriptive account. Social Science & Medicine 1985;20(9):945–53.

• Shi M and Du T. Associations of emotional intelligence and gratitude with empathy in

medical students. BMC Medical Education 2020;20:116. Accessed on 22.12.2022. Available from: https://doi.org/10.1186/s12909-020-02041–4.

3 What Makes a Good Doctor? Sahiba Kukreja Key Points q Patient care is the primary role of a doctor. q There

is a necessity for probity in the medical field.

q Besides

empathy and compassion, effective doctor–patient communication is an important factor for better patient care.

q Lifelong

learning is an obligation for being a good doctor.

INTRODUCTION “A good physician treats the disease. The great physician treats the patient who has the disease.” (Sir Dr. William Osler). Healthcare has been defined as an important and integral part of the society that helps in diagnosing, treating, and preventing physical or mental diseases in a patient. An efficient healthcare system is dependent on a well-trained and empathetic doctor who caters to the requirements of the patient as well as their attendants. The relationship between a doctor and patient has shifted from professional to interactive (Szleza´k et al, 2010). The doctor is now expected to be on the same pedestal as the patient and explain the pros and cons of the treatment to the patient in a detailed manner. The lack of such interactions between a patient and a doctor has resulted in a sudden increase in the malpractice lawsuits filed against the doctors (Ranjan et al, 2015). The major reason behind this surge in lawsuits is an absence of clear communication among the doctors and patients. It is necessary for a doctor to understand the emotions, feelings, and worries of their patients. It is important to understand that there is no good or bad doctor. The basic education and training provided to these professionals is almost the same everywhere. The difference lies between the extra social skills inculcated in them. Clinical practice is always considered paramount in contrast to all possible attributes, yet it is insufficient when practiced alone. Clinicians have their own perception regarding the various essential attributes of a good doctor. A good doctor is not just an excellent clinician, but he/she has to have a strong commitment towards self, family, and community that he/she serves. 16

17

What Makes a Good Doctor?

TEN TOP RANKED ATTRIBUTES A doctor may ensure better care of the patient by implementing system-based practice (SBP). In SBP, a physician is required to understand the correlation among the patient care and system as a whole. The system can then be modified in a manner that can benefit and improve the patient care, thus focusing towards the whole system instead of system components. There is also a need to focus on interpersonal skills, something that is lacking in the healthcare system these days. This would need collaboration among different specialists, thus ultimately benefiting the patients. There is also a need to focus on interpersonal skills, something that is lacking in the healthcare system these days. This would require collaboration among different specialists, thus ultimately benefiting the patient. There are other attributes besides clinical skills which are important to be a good doctor. As per the extract from the graduate medical education regulations 2018, an Indian Medical Graduate must be capable of functioning as per the roles of a clinician, leader and member, communicator, lifelong learner, and professional. All these roles help a doctor become effective for the community first and then alleviate themselves as per global standards. A Delphi survey of clinicians has identified some of them and they have been rated on the Likert scale from 1 to 10, where 1 is the most important attribute (Table 3.1) (Lambe and Bristow, 2010). Though there were many attributes, the top rated are included in this review. In a study by Dopelt et al, 2022 parallel surveys were conducted on 1000 physicians and 500 participants from the general public, reported that the most important attributes of a good doctor according to the physicians they surveyed was their humaneness, empathy, knowledge, professionalism, credibility, honesty, caring and devotion. Whereas participants from the general public reported knowledge, professionalism, credibility, honesty, humaneness, listening and patience as attributes of a good doctor. TABLE 3.1: Key attributes of a good doctor as rated and ranked during Delphi survey (Lambe and Bristow, 2010) Key attributes

Delphi panel ranking

Recognition that patient care is the primary concern of a doctor

1

Probity (being honest, trustworthy and acting with integrity)

2

Good communication and learning skills

3

Recognition of one’s own limits and those of others

4

Pro-social attitude (has empathy and is non-judgemental)

5

Ability to cope with ambiguity, change, complexity and uncertainty

6

Commitment to lifelong learning, competence and performance development

7

Compassion

8

Motivation and commitment

9

Ability to be a team player

10

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Humanities in Medical Education

Fig. 3.1: Improving patient care

Unfortunately, the medical curriculum until now provides no formal training; only clinical skills are imparted to the students. In this review, an effort has been made to compile and identify some of these attributes and possible methods of inculcating them.

LEADERSHIP SKILLS: REVOLUTIONIZING HEALTHCARE SERVICES The key attribute of a good doctor is to provide accurate diagnosis and treatment to the patient. It is necessary to ensure that the patient recovers physically, socially, and mentally (Naglaa et al, 2021). There are several ways of ensuring that the doctor considers patient care as an extremely important part of their profession. In addition to clinical responsibilities, it is imperative for the physician to serve as leaders and advocates at individual and community level (Fig. 3.1) (Warren and Carnall, 2011). They are required to have knowledge and leadership skills in clinical settings, research, funding process, organizational details, governance, and for any other leadership roles. An effective leader can ensure that the patient is taken care of in the healthcare setup and the staff workers act in an organized manner. As stated by Lao Tzu, ‘A leader is best when people barely know he exists, when his work is done, his aim fulfilled, they will say: we did it ourselves’. It was always perceived that one is born as a leader and the leadership skills cannot be taught. On the contrary, several articles have stated that leadership is the sum of important qualities that can be taught to an individual through teaching and rigorous training (Rogers, 2005; Cheang, 2011; Volz-Peacock, 2016). Some of the methods that can be commonly applied for this purpose are self-directed learning, one-to-one coaching, action learning, seminars, mentoring, and experiential learning (Warren and Carnall, 2011).As rightly stated by John Quincy Adams, ‘If your actions inspire others to dream more, learn more, do more and become more, you are a leader’.

What Makes a Good Doctor?

19

LIFELONG LEARNER: THE COMPETENT NOVICE We are aware of the aphorism that learning should continue from cradle to the grave, those who do not, ultimately becomes frustrated and burnout (Teunissen and Dornan, 2008). The medical field is dynamic and ever evolving. Each day a number of research articles are published with information regarding newer diseases and newer interventions, earlier unknown to mankind. Therefore, it is a must for a physician to keep themselves updated through reading, or discussions, etc. Being a knowledgeable doctor adds to one’s values and will help them in getting recognition at local level as well as globally. Ever-increasing knowledge helps a practitioner in decision making and planning new strategies for patient care. It is important for continual professional development that all doctors should reflect on their practice. This will help them to identify their own learning needs (Hanis, 2019). Lifelong attributes can be acquired by seeking content or skill-oriented feedback from others. Quality feedback provided by staff and patients can help in continual improvement or can provide new and better perspectives. Another method of learning is to think back on the challenges faced by the physician during their practice and frame new and relevant questions. These questions have to be answered by the physician using available resources, thus adding to the current knowledge (Teunissen and Dornan, 2008). The confidence expressed by the practitioner and the doubts experienced have to be rightfully balanced. Questioning and doubting personal actions and knowledge can provide continual learning experience.

PROBITY: AN INTEGRAL PART OF A GOOD DOCTOR Ethics and moral principles are an integral part of the medical field. The relationship between a doctor and patient cannot merely be termed as professional with context to consumerism. This field has to consider the importance of empathy, honesty, integrity, morality, decency, trustworthiness, honour, etc. Such moral values can lift up the spirits of patients and their attendants, thus helping the doctor in providing better care. It has been rightly stated by Stephen Covey: ‘When you show deep empathy towards others, their defensive energy goes down, and positive energy replaces it. That is when you can get more creative in solving problems’. The factor of trust and respect among the doctor and patient helps in building a better relationship among them. This could improve the treatment and recovery rate of the patient. The Hippocratic Oath taken by the physicians is a clear reminder of the importance of ethics in the medical field (Askitopoulou and Vgontzas, 2018). The physician is also required to remember that they are a part of the society, and will always stay in an equal position with others. They should maintain a humane and empathetic approach towards their patient. The declaration of Geneva and Helsinki clearly indicates the importance of ethics in physician’s life (Parsa-Parsi, 2017). It highlights the fact that the physician has to make informed decisions, thus the patient or the attendant has the right to know the true and honest condition of the patient, or the actual outcome of a procedure (Laurie, 2014). The autonomy and dignity of the patient has to be rightfully addressed by the doctor. This provides the patient with satisfaction that they are taking the front

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Humanities in Medical Education

Fig. 3.2: Probity as an essential characteristic of patient care

seat in deciding their treatment protocol. Dignity is a crucial moral principle that the doctor has to follow at all the times. It is important to consider the patient as a fellow human being and treat them accordingly (Fig. 3.2). This allows the patient to have trust and respect for their doctor (deBronkart, 2015). The attribute of probity, if followed, helps to reduce the number of legal lawsuits (Pringle et al, 2015). The Health and Insurance Portability and Accountability Act of 1996 highlights the importance of dignity and privacy of each and every patient enrolled in the healthcare system (Huntington and Kuhn, 2003). The Act has revolutionised health centres and physicians worldwide. It has introduced legalities or the right of a patient to file a lawsuit for malpractice or for distributing personal information without taking prior consent. The principle of informed consent has helped in providing transparency regarding the medical treatment or procedure to which the patient is going to be subjected. It has helped the patient in making crucial decisions regarding their health by weighing the pros and cons of the treatment (Act of 1996). It has considerably reduced the malpractice and experimental behaviour of certain physicians. This has led to the provision of the much anticipated patient-centered care (Cherry and Fan, 2015).

COMMUNICATION SKILLS: NECESSITY OF THE HOUR Communication skills are an essential and integral part of human nature. It helps in understanding and interpretation of feelings, and emotions. These skills are especially important in the field of healthcare. Doctors are required to be continuously in contact with patients, their attendants, and other human resources associated with them, thus making communication an essential aspect of healthcare facilities. Effective communication skills are dependent on both the verbal and nonverbal cues of an individual. The verbal skills are necessary for developing a better bond with patients (Pulvirenti et al, 2014). Interaction in common vernaculars can buildup trust among the patients and may help in building rapport (Almutairi, 2015).

What Makes a Good Doctor?

21

Verbal communication is often hampered due to poor health literacy among patients, as observed in a number of surveys (White, 2008). It has been observed that cases of health illiteracy result in lack of understanding of instructions given by the physician and fewer queries by the patients. It is, therefore, the duty of a doctor to analyse the level of understanding of their patients, and thus explain to them the procedures and treatment regimens accordingly. The nonverbal communications are essential in complementing the verbal communication (Friedman, 1979). These nonverbal communication skills help patient in understanding the emotions and care provided by the physician. These skills include smile, fear, and grimace expressed by the patient and the comforting touch, facial expression, and communication skills of the physician. It has been observed that in some cases such communications may act as placebo, thus resulting in improving the health and well-being of the patient (Shapiro and Morris, 1978). Workplace violence is another area of concern for doctors these days, conflicts can arise between attending physicians and patients/paramedical staff/other fellow doctors. These ongoing conflicts can affect the staff morale, therefore conflict management can be recognised as an important part of competence in clinical communication (Saltman, O’Dea, Kidd, 2006). More about communication skills have been detailed in Chapter 6 of this book.

COMPASSION AND EMPATHY: NECESSITY FOR QUALITY CARE Compassion is defined as the feeling of concern for the suffering of patients. Such feelings are extremely important for the health and well-being of the patient (Kass, 2001). Similar to compassion, empathy deals with understanding and sharing of emotions and feelings of the patient. Patients and their attendants often consider these as essential attributes (Heyland et al, 2010). Some of the challenges for instituting compassion and empathy among physicians are increased specialization, fragmentation of the healthcare system, explosion of information, technological advances, and traditional education that teaches a physician to maintain distant relationship from their patients (Qidwai, 2017). Nonetheless, despite the hindrance, the advantages will always outweigh the challenges. Patients are often more cheerful and positive in the presence of a compassionate and empathetic doctor. The lack of empathy in physicians is primarily due to the hypothesis that it may increase the risk of burnout (Picard et al, 2016). These soft skills which form important attributes of a good doctor can be taught by literature, art, creative writing, drama, films, music, and philosophy. These tools can help in making doctors more empathic, observant, tolerant, reflective, and appreciative of language making them distinct from robots and more humane (Banaszek, 2011).

INDIAN MEDICAL GRADUATE Medical Council of India (MCI) has defined Indian Medical Graduate (IMG) in its new guidelines as a graduate—possessing requisite knowledge, skills, attitudes, values and

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Humanities in Medical Education

Fig. 3.3: Roles of Indian Medical Graduate

responsiveness, so that she or he may function appropriately and effectively as a physician of first contact of the community while being globally relevant (MCI, 2019). In order to perform his role as IMG, the graduate is required to perform certain roles (Fig. 3.3). Needless to say, these roles in themselves stand tall as attributes of a good doctor. The IMG should be a: • Clinician, who understands and provides preventive, promotive, curative, palliative and holistic care with compassion. • Leader and member of the healthcare team and system. • Communicator who communicates with patients, families, colleagues and community in a humane, ethical, empathetic, and trustworthy way. • Lifelong learner who is committed to continuous improvement of skills and knowledge. • Professional who is committed to excellence, is ethical, responsive and accountable to patients, community and the profession. There are many competencies earmarked under these roles. Inculcating these competencies and performing these roles are certainly going to make a doctor a good ‘Indian Medical Graduate’.

CONCLUSION Besides clinical skills; good communication skills, skills to build interpersonal relationships, empathy, professionalism, understanding sociology of disease, compassion are some of the attributes of a good doctor (list is not exhaustible). These attributes though picked up by students during training by watching role models, the same now needs to be inculcated by direct teaching–learning.

What Makes a Good Doctor?

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BIBLIOGRAPHY • Act A. Health Insurance Portability and Accountability Act, 1996. Public Law 1996;104-91. • Almutairi KM. Culture and language differences as a barrier to provision of quality care

by the health workforce in Saudi Arabia. Saudi Medical Journal 2015;36(4):425–31. • Askitopoulou H, Vgontzas AN. The relevance of the Hippocratic Oath to the ethical and moral values of contemporary medicine. Part I: The Hippocratic Oath from antiquity to modern times. European Spine Journal 2018;27(7):1481–90. • Banaszek A. Medical humanities courses becoming prerequisites in many medical schools. Canadian Med Ass J 2011;183:441–42. • Cheang PP. Learning about leadership: A personal account. Med Teach 2011;33(6):491–93. • Cherry M, Fan R. Informed consent: The decisional standing of families. J Medicine and Philosophy 2015;40(4):363–70. • deBronkart D. From patient centred to people powered: Autonomy on the rise. BMJ 2015;350: h148. • Dopelt, K., Bachner, Y.G., Urkin, J., Yahav, Z.; Davidovitch, N.; Barach, P. Perceptions of Practicing Physicians and Members of the Public on the Attributes of a “Good Doctor”. Healthcare 2022, 10, 73. https://doi.org/10.3390/healthcare10010073 • Friedman HS. Nonverbal communication between patients and medical practitioners. J Social Issues 1979;35(1):82–99. • Hanis T (2019, June 01). The importance of lifelong learning for a doctor. CIMS today; Sept 28, 2016. https://today.mims.com/the-importance-of-lifelong-learning-for-a-doctor. • Heyland DK, Cook DJ, Rocker GM, Dodek PM, Kutsogiannis DJ, Skrobik Y, et al. Defining priorities for improving end-of-life care in Canada. Canadian Med Ass J 2010;182(16): e747–52. • Huntington B, Kuhn N. Communication gaffes: A root cause of malpractice claims. Proceedings (Baylor University, Medical Center) 2003;16(1):157–61. • Kass NE. An ethics framework for public health. Am J Public Health 2001;91(11):1776–82. • Lambe P, Bristow D. What are the most important non-academic attributes of good doctors? A Delphi survey of clinicians. Med Teach 2010;32(8): e347–54. • Laurie G. Recognizing the right not to know: Conceptual, professional, and legal implications. J Law, Medicine and Ethics 2014;42(1):53–63. • Medical Council of India. The regulations on graduate medical education, 1997– Part II, 2019. Accessed on 18.12.2022. Available from: https://www.mciindia.org/ ActivitiWebClient/open/getDocument?path=/Documents/Public/Portal/Gazette/ GME-06.11.2019.pdf • Naglaa A, El-Sherbiny, Eman H, Ibrahim, Nashwa Sayed. Medical students attitude towards patient centered care, Fayoum medical school Egypt. Journal of Medicine 2021;57(1):188–93. • Parsa-Parsi RW. The revised Declaration of Geneva: A modern-day physician’s pledge. JAMA 2017;318(20):1971–72. • Picard J, Catu-Pinault A, Boujut E, Botella M, Jaury P, Zenasni F. Burnout, empathy and their relationships: A qualitative study with residents in general medicine. Psychology, Health and Medicine 2016; 21(3):354–61. • Pringle J, Johnston B, Buchanan D. Dignity and patient-centred care for people with palliative care needs in the acute hospital setting: A systematic review. Palliative Medicine 2015;29(8):675–94.

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• Pulvirenti M, McMillan J, Lawn S. Empowerment, patient-centred care and self-

management. Health Expectations 2014;17(3):303–10. • Qidwai W. Challenges in providing compassionate healthcare in current modern era of advanced technology. Saudi Journal of Medicine and Medical Sciences 2017;5(2):185–86. • Ranjan P, Kumari A, Chakrawarty A. How can doctors improve their communication skills? J Clinical Diagnostics and Research 2015;9(3):JE01–04. • Rogers J. Aspiring to leadership—identifying teacher-leaders. Med Teach 2005;27(7): 629–33. • Saltman DC, O’Dea NA, Kidd MR. Conflict management: a primer for doctors in training. Postgrad Med J 2006;82:9–12. • Shapiro AK,Morris LA. The placebo effect in medical and psychological therapies. In: Garfield SL, Bergin A (Eds). Handbook of Psychotherapy and Behaviour Change: An Empirical Analysis. New York, NY John Wiley & Sons, 1978;369–410. • Szleza´k NA, Bloom BR, Jamison DT, Keusch GT, Michaud CM, Jamison DT, et al. The global health system: Actors, norms, and expectations in transition. PLoS Medicine 2010;7(1):e1000183. • Teunissen PW, DornanT. Lifelong learning at work. BMJ 2008;336(7645):667–69. • Volz-Peacock M, Carson B, Marquardt M. Action learning and leadership development. Advances in Developing Human Resources 2016;18(3):318–33. • Warren OJ, Carnall R. Medical leadership: Why it is important, what is required, and how we develop it? Postgraduate Med J 2011;87(1023):27–32. • White SP. Assessing the nation’s health literacy: Key concepts and findings of the National Assessment of Adult Literacy (NAAL) American Medical Association Foundation, 2008.

4 Stress and Burnout Syndrome Medha Anant Joshi Key Points q Stress or distress affects the physical, physiological and psychological wellbeing of a person. q Burnout is a multi-dimensional syndrome seen in persons associated with human-oriented jobs. q Burnout may reduce the patient safety, and self-efficacy of healthcare professionals. q Different coping strategies are adapted by different persons for different stressful situations to overcome stress. q Coping is a dynamic process that involves both cognitive and behavioural responses to stressful situations.

INTRODUCTION We have often heard students and sometimes even teachers say this after a very busy semester, ‘I am totally stressed out or I am just so exhausted’. Is this stress, exhaustion and burnout related to the work that they are doing or is it just that some people are not able to take on extra workload and feel this way? Or, when a caregiver shows signs of burnout is it due to her job demand or emotional attachment to her patients?

STRESS Certain optimum level of stress is considered as appropriate for being productive and creative and is accompanied with good mental and physical performance. The words ‘eustress’, and ‘distress’, describe the positive and negative aspects of stress in a person’s life. This positive stress is helpful especially when faced with challenging and difficult tasks. But when the optimum stress levels are negatively influenced by internal and external factors, it manifests as physical and psychological disorders and is described as distress. Stress during higher education can lead to mental distress and affect the learning. High levels of anxiety and depression have been reported among college students from all parts of the world. The concepts of stress, mental distress and self-perceived depression overlap to a great extent (M. Dahlin et al, 2005). Stress can be experienced not only during professional studies, but also before, during the transition from undergraduate to professional level, and after, and during the transition to the practicing professional. The cause of stress among the university students may be attributed to academic work, environment, time management, personality traits, and financial burden (Heins et al, 1984). Psychological distress is reported in literature among medical students quite frequently as compared to 25

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general population (M. Dahlin et al, 2005; Dyrbye et al, 2006, 2011; Tyssen et al, 2004). High levels of stress seen in university students, especially during the university examination time, affects their health causing high degree of dropout. Family conflicts, female gender, few sleep hours and poor academic performance are the other stressors among university students.

BURNOUT The term burnout was first coined by Herbert Freudenberger in 1974 in the USA in context of “staff burnout” and correlated job dissatisfaction with work-related stress (Freudenberger, 1974). He described it as a syndrome affecting mostly the persons holding jobs with high ethical and social responsibilities. In the World Health Organization International Classification of Diseases (ICD), 11th revision (Berg, 2019), burnout is included in section on “problems related to employment and unemployment” and is described as ‘feelings of energy depletion or exhaustion, increased mental distance, or feelings of negativism or cynicism related to one’s job and reduced professional efficacy’. In ICD 11 it is identified as an occupational related ailment and not a medical illness. Burnout has been identified as an occupational risk for people dealing with human-oriented professions; be it healthcare, education or caregivers. In all these vocations, altruism, i.e. to be selfless and put others’ needs first, to go beyond the call of duty to ensure that the patient’s, student’s or client’s requirements are met to the best of one’s ability, are taken as primary responsibilities. And then there are organizational factors such as funding, or policies that result in increased workload and reduced resources that affect the person working in such environment. Not only these but other professions where client is considered supreme are also getting affected by the stress and burnout syndrome (Maslach and Leiter, 2016). As described by Maslach and Jackson (1981a), burnout is a three-dimensional syndrome, manifested as excessive emotional exhaustion that is associated with cynical attitude, and an inclination to gauge oneself negatively especially in relation to their work with patients or a declined sense of personal accomplishment (Fig. 4.1). Feeling of being emotionally strained and having worn-out one’s emotional resources is referred as emotional exhaustion. Depersonalization (now labelled cynicism) refers to a negative, callous and detached or inappropriate

Fig. 4.1: Main dimensions of burnout

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attitude towards the people one works with, such as patients, clients or students. When someone assesses his/her own work performance negatively, it denotes reduced personal accomplishment (Schaufeli et al, 2017) or inefficacy. Of these three components, emotional exhaustion has been shown as the key component of the burnout and affects the work performance the most (Wright and Bonett, 1997). While most of the researchers agree on what burnout is, there seems to be no agreement about what it is not. Many a times the terms stress and burnout are used synonymously; conceptually and theoretically it would be better to treat these two terms separately (Guglielmi and Tatrow, 1998). Theoretical framework divides burnout in three models (Oranje, 2001): • The interaction model: This model considers burnout as a problem arising out of one’s inability to cope up with real or perceived stressors in their work environment. • Response or physiological model: When an individual experiences both mental and physical exhaustion when stuck in a situation that results in a heavy emotional toll. • Environmental stressor model: When the stressors like organizational working atmosphere results in burnout, for example, lack of social support between teachers and students, colleagues or superiors trigger burnout syndrome (Brouwers and Tomic, 1999).

BURNOUT AMONG TEACHERS As seen with other human services, burnout has been reported among teachers, too. If teachers continue working even if burnt out, this will have a negative effect, not only on their physical and mental health, but will adversely affect students and educational system. Burnt out teachers manifest irritability and difficulty in handling students’ disruptive behaviour in the classroom (Evers et al, 2004). Students look up to teachers for guidance and as role models. A stressed or burnt out teacher affects the learning environment and ultimately the educational goals of the institution. A burnt out teacher who shows very little interest in her/his students’ progress, is likely to induce apathy among students, cynicism towards students, absenteeism and finally a decision to leave the job. Burnout in teachers is associated with poor physical health, too (Guglielmi and Tatrow, 1998). Changes in medical education, healthcare system and public expectations have increased the demands on medical teachers. When the occupational demands on the medical teacher exceeds his/her capabilities and resources, it invariably results in stress and burnout (Harden, 1999). Three main factors are associated with stress in teachers—total workload and day-to-day work demands, and lack of autonomy to carry out the work, requirement to adapt and adopt teaching–learning (TL) approaches with which the teacher is not familiar. Work burden in medical teachers is related to factors such as increased number of students without suitable increase in number of teachers, and continuous teaching throughout the year without adequate breaks that leaves no time for teachers to

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recover from the work stress. Another important factor contributing to stress is the new curriculum with early clinical exposure, where clinicians are expected to start teaching right from year one. This invariably results in increased workload. Another factor causing stress and burnout is the multiple roles a teacher is expected to take on and the teacher’s ability to meet these expectations. With the new curriculum, the teacher is expected to take part in integrated teaching, student-centred learning strategies, carry out multiple performance assessments, give feedback to student and be a mentor, in addition to the regular teaching in her/his own subject. He/she may not be adequately prepared to take up the new roles and additional responsibilities. Curriculum evaluation, quality assurance and accreditation documentation add to the work demands. The workload is increased both in terms of quality and quantity. A clinical teacher has to balance between the clinical work, teaching responsibilities, research activities and administrative responsibilities within the given time. Such pull from multiple directions may lead to reduced performance and job dissatisfaction. When the teacher is not very clear about his/her role and responsibilities in the newer teaching/learning strategies such as problem-based learning, community based teaching or integrated teaching, this leads to role conflict and ultimately to stress and burnout (Davis and Harden, 1999). In general, teaching load in medical education is high and more demanding. In such a situation, any change itself is likely to induce stress. Three models of stress have been proposed to explain the relation between the stressed and stressors. Person-environment fit model (Harrison, 1978): According to this model, when the job demands and the person’s ability to meet those demands do not match, it results in stress. The effort-reward model (Siegrist, 1996): When the efforts made to meet the work demands do not match with the financial rewards or the promotions, likelihood of stress are high. Demands-supports-constraints model (Payne and Fletcher, 1983): As per this model there is a lack of support or resources to meet the increased demands resulting in stress. Most of the times, changes in medical curriculum are expected to be implemented without much thought for additional resources, either in terms of manpower or infrastructure or financial requirements, leading to stress.

Stress Management Approaches in Medical Teachers Stress in medical teachers is a potentially critical issue that needs to be addressed at individual and institutional level with suitable strategies. Some of the suggested approaches are (Harden, 1999): • Make the roles and responsibilities of the teachers clear while implementing any change.

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• Try to match the capabilities of a teacher with the roles expected of them. • Reward the commitment and efforts of the teacher who excels in his/her work. • Distribute the workload in such a way that no one teacher is overloaded. • May be time is right to employ a few clinicians for teaching only, thereby reducing the workload on other clinicians. • Reducing the top-down approach and giving more autonomy to teachers for planning their teaching learning strategies. • Faculty development programs to be conducted for all faculty members before introducing any new teaching or assessment approaches.

BURNOUT AMONG POSTGRADUATES, RESIDENTS AND CLINICIANS The intense emotional stress that the doctors face in their workplace makes them more prone to burnout. The detrimental consequences of work-related stress and burnout could result in mental depression, medical errors that might ultimately affect the patient safety and potential compromise of quality of care. Postgraduate (PG) training seems to put the PGs under stress leading to burnout, the seeds of which might have been sown during undergraduate studies. Due to stress they may fail to develop an appropriate professional relationship with the patients, and make proper diagnostic or treatment decisions (IsHak et al, 2009). A variety of factors contribute to burnout in physicians, and seems to be a cumulative, long drawn process (ME Dahlin and Runeson, 2007; Dyrbye et al, 2006; McManus et al, 2004). The prevalence of burnout increases as the PG progresses from 1st year to final year. They also become more cynical and less humanistic during the course of study. Both of these may lead to emotional exhaustion and depersonalization, causing burnout. Prevalence of burnout is shown to be correlated with the subject specialty (Martini et al, 2004) with obstetrics and gynaecology and psychiatry residents showing highest burnout rate and family medicine, the least.

Factors Causing Stress and Burnout in Residents Common stressors reported by residents are: Time demands, inapt time management, work planning, organization of work and studies, and interpersonal relationships (Cohen and Patten, 2005). Other stressors that lead to burnout are dissatisfaction with clinical faculty, mood fluctuations, and marital status (Martini et al, 2004). Poor work environment, poor career development, poor work-life balance and financial worries were other stressors identified (Fig. 4.2) (Zhou et al, 2020). Patient violence and suicide aggravate burnout among psychiatry PGs. Being married and having children seems to have a calming effect and less stress. Logically, having added responsibility of a life partner and children would lead to additional stress, but parenting seems to have a softening effect on residents and a protective effect against burnout. Having a child during residency has shown to make the residents less cynical, decreased their suicidal tendency and made them more humanistic (Collier et al, 2002).

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Fig. 4.2: Stressors, effects and preventive interventions for burnout during post graduation

Clinicians seem to manifest the burnout dimensions sequentially, with emotional exhaustion appearing initially. If not identified and treated, it proceeds to depersonaliza­tion in an attempt to deal with exhaustion; finally, the capacity to face the demands of work lessens, resulting in feelings of low self-esteem (Gracino et al, 2016).

Influence of Burnout on Patient Care Stressed or burnt out PGs and clinicians end up making more number of medical errors, have difficulty in rapport building and making accurate diagnostic decisions (Box 4.1). The Accreditation Council for Graduate Medical Education (ACGME) decided to restrict the work hours of residents to 80 hours/week, and no more than 24 hours duty, in July 2003, with the intention of reducing the burnout rate during residency. Though this step has had positive effect on burnout, it has negatively affected the academic activities and surgical work of residents (Martini et al, 2006). BOX 4.1: Burnout among residents/postgraduates • It is due to a complex interaction between environmental stressors, genetic susceptibilities, and coping ability. • It can contribute to multiple physical symptoms, psychological symptoms, and substance abuse. • It affects quality of life, ability to provide reliable and safe patient care, quality of learning and teaching • The negative impact of burnout on patient care includes chances of medical errors, patient safety risks, and reduction of quality of care.

Interventions to Reduce Burnout during Post Graduation Interventions may be implemented at two levels: Interventions at workplace, and interventions at individual level.

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Workplace-based interventions include: Stress reduction programs; increasing awareness of burnout among faculty and staff; ensuring a reasonable workload; introducing them to various other clinician’s roles such as teaching, research, and supervision; formal mentoring program; team building exercises and emotional intelligence training; programs to support residents to handle both personal and professional issues, under strict confidentiality; and programs that teach residents about time management, stress management, meditation and other relaxation techniques. Individual: Interventions to reduce stress and burnout among residents include— consulting peers when faced with difficult cases; spending leisure time with peers, sharing laughs, voicing challenges at workplace; developing work-related social network—this can be done when attending conferences, lectures or workshops; performing physical exercise, meditation reduces anxiety and depression and hence chances of burnout; mindfulness techniques, yoga, reflective writing, spiritual activities, scheduled daily breaks for rest, music, massage, and enjoying nature; mentors and faculty members serve as role models and practice some of these techniques for the residents to follow. As Maslach (2003) summed up effective solution for preventing burnout—‘If all of the knowledge and advice about how to beat burnout could be summed up in 1 word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.’

BURNOUT IN MEDICAL STUDENTS Medical students at various stages of their training show signs of stress and burnout (Dyrbye et al, 2010). Of the triad of burnout syndrome, high emotional exhaustion is more prevalent among medical students. Students at different stages of study such as preclinical students, paraclinical students and interns have different stressors that cause distress and burnout. First years exhibit emotional and physical exhaustion, whereas paraclinical and clinical students start showing signs of cynicism. Final year students stress out because they feel the education system is not preparing them adequately to face the future with confidence.

Stressors in Medical Students The academic stressors such as heavy curricular load, tight time schedule, demanding and different educational environment, and dissection of the dead bodies are common for new entrants to medical college. The active, student-centered teaching/learning strategies adopted in medical education, which are quite distinct from the ones the students were familiar with during their pre-medical days, becomes a stressor. Language barrier, especially when coming from vernacular background, that leads to faulty communication with peers and teachers, adds to the distress.

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As they progress to 2nd year, contact with very sick patients, dealing with serious illnesses and death, and lack of time for leisure activities with family and friends are contributing factors for inducing stress. Lack of support from teachers and not clear about their roles act as stressors as students’ progress in their studies. Lack of feedback from teachers appears to be a common stress factor through all years of medical studies (M. Dahlin et al, 2005; Dyrbye et al, 2006). Social factors such as staying away from family for the first time, adjusting to new place of living and study, cultural shock for students coming from smaller places are some of the social stressors identified in first year students. Social and family expectations add to the stress levels. Financial problems, as well as uncertainties of the future once they become interns, self-awareness of incompetence to practice independently are the triggers for stress and burnout during the later years of undergraduate studies.

Effects of Distress and Burnout in Medical Students Even if a student shows signs of any one of the three dimensions of the burnout syndrome, it is likely to interfere in their studies as well as manifest in the form of physical symptoms such as drowsiness, fatigue, eating disorders, migraine, emotional instability, and may lead to alcohol and substance abuse (Arora et al, 2016). Psychological morbidity, anxiety, depression and suicidal ideation are much higher in medical students as compared to general, population (Dyrbye et al, 2011; Heinen et al, 2017; Moffat et al, 2004). This is a major problem as burnout affects professionalism, leads to dropout, and desperate measures, and results in higher levels of suicide.

Interventions for Coping Personal traits such as adaptive behaviour, healthy lifestyle, optimism, resilience, greater flexibility, and problem-solving capacity are helpful in copying with distress and burnout. Higher self-efficacy results in mental and physical wellness. Further stress reduction practices like meditation, yoga, relaxation techniques must be adopted. Peer support groups are very important, as are mentorship programs and faculty support and feedback on a regular basis. Students must be encouraged to participate in co-curricular activities. At the same time, psychological and career counselling facilities must be made available free of cost. To address issue of stress and burnout, many medical colleges have started student support groups and other activities that could reduce their stress levels and future burnout. Individual student may develop his/her survival attitude as a copying strategy with the hope that the stressful situation will improve once they enter post graduation. It is essential to select prospective medical students with necessary ability and commitment to pursue career in medicine, to ensure that they understand the demands, and challenges they are likely to face in this profession. Training in humanities would go a long way to teach them to be altruistic, committed to their goals of serving the sick and improving the health of the community.

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BURNOUT AMONG CAREGIVERS Care giving can be rewarding as well as a demanding work. It is observed that the negative consequences outway the positive effects of care giving. Caregivers could be categorised into two categories—informal and formal caregivers. Informal caregivers are those individuals who willingly take the responsibility of caring for a relative or a friend who is ill, facing disability, or any condition that requires specific care (Schulz and Tompkins, 2010). They occupy an important place in enhancing the psychological well-being and physical health of the people suffering from disability and inadequate functioning. Informal caregiver burnout was first described as ‘spouse burnout syndrome’ (Ekberg et al, 1986). They will be able to carry out their task if they are physically and psychologically in good health. Hence, it is essential to focus on the extent and influence of burnout among caregivers to ensure their effectiveness. Informal caregivers show more emotional exhaustion, and, to a lesser extent, depersonalization and reduced personal accomplishment (Gérain and Zech, 2021) as compared to non-caregivers. Informal care giving is associated with increased levels of depression and anxiety, extreme fatigue, stress, anger, frustration, feeling overwhelmed, poorer self-reported physical health, compromised immune function and increased mortality. They feel socially isolated and the financial loss, if they had to stop working (Dharmawardene et al, 2016). Formal caregivers who are engaged in taking care of geriatric population, those with chronic neurological diseases such as Alzheimer’s or dementia, or those providing care at palliative centres or nursing homes are more prone for burnout. This may be due to the frequency of deaths observed, and the stress of caring for physically dependent patients afflicted by severe chronic diseases (Blanchard et al, 2010; Gosseries et al, 2012). Younger age, female gender and workload, especially at night are the predisposing factors for burnout. Burnout in the caregiver may result in absenteeism, leaving the job, depression or suicide (McGilton et al, 2013; Piers et al, 2012). Burnout can have significant consequences on the quality of care. It increases the risk of neglect and abuse, especially in geriatric population (Bužgová and Ivanová, 2011; McDonald et al, 2012). A direct impact on patient mortality is observed, too (Wallace et al, 2010). Preventive measures to improve satisfaction at work and mitigate burnout among informal care givers include: • Doing relaxing activities such as cooking, going to place of worship, or taking on leisure activities they used to do prior to becoming the primary caregiver. • Allowing caregivers regular leisure time. • Counselling—finding someone with whom they can share their feelings. Consult a professional if need be. • Maintaining sense of humor—it is okay to laugh and be humorous to lighten up the stressful moments. • Build a local support system.

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• Mindfulness meditation, focused concentration, open awareness, body/internal focus, nature/external focus, yoga, tai chi, qigong. • Institutional support groups or Balint groups may also prevent exhaustion.

ASSESSING STRESS AND BURNOUT Instruments to measure stress: The stress can be assessed using wide range of measures, like: • Beck’s Depression Inventory (BDI) (Peterlini et al, 2002; Stewart et al, 1997) • General Health Questionnaire 12 (GHQ-12) (Guthrie et al, 1998) • Symptom Checklist (SCL) (Bramness et al, 1991). It can be monitored using specific measures such as: • Perceived Medical School Stress (PMSS) scale (M. Dahlin et al, 2005) • Higher Education Stress Inventory (HESI) (Stewart et al, 1997) Instruments to measure burnout: One of the most popular instruments was introduced by Maslach and Jackson in 1981, the Maslach Burnout Inventory (MBI) (Maslach et al, 1996; Maslach and Jackson, 1981b). The MBI is designed to assess the three dimensions of the burnout experience. Later on, versions specific to educators (MBI-ES), human service workers (MBI-HSS) and for students (MBI-SS) have been constructed and widely used. The Bergen Burnout Inventory (BBI) (Salmela-Aro et al, 2011) assesses three dimensions of burnout at work. The Oldenburg Burnout Inventory (OLBI) assesses the two dimensions of exhaustion and disengagement from work (Halbesleben and Demerouti, 2005). The Copenhagen Burnout Inventory (CBI) (Kristensen et al, 2005), and the student version (CBI-SS) is another widely used inventory to measure burnout in general population and students, respectively.

COPING WITH STRESS All of us have faced stressful situations in our lives, some time or the other. How each individual responds to stress is quite different, a situation considered as stressful by one person may not be perceived as stressful by another. As per the transactional model of stress and coping (RS Lazarus, 1984), the experience of stress is an interaction of the person and the situation. A situation considered as harmful, intimidating or challenging and that cannot be handled with the available resources are perceived as stressful. Here the resources are one’s personality, education, previous experience, age, physical and mental health, social support and finances (Stephenson and DeLongis, 2020). The intellectual and behavioural responses implemented to face the situation is called coping (Folkman et al, 2000). Both effective and failed attempts at managing stress are included as coping. As coping strategies vary from person to person and from one situation to another it is very difficult to match a particular stressor to a definite coping method. Coping is an active process and persons who change their coping style to suit the situation are considered effective copers. For example, the initial response to a diagnosis of

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chronic neurological disease is invariably denial, but as the person and his family members accept the diagnosis, they start adapting to the situation gradually. Tripartite model of coping has been proposed (Stephenson et al, 2016) that addresses different functions of the coping process. 1. Problem-focused coping: This is either focused on the situation when the efforts are directed towards changing the situation or focused on changing ourselves, such as learning new skills to increase personal resources. The steps involved in former coping mechanism include defining the tricky situation, thinking of alternative solutions, comparing these alternatives in terms of their likely costs and benefits, picking the most possible solution, coming up with a plan, and then implementing it. If a situation is perceived as highly threatening, this coping strategy may not work. It is best suited for situations which are considered to be amenable to change. For example, problem-focused coping will not work when one is trying to cope with a death of a loved one. In such situations the emotional-focused strategy may be more effective. 2. Emotional-focused coping: The principal aim of this strategy is to reduce the emotional distress. This could be tried through distancing oneself from the situation, or avoiding it. This type of denial strategies are frequently used during cognitive behavioural therapies (Stephenson et al, 2016). 3. Relationship-focused coping: It is very important to maintain social relationships during the coping stage (Coyne and Smith, 1991). It is important to keep in mind the effect of one’s coping efforts that might have on the close relations. Relationship-focused coping strategies pay attention to providing support, responding compassionately, and trying to resolve issues (O’Brien and DeLongis, 1996) However, such relationship-focused strategies have shown to have both positive and negative effects on the relationships. Based on the situation, these coping functions can be combined effectively. Contextual factors such as the type of the stressful situation, the personality of the individual, and social context can all impact whether or not a particular coping strategy will be effective.

RUST OUT As the name suggests, rust out is burnout’s boredom-based counterpart (Fig. 4.3). Instead of work overload, if someone has to do an uninspiring job that fails to stimulate, is much below one’s capabilities, the person may ‘rust out’. Occupational psychologists believe that the harm caused by boredom may exceed that caused by overwork. Unchecked rust out can lead to depression and even physical symptoms. Similar to rusting of the tool, this too is a slow, long drawn process. It is most commonly seen in midlevel and younger faculty. The causes identified are—lack of empowerment, paperwork overload, endless meetings, repetitive tasks, and no scope for creativity.

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Fig. 4.3: Relation between burnout stress syndrome (BOSS) and rust out stress syndrome (ROSS)

This syndrome can be seen in students, too, especially those who are very bright, talented or gifted. They may find the routine teaching in the class too dull or boring and may stop attending the classes. This ‘one size fits all’ method of teaching may gradually result in loss of interest in the studies, leading to dropout or depression. Rust out may be seen in another set of students, those who do not have any motivation in pursuing their studies, having been forced to take up a professional course which is not of their choice. They become disinterested and apathetic. This rust out stress pushes them towards alcohol and substance abuse (Arora et al, 2016). Whether rust out is affecting the employees or the students, the institutional administrators should recognize this entity and have strategies in place to prevent it. It is important to ensure that people skills and jobs match and that the workplace has, that little bit of stress (optimum) that is good for employees (Fig. 4.4).

Fig. 4.4: Relationship between stress and performance

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The first category of students should be identified during the initial phase and given additional, stimulating inputs. The second category needs to be counselled, mentored and monitored to prevent the rust out.

CONCLUSION Stress and burnout are commonly seen in persons working in human-oriented jobs including teachers, physicians, medical students and caregivers. It is a complex phenomenon that reflects the interaction between environmental stressors, personality of the individual, and coping styles. Burnout can result in physical, and/ or psychological symptoms, and substance abuse, all of which can have a bearing on the person’s quality of life, ability to provide sustainable and safe patient care, quality of learning and teaching, and the overall morale of a caregiver. Burnout must be addressed by leadership in academic institutions and hospitals. As we move toward national healthcare reform and attempt to upgrade our approach to training UGs and PGs, attention must be paid to personal well-being. This is critical to produce effective, humane next generation of physicians.

BIBLIOGRAPHY • Arora, A, Kannan, S, Gowri, S, Choudhary, S, Sudarasanan, S, and Khosla, PP. Substance abuse amongst the medical graduate students in a developing country. The Indian Journal of Medical Research:2016;143(1):101–3.

• Berg, S. WHO adds burnout to ICD-11. What it means for physicians. American Medical Association, Physician Health. July 2019.

• Blanchard, P, Truchot, D, Albiges-Sauvin, L, Dewas, S, Pointreau, Y, Rodrigues, M, Xhaard, A, Loriot, Y, Giraud, P, and Soria, JC. Prevalence and causes of burnout amongst oncology residents: A comprehensive nationwide cross-sectional study. European Journal of Cancer 2010;46(15):2708–15.

• Bramness, JG, Fixdal, TC, and Vaglum, P. Effect of medical school stress on the mental health of medical students in early and late clinical curriculum. Acta Psychiatrica Scandinavica 1991;84(4):340–45.

• Brouwers, A, and Tomic, W. Teacher burnout, perceived self-efficacy in classroom

manage­ment, and student disruptive behaviour in secondary education. Curriculum and Teaching 1999;14(2):7–26.

• Bužgová, R, and Ivanová, K. Violation of ethical principles in institutional care for older people. Nursing Ethics 2011;18(1):64–78.

• Cohen, JS, and Patten, S. Well-being in residency training: A survey examining resident

physician satisfaction both within and outside of residency training and mental health in Alberta. BMC Medical Education 2005;5(1):1–11.

• Collier, VU, McCue, JD, Markus, A, and Smith, L. Stress in medical residency: Status quo after a decade of reform? Annals of Internal Medicine 2002;136(5):384–90.

• Coyne, JC, and Smith, DA. Couples coping with a myocardial infarction: A contextual

perspective on wives’ distress. Journal of Personality and Social Psychology 1991;61(3):404.

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Humanities in Medical Education

• Dahlin, ME, and Runeson, B. Burnout and psychiatric morbidity among medical students entering clinical training: A three-year prospective questionnaire and interview-based study. BMC Medical Education 2007;7(1):1–8.

• Dahlin, M, Joneborg, N, and Runeson, B. Stress and depression among medical students: A cross-sectional study. Medical Education 2005;39(6):594–604.

• Davis, MH, Harden, RM. AMEE Medical Education Guide No. 15: Problem-based learning: a practical guide. Medical Teacher 1999;21(2):130–40.

• Dharmawardene, M, Givens, J, Wachholtz, A, Makowski, S, and Tjia, J. A systematic

review and meta-analysis of meditative interventions for informal caregivers and health professionals. BMJ Supportive and Amp; Palliative Care 2016;6(2):160. https://doi. org/10.1136/bmjspcare-2014-000819

• Dyrbye, LN, Harper, W, Durning, SJ, Moutier, C, Thomas, MR, Massie Jr, FS, Eacker,

A, Power, DV, Szydlo, DW, and Sloan, JA. Patterns of distress in US medical students. Medical Teacher 2011;33(10):834–39.

• Dyrbye, LN, Thomas, MR, Power, DV, Durning, S, Moutier, C, Massie Jr, FS, Harper,

W, Eacker, A., Szydlo, DW, and Sloan, JA. Burnout and serious thoughts of dropping out of medical school: A multi-institutional study. Academic Medicine 2010;85(1):94–102.

• Dyrbye, LN, Thomas, MR, and Shanafelt, TD. Systematic review of depression, anxiety,

and other indicators of psychological distress among US and Canadian medical students. Academic Medicine 2006;81(4):354–73.

• Ekberg, JY, Griffith, N, and Foxall, MJ. Spouse burnout syndrome. Journal of Advanced Nursing 1986;11(2):161–65.

• Evers, WJ, Tomic, W, and Brouwers, A. Burnout among teachers: Students’ and teachers’ perceptions compared. School Psychology International 2004;25(2):131–48.

• Folkman, S, Lazarus, RS, Dunkel-Schetter, C, DeLongis, A, and Gruen, RJ. (2000). The dynamics of a stressful encounter. In: Higgins ET, Kruglanski AW (Eds), motivational science: Social and personality perspectives. Psychology Press; pp. 111–117.

• Freudenberger, HJ. Staff burn-out. Journal of Social Issues 1974;30(1):159–65. • Gérain, P, and Zech, E. Do informal caregivers experience more burnout? A meta-analytic study. Psychology, Health and Medicine, 2021;26(2):145–61.

• Gosseries, O, Demertzi, A, Ledoux, D, Bruno, MA, Vanhaudenhuyse, A, Thibaut, A, Laureys, S, and Schnakers, C. Burnout in healthcare workers managing chronic patients with disorders of consciousness. Brain Injury 2012;26(12):1493–99.

• Gracino, ME, Zitta, ALL, Mangili, OC, and Massuda, EM. Physical and mental health of medical professionals: A systematic review. Saúde Em Debate 2016;40:244–63.

• Guglielmi, RS, and Tatrow, K. Occupational stress, burnout, and health in teachers: A

methodological and theoretical analysis. Review of Educational Research 1998;68(1): 61–99.

• Guthrie, E, Black, D, Bagalkote, H, Shaw, C, Campbell, M, and Creed, F. Psychological

stress and burnout in medical students: A five-year prospective longitudinal study. Journal of the Royal Society of Medicine 1998;91(5):237–43.

• Halbesleben, JR, and Demerouti, E. The construct validity of an alternative measure of burnout: Investigating the English translation of the Oldenburg Burnout Inventory. Work and Stress 2005;19(3):208–20.

• Harden, RM. Stress, pressure and burnout in teachers: Is the swan exhausted? Medical Teacher 1999;21(3):245–247.

Stress and Burnout Syndrome

39

• Harrison, R van. Person-environment fit and job stress. Stress at Work 1978;175–205. • Heinen, I, Bullinger, M, and Kocalevent, RD. Perceived stress in first year medical

students-associations with personal resources and emotional distress. BMC Medical Education 2017;17(1):1–14. • Heins, M, Fahey, SN, and Leiden, LI. Perceived stress in medical, law, and graduate students. Journal of Medical Education 1984;59(3):169–79. • IsHak, WW, Lederer, S, Mandili, C, Nikravesh, R, Seligman, L, Vasa, M, Ogunyemi, D, and Bernstein, CA. Burnout during residency training: A literature review. Journal of Graduate Medical Education 2009;1(2):236–42. • Kristensen, T, Borritz, M, Villadsen, E, Christensen, KB. The Copenhagen Burnout Inventory: A new tool for the assessment of burnout. Work and Stress 2005;19(3):192–207. • Martini, S, Arfken, CL, and Balon, R. Comparison of burnout among medical residents before and after the implementation of work hours limits. Academic Psychiatry 2006;30(4): 352–55. • Martini, S, Arfken, CL, Churchill, A, Balon, R. Burnout comparison among residents in different medical specialties. Academic Psychiatry 2004;28(3):240–42. • Maslach, C, Jackson, SE. Maslach Burnout Inventory—ES Form (MBI) [Database record]. APA Psyc Tests 1981. Accessed on 24.12.2022. Available from: https://doi.org/10.1037/ t05190–000. • Maslach, C, and Jackson, SE. The measurement of experienced burnout. Journal of Organizational Behavior 1981b;2(2):99–113. • Maslach, C, Jackson, SE, and Leiter, MP (1996). MBI: Maslach burnout inventory. Consulting Psychologists Press Palo Alto, CA. • Maslach, C, and Leiter, MP (2016). Burnout. In: Stress: Concepts, cognition, emotion, and behavior (pp. 351–357). Elsevier. • McDonald, L, Beaulieu, M, Harbison, J, Hirst, S, Lowenstein, A, Podnieks, E, and Wahl, J. Institutional abuse of older adults: What we know, what we need to know. Journal of Elder Abuse and Neglect 2012;24(2):138–160. • McGilton, KS, Tourangeau, A, Kavcic, C, and Wodchis, WP. Determinants of regulated nurses’ intention to stay in long-term care homes. Journal of Nursing Management 2013;21(5):771–81. • McManus, IC, Keeling, A, and Paice, E. Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: A twelve year longitudinal study of UK medical graduates. BMC Medicine 2004:2(1):1–12. • Moffat, KJ, McConnachie, A, Ross, S, and Morrison, JM. First year medical student stress and coping in a problem-based learning medical curriculum. Medical Education 2004;38(5):482–91. • O’Brien, TB, and DeLongis, A. The interactional context of problem-, emotion-, and relationship-focused coping: The role of the big five personality factors. Journal of Personality 1996;64(4):775–813. • Oranje, AH (2001). Van ouderenbeleid tot lerarentekort [From Policy on Elderly Workers to Teacher Shortages]. Nijmegen: Mediagroep KUN. • Payne, R, and Fletcher, BC. Job demands, supports, and constraints as predictors of psycho­logical strain among schoolteachers. Journal of Vocational Behavior 1983;22(2),:136–47. • Peterlini, M, Tibério, IF, Saadeh, A, Pereira, JC, and Martins, MA. Anxiety and depression in the first year of medical residency training. Medical Education 2002;36(1):66–72.

40

Humanities in Medical Education

• Piers, RD, Van den Eynde, M, Steeman, E, Vlerick, P, Benoit, DD, and Van Den Noortgate, N. J. End-of-life care of the geriatric patient and nurses’ moral distress. Journal of the American Medical Directors Association 2012;13(1):80-e7.

• Salmela-Aro, K, Rantanen, J, Hyvönen, K, Tilleman, K, and Feldt, T. Bergen Burnout

Inventory: Reliability and validity among Finnish and Estonian managers. International Archives of Occupational and Environmental Health 2011;84(6):635–45.

• Schaufeli, WB, Maslach, C, and Marek, T (2017). Professional burnout: Recent developments in theory and research. 1st edition. Routledge.

• Schulz, R, Tompkins, CA (2010). Informal caregivers in the United States: Prevalence, characteristics, and ability to provide care. In: Human Factors in Home Healthcare. Washington, DC: National Academies of Sciences Press.

• Siegrist, J. Adverse health effects of high-effort/low-reward conditions. Journal of Occupational Health Psychology 1996;1(1):27.

• Stephenson, E, and DeLongis, A. Coping strategies. The Wiley Encyclopedia of Health Psychology 2020;55–60.

• Stephenson, E, King, DB, and DeLongis, A (2016). Coping process. In Stress: Concepts, cognition, emotion, and behavior (pp. 359–364). Elsevier.

• Stewart, SM, Betson, C, Lam, TH, Marshall, IB, Lee, PWH, and Wong, CM. Predicting stress

in first year medical students: A longitudinal study. Medical Education 1997;31(3):163–68.

• Tyssen, R, Hem, E, Vaglum, P, Grønvold, NT, and Ekeberg, Ø. The process of suicidal

planning among medical doctors: Predictors in a longitudinal Norwegian sample. Journal of Affective Disorders 2004;80(2–3):191–98.

• Wallace, SL, Lee, J, and Lee, SM. Job stress, coping strategies, and burnout among abusespecific counselors. Journal of Employment Counseling 2010;47(3):111–22.

• Wright, TA, and Bonett, DG. The contribution of burnout to work performance. Journal of

Organizational Behavior: The International Journal of Industrial, Occupational and Organizational Psychology and Behavior 1997;18(5):491–499.

• Zhou, AY, Panagioti, M, Esmail, A, Agius, R, Van Tongeren, M, and Bower, P. Factors

associated with burnout and stress in trainee physicians: A systematic review and metaanalysis. JAMA Network Open 2020;3(8):e2013761.

5 Human Touch in Doctors Narendra Nath Laha Key Points q Human touch in doctors plays an important role in patient care. ‘The doctor–patient relationship’ has been and remains a keystone of patient care. q Empathy

is a cornerstone of healthcare profession.

q Understanding

modality.

psychology is important in doctors. The psyche of a patient decides the treatment

INTRODUCTION Human touch in doctors for patients makes a relationship which is the keystone of care. The faith factor has to be developed. The doctor should be more interested in patient care rather than earning money. Psychology plays an important role. Sympathy and empathy are important. Positivity and bed side manners are important. Ample time should be given to the patient. Modern tools in patient care are needed. Attendants should be attended. Financial barriers have to be overcome. Robot needs thinking. High-tech interactions have gained legality and popularity. A doctor is basically meant to treat patients. Obviously the job is to reduce suffering. There is a huge list of medicines. But to give the correct medicine, a doctor is needed. ‘The doctor–patient relationship has been and remains a keystone of care: The medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation and support are provided’ (Dorr and Mack, 1999). In the present era doctor–patient relationship has touched a low ebb. The faith factor has vanished. It is strictly on the professional basis that treatment is going on. If the patient recovers then the doctor is good otherwise he/she is bad to worse. The big question is that who is responsible for this debacle? This brings us to the question of human touch in doctors. This is a fact that this touch is fast vanishing. But it is needed that human touch in doctors should come. If a student enters the medical profession then it should be for the love of it and with a spirit to serve the suffering humanity. If it is for the lure of money, then he/she may be happy but will leave behind grim faces. ‘A core element of physical examinations is human touch. Touch is a dominant form of nonverbal communication used in clinical care. 41

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Although nonverbal communication is addressed in many medical school curricula, the focus tends to be on body language and use of gestures rather than the intimacy of touch’ (Kelly et al, 2014).

THE CHANGING SCENARIO Is the medical profession a business? In the present era this is becoming a truth. But that is not good in the long run. One can earn money from the patient, but should leave behind a recovered patient with smiling faces all around. Understanding psychology is important in doctors. The psyche of a patient decides the treatment modality. A doctor should understand this. One cannot treat every patient with the same yardstick. This means that the doctor should first understand the thinking of the patient and then explain the treatment. This is a part of human touch in treatment. In any era, human to human transaction is very important. There are many points besides the disease which needs understanding by the doctor. This only comes when the doctor talks with the patient. This will make treatment more successful. There are three things in doctor–patient relationship. They are sympathy, empathy and not bothering at all. Empathy is needed because the doctor is in touch with the patient although complete relationship is not developed. This barrier is important. ‘Throughout medical school, my instructors stressed the importance of empathy, generally defined as the understanding of and identification with another person's emotional state. Sympathy and empathy, commonly confused with each other, are not the same. Sympathy is a statement of emotional concern while empathy is a reflection of emotional understanding. The applications of empathy are widespread and are especially relevant in fields such as medicine where the successful treatment of patients depends on effective patient–physician interactions’ (Elliot, 2007). It is the job of the doctor to bring the patient out of isolation and depression. Disease itself is a big cause of isolation and depression. Encouragement is essential from the doctor’s side. Facts can be told in a nice manner. This is an art which has to be developed in every doctor. Positivity should be encouraged in the patient. In the present era this is very important in every sphere of life. Counseling helps a lot.

SMALL CHANGES: HUGE REWARDS Bedside manners are a very important part of treatment. The doctor should be immaculately dressed. This means decent clothes with no shabbiness. This creates a very good impression on the patient. Soft speaking is also helpful. Using the correct words helps. If the patient is rough in talking then also the doctor should be cool. The conversation should start with ‘namaste’ or ‘good morning’ or ‘any form of greetings’. It is universal facts that the practice of medicine, the scientific part of medical practice, changes with time as we develop better techniques for diagnosis and improved therapies for treatment; but the art of medicine remains constant over the millennia because human nature is unchanging. Patients bring fear, anxiety, and self-pity into the exam room. It has always been the doctor’s responsibility to

Human Touch in Doctors

43

calm their fears and provide hope. The accomplished doctor has a bedside manner that is humane and compassionate, empathetic and supportive (Silverman, 2012). The doctor should give ample time to the patient. One should never go by the clock. This does not mean that time should be wasted. There should be justified time for every patient. It should not be that one is looked after too much and the other is neglected. Listen to the patient and show interest. Sometimes the patient talks things which are not worth it. But that also should be heard carefully. For, this is the art of history taking. In case of psychiatric patients this is more important to make a correct diagnosis. We all are aware that ‘being a physician’ always has been a busy job. Achieving the goal of comprehensive patient-care requires time, availability and effective use of the local healthcare system, along with a broad spectrum of medical knowledge (Dugdale et al, 1995). Patients are more interested to see their doctors in person rather than on live. Their problems lessen on seeing their doctor. Tele-consultation, though an effective method of dealing with shortage of doctors, fails to provide human touch. Doctors themselves can adopt a novel approach to deal with shortage of physicians and time—the working staff should be trained by the doctor. Perhaps he/she spends more time with the patient than the doctor. So, if the doctor is the base for diagnosis, the working staff may form the core for carrying out instructions and caring for the patents. Employees should be taught how to use the modern tools. Healthcare information technology (IT) tools help providers and patients to manage vital health information. They also help improve the quality of care and make healthcare more cost-effective for providers and patients. Such tools include—electronic health records, referral trackers, patient portals, remote patient monitoring, computerized provider order entry. Taking care of attendants is a very important part of treatment. They are of different types and usually one of them is hostile. They should be explained everything in detail. All questions should be heard to and explained. A very important element is the human touching of the patient. In the present days, this is at low ebb. Because of the corona epidemic the doctors avoid touching the patients. This issue needs to be addressed. The non-touch technique is OK but the patient is seldom satisfied. Every doctor has to solve this problem in his/her own way. The doctor should encourage the patients so as to develop a positive attitude. Almost every patient is in a negative frame of mind. It is the job of a doctor to use encouraging words and help in making a positive frame of mind of the patient. The guarded prognosis can be explained to the attendants, but the patient should always be given a positive understanding. It is documented in the literature that extreme positive thinking may promote alternative forms of medicine that ultimately substitute effective treatment, and this is unethical. The emphasis on positive thinking for cancer patients may be too burdensome for them. Likewise, unrestricted positive thinking is not necessarily good for mental health (Andrade, 2019). Faith is a very important factor in patient care. It takes a long time before the doctor can make his/her impact on the society. A serving job with only the purpose

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of solving the disease should be the prime thinking in the mind of the doctor. Once a faith is developed then treatment becomes easier and rewarding. Financial barriers have to be overcome. What is the use of writing a host of investiga­tions when the patient cannot afford to even have two square meals in a day? Each patient has to be treated by individual methods. Number of times patient has to be referred to another doctor. This reference should be explained to the patient in full. Today is the era of specialties and super specialties. This does not hamper the prestige of the referring doctor. But it is very important that the reference should be correct.

THE CLASSICAL TRIAD It is the trio of patient, doctor and pharmacist which can deliver goods in today’s world. The disease and patient care revolves around these three. A mistake from any one is a blunder. The patient should not hide anything from the doctor. The doctor should make a correct diagnosis and prescription. The pharmacist should give the correct medicine. All this is possible if the human touch is there between the three. The time is coming when robot will treat the patient to the extent that surgery also will be done by them. But can the robot treat the mind? Satisfaction of the patient can only come when human touch will be there. One must learn to combine technology with treatment. But technology cannot be everything. Every investigation must be correlated with the clinical picture. And for that, human relationship of the doctor and patient is very essential. High-tech interactions have gained legality and popularity. The doctor should take ample advantage of this and help the patient even if physical presence is not possible. It is the communication which is important rather than the method. The doctor should know the method of giving the bad news. This is an art. This is the most difficult part of the medical profession. Every time the doctor sees the patient, the prescription should be new. This gives satisfaction to the patient that the doctor is taking special care. Scribbling on the same prescription every time becomes irritating. Though, for stable patients with chronic treatment, who has reported for routine check-up, a change of treatment regimen may be uncalled for. Balance of mind of the doctor is very important. He/ she should approach the patient with a smiling face and nice talking. This is only possible if the doctor is cool in his/her mind.

CONCLUSION Treatment of the patient is an art and science both. This art comes gradually. Taking care of illness and the disease person physically is important aspect of medical practice, but equally important is the art of taking care of the emotions and mind of the diseased person and his/her attendants. In the sunset of life, the doctor should feel satisfied that he/she has been honest to the profession and done his/her best.

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BIBLIOGRAPHY • Andrade G. The ethics of positive thinking in healthcare. J Med Ethics Hist Med 2019;12:18.

Accessed on 30.09.2022. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7166246/pdf/JMEHM-12-18.pdf. • Dorr GS, Mack L Jr. The Doctor–Patient Relationship: Challenges, Opportunities, and Strategies. J Gen Intern Med 1999;14(Suppl 1):S26–33. • Dugdale DC, Epstein R, Pantilat SZ. Time and the Patient–Physician Relationship. J Gen Intern Med 1999;14(Suppl 1): S34–40. • Elliot HM. The Role of Empathy in Medicine: A Medical Student’s Perspective, Virtual Mentor: American Medical Association Journal of Ethics 2007;9(6):423–27. • Kelly M, Wendy T, Lara N. Keeping the Human Touch in Medical Practice. Academic Medicine 2014;89(10):1314. • Silverman BD. Physician behaviour and bedside manners: The influence of William Osler and the Johns Hopkins School of Medicine. Proc (Bayl Univ Med Cent) 2012;25(1):58–61.

2

Focus Areas 6. Communication and Interpersonal Skills 7. Professionalism and Ethics 8. Attitudes, Empathy and Altruism 9. Confidentiality and Privacy 10. End of Life Care 11. Medical Sociology

6 Communication and Interpersonal Skills Jyoti Nath Modi, Anshu, Jugesh Chhatwal, Piyush Gupta, Tejinder Singh, Rajiv Mahajan Key Points q Good communication and interpersonal skills are essential for optimal doctor–patient relationships and contribute to improved health outcomes. q Formal

training in these skills has been fragmentary and nonuniform in most Indian curricula.

q It

is a challenge to ensure that students not only imbibe the nuances of communication and inter­ personal skills, but adhere to them throughout their careers.

INTRODUCTION Good communication skills are essential components of physician training. Effective communication between the doctor and patient leads to better compliance, better health outcomes, decreased litigation, and higher satisfaction both for doctors and patients (Deveugele et al, 2005; Rider et al, 2006; Laidlaw and Hart, 2011; Tamblyn et al, 2007). Some of the major barriers to good communication include use of medical jargon, inability to communicate in simple language, arrogance, lack of enough time dedicated to the doctor–patient encounter, and frequent interruptions while the patient is narrating his problems (Shendurnikar and Thakkar, 2013; RowlandMorin and Carroll, 1990; Silverman and Kinnersley, 2010). Patients expect doctors to be supportive, non-judgmental, empathetic, open and honest about details of their illness, choice of treatment, side effects of medication and expected relief in symptoms (Mehta, 2008). Doctors, who listen actively, encourage their patients to ask clarifying questions, check for understanding and value the privacy and comfort of their patients, are appreciated (Rowland-Morin and Carroll, 1990). In addition, the nonverbal aspects of communication such as body language, eye contact, facial expression, touch, gestures, and interpersonal distance are of extreme importance in building rapport between the doctor and patient (Silverman and Kinnersley, 2010; Mehta, 2008; Anshu, 2016). Besides clinical interactions with patients, doctors also have to communicate in writing for clinical documentation and referrals—all of which have medicolegal implications. Effective communication goes a long way in building a relationship of trust between doctors and patients. Interpersonal skills have been defined as ‘those essential skills involved in dealing with and relating to other people largely on a one-on-one basis’ (McConnell, 2004). Good 49

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interpersonal skills will create a friendly environment for patients and staff thus leading to effective time management, increased productivity and improvement in patient care outcomes (Barakat, 2007). The ‘art and science’ of interpersonal skills and building relations is tightly interwoven with the communication skills of an individual, leading to usage of the term ‘interpersonal communication’ (Chichirez and Purcarea, 2018). In this chapter also, these two will be used in unison.

NEED FOR TRAINING IN COMMUNICATION AND INTERPERSONAL SKILLS Although medical trainees may imbibe some basic communication skills consciously or unconsciously, during their training, by observing their peers and senior colleagues; these are far from adequate to exhibit good communication skills in their professional careers (Aspegren and Lonberg-Madsen, 2005). Sadly, not all senior physicians are good role models, nor do they all demonstrate exemplary communication and interpersonal skills in their work each time. During interpersonal interactions in clinical settings, teachers display both positive and negative role model behaviors. Though not explicitly taught, these unspoken messages form part of the ‘hidden curriculum’ which influences students’ development as physicians (Gaufberg et al, 2010; Benbassat, 2013). Further, communication skills need to be reinforced and practiced frequently throughout the course to be applied by professionals in their future careers (Rider et al, 2006; Laidlaw et al, 2002). Medical students themselves and several medical education bodies have acknowledged the need to incorporate communication skills training within the formal curriculum (AAMC, 1988; Simpson et al, 2002; Council, 2009). In the recent amendments in Graduate Medical Education Regulations, Medical Council of India (MCI) has identified ‘communicator with patients, families, colleagues and community’ as one of the role of the Indian Medical Graduate (MCI, 2019a). The real challenge is to seamlessly integrate communication skills training with clinical training. This chapter will provide a way forward to include training and assessment of communication and interpersonal skills for Indian Medical Graduates within the existing curriculum.

MODELS OF COMMUNICATION IN CLINICAL CONSULTATION With improved understanding and changing times, models of communication during clinical consultations have evolved from simplistic to more complex ones. Some of these models include the Bayer Institute for Healthcare Communication E4 Model, the Three-function Model/Brown Interview Checklist, the CalgaryCambridge Observation Guide, the patient-centered clinical method and the SEGUE framework for teaching and assessing communication skills (Keller and Carroll, 1994; Novack et al, 1992; Stewart et al, 2013; Makoul, 1998). Some of the salient features of these models are outlined in Table 6.1. Each model outlines a framework of clinical consultation that includes clinical data gathering, rapport building and counseling about treatment. They serve as guides for trainees and trainers and also provide a standardized way of assessing (and giving feedback) for communication during a clinical consultation. Most models enlist the key steps in progression of a clinical encounter with component activities that are observable and measurable.

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TABLE 6.1: Models of communication during clinical consultations S. no. Model

Essential elements of doctor–patient interactions and the constituent actions/behavior*

1.

Bayer Institute for Healthcare 1. Engage Communication E4 Model 2. Empathize (Keller and Carroll, 1994) 3. Educate 4. Enlist

2.

Three-function Model (Novacket al, 1992)

1.  Data gathering: Gathering data to understand patient’s problems • Attentive listening, open-ended and closed-ended ques­tions, simple language, facilitating, checking, clarifying, summarizing, etc. 2. Emotions: Developing rapport and responding to patient’s emotions • Reflection, legitimation, understanding, convey empathy, support, partnership, respect 3.  Education and motivation: Patient education and motivation (behavior) • Elicit existing views, educate, negotiate, motivate, reinforce

3.

Calgary-Cambridge Observa­tion Guide (Kurtz and Silverman,1996)

1. Initiating the session • Establishing initial rapport: Greet, introduce, demonstrate respect • Identifying the reason(s) for consultation: Listen identify problem list 2. Gathering information • Exploration of the patient’s problems to discover the bio­medical perspective (disease), essential background history, patient’s perspective (the illness): Encourage, listen attentively, facil­ itate patient’s responses verbally and nonverbally, clarify, encourage patient to express feelings, ask open-ended and closed-ended questions, pick up verbal and nonverbal cues to understand patient’s perspective 3. Physical examination 4. Explanation and planning • Providing the correct amount and type of information • Aiding accurate recall and understanding • Incorporating the patient’s perspective: Achieving shared understanding • Planning: Shared decision making 5. Closing the session • Summary, contract, safety netting, final check

4.

Patient-centered clinical 1.  Assessment of patient’s holistic experience of their healthcare method (Stewartet al, 2013) 2. Integration of the concepts of disease and illness with an understanding of the whole person 3.  Finding common ground with the patient 4.  Maintaining a focus on health promotion and disease prevention 5.  Emphasizing the significance of patient–healthcare– practitioner relationship 6.  Being realistic Contd.

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TABLE 6.1: Models of communication during clinical consultations (Contd.) S. no. Model

Essential elements of doctor–patient interactions and the constituent actions/behavior*

5.

SEGUE Framework (Makoul, 1998)

1.  Elicit information 2.  Give information 3.  Understand the patient’s perspective 4.  End the encounter 5.  If suggesting a new or modified treatment/prevention plan

6.

Kalamazoo Consensus statement (Rider, 2010)

1.  Open the discussion • Allow the patient to complete his/her opening statement • Elicit patient’s full set of concerns • Establish/maintain a personal connection 2.  Gather information • Use open-ended and closed-ended questions appropriately • Structure, clarify, summarize information • Listen actively using verbal and nonverbal techniques 3.  Understand patient’s perspective • Explore contextual factors: Family, culture, gender, etc. • Explore beliefs • Acknowledge and respond to patient’s ideas, feelings, values 4.  Share information: • Use language that patient can understand • Check for understanding • Encourage questions 5.  Reach agreement on problems and plans • Encourage patient to participate in decisions • Check patient’s willingness and ability to follow the plan • Identify and enlist resources and supports 6.  Provide closure • Ask whether the patient has any other issues or concerns • Summarize and affirm agreement with plan of action

*Each of the models enlists several microskills under each essential element or behavior. Only some of these have been given here. These microskills make the process observable and measurable, and facilitate specific feedback.

Since several models were in use, a consensus model delineating the essential steps in clinical consultation was developed by a group of representatives of the five models listed above, that were in contemporary use. This was called the Kalamazoo consensus statement (Table 6.1) (Rider, 2010). While trainees might begin learning the process of clinical consultation by following the steps of one or more models, eventually every physician must develop their own approach that encompasses all the essential elements. These should be visible as their spontaneous professional behavior rather than a mechanical adherence to a protocol.

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COMMUNICATION SKILLS TRAINING SCENARIO IN INDIA The acquisition of communication and interpersonal skills is recognized and documented as a core competency for physician training in many countries including the USA, Canada and the UK (Batalden, 2002; Frank, 2005; GMC, 2009).In India, while this is included as a requirement in the 1997 Graduate Medical Education (GME) regulations of the Medical Council of India (MCI), not enough concerted efforts have been made to teach or assess them in most medical schools (MCI, 1997). In the absence of proper training, Indian medical students often have less than adequate communication skills (Adkoli and Sood, 2009) and the demand for formal training in this area has often been echoed (Verma and Singh, 1994; Chhatwal, 2009; Supe, 2011; Choudhary and Gupta, 2015). Recently, in a positive move, the MCI has introduced a longitudinal training module for Attitude, Ethics and Communication (AETCOM) skills training in a phased manner (MCI, 2018). The utility of this longitudinal training for communication skills can be emphasized on two counts: Firstly, communication skills are best learnt when taught as part of a longitudinal teaching plan rather than as a single occasion training (Deveugele et al, 2005; Rider et al, 2006; Van-Dalen et al, 2002). And secondly, there is evidence in literature that the communication skills of medical graduates actually decline over four years of medical school when not reinforced periodically (Rider et al, 2006). Introduction of a longitudinal program of communication skills training spread over the entire MBBS course is, therefore, appreciable. In the revised Graduate Medical Education Regulations, ‘communicator’ has been defined as one of the five roles of Indian medical graduate (IMG). The competencies expected from IMG for this role have been well documented (Box 6.1) (MCI, 2019a). BOX 6.1: Competencies expected from IMG for the role as communicator Indian Medical Graduate (IMG) is a communicator with patients, families, colleagues and community, who: • Communicates adequately, sensitively, effectively and respectfully with patients in a language and manner that will improve patient satisfaction and healthcare outcomes. • Establishes professional relationships with patients and families that are positive, understanding, humane, ethical, empathetic, and trustworthy. • Communicates with patients in a manner respectful of patient’s preferences, values, prior experience, beliefs, confidentiality and privacy. • Communicates with patients, colleagues and families in a manner that encourages participation and shared decision-making.

TRAINING IN COMMUNICATION SKILLS A good communication skills training program should be multi-session and multidisciplinary, use multiple methods, and have opportunities for demonstration, discussion, reflection, practice and feedback (Rosenbaum et al, 2004; Brown and Bylund, 2008). A longitudinal teaching plan which defines the objectives based on

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contextual requirements for that phase of training and introduces complexities of doctor–patient communication sequentially through the course is recommended (Deveugele et al, 2005; Rider et al, 2006). AETCOM module by MCI is one such good example. We have tried to outline the different competencies which can be delivered to medical graduates in the three phases of the MBBS curriculum in Table 6.2 that also identifies settings in the existing curriculum where all departments can together teach and assess these competencies. For communication skills training, instructional methods such as lectures and seminars are less effective than experiential methods supplemented with feedback (Aspegren, 1999; Shapiro et al, 2009). Experiential methods (like role plays or interaction with simulated and real patients) are preferred by students as they help in reinforcing strengths and identifying weaknesses in the component skills of communication (Mehta, 2008; Rees et al, 2008). Various methods like cinemeducation, role plays, forum theatre and reflections have been detailed in different chapters of this book. Trained simulated patients are also useful for learning communication skills, and can be used multiple times for the same scenario or different scenarios (Linssen et al, 2007). Simulated patients can also be trained to give feedback in some situations (Liew et al, 2014). The appropriate selection of case scenarios to match the suitable simulated patient needs careful attention. Their training has to be ongoing; they need to be adequately paid and given enough time to learn. The simulated patient program needs significant administrative inputs to maintain records, develop case scenarios and run the sessions. TABLE 6.2: Key communication competencies that can be taught and assessed in different phases of the MBBS curriculum Time in MBBS course

Key competencies to be delivered

Possible settings in existing curriculum

Phase 1 (I–III semester; Preclinical and early paraclinical)

• Building rapport with • Community people exposure visits • Basic interviewing and • OPD settings data gathering skills: • Communication Active listening, display skills laboratory respect, being mindful; awareness of barriers to com­­­munication; nonverbal communication and body language; awareness of cultural contexts of patients; demonstrates empathy • Demonstrates ability to work in a team • Demonstrates respect for patients, peers, seniors and other healthcare pro­fessionals

Possible training Possible assessmethods ment methods • Writing reflections • Role plays • Group discussions • Group projects

• Grading and feedback on reflections

Contd.

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TABLE 6.2: Key communication competencies that can be taught and assessed in different phases of the MBBS curriculum (Contd.) Time in MBBS course

Key competencies to be delivered

Possible settings in existing curriculum

Phase 2 (IV–VII semester; Paraclinical and early clinical)

• Awareness of professio- • Clinical postings: nal roles and responsi­ OPD and wards bilities of a physician • Community • History taking and clinical visits examination skills • Lectures • Demonstrates respect • Communication for patient privacy skills laboratory and confi­dentiality in patient care • Awareness of work ethics and medicolegal aspects • Taking informed consent • Proper prescription writing • Addressing patient queries about procedures; explaining diagnostic and therapeutic options to patients or family members; checking understanding when giving instructions

Possible training Possible assessmethods ment methods • Role plays • Videos • Sessions on prescription writing • Observing and shado­ wing clini­ cians • Practice sessions using real or simulated patients • Writing reflections

• OSCE • Feedback from trained simulated patients

• Role plays

• Feedback from trained simulated patients

• Mini-CEX • Grading and feedback on reflections

• Allowing patients to participate in decision making; understanding patient perspectives and contexts; reaching a shared agreement on treatment options Phase 3 (VIII–IX semester; Clinical years + internship)

• Counseling skills: Exp­­­ laining diagnosis and prognosis • Providing health education to bring about behavioral change • Breaking bad news • Communicating news of terminal illness • Ability to maintain proper documentation in healthcare

• Clinical postings: OPD and wards • Lectures • Community visits • Communication skills laboratory

• Videos • Observing and shadowing clinicians • Practice sessions with real or simulated patients • Writing reflections

• Mini-CEX • Directly observed procedural skills (DOPS) • Grading and feed­­back on ref­l­ections

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Training in nonverbal communication goes hand-in-hand. Clinicians not only need to convey the appropriate nonverbal cues through their body language but must also be sensitive enough to pick up patients’ nonverbal behavior. Many of these behavior patterns are context-dependent and vary with culture and region. Role plays and ‘theatre’ have emerged as methods of getting the students to reflect and learn about the importance of voice, tone or body language (Anderson and Dow, 2011). Students too have to be aware that besides what they learn during training sessions, they need to observe teachers performing in clinical settings. When they observe gaps between what they see and what they were taught, they must be encouraged to reflect, so that they benefit from both positive and negative experiences. Use of narratives, stories and biographies has been recommended to teach students for this purpose (Gupta, 2007; McNeilly et al, 2006). While a very wide range of behavioral and language characteristics contribute to good doctor–patient interactions, most training programs in communication skills revolve around training for specific situations such as breaking bad news, genetic counseling, handling special situations, etc. (Laidlaw et al, 2002). Training in generic competencies of doctor–patient communication, such as making a patient comfortable and free to express their thoughts, effective interviewing, active listening, discussion of treatment options are often overlooked or it is presumed that they have been taught as part of clinical history taking and management (Deveugele et al, 2005). In the initial years, students should be trained in basic interviewing skills. They should gradually be moved to training in handling specific situations in subsequent clinical years. A similar building block approach to gradually developing a hierarchy of skills is also recommended by Epner and Baile (2011). Several medical schools have now established communication skills laboratories on the lines of clinical skills laboratories (Delottinville, 2006). Under competencybased curriculum, MCI has also mandated all medical colleges in India to establish skill labs for enhancing clinical, psychomotor and communication skills of the students (MCI, 2019b). It is important to create learning opportunities within the curriculum where students receive feedback to inculcate communication skills (Anshu, 2016).

ASSESSMENT OF COMMUNICATION SKILLS Assessment can be conducted both in an artificial exam-like situation and in an authentic workplace situation. A combination of the two is perhaps most desirable. Assessment in exam situations provides students appropriate timely feedback and stimuli to improve. When conducted in a workplace situation with observed feedback, assessment gives students practice in different clinical contexts in a nonthreatening environment. Assessment of communication skills can be designed to conform to desired levels of the Miller’s pyramid (Miller, 1990). While written assessments can theoretically test the ‘knows’ and ‘knows how’ levels, there is a little point in granting much

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interpretative value to these tests, as the communication skills of a person are more as a result of his attitude and behavior than his knowledge. It is more relevant to assess what a student is likely to do (‘shows how’) or what he actually does (‘does’) in a certain situation. This requires careful observation of student behavior. Details about assessment of communication skills as part of medical humanities have been presented in Chapter 24 of this book.

FACULTY TRAINING Faculty must develop a consensus on which component skills of communication are to be tested before choosing the appropriate combination of assessment methods for the purpose. The assessors must be trained in their jobs and the tools to be used must be validated before use. A logical approach for communication skills training is to include stakeholders who are most directly involved—the students themselves, faculty, and patients (Schirmer et al, 2005). The trainers for communication skills can be medical school faculty from multiple disciplines, specialists in communication such as psychologists with interest in medical sciences or general practitioners with an interest in medical communication (Deveugele et al, 2005; Shankar et al, 2006). In addition, nurses, paramedical staff or trained personnel can be used in selected situations. Assessors should not only be trained in use of assessment tools, but also in the skill of observation and feedback. A standard workshop-based training of trainers needs to be developed based on national needs. This should provide faculty trainers with the background and practice on facilitation skills (Bylund et al, 2008). This will also promote use of standard training and assessment practices that are essential to sustain learning. Faculty development sessions are also desirable for all faculty members of medical schools since it increases their motivation and self-awareness as teachers (Bird et al, 1993).

TRANSFER OF COMMUNICATION SKILLS TRAINING TO THE ACTUAL WORKPLACE One challenge with formal communication skills training in medical schools is the gap that students observe between the communication patterns taught in training situations and the actual behavior of physicians in clinical settings (Essers et al, 2012). This can be a major barrier to transfer of training. A possible strategy to remove this barrier could be integration of clinical and communication skills teaching in clinical situations. Further, faculty members have to be sensitized to the ‘hidden curriculum and must be aware that they are role models who are knowingly or unknowingly imparting training in communication skills while providing clinical care. Having good communication skills are the cornerstone of being a good physician. Teaching and assessment of communication skills need to be consciously promoted by faculty of all disciplines during undergraduate training. Further, unless assessment of communication skills is emphasized both in workplace and examination settings throughout the MBBS curriculum, these will be relegated to a forgotten corner.

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Disclaimer: This write-up first appeared as an article in Indian Pediatrics (Teaching and Assessing Communication Skills during Undergraduate Training. Indian Pediatrics 2016;53:497–504) before release of AETCOM module. The article has been reprinted with the permission of the Editor. It has been revised minimally to include current guidelines and adapted as per requirement of the book.

BIBLIOGRAPHY • Adkoli BV, Sood R. Faculty development and medical education units in India: A survey.

Nat Med J India 2009;22(1):28–32. • Anderson AD, Dow AW. Teaching empathy to physicians. The Psychology of Empathy. New York: Nova Science Publishers 2011;267–80. • Anshu, Singh T. The art of talking to patients. Frontiers in Social Pediatrics. New Delhi: Jaypee Brothers 2016;199–209. • Aspegren K. BEME Guide no. 2: Teaching and learning communication skills in medicine: A review with quality grading of articles. Med Teach 1999;21(6):563–70. • Aspegren K, Lonberg-Madsen P. Which basic communication skills in medicine are learnt spontaneously and which need to be taught and trained? Med Teach 2005; 27(6):539–43. • Association of American Medical Colleges (1998). Report I: Learning objectives for medical student education. Medical School Objectives Project. Washington DC. • Barakat NG. Interpersonal skills. Libyan Journal of Medicine 2007;2(3):152–53. • Batalden P, Leach D, Susan S, Dreyfus H, Dreyfus S. General competencies and accreditation in graduate medical education: An antidote to overspecification in the education of medical specialists. Health Affairs 2002;21(5):103–11. • Benbassat J. Undesirable features of the medical learning environment: A narrative review of the literature. Advances in Health Sciences Education 2013;18(3):527–36. • Bird J, Hall A, Maguire P, Heavy A. Workshops for consultants on the teaching of clinical communication skills. Med Educ 1993;27(2):181–85. • Brown RF, Bylund CL. Communication skills training: Describing a new conceptual model. Acad Med 2008;83(1):37–44. • Bylund CL, Brown RF, di Ciccone BL, Levin TT, Gueguen JA, Hill C, Kissane DW. Training faculty to facilitate communication skills training: development and evaluation of a workshop. Patient Education and Counseling 2008;70(3):430–36. • Chhatwal J. Creating a demand for communication skills training in India. Med Educ 2009;43(5): 478. • Chichirez CM, Purcarea VL. Interpersonal communication in healthcare. Journal of Medicine and Life 2018;11(2):119–22. • Choudhary A, Gupta V. Teaching communications skills to medical students: Introducing the fine art of medical practice. International Journal of Applied and Basic Medical Research 2015; 5(1):41. • Delottinville C. An interprofessional communication skills lab: A pilot project. Education for Health 2006;19(3):380–84. • Deveugele M, Derese, A, De Maesschalck, S, Willems, S, Van Driel, M, and De Maeseneer, J. Teaching communication skills to medical students, a challenge in the curriculum? Patient education and counseling 2005;58(3):265–70.

Communication and Interpersonal Skills

59

• Epner, DE, and Baile, WF. Wooden’s pyramid: Building a hierarchy of skills for successful communication. Medical teacher 2011;33(1):39–43.

• Essers, G, Van Weel-Baumgarten, E, and Bolhuis, S. Mixed messages in learning

communication skills? Students comparing role model behaviour in clerkships with formal training. Med Teach 2012;34(10):659–65.

• Frank, JR (2005). The CanMEDS 2005 physician competency framework. Accessed on

23.12.2022. Available from: http://www.ub.edu/medicina_unitateducaciomedica/ documentos/CanMeds.pdf

• Gaufberg, EH, Batalden, M, Sands, R, and Bell, SK. The hidden curriculum: what can we

learn from third-year medical student narrative reflections? Acad Med 2010;85(11):1709–16.

• General Medical Council (2009). Tomorrow’s doctors: outcomes and standards for undergraduate

medical education. London, UK: General Medical Council. Accessed on 20.12.2022. Available from: http://www.gmc-uk.org/Tomorrow_s_Doctors_1214.pdf_48905759.pdf

• Gupta, DS. Between stillness and story: lessons of children’s illness narratives. Pediatrics 2007;119(6):1384–91.

• Keller, VF, and Carroll, JG. A new model for physician-patient communication. Patient Education and Counseling 1994;23(2):131–140.

• Kurtz, SM, and Silverman, JD. The Calgary—Cambridge Referenced Observation Guides:

an aid to defining the curriculum and organizing the teaching in communication training programmes. Med Educ 1996;30(2):83–89.

• Laidlaw, A, and Hart, J. Communication skills: An essential component of medical curricula. Part I: Assessment of clinical communication: AMEE Guide No. 51. Med Teach 2011;33(1):6–8.

• Laidlaw, TS, MacLeod, H, Kaufman, DM, Langille, DB, and Sargeant, J. Implementing a

communication skills programme in medical school: needs assessment and programme change. Med Educ 2002;36(2):115–24.

• Liew, SC, Dutta, S, Sidhu, JK, De-Alwis, R, Chen, N, Sow, CF, and Barua, A. Assessors for communication skills: SPs or healthcare professionals? Med Teach 2014;36(7):626–31.

• Linssen, T, Van Dalen, J, and Rethans, JJ. Simulating the longitudinal doctor−patient

relationship: experiences of simulated patients in successive consultations. Med Educ 2007;41(9):873–78.

• Makoul G. Communication research in medical education. In: Jackson L, Duffy BK (eds). Health Communication Research: A Guide to Developments and Directions. Westport, CT: Greenwood Press 1998;p.17–35.

• McConnell, CR. Interpersonal skills, What they are, how to improve them, and how to apply them. Healthcare Management (Frederick) 2004;23(2):177–87.

• McNeilly, P, Read, S, and Price, J. The use of biographies and stories in paediatric palliative care education. International J of Palliative Nursing of 2008;14(8):402–6.

• Medical Council of India (1997). Regulations on Graduate Medical Education. Accessed on

22.12.2022. Available from: https://www.nmc.org.in/wp-content/uploads/2017/10/ GME_REGULATIONS-1.pdf.

• Medical Council of India (2018). Attitude, Ethics and communication (AETCOM) Competencies for the Indian Medical Graduate. Accessed on 22.12.2022. Available from: https://www. nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf.

60

Humanities in Medical Education

• Medical Council of India (2019a). The regulations on graduate medical education, 1997–Part II. Accessed on 22.12.2022. Available from: https://www.nmc.org.in/ActivitiWebClient/ open/getDocument?path=/Documents/Public/Portal/Gazette/GME-06.11.2019.pdf.

• Medical Council of India (2019b). Skill training module for undergraduate medical education

program, 2019. Accessed on 22.12.2022. Available from: https://www.nmc.org.in/ MCIRest/open/getDocument?path=/Documents/Public/Portal/LatestNews/Skill%20! Module_23.12.2019%20(1).pdf.

• Mehta, PN. Communication skills-talking to parents. Indian Pediatrics 2008;45(4):300–4. • Miller, GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65(9):S63–7.

• Novack, DH, Dubé, C, and Goldstein, MG. Teaching medical interviewing: a basic course

on interviewing and the physician–patient relationship. Archives of Internal Medicine 1992;152(9):1814–20.

• Rees, C, Sheard, C, and McPherson, A. Medical students’ views and experiences of

methods of teaching and learning communication skills. Patient Education and Counseling 2004;54(1):119–21.

• Rider EA (2010). Interpersonal and communication skills. In: Rider EA, Nawotniak RH, eds. A Practical Guide to Teaching and Assessing the ACGME Core Competencies. 2nd ed. Marblehead, MA: HCPro, Inc.

• Rider, EA, Hinrichs, MM, and Lown, BA. A model for communication skills assessment across the undergraduate curriculum. Med Teach 2006;28(5):127–34.

• Rosenbaum, ME, Ferguson, KJ, and Lobas, JG. Teaching medical students and residents skills for delivering bad news: a review of strategies. Acad Med 2004;79(2):107–17.

• Rowland-Morin, PA, and Carroll, JG. Verbal communication skills and patient satisfaction:

A study of doctor–patient interviews. Evaluation and the Health Professions 1990;13(2):168–85.

• Schirmer, JM, Mauksch, L, Lang, F, Marvel, MK, Zoppi, K, Epstein, RM, and Pryzbylski, M. Ass­ essing communication competence: a review of current tools. Fam Med 2005;37(3):184–92.

• Shankar, R, Dubey, A, Mishra, P, Deshpande, V, Chandrasekhar, T, Shivananda, P. Student

attitudes towards communication skills training in a medical college in Western Nepal. Education for Health 2006;19(1):71–84.

• Shapiro, SM, Lancee, WJ, and Richards-Bentley, CM. Evaluation of a communication skills program for first-year medical students at the University of Toronto. BMC Med Educ 2009;9(1):11.

• Shendurnikar, N, and Thakkar, PA. Communication skills to ensure patient satisfaction. The Indian Journal of Pediatrics 2013;80(11):938–43.

• Silverman, J, and Kinnersley, P. Doctors’ nonverbal behaviour in consultations: look at the patient before you look at the computer. Brit J Gen Pract 2010;60(571):76–78.

• Simpson, JG, Furnace, J, Crosby, J, Cumming, AD, Evans, PA, David, MFB, and McPhate, GF. The Scottish doctor–learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners. Med Teach 2002;24(2):136–43.

• Stewart, M, Brown, JB, Weston, W, McWhinney, IR, McWilliam, CL, and Freeman, T (2013). Patient-centered medicine: transforming the clinical method. CRC press.

• Supe, AN. Interns’ perspectives about communicating bad news to patients: A qualitative study. Education for Health 2011;24(3):541.

Communication and Interpersonal Skills

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• Tamblyn, R, Abrahamowicz, M, Dauphinee, D, Wenghofer, E, Jacques, A, Klass, D,

Du Berger, R. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA 2007;298(9):993–1001. • Van-Dalen, J, Kerkhofs, E, van Knippenberg-Van Den Berg, BW, van Den Hout, HA, Scherpbier, AJJA, and Van der Vleuten, CP. Longitudinal and concentrated communication skills programmes: two dutch medical schools compared. Advances in Health Sciences Education 2002;7(1):29–40.

• Verma, M, and Singh, T. Communication skills in clinical practice: fad or necessity? Indian Pediatrics 1994;31:237–37.

7 Professionalism and Ethics Rajiv Mahajan, Tejinder Singh

INTRODUCTION A professional is a person with expert knowledge and skills, who reflects ethical behavior and exhibits integrity and altruism, having a license and is accountable, who is self-regulating—individually and as a group. Professionalism includes attributes, behaviors, commitments, values and goals that characterize a profession (Mahajan et al, 2016). The term professionalism is multidimensional that includes many subcomponents. The scaffold for professionalism includes four pillars— excellence, humanism, accountability, and altruism which rests on a base of ethics, communication skills, and clinical competence (Ludwig, 2014). Professionalism is a sort of bridge between clinical expertise of a clinician and his/her acumen for soft skills. The American Board of Medical Specialties asserts that ‘medical professionalism is a (normative) belief system about how best to organize and deliver healthcare, which calls on group members to jointly declare (‘profess’) what the public and individual patients can expect regarding shared competency standards and ethical values and to implement trustworthy means to ensure that all medical professionals live up to these promises’ (Wynia et al, 2014). The regulatory body in India in its new competency based medical curriculum has identified professionalism as one of the five roles of Indian Medical Graduate as a ‘professional who is committed to excellence, is ethical, responsive and accountable to patients, community and the profession’ (Medical Council of India, 2018a). The five global competencies under the role, professional, include: • Practice selflessness, integrity, responsibility, accountability and respect. • Respect and maintain professional boundaries between patients, colleagues and society. • Demonstrate ability to recognize and manage ethical and professional conflicts. • Abide by prescribed ethical and legal codes of conduct and practice. • Demonstrate a commitment to the growth of the medical profession as a whole. On the other hand, ethics is the study of morality—careful and systematic analysis of moral decisions and behaviors and practicing those decisions. Ethics has always been an essential component of medical practice. Medical ethics focuses primarily 62

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on issues arising out of the practice of medicine. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. Ethical principles such as respect for persons, informed consent, and confidentiality are basic to the physician–patient relationship. Historically, the ethics of patient care has developed along two discrete paths—one branch was influenced by breakthroughs in other academic fields like philosophy and law and the field was known as ‘Bioethics’, and the second branch ‘Professional Ethics’ took its shape from the perceptions centered around the integrity of individual clinician (MacKenzie, 2007). The origin of ‘professional ethics’ dates back to 2,000 B.C. and takes its roots from the code of Hammurabi—the first known code of medical ethics, and later by the 5th century B.C. Hippocratic Oath (Markel, 2004).

ATTRIBUTES OF MEDICAL PROFESSIONALISM Charter on medical professionalism (Medical Professionalism Project, 2002) characterized a set of professional responsibilities for medical professionals as: • Commitment to professional competence • Commitment to honesty with patients • Commitment to patient confidentiality • Commitment to maintaining appropriate relations with patients • Commitment to improving quality of care • Commitment to a just distribution of finite resources • Commitment to scientific knowledge The elements of professionalism, as described under CanMEDS framework (Frank, 2005) include: Altruism, integrity and honesty, compassion and caring, morality and codes of behavior, responsibility to society, responsibility to the profession, including obligations of peer review, responsibility to self, including personal care in order to serve others, commitment to excellence in clinical practice and mastery of the discipline, commitment to the promotion of the public good in healthcare, accountability to professional regulatory authorities, commitment to professional standards, self-assessment, and disclosure of error or adverse events. Three key competencies to execute this professional role have been demarcated as: • Demonstrate a commitment to their patients, profession, and society through ethical practice. • Demonstrate a commitment to their patients, profession, and society through participation in profession-led regulation. • Demonstrate a commitment to physician health and sustainable practice. As is evident, though definitions and explicit meaning of professionalism may differ across different regulatory bodies and medical societies, attributes like integrity, honesty, ethics, compassion, altruism, respect for others, reflective behavior and self-assessment remain uniform elements and attributes of medical professionalism across globe (Fig. 7.1).

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Fig. 7.1: Attributes of medical professionalism

TEACHING PROFESSIONALISM AND ETHICS: RATIONALE It is largely documented that political, legal and market-driven forces leading to commercialization of medical practice is producing huge stress on the clinical practice (Barondess, 2003; Hafferty, 2006). Recognizing that such a stress can disrupt the delicate trustworthiness prevailing among pillars and stakeholders of clinical practice, viz. physicians, patients and society, concerns have been raised about inculcating such skills among medical graduates. Professionalism and ethics are not evident when one practice it; but are documented in no uncertain terms when one fails to practice it—and labeled as unprofessional and unethical. It has been documented in literature that glimpses of this unprofessional and unethical behavior show-up during medical training period itself. Papadakis et al (2004) reported that the physicians facing disciplinary actions by regulatory boards had problematic behavior during their medical school days too. This case control study showed that disciplined physicians were more likely to have concern/problem/extreme excerpts in their medical school file (odds ratio, 2.15; 95% confidence interval, 1.15–4.02; P = 0.02). In another retrospective cohort study, Papadakis et al (2008) concluded that poor behavioral and cognitive performance measures earned during residency is associated with higher risk for state licensing board actions against practicing physicians throughout the career. As is evident from both studies, it is safe to conclude that unprofessional behavior during graduation correlates with subsequent unprofessional behavior during practice, and thus, professionalism should be an essential competency that must be demonstrated for a student to graduate from medical school.

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Our medical education has made little efforts in teaching professionalism and ethics to medical students. On the other hand, it has been repeatedly reported that most of the doctor–patient disputes and litigations are not due to lack of clinical competence on part of treating physicians, but are due to lack of professional competence and ethical behavior. Thus, the rewards of teaching professionalism and ethics to medical graduates are unequivocal.

TEACHING PROFESSIONALISM AND ETHICS: OPERATIONAL ASPECTS Professionalism has been recognized by all regulatory and licensing authorities across the globe as a core competency/role of physicians. However; our medical education has made little efforts in teaching professionalism to medical students (Cruess et al, 2014). Similarly, we are paying attention to bioethics and ethical regulations from a long period of time, but paying little attention to include any formal course work for same in medical training. Though medical education regulatory body in India has made substantial efforts to define competencies for executing the ‘professional’ role of Indian Medical Graduate (IMG) and releasing a document on attitude, ethics and communication (AETCOM) module, but to inculcate such competencies in medical students, it is expected that the ‘professionalism’ must be reflected in the vision and mission document of the institutes. An institutional framework, detailing content, teaching and assessment tools and assessment opportunities can definitely help in effective teaching of professionalism and ethics (Modi et al, 2014). Professionalism and ethics training must be a longitudinal program, spread across undergraduate training, internship and postgraduate training. It must be included in the formal curriculum. However, delivery through ‘hidden curriculum’ will go unabated. Many teaching tools have been documented in literature, which can help in the delivery of such curricular content like interactive lectures, case based learning, reflective practice, portfolios, art-based techniques (Modi et al, 2014). Role plays, standardized patients, group discussions are other documented methods of teaching professionalism and ethics (Birden et al, 2013). Cinemeducation—use of cinema for medical education—has also been used as a method to teach professionalism. Klemenc-Ketis and Kersnik (2011) concluded that controlled environment of movies enable students to explore values and attitudes without affecting their personal integrity. In an observational cross-sectional study in obstetrics and gynecology department, Panda et al (2022) suggested nine possible strategies of teaching and learning professionalism, which included: Professional role model; early clinical exposure; recruiting faculty who had compressive training in medical education before joining medical institute; teaching and assessing communication skill to each student; conducting seminars, didactic lectures and small group discussion on professionalism; reflective practice on teaching–learning professionalism; mentorship; faculty development program on professionalism; and old practice of hidden curriculum. Interestingly, preferences of students and faculty for these strategies differ. Strategies preferred by students were—early clinical exposure, recruiting faculty with prior comprehensive training in medical education, and

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reflective practice; while teachers’ preference was for teaching and assessing communication skill to each student, mentorship, and early clinical exposure.

CURRICULAR OPPORTUNITIES Teaching professionalism and ethics as standalone subjects, without any integration with the curriculum proper will be of no use. Sensing the same, regulatory body of medical training in India has tried to integrate training in professionalism and ethics to undergraduate medical students within the curriculum itself (Medical Council of India, 2019). The professional development including attitude, ethics and communication (AETCOM) module is a part of undergraduate medical curriculum in India. The program has been launched with specific objectives (Box 7.1). Separate time slot has been allocated for this program, during all professional years of medical undergraduate training. This is a longitudinal program and separate AETCOM module has been released by regulatory body for the purpose of instructions (Medical Council of India, 2018b). Another important document related to professionalism and ethics is the Indian Medical Council (professional conduct, etiquette and ethics) Regulations, 2002 (Medical Council of India, 2002). This document deals with the professional conduct and ethical regulations that must be followed by Indian physicians while practicing ‘medicine’ in India. It is important to sensitize undergraduate medical students about these regulations during training itself, to avoid future complications.

BOX 7.1: Objectives of the professionalism and AETCOM module of National Medical Commission At the end of the program, learner must demonstrate the ability to: • Understand and apply principles of bioethics and law as they apply to medical practice and research • Understand and apply the principles of clinical reasoning as they apply to the care of the patients • Understand and apply the principles of system based care as they relate to the care of the patient • Understand and apply empathy and other human values to the care of the patient • Communicate effectively with patients, families, colleagues and other healthcare professionals • Understand the strengths and limitations of alternative systems of medicine • Respond to events and issues in a professional, considerate and humane fashion • Translate learning from the humanities in order to further his/her professional and personal growth (Medical Council of India, 2019)

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ASSESSMENT OF PROFESSIONALISM AND ETHICS There must be ample assessment opportunities—both formative and summative— for assessment of professionalism and ethics during medical training itself. Without assessment, teaching would not prove effective. Moreover, without assessment, teachers would not get an idea if the objectives are being achieved or not. For assessment to be effective itself, it must be made longitudinal, woven within course delivery, and should not be conducted as ‘screen-shot’ and ‘standalone’ assessment events. Such longitudinal and observational based assessment of professionalism and ethics will remove the possibility of ‘Hawthorne effect’ also. Though, our over-reliance on objective assessment and denial of subjective assessment will be a big issue while assessing professionalism and ethics, nonetheless by using multiple assessors, multiple tools, and multiple assessments rule; the reliability of such subjective assessments can be improved. Other concern while assessing professionalism will be the lack of uniformity in ‘stated definition’ and ‘cultural context’ of such definitions. What is unprofessional conduct in one culture may not be same in another culture, making assessment difficult. Lack of training of faculty to conduct assessment on such attitudinal and conduct criteria is the biggest challenge. Another dilemma is—to choose between checklist based assessment and global ratings. Though the documented literature has time and again established the equivocal assessment value of checklist and global ratings in assessment of professional behavior (Turner et al, 2014), our fixation for objectivity is hampering the free use of global rating scales for assessment of professionalism and ethics. As professionalism and ethics is multidimensional, so a combination of assessment tools is required. Nine clusters of assessment tools were identified by Wilkinson et al (2009) as: Observed clinical encounters, collated views of coworkers, records of incidents of unprofessionalism, critical incident reports, simulations, paper-based tests, patients’ opinions, global views of supervisor, and self-administered rating scales. Many tools for assessment of professionalism have been reported under these clusters. Few tools for assessment of professionalism have been detailed in Table 7.1. The specific tool: Professionalism Mini-Evaluation Exercise (P-MEX) has been explained in Chapter 24 of this book. TABLE 7.1: Tools for assessment of professionalism Tools

Context

Miller’s level

Professionalism Mini-Evaluation Exercise (P-MEX)

Observation based

Shows

Standardized direct observation assessment tool

Observation based

Shows

Multisource feedback

Collated views

Does

Incident reporting form/critical incident report

Record of incidents of Does unprofessionalism

Case based discussion

Real/simulated patient

Multiple choice questions, objective structure video Paper-based tests examination

Knows how Knows

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Similarly, paper based tests, direct observation, multi-source feedback, peer feedback, critical incident report can be used for assessment of ethical behavior and conduct. Opportunities like reflective writing, role plays, cinemeducation can be used for both teaching and assessment of professionalism and ethics.

CONCLUSION In the absence of uniformity about the attributes of professionalism and ethics, social and cultural influences on professional conduct and lack of curricular mandate, the process of teaching and assessment of professionalism and ethics as part of routine medical training has not been developed to its full potential. Though efforts have been made in bits and pieces, it must be incorporated as a regular component of medical undergraduate and postgraduate training. Such incorporation will go a long way in building healthy doctor–patient relationships.

BIBLIOGRAPHY • Barondess JA. Medicine and professionalism. Arch Intern Med 2003; 163:145–49. • Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. Med Teach 2013;35(7):e1252–66.

• Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. Acad Med 2014;89(11):1446–51.

• Frank JR (ed). The CanMEDS 2005 physician competency framework. Better standards

better physicians, better care. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2005. Accessed on 29.09.2022. Available from: http://www.ub.edu/medicina_ unitateducaciomedica/documentos/CanMeds.pdf.

• Hafferty F. Viewpoint: the elephant in medical professionalism’s kitchen. Acad Med 2006;81:906–14.

• Klemenc-Ketis Z, Kersnik J. Using movies to teach professionalism to medical students. BMC Med Educ 2011;11(1):60. Accessed on 10.10.2022. Available from: http://www. biomedcentral.com/1472-6920/11/60.

• Ludwig S. Domain of competence: Professionalism. Acad Pediatr 2014; 14(Suppl 2):S66–69. • MacKenzie CR. Professionalism and Medicine. HSS J 2007;3:222–27. • Mahajan R, Aruldhas BW, Sharma M, Badyal DK, Singh T. Professionalism and ethics:

A proposed curriculum for undergraduates. Int J of Appl Basic Med Res 2016;6(3):157–63.

• Markel H. “I swear by Apollo”—on taking the Hippocratic oath. N Engl J of Med 2004;350:2026–29.

• Medical Council of India in 2018a. Competency Based Undergraduate Curriculum for the Indian Medical Graduate. Accessed on 30.09.2022. Available from: https://www. nmc.org.in/wp-content/uploads/2020/01/UG-Curriculum-Vol-I.pdf.

• Medical Council of India in 2018b. Attitude, Ethics and Communication (AETCOM)

competencies for the Indian Medical Graduate. Accessed on 10.10.2022. Available from: https://www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf.

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• Medical Council of India. Indian Medical Council (Professional conduct, Etiquette and

Ethics) Regulations, 2002. Accessed on 10.10.2022. Available from: https://www.nmc. org.in/wp-content/uploads/2017/10/Ethics-Regulations-2002.pdf. • Medical Council of India. Regulations on Graduate Medical Education (Amendment), 2019. Accessed on 10.10.2022. Available from: https://www.nmc.org.in/ActivitiWebClient/ open/getDocument?path=/Documents/Public/Portal/Gazette/GME-06.11.2019.pdf. • Medical Professionalism Project. Medical professionalism in the new millennium: A physicians’ charter. Clin Med 2002; 2(2):116–18. • Modi JN, Anshu, Gupta P, Singh T. Teaching and assessing professionalism in the Indian context. Indian Pediatr 2014;51(11):881–88. • Papadakis MA, Arnold GK, Blank LL, Holmboe ES, Lipner RS. Performance during internal medicine residency training and subsequent disciplinary action by state licensing boards. Ann Intern Med 2008;148:869–76. • Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79:244–49. • Turner K, Bell M, Bays L, Lau C, Lai C, Kendzerska T, et al. Correlation between global rating scale and specific checklist scores for professional behavior of physical therapy students in practical examinations. Education Research International, 2014. Accessed on 12.10.2022. Available from: https://downloads.hindawi.com/journals/ edri/2014/219512.pdf. • Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: Results of a systematic review. Acad Med 2009;84(5):551–58. • Wynia MK, Papadakis MA, Sullivan WM, Hafferty FW. More than a list of values and desired behaviors: A foundational understanding of medical professionalism. Acad Med 2014;89(5):712–14.

8 Attitudes, Empathy and Altruism Shaista Saiyad Key Points q In health profession, appropriate attitude is important as it is directly related to clinical competence and performance of doctors. q Clinical

empathy involves affective appreciation of patient’s feelings followed by empathetic behavior back to the patient.

q Altruism,

the selfless behavior of the doctor enhances wellbeing of the patient. q Attitudes, empathy and altruism can be learned, modulated and enhanced. Cultivation of these attributes early in medical curriculum can help students become unconsciously competent.

INTRODUCTION Attitudes, empathy and altruism are inherent humanistic qualities of a human being. These humane attributes originate from subcortical areas of central nervous system mainly limbic system and hypothalamus. These can be considered as basic instincts or innate human attributes. These attributes determine social relationships and human behavior in general.

ATTITUDE According to Gordon Allport (1935), ‘an attitude is a mental and neural state of readiness, organized through experience, exerting a directive or dynamic influence upon the individual’s response to all objects and situations with which it is related’. Attitude is a learned human attribute to evaluate people, issues or events in a particular manner. Attitudes can be learned and/or modulated by conditioning the nervous system. Attitude is ‘reaction or way of being, in relation to people and objects’. Overall attitude of a person determines the response, which in turn depends upon the intention. Attitude determines one’s behaviour. Every attitude has three components which can be represented in ABC model of attitudes (Fig. 8.1) (Long-Crowell, 2020). Affective component refers to the emotional reaction doctor has towards the patient and is called affectively based attitude. This type of attitude demonstrates moral values and beliefs. Behavior component refers to how a doctor behaves when they come in contact to patients—whether positive attitude or negative attitude. Cognitive component refers to our thoughts and beliefs about the patient. Although 70

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Fig. 8.1: Components of attitude

every attitude has these three components, a particular attitude can have one component more than the other. Attitudes of individuals are acquired and developed during life. They belong to four groups based on their functions: Utilitarian, knowledge, ego defensive, value expressive (Katz D, 1960) (Table 8.1). According to mere-exposure effect, people are more likely to have positive attitude when exposed to them more frequently (Zajonc et al, 1968). Hence, whatever the attitude an individual has, they can be learned and modified too. Attitudes, unlike personality, can change with experiences. As far as medicine is concerned, attitude is related to characteristics and behavior of the physician towards patients and all the stakeholders. Attitude is exhibited in terms of taking appropriate consent from patient before any intervention; causing no harm to the patient—directly or indirectly; provide treatment to the best of knowledge attitude and skills; confidentiality and privacy; nonjudgmental, respectful, and good communication; practicing good moral values and ethics; and listening skills. Appropriate attitude is important as it is directly related to TABLE 8.1: Groups of attitudes according to their function Utilitarian function attitudes

These attitudes are manifested to amplify rewards and minimize punishments (Katz D, 1960). These help in increasing utility and improve quality of life by increasing task efficiency

Knowledge function attitude

These help individuals to understand world around them. Such individuals try to understand occurrences out of their desire and not due to their relevant needs (Carpenter C et al, 2013)

Value expressive function attitudes These attitudes help in outward expression of innate values and self concept. Expression of these attitudes communicate vital ideas about self to others (Carpenter C et al, 2013) Ego defensive function attitude

These attitudes help to protect self-worth and self-esteem of individual from internal as well as external unpleasantness

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clinical competence and performance of doctors. Using appropriate learning and assessment methods, positive attitudes can be inculcated in the learners. Educational interventions for improving attitudes of medical students have shown encouraging and mixed results (Leaune E et al, 2021). In India, National Medical Council has rolled out attitude, ethics and communication (AETCOM) module for acquisition of competency in attitudinal domain. The basic concept of AETCOM module is, changing a person’s attitude can change his/her behaviour (MCI, 2018).

EMPATHY Empathy is the capacity to share the emotional states of others. Origin of word ‘empathy’ is from German term ‘einfuhlung’ literally meaning ‘in feeling’. Sympathy means just ‘feeling sorry’ for the sufferer and acknowledging their suffering, whereas empathy means literally going through and feeling other person’s suffering or emotions, by imagining oneself in their shoes. It includes attributes like knowing other’s thoughts and feelings, feeling sadness or distress by witnessing other’s suffering and thus imagining how sufferer experiences pain or distress. Empathy includes empathetic receptivity, empathetic understanding, empathetic interpretation and empathetic listening (Fig. 8.2) (Agosta, n.d). Hence, the capacity to understand and going through another feelings is supported by both affective (e.g. after resonance) and cognitive (e.g. perspective taking) mechanism in the brain. ‘Clinical empathy’ is affective appreciation of patient’s feelings followed by empathetic behavior back to the patient. It has been observed that doctors who are more empathetic are less prone to stress and have high levels of job satisfaction. It has been discovered that there is special gene for empathy, kindness and humanism, which indicates that some individuals are bound to be more empathetic and compassionate. However, recent research has shown that empathy can be cultivated as well as enhanced (Kelm et al, 2014). It can also be learned, measured, modified, sustained and role modeled. Empathy is considered to be important component of human altruism.

Fig. 8.2: Components of empathy

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‘Cognitive empathy’ indicates understanding of other person’s state through cognitive process. It includes specific thought process that occurs to understand, empathize and provide help to the needy. This is the need of the hour in current Indian Medical Graduates (IMG). Since the cognitive attribute is too high in medical students, they can be taught to develop clinical empathy which would improve doctor–patient relationship and help society in long run. Compassion is a step further than empathy. It is feeling of someone’s suffering and wanting to help them. The desire to help distinguishes compassion from empathy. In context to medical education, IMGs should not only be empathetic but also compassionate. Compassion can lead to altruism—helping others even if it involves sacrifice, on part of the doctor.

ALTRUISM Altruism is unselfish or selfless behavior of doctor to enhance wellbeing of the patient. It is behavior intended to benefit others, even if it requires sacrifice on part of the altruistic individual. Also, altruism is complete only if it includes action, in addition to good intentions and wellbeing thoughts. Altruism should be performed without any anticipatory reward or welfare by altruist. In medicine, doctors exhibit altruism in many forms like working in hospitals beyond duty hours, donating blood and money for the patients, providing free of cost treatment to patients, risking their lives during disease outbreaks, wars, emergencies, etc. (Jones, 2002). Since long, it has been accepted as a part of the duty of the doctors. Epstein and Hundert (2001) have defined professional competence as ‘the habitual and judicious use of communication, knowledge, skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served’. Hence, professional competence includes placing selfinterest below interest of patients and thus trying to achieve high moral standards and investing in humanistic core values. Altruism cannot be called a fiduciary duty of doctor, but, medical professionals should constantly try to achieve it consciously. It has been observed that altruism trait is on decline among doctors (Burks et al, 2012). This has resulted in mistrust in doctor–patient relationship. Practicing true ‘altruism’ has been criticized by some as far as medical practice is concerned. Some medical professionals are of the opinion that practicing ‘true altruism’ is like putting too much demands on doctors and is highly overrated. ‘Prosocial behavior’ or ‘beneficence’ is considered to be more appropriate than altruism. As discussed earlier, compassion leads to altruism or in other words, compassion is main motivator of altruism. Altruism is associated with any type of helping behavior. It is a motivational state with the ultimate goal of protecting the welfare of patients, without the expectation of reciprocity or compensation. Altruistic individuals place interest of others before their own. Empathy–altruism hypothesis claims that empathy evokes altruism (Batson et al, 2015; Batson et al, 1981). It is

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said that altruistic actions help the altruistic person achieve peace and stress-free attitude, in addition to helping the needy. Altruistic behavior promotes moral and ethical behavior and lack of it is a threat to society as a whole. Altruism is called ‘reciprocal altruism’ when we expect people, whom we helped to help us in future. Training doctors and medical students in meditation, self-assessment, selfreflection, and emotional intelligence will help healthcare professionals to cultivate altruism or pro-social behavior. For successful and competent IMGs, altruism and other attributes of humanism should be incorporated into roots of medical curriculum.

ATTITUDE, EMPATHY AND ALTRUISM IN CONTEXT TO MEDICAL CURRICULUM It has been observed that empathy, altruism and attitude show a decline in medical students as they progress forward through their medical education. This can be related to extreme stress and work pressure encountered by students during their medical studies. Students show increased sense of detachment from suffering of patients and their emotional demands. It maybe their self-preservation or protective technique to face adverse challenges during medical education and thereafter. Down regulation of soft skills can be attributed to medical training stress, stressful learning environment and race for mastering medicine. Today’s medical education is predominantly disease centered rather than humanistic and patient centered. This has led to disconnected, clinically neutral and socially detached doctors. Since most of the medical students learn soft skills by role modeling, appropriate learning environment for imbibing humanistic qualities are limited. This has resulted in faulty—‘art of doctoring’. Traditionally, medicine has always been related to patient suffering domain, giving it a dark tag. In fact, it is the only profession which is related to sense of achievement or wellbeing, because at the end of the day, doctors heal patients. But this aspect of doctors has never been highlighted. Today’s medical students have been trained for linear, analytical and evidence-based thinking only. This approach hinders them in generating new ideas and lateral, horizontal thinking. Halpern in her work strongly makes an argument for developing empathy in clinical encounters and healthcare as the way forward to humanize medical practice (Halpern, 2001). The poem by Paralikar (2019), ‘Are they still noble?’, aptly captures the issue of downfall of empathy and altruism in doctors (Box 8.1). The overall goal of undergraduate medical education program as envisaged in the revised Regulations on Graduate Medical Education is to create an Indian Medical Graduate (IMG) possessing requisite knowledge, skills, attitudes, values and responsiveness, so that he or she may function appropriately and effectively as a physician of first contact of the community while being globally relevant (MCI, 2019). In order to fulfill this goal, the IMG must be able to function appropriately and effectively in her/his roles as clinician, leader and member of the healthcare team and system, communicator, lifelong learner and a professional. Of the five roles, our IMGs are most proficient in role of clinician. Some IMGs are good communicators, some are lifelong learners, some professionals and some are leaders. For competent

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BOX 8.1: A poem depicting downfall of empathy and altruism in doctors Are they still noble? Noble men in a noble craft, Then why do the restless folks repeatedly ask: Are these men noble indeed, Still in their cherished craft? They care compassionately for the sick, And tend undaunted to the wounded: It’s only that some of their acts, Seem brazenly unfounded. No history and laboratory tests galore; Physical examination just ignored; When they pen down the list of drugs, They are much more than needed for the bugs. Then there are righteous men too, Who dutifully abide by the ethical principles, Laid down by the Luminaries of this noble profession. To state it simply: Shades of grey, And not black and white, Represent the reality. Yes, some men, Do indulge in Not so noble deeds; But does it make all of them shady indeed? [Reproduced with permission from author, editor and journal publisher: Paralikar S. Are they still noble? J Res Med Educ Ethics 2019;9(2):91-92.]

doctor, we require our IMGs to possess all roles in equal proportion, without any element of ‘some’, because medical professionals deal with human lives. Also five roles can be inculcated in IMGs only if they are competent in all the three domains: Cognitive, psychomotor and affective. Affective domain involves feelings, emotions and attitudes. It typically deals with sensitization, awareness and growth in attitudes. The affective domain (Krathwohl et al, 1964) can be broken down into a hierarchy. The hierarchy includes five different levels of affective domain including attitudes, from the simplest to the most complex (Fig. 8.3). The attitudes in the affective domain are divided into five different levels, ranging from the most simple—basically the willingness to pay attention, to the most complex—when a person’s behaviors are consistently controlled by their value system. Domain forms hierarchical structure, based on principle of internalization. Internalization is a process which goes from general awareness to a point where

Fig. 8.3: Hierarchical level of affective domain

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effect is internalized and consistently controls our behavior. It is the state of total automatic performance, without effort. While learning attributes of humanities like attitude, altruism and empathy, students pass through various domains ranging from receiving to characterization. When the values get embedded in the roots of students, they become unconsciously competent in providing holistic care to the patients. According to AETCOM module, undergraduate medical students are expected to acquire and demonstrate following attributes towards patients, colleagues and self; by the time they graduate (Table 8.2). Dhaliwal et al has proposed ABCDE paradigm as an integrated, interdisciplinary medical humanities approach to teach medical students; comprising of: Appropriate, analytical attitude, ethical and professional behaviour, effective communication, respect for diversity, empathy (Dhaliwal et al, 2015). The ABCDE paradigm refers to our belief that the medical humanities can be used to help medical practitioners develop “ethical and professional attitudes and behavior”, while also honing communication skills, respect for diversity, and empathy. TABLE 8.2: Expected attributes from medical students, related to affective/attitudinal domain (MCI, 2018) Patients

Colleagues and other stake- Self holders

• Develop appropriate attitude with patients in terms of attributes like—nonmaleficence, autonomy, shared responsibility, beneficence, justice, patient privacy, consent, confidentiality, conflict of interest, empathy, altruism. • Communicate to patients in a patient, respectful, nonthreatening, nonjudgemental and empathetic manner • Follow risk management and medical error reduction practices where appropriate • Have awareness regarding implications and response to medical negligence, malpractices

• Respect physician industry relationship • Respect in relationship with patients, colleagues, fellow team members, superiors and other healthcare workers • Respect and follow the cor­rect procedure when handling cadavers and other biologic tissues • Have awareness regarding conflicts of interest in professional relationships and the correct response to these conflicts • Work in a mentoring relationship with junior colleagues

• Have adequate knowledge and use of information tech­­ nology for appropriate patient care and continued learning • Have adequate and appropriate personal grooming for healthcare responsibilities • Demonstrate awareness of one’s limitations and seek help and consultations appro­ priately • Form and function in appropriate professional networks • Pursue and seek career advance­ ment • Time management • Balance personal professional priorities

CONCLUSION Attitude, altruism and empathy are essential components of humanities. Honing of these attributes by medical students and doctors help them in ‘art of holistic healing’. These are absolutely required for becoming competent healthcare professionals, benefiting society and overall healthcare system.

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BIBLIOGRAPHY • Agosta, L (nd). Empathy and Sympathy in Ethics. Internet Encyclopedia of Philosophy.

Accessed on 24.12.2022. Available from: https://www5.iep.utm.edu/emp-symp/ • Allport, GW (1935). Attitudes. In: CM Murchison (ed.), Handbook of Social Psychology. Winchester, MA: Clark University Press. • Batson, CD, Duncan, BD, Ackerman, P, Buckley, T, Birch, K. Is Empathic Emotion a Source of Altruistic Motivation? J Personality Social Psychology 1981;290–302. • Batson, CD, Lishner, DA, and Stocks, EL (2015). The empathy–altruism hypothesis. In DA Schroeder and W. G. Graziano (Eds.), Oxford library of psychology. The Oxford handbook of prosocial behavior (p. 259–281). Oxford: Oxford University Press. Accessed on 24.9.2022. Available from: https://doi.org/10.1093/oxfordhb/9780195399813.013.023 • Burks DJ, Kobus, AM. The legacy of altruism in healthcare: The promotion of empathy, prosociality and humanism. Med Educ 2012;46(3):317–25. • Carpenter, C, Boster, F, and Andrews, KR. Functional attitude theory. In: Dillard, JP, and Shen, L (eds.). The SAGE handbook of persuasion: Developments in theory and practice 2013;104–119. • Dhaliwal, U, Singh, S, Singh, N. Promoting competence in undergraduate medical students throughthe humanities: The ABCDE paradigm. RHiME 2015;2:28–36. • Epstein, RM. Defining and Assessing Professional Competence. JAMA 2002;287(2):226. • Halpern, J. From detached concern to empathy: Humanising Medical Practice. Oxford: Oxford University Press. • Jones, R. Declining altruism in medicine. BMJ 2002;324:624–25. • Katz, D. “The functional approach to the study of attitudes”. Public Opinion Quarterly 1960;24(2):163–204. • Kelm, Z, Womer, J, Walter, JK, and Feudtner, C. Interventions to cultivate physician empathy: a systematic review. BMC Medical Education, 2014;14(1):219. Accessed on 24.09.2022. Available from: https://bmcmededuc.biomedcentral.com/ articles/10.1186/1472-6920-14–219. • Krathwohl, DR, Bloom, BS, Masia, BB (1964). Taxonomy of educational objectives Handbook II: Affective domain. New York: David McKay Company. • Leaune, E, Rey-Cadilhac, V, Oufker, S et al. Medical students attitudes toward and intention to work with the underserved: a systematic review and meta-analysis. BMC Med Educ 2021;21:129. • Long-Crowell, E. (instructor) (2020). The ABC model of attitudes: Affect behavior and cognition. Accessed on 24.9.2022. Available from: https://study.com/academy/lesson/the-abcmodel-of-attitudes-affect-behavior-cognition.html. • Medical Council of India (2018). Competency based undergraduate curriculum for the Indian Medical Graduate, Vol-II. Accessed on 18.12.2022. Available from: https://www.nmc.org. in/wp-content/uploads/2020/01/UG-Curriculum-Vol-II.pdf • Medical Council of India. Attitude, Ethics and Communication (AETCOM) Competencies for the Indian Medical Graduate; 2018. Accessed on 18.12.2022. Available from: https:// www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf • Paralikar, S. Are They Still Noble? Journal of Research in Medical Education and Ethics 2019;9(2):91. • Zajonc, Robert B. “Attitudinal effects of mere exposure”. Journal of Personality and Social Psychology 1968;9(2, Pt.2):1–27.

9 Confidentiality and Privacy Sunita Y Patil Key Points q Confidentiality is the right of every patient and reflects the respect and dignity. q Confidentiality

is based on the four grounds of patient autonomy, implied promise, virtue ethics and consequentialism.

q Clinical practice requires the doctors to share the confidential information of the patients to specific

authorities and third parties under special circumstances.

q It

is important to develop a system to protect patients’ personal digital data and medical records.

q Taking

steps to address privacy concerns by developing social media policies and implementing strategic safeguards help protect patients and reduce liability exposure.

q Though

there are no specific laws related to confidentiality in medical practice in India, National Medical Commission has regulations concerned with confidentiality and patient privacy.

INTRODUCTION Confidentiality in the medical setting refers to ‘the principle of keeping secure and secret from others, information given by or about an individual in the course of a professional relationship’ and ‘it is taken to the right of every patient, even after death’ (Bourke J et al, 2008). ‘I shall respect and maintain my patients’ secrets. Where required, with the patient’s permission, I shall also take into confidence the family, so that my patient gets the best treatment possible. There will be occasions when, in the greater interests of society, I am required by law to divulge confidential information. I will do all I can to ensure that my patient’s interests are protected and that the need for making confidential information public is known to my patient’. — Hippocratic Oath

‘I will respect the secrets which are confided in me even after the patient has died’. — Geneva Declaration

Every individual values privacy and hence every patient has the right to determine how, when, why and to what extent the information about the self can be revealed 78

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to the third person/party. As stated in the Hippocratic Oath above, confidentiality is one of the pillars of professionalism in medical practice and as per the Geneva Declaration, confidentiality has to be maintained even after the death of the patient. It reflects the respect, dignity and rights of the patient, and lies at the heart of the doctor–patient relationship. Confidentiality is one of the cornerstones of trust between a doctor and a patient that enables the patient to open up about their symptoms and health issues so that appropriate treatment decision is made. Most of the information that the patient gives to a doctor is confidential. No one is to be made privy to this information without the patients’ permission (Hope T et al, 2003). Hence, confidentiality is said to be present, ‘when one person discloses information to other and the person to whom the information is disclosed pledges not to divulge that information to a third party without the confider’s permission’ (Beauchamp TL et al, 2001). Though the terms are used interchangeably, confidentiality and privacy are different. Confidentiality is concerned with the ‘personal information’ or data, whereas privacy is primarily concerned with ‘persons’ or ‘individuals’. Privacy is the larger set of which confidentiality is a subset. Privacy implies keeping the medical records restricted or protected from public access as it protects the patient's identity. There are three major categories of medical privacy: • Informational: The degree of control over personal information. • Physical: The degree of physical inaccessibility to others. • Psychological: The extent to which the doctor respects patients’ cultural beliefs, inner thoughts, values, feelings and religious practices, and allows them to make personal decisions. Confidentiality belongs to the category of informational privacy (Serenko et al, 2013).

THE FOUNDATIONS OF CONFIDENTIALITY All the health professionals including medical students have access to confidential information like clinical notes, health records, diagnostic reports and personal details of the patients. Every healthcare professional is expected to maintain the standards of professionalism and follow the ethical code of conduct while dealing with confidential information related to patients. Confidentiality is an integral part of patient’s privacy. The importance of the confidentiality is based on the following four foundations of doctor–patient relationship (Fig. 9.1) (Hope T et al, 2003).

Respect for Patient Autonomy Patient autonomy or the patient’s rights is another important principle of medical ethics. It emphasizes that the patient has the right to choose who should have the access to their personal/medical information.

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Fig. 9.1: The four foundations of confidentiality

Implied Promise The common public perception and the societal belief is that the doctor–patient relationship is an implied contract, which includes an element of trust wherein the patient believes that their information will be kept confidential. This is like an ‘Implied promise’.

Virtue Ethics This focuses on the position of the doctor rather than the patient. One of the virtues of a doctor is to be trustworthy and respect the confidence their patients entrust in them. Hence, breach in confidentiality implies a critical lapse of virtue.

Consequentialism Breach of confidentiality can have different consequences on the patient as well as the doctor. Patient may get upset or angry on realising that the information was shared with a third party without their consent. It can have a psychological impact on patients and their family. However, these consequences depend on the seriousness of the information and/or breach of confidentiality (Hope T et al, 2003). The patient may lose faith in that particular doctor and not willing to consult him/her again which can lead to poor health outcome. If this information becomes known widely to the public, other patients too may lose faith in that doctor leading to deleterious effects on healthcare. Such incidents can also tarnish the reputation of the doctor. In

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a larger public interest, it is important for the doctors and healthcare professionals to maintain high standards of confidentiality and consequently the trust of the patients.

THE SITUATIONS OF POSSIBLE BREACH IN CONFIDENTIALITY IN CLINICAL PRACTICE The healthcare consists of a team of multiple healthcare personnel. There are certain situations in a routine clinical practice wherein breach of confidentiality can occur unintentionally. Few examples of such situations are (Hope T et al, 2003, Beauchamp TL et al, 2001): a. Breaches can occur during the casual gossip between medical students, interns, residents, doctors or other healthcare professionals (Case Scenario 1, Box 9.1). b. Leaving the clinical notes and diagnostic reports on the desk where it is accessible to others who are not directly involved in patient care. c. Access to medical records in electronic data for all healthcare professionals. d. Conversations over telephone: Presence of third person while referring a patient or discussing a case with other specialists. e. Third person(s) posing as close relative(s) of a patient to get the information (exemployers trying to get an information on a health status of employee). Confidentiality is an integral aspect to doctor–patient relationship, but it is important to be mindful of circumstances where doctors are obliged to relay certain confidential information to specific authorities and third parties (Hope T et al, 2003, Beauchamp TL et al, 2001). BOX 9.1: Example of breach of confidentiality in clinical practice Case Scenario 1: One of the young nursing staff visits psychiatry outpatient department (OPD) for consultation. She is diagnosed with schizophrenia. A medical female intern present there gets to know the diagnosis after seeing the clinical case sheet of that nurse. She discusses the nurse’s diagnosis with her room-mate, who is also an intern and reveals her identity. Coincidentally, the nurse is working in the same ward as the intern’s room-mate. Next day the Intern’s room-mate behaves with that nurse in the ward with a different attitude, becomes judgemental and avoids talking to her. At the sametime, she shares the nurse’s diagnosis with her other friends in the ward.

SITUATIONS WHERE DOCTORS ARE OBLIGED TO GIVE INFORMATION TO THE SPECIFIC AUTHORITIES • In the interest of public and third parties: – Notifiable infectious disease: To the designated health authorities (e.g. HIV, hepatitis B, sexually transmitted diseases (STDs), etc.) – Infectious diseases where the infected person can pose a risk to the community (e.g. tuberculosis, Covid-19, etc.) – Serious mental health issues that may pose a risk to the society.

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• Criminal proceedings and police investigations: – Medicolegal cases – Injuries suspected to be due to Criminal Act – When necessitated by the court of law for any patient information including medical records. • Medical conditions affecting fitness to drive: For example, a driver with colourblindness may be a risk to the society. Such information needs to be informed to the concerned authorities. • For the records of health statistics • Medical termination of pregnancy • Births and deaths

SITUATIONS WHERE DOCTORS ARE OBLIGED TO SHARE THE INFORMATION TO THE THIRD PARTIES • When the third party is at a significant risk of harm. For example, spouse of HIV positive individual or with STDs (Case Scenario 2, Box 9.2). BOX 9.2: Example of a situation where the doctor is obliged to share the information with the third party Case Scenario 2: Mr Shyam, is a 32-year-old affluent businessman and a happily married man. Recently, he has developed on and off fever. He visits the physician for fever and swelling in the neck (cervical lymphadenopathy). After detailed history taking and examination, doctor advices investigations including HIV test. Mr Shyam tests positive for HIV. The doctor breaks the news to Mr Shyam and explains to him that his wife be brought for the testing as she is likely to be positive. Mr Shyam is devastated as his wife is pregnant with their first child and he lives in a respectable joint family. He requests the doctor not to reveal it to his wife and family as he feels it is humiliating for him to face his wife, family and society. In this case the doctor is obliged to share the information with his wife and family as he poses a significant harm to his wife as well as the unborn child who can be treated. Doctor should counsel him on the ill effects of hiding the diagnosis from wife and convince him to discuss with his wife and get his wife for HIV testing so that further management can be planned.

• Sharing information to the other members of the healthcare team in the interest of the patient (referring a patient to other specialists). • Sharing information to professional colleagues or members of healthcare team for the scientific purpose, research and publications (Hope T et al, 2003, Beauchamp TL et al, 2001). The doctors have a discretion in that confidentiality can be over-ridden by the duty to protect a third party from a serious physical harm and that one must weigh the duty towards the patient against the duty to others and society (Case Scenario 3, Box 9.3).

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BOX 9.3: Situation where the doctors have the discretion to share the information Cases Scenario 3: Dr Mrs Sharma is an obstetrician practicing in a small town. A 17-yearold student from a nearby locality, Miss Sarita visits Dr Sharma’s clinic with history of amenorrhea of 3 months duration. On detailed history and leading questions, the girl admits to have a boyfriend and being in a physical relationship with him without the knowledge of the family. On examination and investigations, she is found to be pregnant. The doctor asks Miss Sarita to inform her parents about it, but Miss Sarita is very upset and pleads the doctor not to tell anyone and leaves the clinic. The nurse in the clinic has observed Miss Sarita and knows her family as they live in the same locality. The nurse tells the doctor she will inform her family in good faith as she is known to them. In this case, the doctor is not obliged to give the information to her parents as neither she is posing any potential harm to the third part nor to the society. Though the girl is a minor, she has the right to confidentiality. Here, the doctor can counsel and convince her to inform her parents to avoid further complications in the best interest of herself.

PRINCIPLES TO DISCLOSE THE CONFIDENTIAL INFORMATION If confidential information about the patient must be shared to specific authorities or third parties, the following principles need to be followed while disclosing it (Hope T et al, 2003): • Acquire consent for disclosure: First step is to ensure the patient understands what is to be disclosed, the reasons for it, and any potential consequences that may arise. Consent must be sought after articulating all these to the patient. • Anonymise the data, whenever possible. • Keep disclosures to the minimum necessary. The improper disclosure of highly sensitive information could harm patients’ reputation or result in lost opportunities, financial commitments, and even personal humiliation (Hope T et al, 2003).

Confidentiality and the Healthcare Team Medicine today is practiced by healthcare teams formed not only by physicians, residents and nursing staff but also by nursing assistants, administrative personnel and even students. Patients are usually aware of the large number of people in hospitals who need to access their medical records to provide the best possible healthcare. It is the duty of every healthcare professional to protect the confidential and related information of their patients (Beltran-Aroca et al, 2016). At the same time patients have the right to expect that their information is kept confidential and within the bounds of the healthcare team. Disclosures within the team should be done with utmost care (Hope T et al, 2003). Since the patients have already consented for the treatment, express consent is not necessary for sharing the information within the healthcare team. However, patients should be made aware of this fact. The doctor should make sure that the team member to whom this information is shared understands that it is given to them in confidence which they must respect (Bourke J et al, 2008, Hope T et al, 2003, Beauchamp TL et al, 2001).

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Confidentiality and Medical Students Since medical students have often been a part of the healthcare team, they have access to patient information for the purposes of learning. It is the duty of the students to maintain confidentiality of patient information. Hence, they should be made aware of the same in the beginning of their course (Hope T et al, 2003).

Confidentiality and Incompetent Patients and Children In certain circumstances like unconscious or mentally challenged patients, it might not be possible to obtain consent for sharing of the information. This is also true with children below 18 years of age. Since their rights to protect their personal information is the same as that of other patients, the doctor should take the consent of a close relative or family member and use their own discretion (Hope T et al, 2003, Beauchamp TL et al, 2001).

Confidentiality and Research and Publications Research using patient data proceeds on the basis of informed consent which is ensured by expert review and approval by respective ethics committees. This has been further emphasized by the requirement of ethical approval by most journals for publication. Research and publication requires certain identifiable and unidentifiable patient details and clinical information. Hence, it requires that patient data should be anonymised and consent from the patient must be obtained even if one is using the anonymised data (Hope T et al, 2003).

Confidentiality and Manual Medical Notes and Records One of the biggest challenges encountered in medical practice is maintaining confidentiality of manual medical notes. It is important to have a system in place to secure the manual notes and records with access to only those who are directly involved in providing healthcare (Hope T et al, 2003).

Patient Privacy and Electronic Data Protection in India With advances in technology there has been an increase in the range of electronic or digital health data that is being collected, including clinical, administrative, genetic, behavioural, and demographic data. Patients’ personal data is collected by all the healthcare providers ranging from doctors, private or public sector hospitals to allied health professionals. Healthcare providers should maintain the privacy, confidentiality and accuracy of the data collected, in order to establish trust with the patient. Hence, securing the patients’ personal digital data is at the heart of confidentiality and privacy (DSCI Sectoral Privacy Healthcare Guide, 2021). In India, health data or data collected and used for health-related purposes, is currently not regulated by a single national privacy framework. For entities involved in National Digital Health Mission (NDHM), the health data management policy serves as a guidance document across the National Digital Health Ecosystem. It

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sets out the minimum standard for data privacy protection that should be followed across the board in order to ensure compliance with the applicable laws, rules, and regulations (NDHM Health Data Management Policy, 2020). Recommendations of Data Security Council of India (DSCI) for securing patients’ personal data (DSCI sectoral privacy healthcare guide, 2021): • Maintain transparency on how personal data is handled across business processes, functions, and operations of the organization. • Destroy or de-identify/anonymise personal health data that is no longer needed. • Create a map of the users, identifying their roles and identify those who have access to the data against each set of data elements. Validate the access against the access requirements to execute the intended data transaction. • Create a system for reporting and handling of data breaches. • Ensure that a documented information security policy is in place within the organisation, including internal and external stakeholders. • Healthcare service providers must strive to protect privacy by design in their organisa­tion with implementation of acceptable national/international security standards. • Data protection impact assessment should be undertaken to identify processes involving new technologies or large-scale profiling or use of sensitive personal data such as genetic data or biometric data, or any other processes that carry the risk of significant harm to individuals. With evolving privacy policies and national level legislative measure towards a single national privacy framework, it would become imperative for healthcare service providers to create visibility and transparency around the purpose and usage of personal data, as well as incorporate fundamental principles and best practices as a part of their organisational system (NDHM Health Data Management Policy, 2020).

Confidentiality and Social Media In a technology-driven culture of today, the major challenge is to maintain the privacy and confidentiality of patients. While sharing patient information like diagnostic reports with their names, personal details and images on Whatsapp by nurses, technicians, interns, residents to their consultants and colleagues for clinical and academic purposes has become a kind of a norm, the organizations and consultants using social media for educational and marketing purposes on various platforms like facebook, twitter, instagram, etc. has become a trend. With widespread proliferation of social media across the globe, it is unreasonable to expect healthcare workers to avoid using it. There are instances of unreasonable breaches in privacy and confidentiality, where the healthcare team member(s) have shared the images and videos of diseased or deceased celebrities or other patients on social media without their permission. Revealing any personal information of a patient like name, details, photographs and the diagnosis without their permission, could arguably be considered unlawful disclosure (social media and privacy in healthcare). However, there are no articulate medicolegal implications of such breaches in privacy and confidentiality on social media.

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To maintain the standards of professionalism certain guidelines need to be followed (social media and privacy in healthcare): • The organizations should educate all the healthcare professionals about social media risks, offer best practices, and implement reasonable social media policies. • Educate the healthcare providers about the consequences of posting a content on social media that contains patient details or identifiable information, preferably by providing real-life examples to illustrate intentional and inadvertent privacy breaches. • The organisations can sign confidentiality agreements, and maintain a signed copy of the agreement in each employee’s personal file. • When posting a content containing patient identifiable information on the social media or the organization’s website, ensure patient consent is obtained. The consent should explicitly state how the information will be used. • One should be aware that, whilst a patient may publish their own information, the doctor should not respond to their comments or reviews as it does not give a doctor the right to disseminate the information. • Doctors must understand the technical limitations and terms and conditions of any social media sites that they plan to use. For example, the messages shared in that particular site may or may not be encrypted and the site might maintain the right to access any personal information. Taking steps to address privacy concerns by developing social media policies and implementing strategic safeguards help to protect patients and reduce liability exposure as well.

LAWS GOVERNING THE CONFIDENTIALITY AND PRIVACY OF A PATIENT IN INDIA According to the Code of Medical Ethics Regulations, 2002 (amended up to 2016) by Medical Council of India, now National Medical Commission (NMC), regulations concerned with confidentiality and patient privacy have been mentioned (MCI, 2002). • It has been stated under Chapter 7 of code of Medical Ethics Regulations, 2002 by NMC (under point 7.14), that the registered medical practitioner shall not divulge any of the secrets of a patient that have been acquired in the exercise of his/her professional skill or while conducting the treatment except: 1. In a court of law under orders of the presiding judge; 2. In circumstances where there is a serious and identified risk to a specific person and/or community; and 3. Notifiable diseases. • In case of communicable/notifiable diseases, concerned public health authorities should be informed immediately. • Consequences of the violation of confidentiality and privacy are stated in Chapter 8 of code of Medical Ethics Regulations, 2002 by NMC (under point 8.2). It explains that if any complaint is made regarding the professional misconduct of any registered

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medical practitioner and the same is brought before the medical council of disciplinary action, then the appropriate medical council will hold an inquiry and will also give the opportunity to the registered medical practitioner to be heard in person or by a pleader. And if during the course of the inquiry or proceedings, the registered medical practitioner is found guilty of committing professional misconduct, they will be awarded with the punishment as deemed necessary or may direct the removal of the name of the delinquent registered practitioner from the register, altogether or for a specified period. Deletion from the register shall be widely publicized in local press as well as in the publications of different Medical Associations/Societies/Bodies. • It is also stated in Chapter 8 of code of Medical Ethics Regulations, 2002 by NMC (under point 8.5), that, if the decision is pending on the complaint registered against them, then the appropriate council may restrict the physician from performing the procedure or practice which is under research/scrutiny. Other than the code of ethics by NMC, there are no such specific laws in India which protect the privacy and confidentiality of the patient’s data. However, if in any case, personal medical information reaches the unauthorized third party and the identity of a patient is ascertained or known without the consent of the patient then such patient can take legal action (Kant P, LSI).

CONCLUSION Confidentiality and privacy are the rights of every patient and form the basis of the trust between a doctor and the patient. There are certain situations when the patient’s personal information needs to be shared with third party and specific authorities and every healthcare professional should be aware of them. Every healthcare provider should have a privacy policy and system in place to protect the patient data in medical records. Medical students and doctors must be aware of, and follow the guidelines while using social media to maintain the standards of professionalism. Breach in the confidentiality not only breaches the trust in a doctor–patient relationship, it can also be liable for legal actions depending on the content and the extent to which the breach has taken place. Medical students and doctors must be aware of, and follow the guidelines while using social media to maintain the standards of professionalism. National Medical Commission mentions the governing rules regarding confidentiality and privacy.

BIBLIOGRAPHY • Balancing Social Media and patient privacy in healthcare. Accessed on 28.02.2022.

Available from: https://www.medpro.com/patient-privacy-social-media. • Beauchamp TL, Childress JF. Principals of Boimedical Ehics, 5th Edn, Oxford University Press, 2001. • Beltran-Aroca, Girela-Lopez, Collazo-Chao, Barquero MP, Muñoz-Villanueva MC. Confidentiality breaches in clinical practice: What happens in hospitals? BMC Medical Ethics. 2016, p.1–12.

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• Bourke J, Wessely S. Competenant Novice: Confidentiality. BMJ 2008;336:888–91. • Code of Medical Ethics Regulations, 2002 (amended up to 2016), Medical Council of India.

Accessed on 25.02.2022. Available from: https://www.nmc.org.in/rules-regulations/ code-of-medical-ethics-regulations-2002/ • Health Data Management Policy, National Digital Health Mission (2020). Available from: https://ndhm.gov.in/documents/Health Data Management Policy. • Hope T, Savulescu J, Hendrick J. Confidentiality. In: Medical Ethics and Law: The Core Curriculum 2003, Churchill Livinstone, 2nd ed. London, p. 81–97. • https://www.dsci.in/sectoral-privacy-project/wpcontent/uploads/2021/08/DSCI_ Sectoral-Privacy-Healthcare-Guide1136279132045723835.pdf • Kant P. Law on Consent and Confidentiality in India: Concept of consent and liability. Legal Services of India. Accessed on 25.02.2022. Available from: https://www. legalserviceindia.com/legal/article-6973-law-on-consent-and-confidentiality-in-india. html.

• Serenko, Natalia, Lida Fan. “Patients’ Perceptions of Privacy and their Outcomes in Healthcare”. International Journal of Behavioural and Healthcare Research 2013;4(2): 101–22.

10 End of Life Care Jugesh Chhatwal, Sonam Sharma Key Points q End of life care is the care of patients likely to die within the next 12 months. q

Besides medical issues, physical support and environment, psychological and emotional support, social issues, communication needs, ethical and legal considerations are necessary components of end of life care.

q

End of life care can make the process of dying more bearable and comfortable.

q

Advance planning is an approach which can facilitate the end stages of life.

q

Educating the healthcare professionals regarding EOLC is essential.

‘To cure sometimes, to relieve often, to comfort always’.

Trudeau EL

INTRODUCTION End of life (EOL) is considered as the phase which leads to cessation of life or death. The word ‘Death’ is not a mere word. It has come to signify a world of feelings, emotions and experiences. But as humans, we have to understand that just as there is a birth—a beginning, so is death—as the end. It is said that one event that is certain at the time of birth is death and the uncertainty is only of the journey from birth to death. In the era gone by, people ended their journey as death happened mostly at home. In the modern times, the progress of medical science and related fields has shifted the scene to healthcare facilities for many persons. The advances in diagnosis, investigation and treatments have made it possible to prolong life for many individuals sometimes inappropriately. Prolongation of living in many such situations may be the opposite of the science of healing as the medical care is expected to be. The stretching of this phase of life especially by unnatural means dehumanizes the life of the ‘living’. Giving dignity and respect to this stage of life is as essential as it is to have joyous celebrations at birth. Just as one anticipates rest and peace at end of any journey, so is the need to have a peaceful end to the journey of life. The EOL period maybe short, i.e. few hours or days as in an acute illness or stroke or trauma while it may be much longer for others as in conditions like dementia or cancer. EOL is a time in which specialized medical care is needed in order to ease suffering and improve the quality of life for whatever time an individual has left. It is often the period in 89

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which treatments and procedures should focus on comfort rather than having the primary goal of curing the underlying disease. In this chapter on end of life care (EOLC), we will be sharing definitions of EOL and some related terms, describing briefly the components of EOLC, highlight some difficult issues and also discuss the related ethical as well as legal concerns.

What is EOL? General Medical Council in UK defines EOL as “Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months”. This includes patients whose death is imminent (expected within a few hours or days) and those with: (a) Advanced, progressive, incurable conditions; (b) general frailty and coexisting conditions that mean they are expected to die within 12 months; (c) existing conditions if they are at risk of dying from a sudden acute crisis in their condition; (d) life-threatening acute conditions caused by sudden catastrophic events (GMC, 2010). There are few terminologies associated with EOL and EOLC which have been defined differently by many authors. For the sake of uniformity, Indian Council of Medical Research (ICMR) has commissioned the definitions of various terms associated with EOL (Salins et al, 2018) (Box 10.1). BOX 10.1: Definition of terms used in care at the end of life: The Indian Council of Medical Research Commission Report (adapted from Salins et al, 2018) Terminal illness: An irreversible or incurable disease condition from which death is expected in the foreseeable future. Death: Irreversible cessation of the heart and circulatory function or neurological function of the brain including the brainstem. EOLC: An approach to a terminally ill patient that shifts the focus of care to symptom control, comfort, dignity, quality of life, and quality of dying rather than treatments aimed at cure or prolongation of life. Do not attempt resuscitation (DNAR): A decision not to initiate or perform CPR on the background of terminal illness in accordance with prior expressed wishes of the patient or surrogate. Euthanasia: Euthanasia is the intentional act of killing a terminally ill patient on voluntary request, by the direct intervention of a doctor for the purpose of the good of the patient. Palliative care: Palliative care is a holistic approach to treatment that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering. Shared decision-making: A dynamic process with responsibility for decisions about the medical care of a patient being shared between the healthcare team and the patient or surrogates. Surrogate: Surrogate is a person or persons other than the healthcare providers who is/are accepted as the representatives of the patient’s best interests, who will make decisions on behalf of the patient when the patient loses decision-making capacity. Advance directives: A statement made by a person with decision-making capacity stating his/her wishes regarding how to be treated or not treated at a stage when she/ he loses such capacity.

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EOLC in India has been observed to be in a nascent stage despite a huge burden of persons in the terminal phase of their life, dying with a need for appropriate care. The reasons have been noted to be a limited awareness among both, the healthcare providers (HCP) as well as the population, along with an absence of a National EOLC policy and legal barriers, even though there is a National Program of Palliative Care launched in 2012, training doctors, nurses and ASHA workers at state level (NPPC, 2012). In the same year the Indian society for critical care medicine (ISCCM) published guidelines for EOLC and palliative care in Indian intensive care units (Mani et al, 2012). The Indian Association of Palliative Care (IAPC) brought forth a consensus position statement for EOLC policy for the dying in 2014 (Macaden et al, 2014). The consensus statement gave the following objectives for EOLC: • Achieve a ‘Good Death’ for any person who is dying, irrespective of the diagnosis, duration of illness and place of death. • Emphasis on quality of life and quality of death. • Acknowledge that palliative care is a human right, and every individual has a right to a good, peaceful and dignified death. Subsequent to above, lot of efforts has been put forward to increase awareness at various levels as well as attention of the legal experts to formulate appropriate laws. An advocacy group ‘End of Life Care India Task Force’ (ELICIT) was formed to address the above (ELICIT, 2019). Later, in 2017, a Citizens Action Needed for Dying in Dignity (CANDID) forum was initiated. The “Mathura declaration—a call to action” was signed by all members of ELICIT and CANDID. The Mathura declaration released on 30 April, 2017, is a call to action for ensuring humane care at the EOL (Mathura declaration, 2017).

WHAT ARE THE ELEMENTS/COMPONENTS OF EOLC? EOLC involves multiple dimensions of care ranging from disease related to legal and spiritual. In 1997, the Institute of Medicine in their report on “Approaching Death” identified six elements of quality EOLC (Fig. 10.1) (Field and Castle, 1997). Singer and Bowman (1997) observed that elements identified by expert clinicians may not be the same as those by the patients themselves. Later in 1999, Singer et al outlined five aspects of EOLC from the patients’ perspective, viz. receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving the burden on loved ones, and strengthening relationships with loved ones. For providing a comprehensive EOLC the components that will need to be considered to a variable extent in individual patients are listed in Box 10.2.

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Fig. 10.1: Six elements of quality end of life care

BOX 10.2: Components of EOLC • • • • • • •

Disease related or medical issues Physical support and environment Psychological and emotional support Social/family related issues Communication needs Financial considerations Ethical and legal aspects

Disease related or medical issues: The EOLC usually moves from curative to a palliative treatment and comfort care. At this time there can be number of symptoms which can cause distress and discomfort. Foremost amongst these is pain especially in advanced cancer patients. A lot of research and literature is available on reducing the pain at this time. The liberal yet judicious use of opioids is one of the main options. Besides pain, a number of other symptoms can be equally distressing and need to be dealt with (Box 10.3) (Lowey, 2015). BOX 10.3: Frequently seen distressing symptoms at EOL (adapted from Lowey, 2015) • • • • • •

Pain, anorexia-cachexia syndrome Weakness, nausea and vomiting Dysphagia, bowel problems Dyspnea and cough, oral problems Skin problems, sleep disturbances Mental issues, e.g. confusion, anxiety, depression, dementia

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Physical support and environment: Many patients may require assistance for daily living and related activities. An appropriately supportive environment and facilities should be available to make the life as comfortable as possible. If needed, trained caretakers can be utilised to provide adequate support to the family. The wishes of the patient in moving from hospital to hospice care (if available) or home care must be considered. Care at any healthcare facility can be a financial burden for many families and hence this requires a thorough discussion with the family. The Kerala model of community-based care, neighbourhood network in palliative care (NNPC), has been successful and effective. The program is characterized by a focus on care at home with outpatient clinics and inpatient units acting in support, attention to social and emotional well-being as much as physical health, mobilization of resources locally and the building up of skills and confidence in the local community (Kumar, 2007). More such support centres in the communities can be very helpful for providing EOLC at the community level. At home or hospice, it is important to keep the environment cheerful, calm and with personal warmth. The room must be disabled accessible with adequate lighting and ventilation. Provision for safety from falls and assistive devices must be taken care of. The family members need to keep up the communication with the ailing patient and try to honour his/her wishes for visitors/foods/music, etc. Psychological and emotional support: Providing emotional and psychological support at the EOL is paramount. Companionship and sharing time with the family, extended family or friends can make a great difference to the quality of life for person in this phase of life. Next to relief from physical pain, the emotional pain can make life a living hell for a dying person. Living isolated from dear ones in a hospital setting is one of the commonest fears of the sick and dying. Spending even quiet time with family members can lift their spirits and make it easier through this tough journey. It is important for the family to maintain a calm and cheerful ambience instead of letting the gloom of death takeover. Although the scenario of a terminally ill person close to the end of life does not appear to be related to hope in anyway but it is important to realise that the concerned person will have hope, hope for life or less pain or other distressing symptoms. One must let the person keep their hopes without giving any false promises. Hope can make the pain less intense. The impending loss of life and the associated suffering can make the patients very depressed and sad. Counselling and family support at this time can alleviate the suffering to some extent. Social and family related issues: A person nearing death can have worries and thoughts of abandoning their families. Concerns about how the family members will cope and their anticipated suffering and pain cause the patient additional distress. Family members and close persons/friends need to reassure and help with the coping mechanisms. Spirituality at this time can be a great source of solace to the patient and family. In India, where religiosity is almost a universal pattern, prayer and spiritual intercourses can provide an emotional anchor. The concerns of the patients and bereaved family were analysed by Motamedi et al (2021) in a scoping review and five themes related to quality EOL emerged, viz.

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(i) Effective communication between clinicians and patients/caregivers which includes accessible and frequent communication with the family sharing clear, comprehensive and consistent information in an open, honest compassionate manner at the right time; (ii) Healthcare that values patient preferences and shared decision making; (iii) Models of care that support quality of life and death with dignity; (iv) Healthcare services that meet patient expectations; (v) Support for family/caregivers in dealing with EOL challenges. A social welfare person in the team can be of help in dealing with many of these issues. Communication needs: A person at the EOL can have numerous concerns and issues which need a conversation. Communication is an essential component of providing EOLC. Beginning from the time of decision making for EOLC, a clear communication channel with the patient and the family must be maintained by the healthcare professionals. One of the foremost steps should be to find out how much information must be shared with the patient himself/herself and the family care givers. The cultural context and the ability of the patient and family to understand the elements of the conversation must be kept in consideration during the communications. The mnemonic VALUE developed by University of Washington End of Life Care Research Program to improve ICU clinicians’ communication with families can be helpful (Box 10.4). BOX 10.4: VALUE (Curtis, 2008) • • • • •

V: Value family statements A: Acknowledge family emotions L: Listen to the family U: Understand patient as a person E: Elicit family questions

While communicating with the patient and/or the family, it is important to involve them in a shared decision making. Motamedi et al (2021) highlighted the aspects of effective communication between clinicians and patients/caregiver as seen in Box 10.5. BOX 10.5: Communication concerns (Motamedi et al, 2021) • Accessible and frequent communication • Communication which involves the whole family and the multidisciplinary team • Clear, comprehensive and consistent information about the patients condition, diagnosis, treatment and prognosis • Open and honest communication • Conversation about EOL • Compassionate communication

Financial concerns: Persons at the EOL will usually be greatly concerned about a number of financial issues. Starting with the medical bills, daily expenses especially related to the caretakers, health insurance and related matters need to be tackled. Concerns about assets, liabilities and will can also be additional sources of stress.

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Legal and ethical issues: Ethical issues are directly at the very foundation of EOLC. These have been greatly discussed and established in this context. The cardinal principle of autonomy or the right to self-determination is the basis of where the decision for EOLC starts in person who is competent to decide. In a person not competent to decide, the other cardinal principles, viz. beneficence, non-malfeasance and distributive justice also need to be considered. Beneficence implies acting in patient’s best interest, non-malfeasance is doing no harm and lastly distributive justice means same level of care similar situations in patients. An advance planning in terms of a living will or wishes expressed to a surrogate decision maker can be considered. For every patient opting for EOLC, a clear consenting process must be in place. The consenting should include a detailed discussion including the family and the possible surrogates for decision-making pathways. All India Institute of Medical Sciences (AIIMS), Delhi, has given clear guidelines on the EOL execution pathway which can be helpful (AIIMS, 2020). The responsibility for decisions for withholding or withdrawing life support and DNAR must be clearly discussed and documented.

WHY EOLC? Beyond a certain age, usually persons start thinking and talking of a ‘Good Death’. Defining a good death may be considered an ambiguity. Yet dying with dignity is often desired by most. What is a good death? The Lancet commission on the value of death—bringing death back into life has highlighted a number of paradoxes associated with death, dying and the inequalities thereof. The commission has brought out recommendations for all populations, civil society, health and social care systems, researchers, governments and policymakers. The authors concluded that death and dying must be recognised as normal and valuable. Care of the dying and grieving must be rebalanced (Lancet, 2022). IAPC takes the position that access to palliative and end of life care (EOLC) is a human right (Macaden et al, 2014). Therefore, everyone with a life-limiting illness has a right to a life free from pain, symptoms and distress; psychosocial and spiritual, and has the right to a dignified life that includes the process of death. In this context Henwood and Neuberger (1999) have put forward 12 principles of a ‘Good Death” as shown in Box 10.6. BOX 10.6: Principles of a good death (Henwood and Neuberger, 1999) • • • • • • • • • • • •

To know when death is coming, and to understand what can be expected To be able to retain control of what happens To be afforded dignity and privacy To have control over pain relief and other symptom control To have choice and control over where death occurs (at home or elsewhere) To have access to information and expertise of whatever kind is necessary To have access to any spiritual or emotional support required To have access to hospice care in any location, not only in hospital To have control over who is present and who shares the end To be able to issue advance directives which ensure wishes are respected To have time to say goodbye, and control over other aspects of timing To be able to leave when it is time to go, and not to have life prolonged pointlessly

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CHALLENGES OR BARRIERS FOR HCP FOR PROVIDING EOLC The challenges and barriers faced by the healthcare providers for providing EOLC have been highlighted in Fig. 10.2.

Fig. 10.2: Challenges/barriers faced by HCP for providing EOLC

Prognostication for end of life: Prognostication is one of the most important steps to begin any process or conversation for implementing EOLC. It is a difficult task to identify when a particular patient is approaching end of life especially for conditions with no definite pattern of progression, like frailty or dementia. The treating physicians are afraid of over or underestimating this period. For any conversation or other processes of EOL, it is essential to prognosticate. Every person associated with the patient and the patient herself/himself and the treating physician, all are anxious to have an answer to the question of “How much time?” The answer is not available in a simple or straightforward manner. The illness trajectories can broadly be of use on guiding prognostication. An understanding of the illness trajectory is helpful for not only prognostication but also for communicating with the patient or caregivers/family. Lunney et al (2002) described four trajectories: • Sudden death: This pattern is seen in situations of acute events, e.g. trauma or accidents and the trajectory is short unless complicated by other events. • Terminal illness: A trajectory seen with terminal illness like a malignancy. In the terminal stages there is a quicker progression to death. • Organ failure: Persons with organ failure tend to have ups and downs in their health till eventually decompensation happens leading to death. • Frailty: A gradually declining functionality as seen with certain longstanding illnesses, e.g. dementia or Alzheimer’s disease.

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A number of tools have been devised but prognostication remains a challenging task. The physicians’ experience, patients’ clinical profile, and lab values can be of help in estimating the survival possibilities. The ISSCM consensus ethical position statement provides a checklist to help the physicians while making decision about EOL (Box 10.7) (Mani et al, 2012). BOX 10.7: Bedside checklist for initiating EOL discussions (Mani et al, 2012) • Advanced age coupled with poor functional state due to one or more chronic debilitating organ dysfunction, e.g. end-stage pulmonary, cardiac, renal or hepatic disease for which the patient has received/declined standard medical/surgical options. • Catastrophic illnesses with organ dysfunctions unresponsive to a reasonable period of aggressive treatment. • Coma (in the absence of brain death) due to acute catastrophic causes with nonreversible consequences such as traumatic brain injury, intracranial bleeding or extensive infarction. • Chronic severe neurological conditions with advanced cognitive and/or functional impairment with a little or no prospects for improvement, e.g. advanced dementia, quadriplegia or chronic vegetative state. • Progressive metastatic cancer where treatment has failed or patient has refused treatment. • Post cardiorespiratory arrest poor neurological recovery after at least 3 days (7 days in case of therapeutic hypothermia). • Comparable clinical situations coupled with a physician prediction of low probability of survival. • Patient/family preference to limit life support or refusal to accept life support.

Breaking the news of EOL: Informing the patient and the family members about the prognosis and the possibility of considering an EOLC can be a difficult task for the treating physician. The responsibility assumed by the physicians as part of their training is to cure and often it can be to heroic extent! The fear of being accused of negligence or suboptimal care usually looms large and is a deterrent for breaking this news. Most doctors stay in their comfort zone and continue till either the family gives up or death happens. But it is important to remember that it is equally essential to do no harm. Treatment beyond knowing the point of no return can be an emotional as well as financial burden for the family. Starting a conversation on EOL with the patient and the family may even be a relief for them. There is a moral and ethical obligation of the treating doctor to share the prognostication and the inappropriateness of non-beneficial therapies. Taking away ‘hope’: Very often a physician may have a guilty conscience of taking away hope of survival by disclosing the prognostication. It is well accepted that prognosis may not be very accurate but not sharing it with the concerned persons is likely to be more troublesome and painful. Physician preparedness and discomfort: As mentioned above, the task of sharing the poor prognosis and death and consequent EOL is a difficult one. Most people hold the belief that medical science will control the disease. Because of the

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institutionalization of death, many people may expect medical solutions at the EOL. Death is often perceived as a failure of medical care. Demand for aggressive treatment at the EOL can become extreme and unrealistic. Discussions of death, in this context, may be shunned as they are a reminder of the gross inadequacies of the healthcare system. The physicians involved with such patients need to train for shouldering this responsibility and with experience one learns to be comfortable yet compassionate, ethical yet empathetic. Readiness of the decision makers (self/surrogate): This is a challenging aspect to deal with as usually no one is ready to hear about the end of life. If the patient has been under the care of the physician for some time and the doctor has been able to build a trusting relationship with the patient and family, the acceptance is much more likely. Ensuring the patient about their best interest and discussing the shift from curative to comfort care is also helpful. A discussion about the likely benefits or hazards/burden of the terminal curative treatment can help start the conversation. It is good to determine how much information the patient is ready to understand or accept. Legal barriers/concerns: The legality of the process of EOL and EOLD has been questioned many a times especially where it concerns the healthcare providers decisions or actions. Many HCPs may not be aware of the legal issues involved or are scared of getting into trouble. Being blamed for providing inadequate treatment and care is a major deterrent for considering EOLC. In India, till recently the legal position or the laws were not explicit regarding these issues. In 2018, the Supreme Court of India, in the instant Writ Petition, has recognized death with dignity as fundamental right and has given effect to Advanced Medical Directives (Living Will) and the Medical Attorney Authorisation to facilitate the exercise of this right (Goswami and Goswami, 2018).

ADVANCE PLANNING Advance care plans involve people making decisions about their future care for EOLC. These plans can include: • Priorities and preferences for care and treatment. • Decisions about resuscitation. • Views about how and where they would like to be looked after in their last days of life. • Who they would like to have with them. • Any spiritual or religious beliefs they would like to be taken into account. • Who they would like to make decisions for them if they are unable to make them for themselves (NICE, 2020).

EDUCATION FOR EOLC Educating the diverse healthcare professionals involved in EOLC and palliative care requires a comprehensive policy. A collaborative work by IAPC and Academy

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of Family Physicians of India. Primary palliative care prepared a competency framework for primary care and family physicians in India covering the domains of knowledge, skills and attitude, ethical and legal aspects, communication and team work (Atreya et al, 2019). A Joint Position Statement of the Indian Society of Critical Care Medicine and the Indian Association of Palliative Care in end of life care policy: An integrated care plan for the dying has highlighted the need for the existing HCP to be educated with appropriate resource materials (Myatra et al, 2014).

CONCLUSION As stated in the Lancet commission report for providing EOLC, a multifaceted, multi­ disciplinary approach is needed, including public health, primary care, community care, acute healthcare and residential care. Discussing death and advance care planning while emphasizing the dynamicity of prognosis along with empowering clinicians to provide sensitive, appropriate care, and improving communication lies at the heart of EOLC (Lancet, 2022). Summarizing the diverse aspects of EOLC as ABCDEFG as given below can be helpful: • A: Advance planning/directives • B: Barriers • C: Compassion and conversations • D: Disease related issues • E: Ethics of EOLC • F: Family involvement • G: Grief handling and bereavement

BIBLIOGRAPHY • Atreya S, Jeba J, Pease N, Thyle A, Murray S, Barnard A, et al. Primary palliative care competency framework for primary care and family physicians in India: Collaborative work by Indian Association of Palliative Care and Academy of Family Physicians of India. J Family Med Prim Care 2019;28;(8):2563–67. • Curtis JR. Caring for patients with critical illness and their families: The value of the integrated clinical team. Respir Care 2008;53(4):480–87. • End of life care in India Taskforce (ELICIT): Improving end of life care and DecisionMaking Information guide to facilitate execution of end of life decisions—For Doctors and Hospital Administrators. Accessed on 20.12.2022. Available from: https://ficci.in/ spdocument/23119/FICCI-ELICIT-Guide-for-Patients.pdf. • Field MJ, Cassel CK. Approaching Death: Improving Care at the end of life, Washington, DC: Institute of Medicine, National Academy Press; 1997. • Final guidelines for end of life care Policy at AIIMS, New Delhi, 2021. Accessed on 20.12.2022. Available from: www.palliativecare.in/wp-content/uploads/2021/03/ Final-Guidelines.

• General Medical Council, treatment and care towards the end of life: good practice in decision-making, 2010.

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• Goswami GK, Goswami S. Right to ‘Die with Dignity’: Analysis of ‘Common Cause Vs.

Union of India.” Journal of the Indian Law Institute 2018;60(1):97–110. • Kumar SK Kerala, India: a regional community-based palliative care model. J Pain Symptom Manage 2007 May; 33(5):623–7. • Lowey SE. Nursing care at the end of life: What every clinician should know. 2015, Open SUNY Textbooks, Milne Library State University of New York at Geneseo, Geneseo, NY 14454. • Lunney JR, Lynn J, Hogan C. Profiles of older medicare decedents. J Am Geriatr Soc 2002 Jun;50(6):1108–12. • Macaden SC, Salins N, Muckaden M, Kulkarni P, Joad A, Nirabhawane V, Simha S. End of life care policy for the dying: consensus position statement of Indian Association of Palliative Care. Indian J Palliat Care 2014 Sep;20(3):171–81. • Mani RK, Amin P, Chawla R, Divatia JV, Kapadia P, Khilnani P, et al. Guidelines for end of life and palliative care in Indian intensive care units’ ISCCM consensus Ethical Position Statement. Indian J Crit Care Med 2012;16:166–-81. • Motamedi M, BrandenburgC, BakhitM, Michalef ZA, Albarqouni L , Clark J, et al. Concerns and potential improvements in end of life care from the perspectives of older patients and informal caregivers: a scoping review. BMC Geriatr 2021;21:729 (2021). https://doi.org/10.1186/s12877-021-02680–2. • Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, et al. End of life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med 2014 Sep;18(9):615–35. • National program for palliative care (NPPC), 2012. Available from: https://www.nhm. gov.in/index1.php?lang=1&level=2&sublinkid=1047&lid=609 • NICE impact of end of life care for adults, 2020.National Institute for Health and Care Excellence 10 Spring Gardens, London, SW1A 2BU. • Report of the Lancet Commission on the Value of Death: bringing death back into life. • Salins N, Gursahani R, Mathur R, Iyer SK, Macaden S, Simha N, et al. Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at the end of life: The Indian Council of Medical Research Commission Report. Indian Journal of Critical Care Medicine 2018; 22(4): 249–62. • Singer PA, Bowman KW Quality end of life care: A global perspective. BMC Palliat Care 2002;1:4–10. • Singer PA, Martin DK, Kelner M. Quality end of life care: Patients’ perspectives. JAMA 1999;281(2):163–68. • The Lancet, 2022; 399: 10327: 837-884Published Online January 31, 2022 https://doi. org/10.1016/ S0140-6736(21)02314-X. • The Mathura Declaration: A Call to Action to Promote end of life and Palliative Care in India. Available from:http://www.ehospice.com/ArticleView/tabid/10686/ ArticleId/22187/View.aspx.

11 Medical Sociology Amrit Virk Key Points q Medical sociology circumscribes a discipline which places health and disease within a social, cultural, and behavioural milieu. q

It has a rich and diverse theoretical foundation that connects the entire social spectrum to health and illness.

q It

is important for medical students to have sociological awareness relevant to medical practice.

q

Alignment of teaching–learning methods and assessment of medical sociology to its expected outcomes is essential to encourage active learning among students.

INTRODUCTION The field of medical science, health, disease and healthcare is undergoing rapid changes due to scientific developments meant to transform medical practice. With the ever-increasing technological progress and scientific discoveries in medical sciences, the art of healing has evolved into a highly specialised field. Medical decisions are now more dependent on technology, resulting in de-humanizing of medical practice. In medical academia, it is vital to have a harmonious equilibrium between the medical ‘know-how’ and ‘social sciences’ as the two fields have always been interwoven. The relevance of teaching social context of health and disease to medical undergraduates is clearly reflected in the Medical Council of India, Graduate Medical Education Regulations, 2019 (MCI, 2019) designed with a goal—to create an Indian Medical Graduate (IMG) who should possess not just knowledge, but also the skills, attitudes, values and responsiveness expected of a first contact physician at primary care level so as to be able to function appropriately and effectively. It is envisaged that the IMG should be able to fulfil the five roles: Clinician, leader, communicator, professional and a lifelong learner. The new curriculum also lays emphasis on relevance of social sciences in undergraduate medical education through collaborative teamwork, professionalism, altruistic values and respect in professional relationships along with due sensitivity to differences in thought, social and economic status and gender. 101

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This chapter aims to integrate the diverse knowledge generated by social sciences into medical education and serve as a resource for teaching medical sociology as part of medical humanities to undergraduate medical students.

TERMINOLOGIES Sociology ‘The function of sociology, as of every science is to reveal that which is hidden’. —Pierre Bourdieu Sociology is an understanding and explanation of the society especially of the social relations of individuals, groups and institutions. A major discipline in social sciences, sociology, the term was first coined byAuguste Comte, a French philosopher in 1838. While the initial work in sociology did not involve medical science or the relations between people and health, their principles have helped explain the influence of politics, family, economics and religion on health, wellbeing and survival of people.

Medical Sociology Medical sociology involves the convergence of two academic disciplines: Medicine which is concerned with the treatment of disease; and sociology concerned with the study of society. Charles McIntire (1991) described medical sociology as ‘the science of the social phenomena of physicians themselves as a class apart and separate; and the science which investigates the laws regulating the relations between the medical profession and human society as a whole; treating of the structure of both, how the present conditions came about, what progress civilisation has affected, and indeed everything relating to this subject’. According to the Committee on certification in Medical Sociology (1986), Medical Sociology is ‘the subfield which applies the perspectives, conceptualizations, theories, and methodologies of sociology to phenomena having to do with human health and disease. As a specialization, medical sociology encompasses a body of knowledge which places health and disease in a social, cultural, and behavioral context’. To put it simply, Cockerham and Scambler (2010) describe medical sociology as ‘the study of social causes and consequences of health and illness’. Medical sociology is considered to be an important field of study for medical graduates because it recognises the critical role that the entire social spectrum plays in determining or influencing the health of individuals, groups and the larger society. As an academic entity, medical sociology has been involved in a lot of controversies by issues of its identity (self) and identification (by others). This controversy has led to many arguments on whether it should be named ‘medical sociology’ or ‘health sociology’ or ‘sociology of health and illness’. Robert Straus (1957) first suggested the division of medical sociology into two categories—the sociology of medicine and sociology in medicine. Sociology of medicine focuses on testing sociological hypotheses, using medicine as an arena for studying basic issues in social stratification, power and influence, social

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organizational structure, socialization, and the broad context of social values. In contrast, sociology in medicine implies that sociologists work as applied investigators, seeking to answer questions of interest to their sponsors, whether government agencies, foundations, hospitals, or medical colleges. In doing so, they collaborate with the physicians in studying a disease process or factors influencing the patient’s response to illness. The scope/subfields of medical sociology include (Fig. 11.1): 1. Focus on the social distribution, social causes of health related outcomes and behaviours and their impact on the population; Social epidemiology. 2. Focus on social, psychological processes that mediate and moderate the social causes and consequences of health-related outcomes and behaviours; Social psychology of health and illness. 3. Focus on issues associated with healthcare delivery and healthcare experiences, medical knowledge, health related social movements (social inequality, social institutions, social health/policy laws, etc.); Sociology of medicine. 4. Focus on issues within institutions of medicine including medical treatment, health professions, marketing of healthcare; Sociology in medicine. More recently, there have been efforts to understand that medical sociology must involve the application of sociological knowledge and concepts to issues related to health and illness as well as the organization and delivery of healthcare.

Fig. 11.1: Subfields of medical sociology (Hill et al, 2021)

SOCIOLOGICAL PERSPECTIVES OF HEALTH AND ILLNESS Medical sociology is a theoretically rich and diverse field of study. Many sociological theories have been proposed by sociologists in the last century. These theories or perspectives (Table 11.1) have tried to explain the why and how of social determinants related to the field of medicine and healthcare. A look at the sociological perspectives may make anyone wonder how it applies to the practice of medicine. Is there a need for medical students to know all of this? How do these sociological theories and social structures relate to the field of medicine? Let’s analyse a few sociological perspectives. The functionalist perspective is a theory propagating that different institutions in a society adjust to minor changes to keep the society stable and functioning. If we analyse the function of medicine in society from a functionalist point of view, then we may want to know the purpose of medicine. People become ill and medical care

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(Contd.) practice TABLE 11.1: Sociological perspectives relevant to medical

Sociological perspectives Key terms

Relevance in medical practice

The functionalist per­ spec­­tive (structural functionalism) Parsons, 1951

Helped develop most important areas of research; patient–physician relationship, illness behavior and need for medical care

• Deviance • Structuralism • Sick role

The conflict perspective • Functionalism Marx, 1963 • Capitalism

Demonstrates how a society’s health and healthcare system impacted from a complex network of conflicting and competing aims and interests based on differences in gender, income, ethnicity, occupation, education, political affiliation leading to health inequalities or disparities

The interactionist • Medicalization of perspective (symbolic deviance interactionism) • Demedicalization Strauss and Wohl, 1958 • Symbolic interactio­ nism

Demonstrates the microlevel social processes of health and healthcare and the role that patients and healthcare providers play in development and transformation of the healthcare systems

The labeling perspective • Self-fulfilling prophecy (social constructivism) • Stigmatization Scheff, 1999 • Social construction • Deviance

Demonstrates the tendency to negatively label minorities or those with behavior deviant from standard cultural norms and the implication of such labeling on mentally ill and HIV/AIDS patients

Feminism Patriarchy Annandale and Clark, 1996

Demonstrates the role of patriarchy and gender in the health and wellbeing of women

Post-structuralism Foucault, 1967

Medicalization of deviance

Demonstrates how people use the discourses of medicine, psychiatry and science to care for and control themselves and others Examined ways in which healthcare providers and people use medical knowledge (self-help literature, medical diets and plastic surgery) to master and control the body

Multiculturalism Lupton, 1994

• Cultural diversity a. Examines three major foci • Cultural competency b. The negative impact of racism, ethnocentrism, and cultural intolerance on health and wellbeing of people c. The ways in which culture affects the practice of medicine and biomedical science d. The ways in which culture affects the health behavior of different populations

Stress and coping Cockerham, 2001

Social stress

Focuses on: a. Role of social factors (poverty, lifestyle, health behavior, occupation, etc.) on creation and exacerbation of stress b. Role of social factors (marital status, kinship networks, financial stability, etc.) on assuaging stress

Professionalism Hafferty and Light, 1995

• Professional dominance • De-professionali  zation

Explores the impact of professionalism on the lives of physicians and patients and the healthcare system as a whole

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ensures that they return to a functional state and can contribute to society. Being sick is detrimental to the wellbeing of the society as a whole. This perspective assumes that a sick person cannot optimally participate as an active member of the society and this in turn can affect the stability of the society. The physician or the healthcare provider can make the sick feel better and the institution of healthcare helps us stabilize the social system. In our day-to-day lives, medicine helps to improve the quality of life for the aging population, allowing them to contribute effectively to society. Thus, we can say that medicine keeps people healthy and functional to fulfil their social responsibilities and be active members of the society. Similarly, the conflict perspective can also be applied to the field of medicine. The conflict theory is concerned with the inequality between different social groups. In medical science, this inequality can have a significant impact on accessibility to health/medical care. The unequal access to valuable resources in society, like education, housing or occupation, leads to health disparities and limited access to healthcare. The theory of social constructionism relates to the idea that society adds value to everything. It also means that as a society, different meanings (stereotype) have been attached to different behaviors associated with preconceived notions about different people (related to their race, ethnicity, religion, social status, etc.). These assumptions about people may be based on their appearance or actions and people are treated differently. Assumptions can prove detrimental to a medical professional. They can affect how a physician treats the patient or affect the diagnosis. The patient– physician interaction can be influenced by stereotype assumptions on both sides. A term used in this theory is medicalization, where patients or physicians construct an illness out of ordinary behavior. A child who cannot sit still in class does not necessarily have attention deficit hyperactivity disorder (ADHD). He or she may just need to get out on the playground and play. Feminist theory is an offshoot of conflict theory that focuses on the inequalities between men and women in society. This disparity in gender can translate into a disparity in power. The gap between sociology and medical science can be bridged with a sound and robust knowledge of how to apply it to medical practice. Medical students are not expected to have an in-depth knowledge of these perspectives, but they should be able to understand the utility of sociological perspectives to medicine and health.

HEALTH Health is a metaphor for well-being which contributes to a person’s basic capability to function. To be healthy means to be of sound mind and body; to be integrated; to be whole. Health is also the basic human right of all the human beings. The preamble to the World Health Organization (WHO) constitution affirms that it is one of the fundamental rights of every human being to enjoy the highest attainable standards of health. Definitions and perception of health can vary systemically among various social groups and it is likely that different accounts of health are drawn according to social circumstances.

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Talcott Parsons (1951) defined health as a ‘state of optimum capacity of an individual for effective performance of the roles and tasks for which he has been socialized’. At the global level, WHO (1948) defines health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’. This definition highlights two major themes. First, health is not just a matter of personal choice, nor is a biological issue; patterns of wellbeing and illness are rooted in the organization of society. Second, health is a social issue and this is borne out of evidence that standards of health have varied over time and also from one society, culture and country to another. The different ways in which health is perceived and defined help us recognise three main dimensions concerned with health—physical, mental and social. Physical health relates to an individual’s physiological and biological wellbeing in the absence of any disability. Mental health denotes a state of mental stability devoid of stress. Social health refers to a state when individual’s relationship with the society and its constituents is acceptably healthy. A sociological understanding of health takes into consideration structural and social factors, rather than simply biological explanations of health and disease.

Social Determinants of Health (SDOH) The diverse social factors determining population health patterns are broad and complex. Individuals lie in the middle and bear constitutional factors that contribute to their health. Factors such as age and gender are biologically and socially determined as our social roles and positions change with the phase of life and gender (Fig. 11.2). The next zone comprises individual behavior and lifestyle, such as drinking alcohol, smoking, physical activity, sedentary habits and eating habits which can be either health promoting or health damaging. The third zone covers social and community interactions for a robust social support system to sustain good health of its members.

Fourth zone consists of living and working conditions inclusive of housing, water and sanitation, occupation and working conditions, income through employment or other sources, education and healthcare services. These factors vary greatly and contribute to maintenance of healthy living. The last zone includes social, structural, cultural and environmental factors that are characteristic of communities and societies and contribute in a large way to population health. As per World Health Organisation (WHO, 2019), social determinants of health are the conditions in and under which people are born, grow, work and live and the broader set of forces and systems that shape the conditions of daily life. It is pertinent to mention here that disparities in morbidity and mortality in a population are systemic and most of the times socially produced. Recognising the role of social determinants of health and the social forces that exert a direct or indirect influence on them is vital to making a positive impact on health outcomes of any population (Sharma et al, 2018).

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Fig.11.2: Social determinants of health

Social forces are the influences and systems (religion, gender, ethnicity, social status, etc.) that shape the conditions of daily life while health outcome is change in the health of an individual, group of people, or population that can be attributed to an intervention or series of interventions.

ROLE OF SOCIOLOGY IN GRADUATE MEDICAL EDUCATION It is now globally realised that medical education is a continuum and training of undergraduate medical students would be incomplete without an understanding of the role played by behavioural and social factors in human health and disease, ways in which these factors can be modified and knowledge of how personal experiences influence physician–patient relationships (Collet et al, 2016). The academic discipline of sociology is rich and varied and allows medical students to obtain a basic understanding of how the social contexts of health, illness and medicine have developed. It serves as a disciplinary framework for explaining relevant sociological theories and concepts to enhance understanding of medicine and facilitates student understanding of the integration of medical science, health and illness with the social determinants. Students can be exposed to an understanding of how the patient’s background and beliefs can affect patient care and wellbeing, how physicians can best interact with patients and their families, how cultural factors influence healthcare and how social contexts, such as health policy and economics, affect the ability of physicians to provide optimal care to patients (Cuff and Vanselow, 2004). Medical students trained in behavioral and social sciences are better equipped to identify patients’ unhealthy behavior (sedentary lifestyle, smoking, excessive alcohol and risky sexual behavior) and social determinants (poverty, illiteracy,

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poor housing conditions, large family size) responsible for disease risk and illness recurrence. Additionally, teaching medical students the social and cultural context of illness, how to function in a team environment, communication skills and understand the available community resources will assist them in building a therapeutic relationship with the patient resulting in overall patient and physician satisfaction.

Inculcating Medical Humanities through Medical Sociology The field of medical humanities explores the convergence of health and illness; healthcare practices; link between care receiver and care provider; the influence of biotechnological advances on healthcare, and the social and political functions of healthcare institutions and society with focus on care and medicine. Transcending the disciplinary divisions; medical humanities engages different areas of study ranging from science, history, ethics, and philosophy, to sociology, literature, religion, and art—in a discourse that looks into the meaning of health, wellbeing, and healing in context to the individual and society, thus justifying the very notion that medical humanities can be well inculcated in undergraduate students through a well-planned and structured medical sociology course-work.

UNDERGRADUATE MEDICAL SOCIOLOGY CURRICULUM CONTENT AREAS RELATED TO HUMANITIES An account of content area related to medical sociology that can be included in a well-designed medical humanities curriculum at undergraduate level is detailed below. The curriculum can be spread across phases so as to have a longitudinal program for students’ development. I. Sociology • Introduction to sociology and medical sociology • Fundamental concepts: Man and society • Components of social structure, social groups, social institutions and social status • Historical development of medical sociology • Sociological theories as applied to medicine • Science of medicine and its relevance to social institution II. Health and disease in a sociocultural context • Diseases, illness, sickness and health • Influence of social, cultural and religious factors on knowledge of health and disease • Influence of social structure on medical care • Social inequalities in healthcare • Key social determinants of health inequality (social class, socioeconomic status, gender, ethnicity, age and disability)

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• Role of discrimination and marginalization on health and disease • Role of social media and social groups on knowledge of health and disease III. Health practices and medical practitioners • System of medical beliefs and practices • Physician–patient relationship • Concept of a patient as a person and concept of a patient as a whole social component in therapy and rehabilitation. • Societal norms, beliefs, values associated with disease treatment and rehabilitation. IV. The process of seeking medical care and the sick role • Role of socio-demographic variables in seeking medical care • Socio-psychological modes of healthcare utilization. V. Social, political and economic determinants of health policy development and medical practice • Social, political and economic contexts influencing framing of health policies and legislations • Influence of various health policies on medical practice • Healthcare delivery system • Social disparities between healthcare need and availability of healthcare resources. VI. Sociological research—action areas • Introduction to different methods of sociological research; quantitative (randomised control trials and surveys) and qualitative designs (in-depth interviews, focus group discussions and observations). • Framing of research questions and choice of the most appropriate research method. • Examples relating to contributions of qualitative research and quantitative research to understanding sociological aspects of health, illness and disease.

MEDICAL SOCIOLOGY: TEACHING–LEARNING APPROACHES ‘Knowing is not enough, we must apply Willing is not enough, we must do’ — Goethe In order to ignite awareness of sociology among medical students the teaching– learning approach has to be such that it allows the students to transform their learning into medical practice. The various sociological theories provide a conceptual framework that helps explain social phenomena in the context of health and illness. The inter-disciplinary, inter-professional, and applied context of medical sociology as a discipline can be achieved only when the teaching and learning methods are shifted from didactic and merely educational and informative to applied forms (Constantinou, 2015).

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Emphasis needs to be laid on learning methods that stimulate the students’ social conscience and promote social transformation through action such as interactive lectures, clinical faculty facilitated small group teaching/work, problem-based learning, team-based learning, flipped classroom teaching, community-oriented and field-based programs for demonstration and participatory education of the undergraduates. Teaching sociology to medical students can be tough and challenging. However, it also needs to be realised that the learners have to be taught sociology essential to the practice of medicine (Kendall et al, 2018). The faculty should have a sound grasp of the subject so that they can facilitate learning of key sociological concepts and its application in medical sciences. It is also essential to have a clear understanding of the learning outcomes so that the teaching–learning approaches and assessment may be aligned with the outcomes expected from Indian Medical Graduates. A few pedagogical approaches to actively engage the medical students on fundamental theories of sociology and promote learning are given in Table 11.2. TABLE 11.2: Key approaches to teach medical sociology Teaching–learning approaches

Advantages

Social learning experiences • Give meaning to reality of living with illness and experiences of medical care Patient educators/patient stories/experience sharing/peer teaching/group projects • Promote group construction of knowledge • Allows students to observe others’ successful models • Encourages students to develop analytical and critical thinking in real life clinical context Co-teaching • Appropriate for emphasizing medical relevance of (For example: The faculty of pathology, sociology and teamwork physio­logy, psychology, sociology, patients and general physicians teach together) Viewing and creating activities Interesting and engaging Visual presentations/videos/podcasts/site visits Creative active learning through perfor­ Engages students in multiple learning styles mance interpretations of: Theatre/dance/ musicals/artistic work/narratives/story writing/poetry/debate/reflective writing Sociocultural case scenarios/vignettes

Provide exposure to authentic contexts and enculturation into medical discipline

MEDICAL SOCIOLOGY: ASSESSMENT Assessment is an essential element of any instructional process. It allows us to gauge the extent to which the learning objectives have been met through the instructional methodology. Assessment also helps the learner to focus on the ‘must-know’ aspects of any curriculum and often drives learning. There are different assessment methods that can be used, each with some advantage over the other. The learning outcomes and competencies in medical undergraduates should be kept in mind while deciding on

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any specific evaluation tool (Kuper et al, 2007). Table 11.3 depicts the main methods of assessing medical sociology with their advantages. TABLE 11.3: Key methods to assess medical sociology Methods

Advantages

Essay questions

• Demonstrate depth of understanding • Demonstrate the ability of student to recognise situations, consider alternative views, evaluate evidence and defend conclusions

Structured questions • Oral • Written

• Offer clarity to students on content asked • Consistency of marking is maintained

Multiple choice questions • Allow for uniformity/consistency in grading (MCQs) • Sampling of student knowledge in any specific topic with vast information • Cost-effective Direct observation • OSCE • Mini-CEX

• Application of sociology in clinical context • Better understanding of clinical relevance of sociological concepts

THE ROAD AHEAD: OPPORTUNITIES AND CHALLENGES Presently in India, health-related social sciences are taught as part of undergraduate medical curriculum by the discipline of preventive and social medicine (PSM)/ community medicine. This curriculum is theoretical and conceptual with content application to health and illness through the family study exercise and exposure to primary care services within the public healthcare network which covers all aspects of comprehensive health services ranging from preventive, promotive, curative and rehabilitative services. It has been a challenging task for medical sociology to find home in medical education both in terms of its status as a subject and the impact of its theories on health and healthcare. As medical educators, it is vital to recognise its contributions and allocate space and time in medical curriculum for its inclusion. A deeper appreciation of the field of medical sociology can help embed this rich and diverse topic into the medical undergraduate curriculum that has the potential to provide medical students with ways of thinking about medicine and healthcare from a sociological perspective to enhance the medical institutional and intellectual development. The latest research in medical sociology can help provide newer insights into the process of evolving patterns of social relationships in health and healthcare. Research in the emergent new areas can provide enough evidence of the relevance of sociology to the field of medical science. These ideas range from influence of social networks and social capital to the internet on health of society, changes in the organization of healthcare delivery to strategies for reforming healthcare systems, from bioterrorism to role of culture, region and spirituality on health, from bioethics to narratives on illness and death in family and role of globalization on health to complementary and alternative medicines. For medical sociologists, the list is endless.

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CONCLUSION Medical humanities attempts to gain an insight into the cultural and social contexts within which varied, yet interwoven issues like human condition, the individual encounters of illness and suffering, and the way medicine is/has been practiced, can be perceived. Sociology plays a critical role in reconceptualization of the medical curriculum for undergraduate medical education, thus acknowledging the multitude of social issues that can impact medical practice for the physicians in the making. As an inherent component of humanities, medical sociology is a key social science that can equip medical students with knowledge and skills essential for their individual practice and for their societal role as healthcare providers.

BIBLIOGRAPHY • Annandale, E., Clark, J. What is gender? Feminist theory and the sociology of human reproduction. Sociology of Health and Illness 1966;18(1):17–44.

• Cockerham, W. and Scambler G. Medical sociology and sociological theory. In: W. Cockerham (ed.) The New Blackwell Companion to Medical Sociology. Oxford, UK: WileyBlackwell 2010;1–26.

• Cockerham, W.C. (2001). The Blackwell Companion to Medical Sociology. Blackwell Publishers Inc.

• Collett, T, Brooks, L, Forrest, S, Harden, J, Kelly, M, Kendall, K, MacBride-Stewart, S, Sbaiti,

M, Stevenson, F. (2016). A core curriculum for sociology in UK undergraduate medical education: a report from the behavioural and social Sciences teaching in Medicine (BeSST) Sociology steering group. Cardiff: Cardiff University; Accessed on 20.09.2022. Available from: https://pdfs. semanticscholar.org/a3fa/753f260055b0852f662c31b766a265da6393.pdf

• Committee on Certification in Medical Sociology. 1986. Washington, D.C.: American Sociological Association.

• Constantinou, Costas. “Individualized Medical Sociology: Placing Sociology in Medical Practice.” Journal of Applied Social Science 2015;9:182–90.

• Cuff, PA, Vanselow, NA (eds) (2004). Improving Medical Education. Enhancing the

Behavioural and Social Science Content of Medical School Curricula. Washington: Institute of Medicine, National Academies Press. Accessed on 20.09.2022. Available from:http:// www.nap.edu/catalog/10956.html

• Foucault M (1967). Madness and civilisation: a history of insanity in the age of reason. London: Tavistock/Routledge.

• Hafferty, FW, Light, DW. Professional Dynamics and The Changing Nature of Medical

Work. J Health and Social Behaviour (Extra Issue) 1995;132–53. • Hill, T, Cockerham, W, Mcleod, J, Hafferty, F (2021). Medical Sociology and its Changing Subfields. 10.1002/9781119633808.ch1. • Kendall, K., Collett, T., Longh, A. D., Forrest, S., Kelly, M. Teaching sociology to undergraduate medical students. Med Teach 2018;40(12):1201–7.

• Kuper, A., Reeves, S., Albert, M., Hodges, B. D. Assessment: do we need to broaden our Methodological Horizons? Med Educ 2007;41(12):1121–23.

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• Lupton, D (1994). Medicine as Culture. London: Sage • Marx, K. (1963). Selected Writing in Sociology and Philosophy. Bottomore, T. B. (ed). London:

C. A. Watts and Co. Ltd. • McIntire, C. The Importance of the Study of Medical Sociology. Sociological Practice 1991;9(1), Article 5. • Medical Council of India (2019). Regulations on Graduate Medical Education, 1997–Part II. Accessed on 20.12.2022. Available from: https://www.nmc.org.in/ActivitiWebClient/ open/getDocument?path=/Documents/Public/Portal/Gazette/GME-06.11.2019.pdf. • Parsons, T. Illness and the role of the physician: A sociological perspective. American Journal of Orthopsychiatry 1951;21(3):452–60. • Scheff, TJ (1999). Being Mentally Ill, 3rd edition, Hawthorne, NY: Aldine de Gruyter. • Sharma, M, Pinto, AD, Kumagai, AK. Teaching the Social Determinants of Health: A path to equity or a road to nowhere? Acad Med 2018;93:25–30.

• Strauss, A, Wohl R. Symbolic Representation and the Urban Milieu. American Journal of Sociology 1958;63:523–32.

• Strauss, R. The nature and status of medical sociology. American Sociological Review 1957;22:200–4. • World Health Organisation (2019). What are the social determinants of health? Accessed on 20.12.2022. Available from: http://www.who.int/social_determinants/sdh_definition/ en/. • World Health Organization (1948). Accessed 20.09.2022. Available from: https://www. who.int/about/who-we-are/constitution.

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Teaching and Learning Methodologies 12. Role of Cinemeducation in Humanities 13. Role Plays 14. Theatre and Forum Theatre 15. Role Modeling 16. Case Studies 17. Creative Writing (From Scalpel to Pen: Chaos, Process and Value) 18. Role of Poetry in Medical Humanities 19. Artwork, Comics and Cartoons 20. Reflections 21. Teaching Medical Humanities: Global Learning Toward Local Caring

12 Role of Cinemeducation in Humanities Anuradha Joshi Key Points q Cinemeducation term comprises cinema + medicine + education meaning use of movies to help teach medicine. q

Trigger films, movie clips, video clips, whole-length films, television series and motion picture are some of the modes of using cinema in education.

q

Cine-movies are one of the strongest medium affecting emotions, thinking, professional behavior and attitude of human beings.

q

Use of cinema for teaching humanities serves as an interesting pedagogical tool to help students think in alternative ways as compared to traditional learning models.

INTRODUCTION There has been an impressive growth in the field of technology which has been a saviour to countless lives, but in the sprint towards such advancements, we are gradually losing touch with certain humane aspects. This loss, in a way, cannot be compensated by any ground-breaking research or invention. While patient care needs to be prioritised, understanding the patient is as important, as treating the disease itself. A sound mental health is vital for life’s support system, hence, strengthening and restoring patient’s faith and psychological health during treatment sometimes works better than any medicine. This calls for stressing the importance of psychological and emotional comfort along with physical well-being, leading to a holistic healing process. Values as these form the basis of the interaction of a doctor with his/her patients and relationships thereof. Since, it is a complex task to teach humane aspects of medicine using conventional approaches, complex emotional, psychological and inter-social aspects of being humane need to be taught by some interesting and innovative ways, such as cine-education. Main purpose of such education is to encourage compassion while treating the patients, understanding their pain and providing relief in terms of physical, psychological, social and spiritual wellbeing. Literature reports medical professionals to be negligent of important soft skills like empathy, work ethics, communication, professionalism and relational skills in the field of medicine (Shankar, 2019). In context to this “Cinema in medical education” 117

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can be used as one of the most effective, essential, influential and creative tool to educate medical students and healthcare professionals regarding importance of soft skills in medical field (Ortiz, 2018). In addition, such educational modes are necessary to prevent one from losing touch with the real world (Blasco, 2001). There are many ways of teaching humanities to medical students, e.g. being role models, bedside visits of patients, role-playing, facilitating problem-based learning classes, using arts and literature, creative writing, storytelling, etc. These methods have been discussed in detail in different chapters in this book. Fortunately, due to proliferation of social media and alternative cinema, as opposed to mainstream cinema, new avenues of education have opened up. In light of this, movies are being increasingly used as teaching learning modality in medicine. It fosters an open, inclusive and an interdisciplinary mode of pedagogy.

CINE-EDUCATION AND CINEMEDUCATION ‘Cine-education’ is defined as the art of using movies, trigger films, movie clips, whole length film and theatre in teaching while the term ‘Cinemeducation’ was first coined by Alexander et al (1994) which refers to use of movie clips from movies and videos to educate medical students and residents about psychosocial aspects of medicine. Cine-movies are a type of aesthetic audiovisual aids that imprint powerful pictorial images in memory and is the strongest medium affecting the emotions, thinking and attitudes of human beings. Most common strategy in cinemeducation is the use of an entire movie or movie clip or video clip to stimulate group discussion and ask trigger questions which are tailored to the teaching goals and objectives. As mentioned above, in past, cinemeducation was primarily meant to teach psychological and social aspects of medicine (Zeppegno et al, 2015). Nowadays, movies are being used to address a variety of topics like medical ethics, doctor– patient relationship, communication skills, end of life conversations, clinical research, mental illness, and professionalism during medical school (Shankar, 2019). Also of interest is its use in mental health and as a tool for psychological therapy for therapeutic purpose. An increasing number of therapists are prescribing movies to help their patients explore their psyches. The term ‘cinema-therapy’ has been coined to reflect its use as a tool which has ‘power to heal’. Simultaneously movies are also being used by many faculties in several fields like family medicine (Lenahanand Shapiro, 2005), clinical pharmacology (Farré et al, 2004), philosophy (Asma, 1999), religion (McCutcheon, 1998), postgraduate psychiatry training (Datta, 2009), etc. Cinema is useful in teaching because it is familiar, evocative, and non-threatening for students. To some people, words do not convey more than just information, hence, movies are helpful to do what the usual textbooks lack. It could be a tedious and unfruitful task to rely on the conventional methods to promote what requires a deep sense of understanding and realisation to bring about a change in the way a student behaves, observes, perceives, and reacts to various situations (Baños and Bosch, 2015).

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ROLE OF CINEMEDUCATION IN TEACHING HUMANITIES ‘Cinema is the greatest mirror of humanities struggle. You see this alternative world, but you are part of it. Everybody is part of it. This is our world’. —LavDiaz (Ingawanij, 2015) Medical humanities is one of the most important aspects of medicine and should be integrated in undergraduate as well as postgraduate curriculum. Although this chunk has been dominated by the use of skills, its importance is unequivocally acknowledged in terms of putting forward the basic human values like empathy, goodwill, altruism, honesty and also assertive skills like decisiveness, leadership qualities and efficient teamwork. Topics pertaining to humanities, physician–patient relationship, medical ethics, professionalism, conduct in clinical trials, research and compassion, hitherto never being taught in medical schools, have often been the centrepieces in these cinematic presentations (Pellegrino, 2002). Hence, in an effort to reach out to the students with these concepts, the approach of movies has been immensely supported (Blasco et al, 2015). As emotions play key roles in learning attitudes and changing behavior, teachers must impact learner’s affective domain. Cinematic experiences provide vivid emotional memories which help develop altruism and conveying concepts of humanities. The main goal of cinematic approach is to promote reflection and provide a forum for discussion (Blasco et al, 2006). The teaching goals of cinemeducation could be the emotional reactions of the viewer, diagnostic and therapeutic decisions, and the balancing of professional life with personal life. Those goals could be reached by stimulating group discussion or asking trigger questions after watching the movies. On the other hand, addressing the emotional needs of dying patients is rarely found to have a place in formal medical curriculum and is also a difficult area to teach through classical medical lectures. Since patients usually present with complicated problems, the real challenge for the clinician lies in “How these disease have affect our patients?” How to teach empathy to medical students?” (Shapiro and Rucker, 2004). While empathy is needed for a deep understanding of the human condition, it could serve as an important link between patient-centered medicine and evidencebased medicine allowing a therapeutic benefit (Blasco et al, 2010). Cinemeducation helps promote learning of soft skills and acquire the art of listening to their fellows and considering their points, and learning from them as well. Blending arts with humanities can help understand human pain and condition, thereby proving holistic care to the patients. Cinema in medical education promotes out of box thinking, creating a sense of self-awareness by giving students an opportunity to form their own belief-system, set of ethics and developing their personality by channelizing their thought-system towards humanitarian aspects. Moreover, the discussions post-movie clips tend to foster harmony, teamwork and general care towards each other forming the founding steps of respecting others. Another interesting form of cinemeducation is trigger films. Trigger films (TFs) are priceless for teaching medical students the intricacies of the doctor–patient

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relationship. TFs, also called trigger videos, are brief (3–10 minutes) clips that can also be used to encourage reflections, stimulate discussion, help learners confront their feelings, and train the learners to respond to various emotional challenges (Ber and Alroy, 2001). Cinemeducations are excellent tool for reinforcing professionalism, ethical issues, communication skills, analytical thinking, intellectual humility, etc. (Lumlertgul et al, 2009). In addition, they play a pivotal role in highlighting the significance of the social, cultural and historical contexts in shaping representations of mental illness, psychiatry, and psychiatrists (Kadivar et al, 2018). Thus, the use of cinema while teaching humanities can help teachers introduce students to some medical scenarios that may be difficult to understand using traditional educational methods. Teaching humanities with help of cinema can leave indelible impressions on the young medical graduates (Joshi et al, 2018). Though using cinemeducation as an educational tool for teaching humanities can be challenging but when carried out in a proper manner, it boasts of numerous benefits.

RECOMMENDED MOVIES Some of the movies with intended message they convey has been provided in Table 12.1. These movies can be a rich source of teaching humanities to undergraduate as well as postgraduate students of health profession. TABLE 12.1: Representative movies along with message they convey for teaching medical humanities to students Name of movie (language, Message year of release) Anand (Hindi movie, 1971) The film introduces the concept of selflessness, altruism and teaches one is an Indian drama film to always look at the brighter side of the world and diversity of life leaving behind all the despair and suffering The movie emphasizes on significant learning experiences of life through interesting dialogues like “life should be ‘big’ not ‘long’ and that one should enjoy life with laughter and not stop living life in fear of death.” The movie highlights the importance of positive personal attributes of a doctor and de-stressing in medical professionals (Kushwaha, 2016) Still Alice (English movie, Movie depicts a tearfully gripping story of an early-onset Alzheimer’s 2014) is an American indepe- wherein a professor is diagnosed with familial Alzheimer’s disease. The ndent drama film professor here is an educator, mother, wife, a grandmother, jogger, cook, dishwasher, vegetable chopper whose life suddenly come to an abrupt stop. The movie showcases the effects of a debilitating disease on patients body and routine activities The movie is based on Lisa Genova’s extraordinary New York Times bestselling novel about the story of an accomplished woman who slowly loses her thoughts and memories to Alzheimer’s disease—only to discover that each day brings a new way of living and loving (Genova, 2009) Dil Ek Mandir (Hindi movie, The film gives a message regarding ethical moral dilemmas in medical 1963) profession (Sridhar,1963). It highlights the importance of factors affecting ethical behavior while treating patients, like knowledge, values, personal goals, morals and personality Contd.

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TABLE 12.1: Representative movies along with message they convey for teaching medical humanities (Contd.) to students(Contd.) Name of movie (language, Message year of release) The Doctor (English movie, 1988) is based on Dr Edward Rosenbaum’s 1988 book, i.e. A Taste of My Own Medicine (Rosenbaum, 1988)

Depicts the life story of a medical doctor and narrates his perceptions on life’s illness and human relationships. Video clips from ‘‘The Doctor’’ have been used to teach residents in psychosocial aspects such as delivering bad news, the impact of terminal illness, and cross-cultural issues in medicine (Ozcakirand Bilgel, 2018) “The Doctor” movie is a good instrument to discuss some topics that are ignored during the medical education, e.g. feelings, frights, embarrassments, and vulnerability of the patients. The movie conveys that to be a doctor one ought to feel like a patient, so as to understand and treat patients in a better way Such movies have been used by medical educators to teach importance of effective communication and patient–doctor relationships which are the core elements of medical humanities

Munnabhai MBBS (Hindi The movie shows how respecting a colleague, showing gratitude and movie, 2003) (Pai, 2004) acknowledging the role of each person in an organization goes a long way in harmonizing and the prevention of burn out and stress. Also there are humorous illustrations of valuing hug, a simple touch, and empathy to deal with tension, stress, and life’s troubles Movie also brings to light, importance of attending to the patient immediately in emergency situations as against filling up forms and getting tied down by formalities Patch Adams (English movie,1998) is an American semi-biographical comedydrama film based on life story of  Dr Hunter “Patch” Adams (Yuniati,2009)

Patch Adams delivers a powerful message of how to just be silly and break the rules when it is in the best interest of everyone around. The movie depicts the importance of human emotions, and impact of laughter in good health. The movie emphasizes that along with cure, care is equally important for treating the patient Students learn regarding characters developing different patterns of relationship with their patients, and how patients react to their doctors with different attitudes The 2003 Bollywood film Munna Bhai MBBS as mentioned above, was inspired by Patch Adams movie and brought Adams’ methods to the forefront in India and Pakistan, where conventional methods were predominant (Chaturvedi, 2004)

Awakenings (English movie, Depicts the story of a dedicated, genuine, compassionate physician 1990) is an American dram working on catatonic patients. The movie highlights the importance of film (Sacks, 1991) empathy displayed by a doctor for his patients and the conflicts arising out of discovering a novel drug for his ailing patients. The movie also indicates relevance of abiding by the laws and standards, informed consent and role of ethics committee in clinical trials. The movie showcases “how a relationship between a patient and a doctor can be beyond professionalism” The Constant Gardener The plot of the film is loosely based on a real-life case in Kano, Nigeria (English movie, 2005) is a involving antibacterial testing on small children (Totten, 2016). It depicts drama thriller film the influence of pharmaceutical industry on research regulations and the constraints faced by US FDA in enforcing health and safety regulations in an increasingly globalized world Contd.

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TABLE 12.1: Representative movies along with message they convey for teaching medical humanities to students (Contd.) Name of movie (language, Message year of release) Since African countries have been common sites for clinical trials by large pharmaceutical companies, the movie raises concern over human rights and highlights the dynamics of conduct in clinical trials in Africa in slum areas. Incidents of unethical experimentation, clinical trials lacking properly informed consent, and forced medical procedures have been claimed and prosecuted (Kashani, 2012) My Left Foot (English movie), Describes the story of a cerebral palsy patient born into a poor family in is an Irish biographical slum struggling with disability and economic hardship. It portrays human comedy-drama film courage and determination amidst the challenging times Wit (English movie, 2001) Wit is a powerful drama about dying and death, educating the medical is an American television students about personal meaning of terminal illness and small acts of movie kindness (Ozcakirand Bilgel, 2014) Wit draws attention to various things affecting the patient like tests from laboratory technicians; ‘grand rounds’, where the patient is prodded by medical students and treated like a specimen rather than a human being; the loneliness of time spent in an isolation ward; the terrible side effects of the chemotherapy; and then the pain of the still spreading cancer Extraordinary Measures Extraordinary measures is the story of a family wherein in a family of four, (American medical drama the kids are diagnosed to be suffering from a fatal disease. Following this film, 2010) the film unfolds the measures undertaken by father and his devotion to searching for a treatment for his children so as to save them from the life-threatening disease. Also, the film portrays his continuous battle with the corporate sectors trying to race against time for finding the remedy

CHALLENGES While there is no questioning of the fact that movies can be a competent method of education, there are still several challenges which need to be addressed so as to be accepted universally. For conventional teachers, adopting cinemeducation as a teaching tool for humanities can be an arduous task. Showing full movie available in open resources might have time constraint, cutting and editing a movie to solve the purpose can land medical educators in copyright infringement issues. While there can be various possibilities and concerns of choosing a contextual movie for an effective learning outcome, teachers should bear the following principles in mind before applying “cinema in medical education” to teach humanities: 1. Movies play a phenomenal role in showcasing public opinions on certain medical problems, so the choice of films should be appropriate for students’ knowledge as this information is invaluable when dealing with patients and families. 2. A thorough review of various movies/clips/videos is a must to identify the most relevant scenes for the educational objectives and for the purpose of generating a productive discussion/debate. 3. An in-depth review of available literature is equally useful to meet the specific objectives of session.

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4. Medical educators can refer to specific experiences and recommendations on using popular movies as teaching tools for medical students. 5. A general reminder for teachers would be that the most popular films are not always applicable for teaching humanities, because the characteristics that make a film popular for the general public differ from those that make it useful for medical education. 6. Taking notes and preparing a discussion guide after viewing the movie, helps improve the quality of sessions. 7. Teaching activities using films should be planned like all other activities included in the curriculum. 8. Discussion of the film should focus on pre-planned questions. To maintain the audience’s attention and interest, teachers should use effective strategies to spark the debate. 9. Medical educators need to impress upon students, to not let emotions overvalue the real message of the movies. The former should express his or her view only after all the students have shared their thoughts and with a clear understanding that the teacher’s view is equal to that of any other and is not authoritative. 10. Teachers need to take into account the students’ current knowledge, and use realistic assessment measures that are appropriate for the activity.

CONCLUSION Currently use of cinema in medical education is in a nascent stage and at the same time gaining acceptability at a rapid pace. Cinemeducation helps students learn to look at situations from various perspectives. It also serves to enhance teaching by providing a dynamic and humanistic depiction of clinical situations. This in turn leads to triggering of opinions from the students and ultimately helps foster soft skills, intellectual humility and critical thinking.

BIBLIOGRAPHY • Alexander, M, Hall, MN, and Pettice, YJ. Cinemeducation: an innovative approach to teaching psychosocial medical care. Family Medicine 1994;26(7):430–33.

• Asma, ST. Descartes Goes Hollywood: Using Movies to Bring Philosophy to Life in the Classroom. Chronicle of Higher Education 1999;45(19):B6.

• Baños, JE, and Bosch, F. Using feature films as a teaching tool in medical schools. Educación Médica 2015;16(4):206–11.

• Ber, R, and Alroy, G. Twenty years of experience using trigger films as a teaching tool. Acad Med 2001;76(6):656–58.

• Blasco PG, Moreto G, Roncoletta AF, Levites MR, Janaudis M.A. Using movie clips to foster learners’ reflection: improving education in the affective domain. Family Medicine 2006;38(2):94–96.

• Blasco, PG. Literature and movies for medical students. Family Medicine 2001;33(6):426–27.

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• Blasco, PG, Garcia, DS, de Benedetto, MAC, Moreto, G, Roncoletta, AF, and Troll, T.

Cinema for educating global doctors: from emotions to reflection, approaching the complexity of the Human Being. Primary Care 2010;10(3): 45–47. Accessed on 25.12.2022. Available from: http://aebioetica.org/archivos/wcwe09.pdf

• Blasco, PG, Moreto, G, Blasco, MG, Levites, MR, and Janaudis, MA (2015). Education

through Movies: Improving Teaching Skills and Fostering Reflection among Students and Teachers. Journal for Learning through the Arts, 11(1). Accessed on 25.11.2022. Avaialble from: https://files.eric.ed.gov/fulltext/EJ1086983.pdf • Chaturvedi, S. Palliative care education by Munnabhai MBBS. Indian Journal of Palliative Care 2004;10(1):30–31. • Datta, V. Madness and the movies: an undergraduate module for medical students. International Review of Psychiatry 2009;21(3):261–66. • Farré, M, Bosch, F, Roset, PN, and Baños, JE. Putting clinical pharmacology in context: the use of popular movies. The Journal of Clinical Pharmacology 2004;44(1):30–36.

• Genova, L (2009). Still Alice. Simon and Schuster. Accessed on 24.12.2022. Available from:

https://www.simonandschuster.com/books/Still-Alice/Lisa-Genova/9781439102817 • Ingawanij, MA. Long Walk to Life: The Films of Lav Diaz. Afterall. A Journal of Art, Context and Enquiry 2015;(40):102–15. • Joshi, A, Singhal, A, Loomba, P, Grover, S, Badyal, D, and Singh, T. Humanities in Medical Education. Journal of Research in Medical Education and Ethics 2018;8(SI):3–9. • Kadivar, M, Mafinejad, MK, Bazzaz, JT, Mirzazadeh, A, and Jannat, Z. Cinemedicine: Using movies to improve students’ understanding of psychosocial aspects of medicine. Annals of Medicine and Surgery 2018;(28):23–27. • Kashani, BM (2012). Regulatory Oversight of Foreign Clinical Trials: An Examination of the Industry’s Influence on FDA Pharmaceutical Regulation and the Implications for enforcement activity both domestic and abroad. Accessed on 25.12.2022. Available from: https://pdfs.semanticscholar.org/422c/6618814bef80ef94471067d02dabbaa56c3e. pdf?_ga=2.203062417.141765879.1587797472-1502408398.1571124773 • Kushwaha, RS. Hindi Cinema in Contemporary India. Amity Journal of Media and Communications Studies 2016;5(3):72–76. • Lenahan and Shapiro Lenahan, P, and Shapiro, J. Facilitating the emotional education of medical students: using literature and film in training about intimate partner violence. Family Medicine 2005;37(8):543–45. • Lumlertgul, N, Kijpaisalratana, N, Pityaratstian, N, and Wangsaturaka, D. Cinemeducation: A pilot student project using movies to help students learn medical professionalism. Med Teach 2009;31(7):e327–32. • McCutcheon, RT. Redescribing “religion and…” film: Teaching the insider/outsider problem. Teaching Theology and Religion 1998:1(2):99–110. • Ortiz, MBA. Commercial Cinema as a learning tool in medical education, from potential medical students to seniors. MedEd Publish 2018;7(4):17. Accessed on 25.12.2022. Available from: https://www.mededpublish.org/manuscripts/1895. • Ozcakir, A, Bilgel, N. Educating medical students about the personal meaning of terminal illness using the film, “Wit”. J Palliative Medicine 2014;17(8):913–17. • Ozcakir, A, Bilgel, N. “The Doctor” Teaches Humanities to Medical Students. European Scientific Journal 2018;14(3). Accessed on 25.12.2022. Available from: https://www. academia.edu/35879049/_The_Doctor_Teaches_Humanities_to_Medical_Students.

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• Pai, S. Munnabhai MBBS. BMJ 2004;328(7443):841. • Pellegrino, ED. Professionalism, profession and the virtues of the good physician. Mt

Sinai J Med 2002;69(6): 378–84. • Rosenbaum, EE (1988). A taste of my own medicine: When the doctor is the patient? New York: Random House. • Sacks, O. (1991). Awakenings. London: Pan Macmillan. • Shankar, PR. Cinemeducation: Facilitating educational sessions for medical students using the power of movies. Archives of Medicine and Health Sciences 2019;7(1):96–103. • Shapiro, J, and Rucker, L. The Don Quixote Effect: Why Going to the Movies can Help Develop Empathy and Altruism in Medical Students and Residents. Families, Systems, and Health 2004;22(4):445–52. • Sridhar, CV (1963). 01 Dil Ek Mandir. Accessed on 20.12.2022. Available from: https:// en.wikipedia.org/wiki/Dil_Ek_Mandir

• Totten, VY. How to design a study that everyone will believe: The challenges of doing

international research. In: Wilson, MP, Guluma, KZ, Hayden, SR (eds). Doing Research in Emergency and Acute Care. Wiley Online Library. 2015;pp. 133–137. • Yuniati, RF (2009). The struggle of Patch Adams to be a doctor in Tom Shadyac’s Patch Adams: an individual psychological approach (doctoral dissertation, universitas muhammadiyahsurakarta). Accessed on 25.12.2022. Available from: https:// pdfs.semanticscholar.org/ced2/7b50a9be9595083aa00e0322f4baa8bc1a8f.pdf?_ ga=2.64108335.141765879.1587797472-1502408398.1571124773 • Zeppegno, P, Gramaglia, C, Feggi, A, Lombardi, A, and Torre, E. The effectiveness of a new approach using movies in the training of medical students. Perspectives on Medical Education 2015;4(5):261–63.

13 Role Plays Kapil Gupta Key Points q Role play is a simulation based technique that promotes experiential learning. q

Role play mostly involves ‘student doctor’ and ‘student patient’, and can be used to foster empathy, communication skills, ethics—in short humanities competencies.

q

With suitable planning, same role play can be used for separate set of learners, so it is cost-beneficial.

q

Role play promotes both ‘reflection in action’ and ‘reflection on action’.

q

Role play provides opportunities for formative assessment of medical humanities.

‘All the world’s a stage, and all the men and women merely players; They have their exits and their entrances; And one man in his time plays many parts. His acts being seven ages’. —William Shakespeare

INTRODUCTION Role play is the art of understanding human perspective and its interaction with the surrounding for various medical and social issues in a certain context. It explores the human side of medicine and is the intersection of art and medicine (Shankar et al, 2013). Role play can be used to teach, express and assess the qualities of humanity, compassion, creativity, ethical behavior, professionalism, self awareness and communication skills by targeted practice to understand the problems and empathize. Role play, an experiential learning technique, is commonly used to develop and enhance communication and behavior skills (Charlton, 1993; Hargie et al, 1997; Nair, 2019), to help the students to acquire mastery in all the three domains—knowledge, skills and attitude, to enhance and reinforce the knowledge of medicine and to apply it in real life situations, thus fostering humanities competencies (Bell, 2011). It is a simulation based methodology, laying stress on learning in a social context and can be used in all disciplines and with students of all phases (Nestel and Tierney, 2007). Van Ments (1989) defines role play as ‘One particular type of simulation that focuses attention on the interaction of people with one another. It emphasizes the functions performed by different people under various circumstances. The idea of role-play, in its simplest form, is that of asking someone to imagine that they are either themselves or another person in a 126

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particular situation. They are then asked to behave exactly as they feel that person would. As a result of doing this they, or the rest of the class, or both, will learn something about the person and/or situation. In essence, each player acts as part of the social environment of the others and provides a framework in which they can test out their repertoire of behaviors or study the interacting behavior of the group’. It is an educational technique in which people spontaneously act-out problems of human relations and analyze the enactment with the help of other role players and observers.

PLAYING ROLE PLAYS Role play exercises can be performed in various ways. For teaching and learning of patient-focused interviewing skills, the students assume their job as medical students, so they are relied upon to execute the roles as they would do in genuine clinical experiences. Usually one person acts as ‘student doctor’ and other as ‘student patient’. However, depending upon the learning requirements, many variations can be designed on this theme. Role play can be completely scripted (all players’ demonstration from verbatim contents) or incompletely scripted (players have certain prompts—frequently an opening line). Here, one player is given a portrayal of their job, while the other is furnished with their errand. Players can exchange their roles within a single role play with the aim of gaining understanding into different roles or viewpoints. In another variation, players can be substituted at different focuses in the role play by onlookers. Such spectators are called Spect-Actors. The details of such role plays have been given in next chapter. Some role play exercises use role cards as a method for embeddings new data into a role play (Nestel, 2007).

PLANNING AND EXECUTION OF ROLE PLAYS The planning and execution of role play activity should be very clear, comprehensive and structured with stress on enhancement of social and interpersonal interactions. Goals of the role play must be clearly defined through ample pre-discussion on it. Roles should be assigned to the students well in time, as per their previous experiences to enhance their confidence. There must be some reserved time for structured feedback after the role play. Joyner and Young (2006) have suggested 12 tips to keep in mind for an effective role play resulting in high level of engagement and active learning. These tips have been highlighted in Box 13.1 and discussed in detail below. 1. A good preparation for role play is desired. Necessary preparation and update of information about the subject of role play keeps up the believability of this instructive methodology. It includes sufficient time for preparation, reviewing the roles allotted, considering the suggestions of previous students—groups and update of knowledge about the subject of interest of role play. 2. The learning objectives should be clear and concise with inclusion of all domains of learning.

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BOX 13.1: Tips for executing effective role plays • • • • • • • •

Prepare sufficiently Define clear and concise learning objectives Select challenging conditions and cases Prepare script well in advance Allot time for each part judiciously Provide equal opportunity of participation and observation to all students Provide feedback after role play, keep separate time for it Promote self-reflections by participants and observers

3. The conditions/cases selected for role play should be challenging like diabetes, HIV, Asthma, etc. so that they stir emotions, and provide opportunities for— practice of interviewing skills and to deal with patients of all ages, gender, ethnicity and religion. 4. Put together the role of patient, doctor and observer in advance. Prepare the clinical notes for the student ‘doctor’, student ‘patient’ and provide one copy of each to the observers/examiners. The student ‘doctor’ notes can be case summary or an outline of interview for management, while the student ‘patient’ notes can be about selected medical problem, description of history and associated issues with it. The observers should also be provided with updated information about the selected case, relevant features of the case and scoring sheets. The whole set of templates can be reused again for next batch of students. 5. Provide time to students to prepare their roles and clarify the ground rules to be followed in advance. Similarly, define the time for each part of role play, i.e. presentation of case, consultation, management. Allot more time after the role play; keeping it for feedback about the performance, explanation of medical concerns and recognition of further learning prospects. 6. Provide equal opportunity for participation and observation to all students, so that the students can understand the process and content and can recognize the ways for improvement of role play and management of case. 7. The involvement of teacher in any role can also be there. Roles should be given wisely with the options left open for student to accept or reject it. Feedback should be constructive, appropriate behavior of students should be demanded and privacy should be maintained in every stage of role play. 8. Involve the observers in scoring the interview of role play and motivate them to distinguish extra issues for discussions and asking questions after the role play. Furnish them with subtleties of the role play and if possible divide different parts to be observed by different observers. 9. The role plays should be meant for formative assessment. Feedback form should be structured and detailed and must stress on assessing the communication skills, interviewing skills and content.

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10. Ask the participants of role play to self reflect, begin with what went well and then the focus on concerns and suggestions. Similarly, take feedback from observers for content, communication, interpersonal behaviors. 11. Promote lot of discussion by posing open inquiries by exploring the clinical case. 12. Make it learning with fun.

GUIDING PRINCIPLES FOR ROLE PLAYS Role play is based on principles of adult learning. Role play involves the student— who have a need to know, who is self coordinated, who have prior experiences and can make abstract meaning from various experiences, who has an inclination to learn from issue-focused learning and who have an interior inspiration to learn (Knowles et al, 2005). The role play also stresses on experiential learning or learning by doing. Kolb and Fry (1975) portray four “learning environments” in their hypothesis of experiential learning—affectively-oriented (feeling), symbolically-oriented (thinking), perceptually-oriented (watching) and behaviorally-oriented (doing) and each condition has two errands. First is, “grasping” which comprises solid encounters and dynamic conceptualization and second “transforming” which comprises reflection and action. Learning is upgraded, when students are urged to utilize every one of the four “conditions.” Structured role play with feedback empowers students to finish the two errands in every one of the four “situations.” The practice of reflection is also portrayed in role play. In light of his perceptions of various expert gatherings, Schon (2011) described that experts react by ‘reflecting in action’ or later by ‘reflection on action’. Reflecting in action or “thinking and reacting quickly” is a procedure by which a professional draws on a collection of current encounters—pictures, thoughts, activities, designs, so as to understand the issue going up against them. The practitioner means to put the issue inside their own edge of reference, so as to search out the best arrangement and foresee its results. Reflecting on action, also known as “retrospective reasoning” happens after the unforeseen occasion or issue and has specific significance for feedback since discussion of what has occurred can help the practitioner expand their base of involvement and thus broaden their collection. Once more organized, role play empowers learners to reflect both “in” and “on” activity. Structured role play guides learners to consider what had occurred in every role play as well as value of it before and after participation. It is additionally crucial to recognize that students learn in various ways and that role play might be the favored strategy for students who learn through solid encounters.

SIGNIFICANCE OF ROLE PLAYS In role play, learners institute a specific role according to the content planned. Hardly any preparation is required for conducting role play and there are abundant opportunities for practices, imagination and impromptu creation. Same content can be utilized with various sets of learners in different sessions.

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Educators and viewers can generally give feedback—subsequently making it a perfect ‘assessment for learning’. Any potential specialist patient experience can be changed over in to a role play, as—conducting sensitive interviews, dealing with difficult patients, any OPD or IPD setting, taking history, educating patient about changed dietary habits, motivational interviews or breaking bad news without the requirement of any specific equipments or acting skills (Steinert, 1993). Still formal teaching through role play is not usually done in many medical colleges except for developing communication skills, with the commonest scenario of “you be the doctor and you be the patient” (Fertleman et al, 2005). Role play includes practice sessions managing genuine circumstances without the restrictions forced by real patients, and enables healthcare students to encounter the point of view of both the clinician and the patient, resulting in more noteworthy familiarity with the requirements of both. It fits perfectly in to the future needs of the healthcare students by allowing them to rehearse their clinical, analytic and persistent administration abilities. The student tries to feel the part of character; not by simply hearing or telling, but by living through it, which arouses the interest in the problem and helps to develop leadership skills in dealing with it. It requires minimal equipment and student can experiment with behavior, make mistakes and try new skills without risk of experimentation in real life situations. The role play can help the students to conceptualize their roles and to improve their professional and interpersonal behaviors (Clapper, 2010).

ROLE PLAYS FOR INCULCATING MEDICAL HUMANITIES Role plays can be suitably adapted to target teaching–learning of almost all soft-skill constructs, viz. communication skills, empathy, professionalism, ethics, altruism— in short all aspects of humanities. As such, role plays are handy tools to inculcate humanities competencies in the students. Role play can be easily used to teach communication skills with patients, colleagues and members of healthcare team, and this learning tactic becomes important in present scenario with one of Indian Medical Graduate roles as communicator in competency based medical education. Although introduction of it in the group always meets with anxiety/resistance or feeling of humiliation to perform in front of all, but importance of it when based on a real life problem orientated clinical situation for gaining the experience and to learn the fine features of clinical, behavioral, theoretical and practical aspect in holistic manner and amicable environment cannot be denied. The role play can be a nice platform to get students involved in subject. It is not only limited to playing people, but to understand the system of action underlying certain behavior. It allows students to develop an understanding of others’ perspectives. This ensures inculcation of reflective behavior, altruism and compassion. Role play cultivates empathy. Students pick up various new view points on the subject which further helps them to comprehend and analyze the material better

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and develop solutions. It connects them to certifiable clinical cases and procedures and expands their attention to the issues having multi-facet orientation. Role play reinforces ethical and moral values. Role plays can be used to promote interpersonal relationship skills. Role plays can go a long way in inculcating medical humanities competencies in the medical students (Box 13.2). BOX 13.2: Use of role plays in inculcating medical humanities competencies Role plays can be used to inculcate medical humanities competencies pertaining to: • Interpersonal relationships • Communication skills (both verbal and nonverbal) • Counseling skills • History taking • Diagnostic and observational skills • Motivating for lifestyle modification • Professionalism • Ethical principles • Preventive and promotive healthcare outcomes • Sensitization of sensitive issues

ADVANTAGES OF ROLE PLAYS Role plays are not resource intensive; same script can be used with different set of students. They can be performed with limited number of student-actors. On the other hand, with seasonal variations in patient’s problems, the different role play scenarios can be created to provide central learning experiences, thus rendering role play a flexible educational method with wide variation in depth and focus to understand complex social and medical issues (Littlefield et al, 1999). Role plays promote both—‘reflection in action’ and ‘reflection on action’, provide a good formative assessment opportunity along with self discovery and selfunderstanding for both the performer and observer (Lane et al, 2001). Time can also be predefined in any role play, once it has been enacted for providing feedback by the facilitator and for group discussion. This also helps in developing abstract concepts and provides opportunities for ‘assessment for learning’ (Fig. 13.1). Role plays result in high level engagement (Bell, 2001) and promote active learning (Van Ments, 1999); provide need based feedback to students for training and improving of skills and targeted practice (Kiger, 2004). Role plays help to practice skills like history taking, diagnosis, management of general disease patterns, promotive and preventive health outcomes. Role plays can also be used to explore highly sensitive issues, to motivate for lifestyle modifications, to expose hidden behaviors and to sensitize the observers for the given issue (Joyner and Young, 2006). They emphasize on revisiting the interpersonal and professional behaviors by putting into other’s shoes. In a given educational and clinical setting, role plays help to reinforce the theoretical concepts, practice learned skills in integrated manner

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Fig. 13.1: Advantages of role plays

to reach probable diagnosis (Littlefield et al, 1999), understand patient’s emotions and motivations and empathize, thus maintaining student’s interest for a extended period of time. The role plays can also be functional for the facilitator. They provide the teacher an opportunity to observe the student in simulated conditions, focus on his needs and provide timely feedback. It helps the teacher to encourage the learner to shift from dependent stage to self-directed learner. The student-actor works like a clinician, takes the history, gathers and analyzes data, makes the diagnosis and manages the issue, thus role play helps to inculcate professionalism, observational and diagnostic skills and communication skills in him. Role plays provide a low-risk and safe environment for understanding of complex health issues, bring verve to highly descriptive academic material (Van Ments, 1999), make the transition to clinical setting comfortable (Littlefield et al, 1999), deliver detailed information in all three domains than traditional lectures and make the learning fun (Ladousse, 1987).

ASSESSMENT OF STUDENTS USING ROLE PLAY The formative assessment of students involved in role play can be done either by a pre-designed validated checklist or on global-rating scale. The pre-designed, validated checklist should be with observer before the commencement of role play and should have components of assessments before, during and after the role play within knowledge, attitude and communication domain. The before-role play component may be based upon student’s ability to identify and understand the imaginative context of role given, understand the problem,

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establish relationship among different components of problem, use of mood elements to stress upon the key points and participation in refining and rehearsals before the actual implementa­tion. During role play, the checkpoints can be student’s ability to perform the role in expressive way, use of body language, expression, attitude, feelings and voice modulation for development of scene, ability to collect, organize analyze and making inference from data, performance in group work and conveying critical information in suitable way. The after-role play component may include ability to make inference about impact of represented conflict on society and ability to suggest alternative approaches for conflict and problem solving strategies (Abour, 1995).

ISSUES WITH ROLE PLAYS In spite of the utility of role plays in teaching and developing communication and inter­personal skills, and fostering humanities competencies in the healthcare students, there are some barriers hindering its appropriate utilization for teaching– learning. For this simulation to happen the participants (student actors) must acknowledge the obligations and duties of their future jobs and works, and act accordingly; but this interdependence of learning in role play can be a hurdle to some students who may be unfamiliar of the duties or are unwilling to participate (Tompkins PK, 1998). Students who are unaccustomed to work in experimental conditions or experience social or cultural barriers are going to experience the same as learning barrier in role plays (Burns AC, 1998). Every student may not be comfortable with role-playing, may feel anxious or threatened to perform some roles in open and this can affect performance. Some students may be very comfortable with it, while some display less adaption to simulated conditions. The environment and the conditions of role play also affect and can impede learner’s confidence and contributions to such a session. Therefore, role play should be introduced gradually and as an “assessment for learning”, “not assessment of learning”. For some students, the session of role playing become overwhelming, and the chance to learn is forgotten in favor of turning the session into pure entertainment. To tackle these, the ground rules should always be set before hand—no annoyance should be tolerated and lots of discussion should be promoted regarding the scenario of role play and its usage in different contexts (Joyner and Young, 2006). The facilitator’s guidance, imaginative and leadership qualities also affect the session of role play. Another major factor worth consideration is time taken to develop group readiness; therefore role play should not be used when time constrains are there.

CONCLUSION Role plays are simple, cost effective and easy means of experiential simulation strategies, fostering soft skills and humanities competencies in students. With added

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advantages of reflection and feedback opportunities, role plays promote ‘assessment for learning’. With little planning, this tool, promoting contextual learning, can be very effective in making our students ‘humanistic healthcare providers’.

BIBLIOGRAPHY • Abour, HC and Christine, HS. Maximizing Learning: Using Role Playing in the Classroom. The American Biology Teacher 1995;57(1):28–33.

• Bell, M. Online Role-Play: Anonymity, engagement and risk. Educational Media International

2001;38(4):251–260. Accessed on 20.12.2022. Available from: http://www.tandf.co.uk/ journals (last accessed on April 14th, 2020). • Burns, AC and Gentry, JW. Motivating students to engage in experiential leaning: a tension-to-learn theory. Simulation and Gambling 1998;29,133–52. • Charlton, R. Using role-plays to teach palliative medicine. Medical Teacher 1993;15(2–3):187–93. • Clapper, T (2010). Role play and simulation: returning to teaching for understanding. Education Digest: Essential reading condensed for quick review. Accessed on 20.12.2022. Available from: https://www.researchgate.net/publication/234567370_Role_Play_ and_Simulation_Returning_to_Teaching_for_Understanding (last accessed on April 14th, 2020). • Fertleman, C, Gibbs, J, and Eisen, S. Video improved role play for teaching communication skills. Medical Education 2005;39:1155–56. • Hargie, O, Dickson, D, Boohan, M, and Hughes, K. A survey of communication skills training in UK Schools of Medicine: present practices and prospective proposals. Medical Education 1997;32(1):25–34. • Joyner, B, and Young, L Teaching medical students using role play: Twelve tips for successful role plays. Medical Teacher 2006;28:225–29. • Kiger, AM (2004). Teaching for health. Edinburgh, Churchill Livingstone. • Knowles, MS, Holton, EF, and Swanson, RA (2005). The adult learner: The definitive classic in adult education and human resource development. 6th edition. Elsevier, USA. • Kolb, DA, and Fry, R (1975). Toward an applied theory of experiential learning: In Theories of Group Process. Edited by John CC. Wiley, London. • Ladousse, GP (1987) Role Play. 1st edition. Oxford, Oxford University Press. • Lane, JL, Slavin, S, and Ziv, A. Simulation in medical education: a review, Simulation and Gaming 2001;32:297–314. • Littlefield, J, Hahn, B, and Meyer, A. Evaluation of a role playing learning exercise in an ambulatory setting. Advances in Health Sciences Education 1999;4:167–73. • Nair, BT. Role play: An effective tool to teach communication skills in Pediatrics to medical undergraduates. J Edu Health Promot (online) 8:18. Accessed on 20.12.2022. Available from: http://www.jehp.net/text.asp?2019/8/1/18/250932. • Nestel, D, and Tierney, T. Role-play for medical students learning about com­ munication: Guidelines for maximizing benefits. BMC Medical Education 2007;(7):1–9. Accessed on 20.12.2022. Available from: https://bmcmededuc.biomedcentral.com/ articles/10.1186/1472-6920-7-3 [last accessed on Dec 30th, 2019]

• Schon, DA. The Reflective Practitioner: How professionals think in action? Journal of Policy Analysis and Management 2011;34(3):29–30.

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• Shankar PR, Piyani, RM, Singh, KK, and Karki, BMS. Student Feedback about the use of Role Plays in Sparshanam, a Medical Humanities Module. F1000 Research 2012;65(1). Accessed on 20.12.2022. Available from: https://f1000research.com/articles/1–65

• Steinert, Y. Twelve tips for using role-plays in clinical teaching. Medical Teacher 1993;15(4): 283–91.

• Tompkins, PK (1998). Role Playing/Simulation. The Internet TESL Journal, IV, 8. Accessed on 20.12.2022. Available from: http://iteslj.org/Techniques/Tompkins-RolePlaying.html.

• Van Ments, M (1989). The Effective use of Role Play: A Handbook for Teachers and Trainers. New York: Nichols Publishing.

• Van Ments, M (1999). The Effective use of Role Play. 2nd edition. London, Kogan Page.

14 Theatre and Forum Theatre Upreet Dhaliwal, Navjeevan Singh Key Points q Theatre is an engaging way to help medical students learn about self and about others. q

Because of its visual appeal and its ability to engage the senses, theatre can be used to hone competencies in the affective and communication domains.

q Forum

theatre, because it is experiential in nature, can help students experience empathy and learn ethics and professionalism.

INTRODUCTION As medical teachers, we are expected to help students learn how to ‘perform’ to a desired level of competence. We guide them through the ‘roles’ they have to play as clinicians, as team leaders and team members, as communicators, as lifelong learners, and as professionals. Theatre, too, is about performance—it also involves people playing roles. These are two very good reasons to believe that theatre could help in medical education. Learning involves observation, reflection, exploration and creative experimentation, and theatre is an appropriate vehicle to hone these qualities in medical students and, thus, prepare them for a lifetime of self-care and of competent patient-care (Kohn, 2011; Hobson et al, 2019). Above all, theatre is drama, and drama is known to stimulate and to act as therapy (McCullough, 2012)—both of these are important ingredients in the overall development of medical students and in their transition into well-rounded practitioners of medicine.

TYPES OF THEATRE The types of theatre and their characteristic features are briefly described in Box 14.1 and are detailed below.

Conventional or Traditional Theatre This is a drama that is enacted in front of an audience of people who are expected to accept the play as it is without interacting with the story or trying to change a scene or the outcome. The actors, similarly, do not interact with the audience in the sense 136

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BOX 14.1: Different types of theatre and their characteristic features Types of theatre

Characteristic features

Conventional theatre

For entertainment purposes; no influence of the audience on the story Educative; in a community setting; no influence of the audience on the story Educative; in a classroom setting; is often followed by a discussion to clarify learners’ doubts Transformational; encourages reflection on issues of interpersonal conflict; showcases the struggle and allows members of the audience to attempt to change the outcome by becoming the person who is struggling

Propaganda theatre Pedagogical theatre Liberatory theatre

that they do not change anything in the play in reaction to anything the audience says or does. This is theatre for entertainment and most of us are familiar with it.

Propaganda Theatre This is a play that gives the audience a message—it is educative, but it represents the particular point of view of the actors and does not allow for debate or discussion. Street theater is the prototype and it has been extensively used in medical education to educate communities about health issues that plague them. As far as the audience is concerned, while it purports to tell the truth, street theatre could offer a truth that some in the audience may find difficult to apply in their own lives because of their particular contexts. In that sense, it is seen as elitist or bourgeois (Gupta and Singh, 2011).

Pedagogical Theatre This refers to theatre that has been incorporated into the curriculum and it is exemplified by the ubiquitous role play (Joyner and Young, 2006; Acharya et al, 2014). Role plays are used in medical education by various disciplines to promote active learning. Students prepare plays that depict a context (outpatient department, emergency room, community) and show an interaction (between patient and student, between student and other team members) that demonstrates the wrong way and/or the right way of dealing with a situation. The role play, usually done in a classroom setting, is followed by a discussion that clarifies any doubts and allows students to prepare for real-life interactions with actual patients. Role play has been described in detail in Chapter 13 in this book.

Liberatory Theatre This is theatre that purports to set individuals or groups free from the bondage of oppressive socioeconomic problems, or ideas, people, departments, institutions or governments. Named variously as theatre of the oppressed (TO) or theatre of/for the

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living, it was devised by Brazilian theater practitioner and political activist, Augusto Boal. Using a range of theatre games and exercises, it seeks to empower participants to take charge of the narrative by speaking of the oppression, enacting it, and looking for ideas on how to stand up to it. In a sense, it is also a simulation exercise that helps people rehearse—they practice ways in which they might change the outcome of their real-life struggles. TO is lead by a facilitator, who is known in TO parlance as the Joker. The Joker structures the games and exercises so that they become more and more complex and invoke deeper reflection by the participants as time passes. Ultimately, by building trust and encouraging the sharing of thoughts and feelings, participants are ready to vocalize, or depict through bodily images (image theatre), their stories of struggle. The stories are converted into short plays that highlight the oppression and showcase the character’s struggle against it (Singh et al, 2019; Love, 2012).

FORUM THEATRE TO often culminates in forum theatre where an audience witnesses the short plays (mentioned in the preceding paragraph) of the real-life struggles faced by the participants. Spectators, who are drawn from the same community as the participants (actors), are invited to stop the play at any point and step onto the stage to replace the actor who is struggling. The spectator, now called spect-actor, then faces up to the oppressor, and shows what he would do differently in the face of that particular oppression. The hallmark of TO is that the issues are identified by the participants themselves and so they are contextual and relevant. So, also are the proposed interventions—since they come from the community, they are meaningful to them and they feel involved as stakeholders. Even if the interventions by the audience offer no lasting solutions to the conflict, it prepares them to go out and actively face up to the oppression. The resolution may not come on the day of the play, but the people who participate are better prepared to achieve resolution than they were before (Singh et al, 2017).

ROLE OF THEATRE IN DEVELOPING LEARNER'S COMPETENCIES IN DIFFERENT DOMAINS The role of theatre in developing learner’s competencies in different domains has been delineated in detail below (Keskinis et al, 2017; Unalan et al, 2009; HoffmannLongtin et al, 2018; Hostetter and Stewart, 2018; Ivory et al, 2016).

Clinician • Opportunities for feedback and reflection, if provided after a role play exercise, can allow different perspectives to be discussed and debated—this is preparation for their role as problem solvers. • Role plays act as simulation exercises which, by providing varied contexts and circum­stances, can prepare students for real-life interactions with peers, other healthcare team members, and patients in the future.

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• Considering the unique struggles that are inherent to the medical community, TO and forum theatre can be used in medical education to help students and practitioners make sense of their struggles and to freely collaborate with each other to discover options that might help them when they return to the workplace as clinicians. • Being an active learning method, TO encourages analytical reasoning and problem solving. • When they step into the shoes of people who are struggling and embrace their lives during forum theatre, learners are exposed to diversity and can experience empathy.

Team Leader and Team Member • Medical students can rehearse for and stage a play for entertainment or for propaganda—in the process, they learn teamwork and hone their planning and organizational skills. • Learners can better understand the roles of other stakeholders when they play those parts in a role play.

Communicator • Some may discover talents for creativity which can help improve self-esteem and self-confidence. • Participation in theatrical ventures can help them develop social skills and understand the importance of rehearsing so as to communicate effectively (useful in the future, say, when they have to break bad news). • Students are exposed, in the safe environment of the classroom, to the complexities of interpersonal communication that they can expect to encounter during doctor– patient or peer-to-peer interactions.

Lifelong Learner Given the space and the time to prepare role plays or street plays, students can engage better with the curricular content and are exposed to a different way of learning.

Professional • Medical plays, even if staged for entertainment, that show ethical dilemmas may provide an opportunity to reflect on and learn about the struggles that professionals go through during decision-making. • Taking time out from their arduous curricular commitments to watch such plays can help medical students unwind, socialize, and avoid burnout. • TO is an active form of theatre that encourages dialogue and debate between actors and spectators on issues which are not otherwise addressed during the

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conventional medical curriculum. These could include issues of professionalism, ethical dilemmas, sexual harassment, gender discrimination, ragging, peer-topeer conflict, departmental conflict and many more.

INCORPORATING THEATRE IN COMPETENCY BASED MEDICAL CURRICULUM As the proceeding section shows, theatre is a versatile tool—its many advantages argue for it being given space in a competency-based curriculum. The foundation course in the first month after admission is a good time to start with role plays or TO to introduce students to their expected roles and responsibilities as medical graduates. Role plays already enjoy a place in the curricula of individual specialties; however, an interdisciplinary, longitudinal approach could be used to teach about ethics and professionalism. In fact, theatre of the oppressed (TO) would be even more useful in this regard—with its inherent ability to showcase struggle, it would allow debate on what is right and what is wrong, and learners could experience how to handle ethical problems. A session every semester could be arranged, with the level of learners determining the type of issue to be showcased. A monthly play for entertainment, for destressing and/or for learning could be made a regular feature in medical campuses. Forum theatre could be incorporated in annual student festivals to address areas where students and faculty struggle and which impacts their wellbeing and erodes their performance on the ground.

CONCLUSION Theatre, in its myriad forms, offers a dramatic way of engaging the learner’s interest and can help them understand medical content along with enhancing their skills of observation, analytical reasoning, active learning, communication, problem-solving, teamwork, self-reflection, respect for diversity, empathy and self-care. While most forms of theatre are intuitive, training in theatrical techniques may help teachers who wish to use it in their classrooms. Theatre of the oppressed, on the other hand, is rather more complex and teachers would benefit from undergoing training to fulfill the role of the Joker so that they can effectively use this form of liberatory theatre with their students.

BIBLIOGRAPHY • Acharya S, Shukla S, Acharya N, Jayanta V. Role play—an effective tool to teach clinical medicine. Journal of Contemporary Med Educ 2014;2(2):91–96.

• Gupta S, Singh S. Confluence: Understanding medical humanities through street theatre.

Med Humanities 2011;37:127–28. • Hobson WL, Hoffmann-Longtin K, Loue S, Love LM, Liu HY, Power CM, Pollart SM. Active Learning on Center Stage: Theater as a Tool for Medical Education. MedEdPORTAL: the Journal of Teaching and Learning Resources 2019;15:10801. Accessed on 20.01.2022. Available from: https://www.mededportal.org/doi/full/10.15766/mep_2374-8265.10801.

• Hoffmann-Longtin K, Rossing JP, Weinstein E. Twelve tips for using applied improvisation in medical education. Med Teach 2018;40(4):351–56.

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• Hostetter E, Stewart M. Teaching empathy? Implementing theatre pedagogy in the

medical school curriculum. Journal of the International Association of Theatre Critics, 2018 June; 17. Accessed on 20.01.2022. Available from: http://www.critical-stages.org/17/ teaching-empathy-implementing-theatre pedagogy-in-the-medical-school-curriculum/ • Ivory KD, Dwyer P, Luscombe G. Reactions to diversity: using theater to teach medical students about cultural diversity. Journal of Medical Education and Curricular Development, 2016;S37986. Accessed on 20.04.2022. Available from: https://doi.org/10.4137/JMECD. S37986 • Joyner B, Young L. Teaching medical students using role play: Twelve tips for successful role plays. Med Teach 2006;28(3):225–29. • Keskinis C, Bafitis V, Karailidou P, Pagonidou C, Pantelidis P, Rampotas A, Sideris M, Tsoulfas G, Stakos D. The use of theatre in medical education in the emergency cases school: an appealing and widely accessible way of learning. Perspectives Med Educ 2017;6:199–204.

• Kohn M. Performing medicine: the role of theatre in medical education. Medical Humanities

2011;37(1):3–4. • Love KI. Using Theater of the Oppressed in Nursing Education: Rehearsing to be change agents. Journal for Learning through the Arts 2012;8(1). Accessed on 20.01.2022. Available from: https://escholarship.org/uc/item/4wr3c05w • McCullough M. Bringing drama into medical education. Lancet 2012;379(9815):512–13. • Singh S, Barua P, Dhaliwal U, Singh N. Harnessing the medical humanities for experiential learning. Indian J Medical Ethics 2017;2(3):147–52. • Singh S, Kalra J, Das S, Barua P, Singh N, Dhaliwal U. Transformational learning for health professionals through a theatre of the oppressed workshop. Medical Humanities, Published Online First: 13 October 2019. Accessed on 20.01.2022. Available from: https:// doi.org/10.1136/medhum-2019-011718 • Unalan PC, Uzuner A, Cifcili S, Akman M, Hancýoglu S, Thulesius H.O. Using theatre in education in a traditional lecture-oriented medical curriculum. BMC Med Educ 2009;9(1):73. Accessed on 20.01.2022. Available from: https://doi.org/10.1186/1472-6920-9-73

15 Role Modeling Neloy Sinha Key Points q Action speaks louder than the words, is the nearest definition of role model. q

In practice a ‘role model’ can be identified swiftly than being personified as one.

q

Self-instruction, positive vision, attitude beyond reproval and shift from sermon are few of the revered attributes are the repertoires of a quintessential ‘role model’.

q

Learning from a role model is called ‘identification’.

INTRODUCTION By definition—anyone whose behaviour, antics, style, statement or actions are worth imitable or followed by many without any active persuasion or external influence is a ‘role model’. An influencer by definition cannot be a role model but the reverse is true. It is either ‘us’ or ‘them’ who are learning vicariously. Those who follow or worship the role models are never copy-cats or doppelgangers. The credit goes to sociologist Robert. K. Merton for coining the term ‘role model’ in relation to social learning as a part of self-fulfilment drive (Rourke, 2003). He hypothesized that individuals compare themselves with reference groups of people who occupy prominent, coveted and visible social roles which they want to aspire. The ‘role models’ are neither red herrings nor extinct dodos. Think about your own case. The day you took your admission at a prestigious medical institution you became ‘Neighbour’s Pride’. Role modeling is becoming a pervasive means of situational learning. Once upon a time I became momentary a role model! The biology teacher of our school knew that I was not the one who could break the glass ceiling of medical entrance. Somehow a miracle happened. For few subsequent batches he was heard to say, “If Neloy could do it, you can do it too”.

WHY ROLE MODELS? Role model is the ‘Holy Grail’ of medical education. Whether a fresher or a veteran, everyone is in search for it in the professional life to grow as a follower and later as a role model. Following admission, the students are in search of role models to fulfil their academic, intellectual and professional identities. The sought-after person can 142

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be a teacher or anybody. Freshly joined faculties too, are in search of academic role models for enhancement of their journey as a complete teacher. Visibility plays an important part in making someone a role model. Naturally a learned, talented yet reclusive person will miss the above-mentioned role. Generally, the young students who are in the process of finding their own identity try to emulate their role model either in the present or in the future. It is a part of social learning theory as suggested by Albert Bandura, a psychologist and social scientist (Bandura, 1986). A role model is always in demand in the domain of teaching and learning, being partly informal but to a major extent within a hidden curriculum. Professional societal set up plays a big part in role modelling in a learner’s community. A role model facilitates more than learning in theory and practice, and the sum of the individual attributes is less than the percolated influences, a ‘Gestalt’. An educator with creative mind and intuition can fit in the shoes of a role model, because he/ she is worthy of imitation. On the other hand, in our rich Indian heritage of philosophy on life and work, we find inspiration and strength and such philosophy act as inspirational role model.

;s ;Fkk eka izi|Urs rkaLrFkSo HktkE;ge~A ee oRekZuqorZUrs euq’;k% ikFkZ loZ”k%AA4-11AA ye yathā māṁ prapadyante tāns tathaiva bhajāmyaham mama vartmānuvartante manuṣhyāḥ pārtha sarvaśhaḥ Bhagavad Gita 4.11: In whatever way people surrender unto Me, I reciprocate accordingly. Everyone follows My path, knowingly or unknowingly, O son of Pritha (Bhagavad Gita, na). Such pronouncements by the icons of Indian culture and heritage do act as inspirational ‘role model’. Educators can be credible role models if they can demonstrate agreement between their claims and commitments. In Indian philosophy, like beauty, the role model is in the eye of the beholder and in the mind of a visionary. The role model is adored and adulated by a slew of followers. Role models are inspiration for academic career climbers.

CHARACTERISTICS OF ROLE MODELS Whenever we talk about role model, technically we are talking about the followers (fans). The role model might be oblivious about the existence of a huge follower or fan base. It may be a silent following and admiration in the sphere of teaching and learning. It is a kind of psychological dependence which may persist beyond the tenure of the ward posting. It is usually noted that the image of a role model is likely to etch in the mind of a young more likely because it is impressionable to the external influence. For this to happen, certain values and characteristics are expected from role models (Box 15.1).

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BOX 15.1: Things we expect from a role model • • • • • • • • • • •

A progressive person anchored with reality One who is open to accept criticism and suggestions Having unassuming leadership quality Eager to learn from others and from own mistakes A positive outlook even in adverse scenario Shows respect to lifelong learning process Engages oneself beyond the professional boundary Apolitical, above religious bias and agnostic philosophy of life Respectful to the students and patients Abreast with the recent development in one’s speciality Takes up the challenges

• Should have interest in extracurricular activities and hobbies • An infectious passion for profession • Having clarity of vision and values

TYPES OF ROLE MODELS This discussion is to sensitize about the road map and diversity of the role models in and around us. A role model from ‘Deep South’ may not be acceptable in the ‘North’ and vice versa. In India, because of heterogeneity of cast, culture and social obligations the role models are in the flux. It is a journey through the infatuation over role models from cartoon comic strips to mythological or real life characters. Gods and Goddess are set pieces of role models. We appreciate through reflective rumination the higher power as a role model in lives and professional growth. Our mythological scripts churn out ample evidence in favour of this. The omnipresent God men are noted as role model for all and sundry, barring an argumentative minority. As long as it promotes a 360° professional growth and evolution in the educational parlance there is nothing against this trend. Parents and elders nurture our intellect and curiosity through bed time stories where the good ones carry the role model flags and the bandicoots (Pandikokku (పందికొక్కు), Telugu) becomes abominable. This odysseus journey is to be continued for role model touch stones that will change the perspectives around us. The onus and discretion will be on the individual to find out one’s own. Let’s understand the concept through some noted examples.

A Role Model with Vengeance Who can forget the story of Ekalavya and his ‘role model’, Guru Dronacharya, in the epic Mahabharata. It is a classical example of role model with a vengeance (Box 15.2).

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BOX 15.2: A piece of advice from Indian epic, Mahabharata A barking dog was silenced aesthetically (!) by a prodigious young archer through a series of slick manoeuvres, not included in the archery skill module. Ekalavya, the mythological Nishadha prince, was self-motivated, focused and dedicated. He achieved everything through worshipping a role model till the day he was destined to meet him in person! (Singha, 2005).

A Pioneer Role Model ‘Role model’ is one who is never hesitant in starting a new project in his field and influences his/her followers. Being pioneer in his field, he may be a standalone figure! (Box 15.3). BOX 15.3: Pioneer role model—a standalone figure Dr Maurice Henry Pappworth was a strategic whistle blower who tutored more than 1600 junior doctors to pass exam for Membership of the Royal College of Physicians. During World War II, as a member of British Medical Corps, he was stationed in India. He was the one who raised his voice against ‘Human Guinea Pigs’ in his eponymous book. He was interested in photography, politics, philosophy and painting too (Pappworth, 1990; Seldon, 2017).

An Ordinary Man Role models do not descend from skies. They are the same ordinary men living in our society, who do extraordinary things, for the benefit of the common people and inspire others (Box 15.4). BOX 15.4: From Mythology to Manjhi Eldest son of Dashrath inspired his subordinates to build a bridge in the prelude of a rescue mission. Dasharath Manjhi, an unsung role model single handedly built a road cutting through a hill to shorten the distance between hospital and his village by 40 km, after 22 years of labor (1960–1982)! Had the road been there in 1959 he could rescue his better-half Phalguni Devi from an untimely death (Mascarenhas, 2015).

A Junior Teacher as Role Model Role models need not be very high-up in the hierarchy or need not be a person with huge experience. A junior faculty member may be a role model for students. It is the hardwork, dedication and sincerity that count (Box 15.5). BOX 15.5: A survivor’s anecdote Before final MBBS, we were shaky about surgical long cases. A young registrar took it seriously and couched us for probable prototypes of lumps and bumps. In those pre ultrasound days, palpation and X-rays were mainstay of clinical argument. A lump on any flank was presumed to be a renal lump of tubercular origin. In my notes, the answer to the imaginary last question was ‘a golf-hole ureter’. ‘What change will you expect to see by urethroscopy’ asked my illustrious external examiner, towering over me. With a deliberate pause I answered, ‘Sir, I will not be surprised if I see a kind of Golf…’ ‘Good, you may go now’, the examiner concluded. Sarkar Sir (may his tribe increase!) will always remain as a role model.

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ROLE MODELS: REAL LIFE EXAMPLES Restricting the search for role models only by yardstick of success might be erroneous because of existence of eccentric genius. Bobby Fischer after being a world champion did not come back in the competitive chess. Vincent Van Gogh could not sell any of his paintings in his life time. ‘The Lust for Life’ of Vincent V Gogh by Irving Stone and ‘The Moon and Six Pence’ by Maugham on Paul Gauguinare the poignant testimonials of two artists who were possibly ahead of their time and eccentric (as role models). We will try to stick around ‘Humanities’ while browsing through the role models. Who could be our best guide in this respect? Mentioning potential of MKG will be no less than a cliché. We will look for the role models among eminent public figures like Dr Bidhan Chandra Roy or Dr Dwarkanath Kotnis or an Ex-President Mr APJ Abdul Kalam. In the Western world, Madam Marie Curie, the first and only person to win the Nobel Prize twice, Mr Abraham Flexner a medical reformist from the past, or my personal favourite Dr Maurice Henry Pappworth, any of them can fit to the role of a model. We believe that a ‘role model’ should be able to express the humanistic elements of life over and above the professional excellence. Doctors who had taken literature as a pursuit of expression could give us insight about humanity. I will mention not in chronology but according to the heart. I always regard poets at a higher pedestal than that of the novelists. William Carlos Williams was a physician-poet who could make “A River of Words” while “He had something to say”. He delightfully created a bridge, might be paper thin, between the words and ailments. William Carlos Williams was a recipient of a Pulitzer Prize in poetry. He is best remembered for his short poem ‘This is just to say’(8). In W Somerset Maugham ‘Of Human Bondage’, Philip the protagonist had to struggle against personal disabilities along with the ghosts of other uncertainties. Sir Arthur Ignatius Conan Doyle’s elementary observations ignite mind. There are many to mention from our own, with notable inclusion of Dr Siddhartha Mukherjee, Dr Taslima Nasreen (whom you cannot ignore), Amit Majumdar (Poet radiologist), Dr Abraham Verghese and Dr Atul Gawande who can spin the web of communication between the people and profession. Each propagates the humanitarian side of the practice of medicine which are bypassed in the mainstream subjects. The scenario in configuration of role model is changing rapidly since the start of the pandemic with the shift of priorities and need for novelties. In this time of uncertainties people may read ‘Love in the time of Cholera’ in preference to ‘The Citadel’ by A J Cronin which was the time of another epidemic and I will take the opportunity to mention ‘Plague’ by Albert Camus. The two Socrates fit in the shoes of role model. One of them was Stoic philosopher who did not hesitate to ingest infusion of Conium maculatum (hemlock). The other eponymous person was Brazilian physician, political activist, columnist and an attacking ball player, Socrates Brasileiro who captained the soccer team in the 1982 FIFA World Cup.

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Medicine and humanities are inseparable. The scientific dialogues are cured with the magic potion of humanistic touch. The true role models transcend the borders of specialities and are always a few steps ahead of the rest. In essence the role model exudes extra qualities beyond the presumptive and descriptive qualities. Many doctors of medicine like Shree Ram Lagoo, Mohon Agashe and others played their multiple roles in Bollywood. They linked arts and humanities as essential backbone for a lifelong carrier in human relationship. An actor needs to emote multiple personalities according to the demand of the script. A physician does almost the same performance spontaneously and daily for umpteenth times, only without a script. In Boris Pasternak’s novel, Dr Zhivago is more of a poet and a visionary and portrayed convincingly the essential role of a doctor in the time of turmoil of revolution. Conversely, Che Guevara shifted from his role as a healer and became an Argentine Marxist revolutionary and guerrilla leader and military theorist. A debate might ensure whether he was a rebel with/without a cause. If a doctor can accommodate in various other occupations, he can be an ideal role model. In essence, role models and educational leaderships cannot be separated and their arbitrary borders overlap at many areas than we can anticipate or appreciate. As the present curriculum is becoming heavier by its content against the time allotted, the students are confused and concerned to pick up a role model. The clinical posting is the best time to find a suitable role model to observe them at work, communicating with patients and students with equal ease. A role model may even be idolised being suave and smart and the way she/he remembers the names of most of the juniors in the unit.

ROLE MODELS AND MEDICAL HUMANITIES The study of clinical medicine is dependent on observation from various angles but not limited to bedside techniques, etiquettes or mannerism. This ability helps a student to explore beyond to complement and or augment one’s acquisition of social and academic mannerism. Students are in a pool of mix and match pattern regarding the options of either social ascend or for the academic pursuit. Sometime they go for a grid search operation and not surprisingly few of them find their role models. In this perspective one does not need to follow a senior faculty but a postgraduate trainee, a senior student or even a peer can pick up the hat of a ‘role model’ because of the style, way of presentation, analytical mind and that of the leadership qualities which they have been harbouring or inculcating at the early phase of their training tenure compared to the rest of the batch. The prospects of being a teacher/learner in the current field of ‘medical education’ and the emerging curriculum have their own sets of stresses and anxieties. No one is immune to those challenges at an early part of life and career. More so when the students cannot see the source of light at the end of the tunnel. That is the time when a role model can be a torch bearer and aklleviate the quantum of stress. Glimpses of expertise and nuances of skill can be a life line and source of renewed inspiration in difficult time.

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Two recent movies, released back-to-back came with interesting titles, ‘No Way Home’ and ‘No Time to Die’ respectively. Both depicted a dystopian world which was not far from the reality. From a different perspective the titles were about the unseen ‘role models’ working in the wards and ICUs on a day in and day out basis, also about people involved in the testing and research laboratories, engaged in task of producing vaccines and those in the maintenance of law and order. Many of them had forgotten the way home and address that led to. Nearly eight hundred doctors died in the second wave of the Covid-19 pandemic. The number would swell further if we add the sacrifice of the other health professionals involved. They are the protagonists and thespians of the ‘Greek tragedy”. Collectively they were trying hard to save the world without playing the role of saviour and paradoxically they have ‘no time to die’ being burdened with responsibilities. Collectively in real life scenario between donning and doffing they remind me the stoic protégé of Camus, Dr Rieux. We feel proud to be linked with them through our profession who are gleaning relentlessly to make the world safe for the future. The role model is secretly followed and watched by aspiring students and candidate teachers. A role model does not know or can see the extent of the followers/popularity/acceptance by the students or public. Naturally one should think twice about one’s behaviour and public life/social life (including the alter ego in the smart phone) before passing a comment or taking an action over and above the professional commitment. The role models are under the public scanner. The role models sow the seeds of self-instruction process which is the beginning of an independent initiation of responsible learning (a kind of self-directed learning). In the field of education every qualified teacher has a potency to become a role model!

CONCLUSION A role model should be charismatic to attract students and colleagues alike. They will be able to juggle among private, public and professional lives and maintain a fine balance. Otherwise, a small spark of controversy will tarnish the image with a hard crash. Simultaneously many secret followers will have a broken dream. The enigma of role model will continue along with debate about the validity and criteria of designation. There is nothing wrong in expression and acceptance of multiple ideas instead of being dogmatic. A model is a creation from a set of prefixed data and benchmarks as assigned by the creator or by the consent of the societal norms and guideline appropriate for the time and existing culture. By these criteria, a role model can be an urban myth or legend! In the specialty of medicine, a role model will be assessed through the knowledge, skill and practice domains. It is rare to find an individual who is proficient in all aspects of profession but a veritable mixture of each. In an imperfect world we should try to thrive and remain satisfied with the good qualities of an individual. For a perfectionist the hunt for role model will be a relentless process till one day that individual himself will be a perfect fit in the ‘right shoe of a millennial role model’.

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BIBLIOGRAPHY • Bandura A. Social foundations of thought and action: A social cognitive theory. New Jersey, USA: Prentice-Hall Inc.; 1986.

• Bhagavad Gita. The song of God. Accessed on 30.09.2022. Available from: https://www. holy-bhagavad-gita.org/chapter/4/verse/11

• Mascarenhas JA. The man who carved a road through the mountain so his people could

reach a doctor in time. The Better India, January 16, 2015. Accessed on 30.09.2022. Available from: https://www.thebetterindia.com/18326/the-man-who-moved-a-mountainmilaap-dashrath-manjhi/.

• Pappworth MH. Human Guinea Pigs: A history. BMJ 1990;301(6766):1456–60. • Rourke M. Robert K. Merton, 92; Pioneering Sociologist Coined ‘Role Model’ and Other

Popular Terms. The Los Angeles Times; March 2, 2003. Accessed on 30.09.2022. Available from: https://www.latimes.com/archives/la-xpm-2003-mar-02-me-merton2-story.html

• Seldon J. The Whistle-Blower: The Life of Maurice Pappworth: the story of one man’s battle against the medical establishment. Buckingham, UK: University of Bucingham Press; 2017.

• Singha KP. Mahabharat, 1st ed, Vol. 1 (Bengali edition). Kolkata: Tulli Kala Publishers; 2005: pp. 162–163.

16 Case Studies Juhi Kalra Key Points q Cases are stories with a message, real or hypothetical. These stories, when discussed, analyzed and reflected upon, can transform classes into active learning sessions. q

Most often, paper cases appear bland, impoverished, theoretical and far away from reality due to lack of emotions, drama and feelings.

q Case

scenarios; supplemented with paintings, poetry, sculptures, drama, films, role plays get transformed into more effective tools to explore human perception and experience of illness.

INTRODUCTION Case studies are an important pedagogic tool. They are the heart of any teaching and learning process as they leave an everlasting anecdotal memory. Cases are stories with a message, real or hypothetical and these stories when discussed, analyzed and reflected upon, can transform classes into active learning sessions. They can promote active learning by challenging reasoning and thinking patterns that govern specific situations narrated in the cases. The lack of emotions, drama and feelings make paper cases appear bland, impoverished theoretic and far away from reality. If judiciously used, these case scenarios can be laced with wide range of elements from humanities to effectively bridge the gap between theory and practice. The emotion that is so deeply entwined with words and expressions of a narrative, poetry, theatre, film, literature or music can be embedded as an essential tool when teaching how to delve with a wide range of human emotions and reactions that arise when different people are exposed to a similar situation. Case scenarios that use paintings, literature, sculpture, drama, films, role plays, excerpts from anthropological and psychology-based research, can be used to explore human perception and experience of illness. Case studies can help explore the lacunae in doctor–patient relationships and bridge the insurmountable gap that seems to have inadvertently cropped up in times of technological advancement and recession in human interactions. ‘It is over Debbie’ was a factual, anonymous account by a doctor that brought the subject of whether a doctor can assist death and helped us re-examine the controversial ethical issue where overdose of morphine was given to speed up death. These cases can be used for debating complex ethical issues. 150

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STEPWISE APPROACH TO USING CASE STUDIES IN PRACTICE OF MEDICINE Scientific discussions and problems can be better understood, evaluated and sorted out through the variety of experiences embedded in the active components of the term medical humanities. We can incorporate narratives of illness, poetry, graphic medicine, ethical dilemmas, films and documentaries, overlay films with literature to make case-based learning an ideal platform to teach attitudes, ethics, right communication and cultural sensitivities. Angelo and Boehrer (2002) have detailed about systematic approach to case studies. Various steps in case-based discussion and learning have been depicted in Fig. 16.1.

Fig. 16.1: Steps in case-based discussion and learning

Various approaches of teaching by using case studies have been outlined in Box 16.1. BOX 16.1: Approaches for teaching case studies • Small group discussions • Panel discussions • Hybrid techniques • Self-directed learning modules

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TOOLS FOR CASE-BASED LEARNING OF HUMANITIES Various tools can be utilized for case-based learning of medical humanities as detailed below.

Narratives Patient narratives can represent illness in the way the patient sees it, making them an extremely useful tool for understanding the concerns and fears of patients. Patient stories, when used as cases for teaching, can help revisit and reflect upon the principles of altruism, autonomy, shared decision-making. Smith has beautifully narrated how stories can contribute to understanding of dilemmas of medical ethics (Smith, 1999). Both fictional and real stories can be used and their content evaluated to re-examine the practice of medicine and its ethical counterpart. Smith (1999) says ‘to understand and accept a patient’s moral choices, a practitioner must acknowledge that the illness narrative has many potential interpretations but that the patient is the ultimate author of his or her own text’. While patient narratives are often more anecdotal, doctor’s narratives can be more technical and can highlight a specialist’s take on the same issue. They overlay of opinions when confronting illness can reveal two sides of the coin—with the ‘caregiver’ on one side and the receiver on the other. It can lay foundation for more amicable solutions and to pave way across the great divide between technological advancements in medicine and the basic human needs for empathy and compassion. Analyzing the differences may help find a meeting ground, to find the unspoken, muted and desolate gaps in a doctor–patient relationship. Charon (2000) mentions ‘the neurologic and protopsychiatric case histories of Josef Breuer, Sigmund Freud, and, later, WRH Rivers reveal all the more powerfully the innate relation between telling and healing’.

Literature Literary works of great authors can be used as cases in day-to-day teaching in medical schools. Coles (1998) states ‘the study of literature can broaden and deepen the inner lives of medical students and encourage moral reflectiveness’. He also talks about use of literary works of great novelists like George Eliot and Scott Fitzgerald. He makes a mention of George Eliot’s novel ‘Middlemarch’ where wanderings of a young doctor from idealistic commitments is a good read, others being: Chekhov’s—‘Anyuta’, Tolstoy’s—‘Death of Ivan Ilyich’, among the myriad that decorate libraries (Coles, 1998). Literature can offer retrospective reconstruct of a situation in the current context (Hunter, 1996) because case narratives add to the experience of clinical judgment and can be revaluated to current times and context.

Anthropology Anthropological research has been used in past for solving public health issues. At the Centre for Medical Humanities at Durham University, literary accounts revealed

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how smoking goes deeper than the apparent physical harm it causes. Borges (2008) in his article mentions uses of semistructured interviews to explore stages of smoking cessation and how smoke affects psyche of the smoker.

Graphic Medicine Comics too can be used to express complex stories and intense emotions through pictorial impressions. Mapping of the progress of dementia through comics has acted as a tool to delve into intricacies of the disease like Alzheimer’s that often leaves long-lasting impressions. Leavitt (2014) in her comic describes Alzheimer’s disease. Narratives in pictorial form can express through closer to life images. Disease often leaves its indelible impressions on our faces that speak for themselves; pain in the furrows and pleasure in the laughter lines often replace words very explicitly. Some part of illness narrative is always hidden in the body language, in muted expressions and these speak well through sketches. Comics are like poetry in action.

Films Fictional presentations of a situation that demand discussion on morals and ethics can be easily taken up as cases and discussed using films as media to represent problems at a single visual plane. However, real life may not conform to the watertight compartment of the film because such idealism may not be applicable in more dynamic real life situations which may escalate to several dimensions as soon as the director of film is replaced by a doctor–patient interaction. But films can effectively portray and transmit a complex situation to a larger audience.

Overlay of Films and Literature Films are stories on screens that create audiovisual impact and can bring out sensitivities of real issues on a visual and emotional plane. When adapted from literary works, novels and famous stories by authors, this overlay of films and literature can bring to light the complementary and intensely interconnected internal and external factors that plague an observable situation. Friedman mentions that films deserve a special place in humanities curriculum in medical schools (Friedman, 1995).

Theatre of Oppressed (TO) In forum theatre, real life stories are enacted. It empowers the audience as ‘spectactors’, thus involving them to think critically and find solutions from among the spectators (Singh et al, 2012). The process of enacting the story makes it alive with emotion and the reactions that genuinely accompany these situations. The solutions that emerge are more compatible with reality, societal expectations and its limitations. Since collective intelligence emerges, the theatrical experience to problem can be used as a forum to teach ethics, professionalism and to find solutions to daily dilemmas in complex situations arising in practice of medicine. Theatre of oppressed can also be used to teach professionalism (Modi et al, 2014). More of TO has been detailed in Chapter 14.

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LIMITATIONS OF CASE STUDIES The limitations of case-based discussion and learning have been briefed in Box 16.2. The main limitation lies in striking a balance between documentary truths, literary contexts and the real life. It is not always possible to translate the documentary truths into real life situations. Moreover, cases may be dull and lifeless, if not relatable or when ill-framed. Poor case workup and closure may violate the very essence itself. Though much confidence has been vested in using panel discussion to round off the case, but it has been argued that a panel discussion by group of specialists may not be very beneficial. Chosen cases may not be updated with changing times, protocols, ethics and guidelines. This may render the entire teaching methodology ineffective. Hence; students must be able to understand things in context of the changing societal ideologies and professional guidelines. This is especially true for cases that are intended to discuss ethics. BOX 16.2: Limitations of case studies • Difficulty in striking a balance between literary context and real life. • Poor case workup and closure may affect the learning potential. • Films and other literary context will often fail to stay updated with changing protocols and guidelines.

HOW TO CONVERT WEAKNESSES OF PAPER CASES INTO STRENGTHS? Make Paper Cases More Representative of Real Life Situations This can be done by adding emotions and reactions through addition of poems, films, documentaries, literary context, sketches, and patient stories to cases. This will evoke the necessary response among learners that may come handy to them when confronting a similar situation in real life. The visual narrative of a film as well as judicious use of literary pieces like novels, poetry, anecdotes or narratives can dissolve boundaries between art and science. They can deliver a problem that touches the five senses and beyond, while retaining the moral and scientific essence in its most subtle and unforgettable way.

Facilitate the Group Discussions Directionless groups are hopeless isolations and hence group discussions must be facilitated to help elicit useful perspectives from multiple sources. Facilitation offers a healthy platform for debating the workable and non-workable options for a given situation. Expert facilitation may help penetrating several intersecting planes, especially where emotional undercurrents may be closely braided with physical and psychological components.

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Offering Scope for Variations to the Basic Case As there is no single well-defined straight course to solve a problem, a similar problem is often perceived and dealt differently across nations and communities. Understanding cultural sensitivities while still being scientifically correct are some of the challenges in conventional system of teaching and they can be emphasized well through case-based discussions. We can enliven cases by incorporating all imaginable variations to the conventional responses and upgrade the difficulty level of cases.

HOW TO CHOOSE AN APPROPRIATE CASE? Case studies are truly a magic wand in the hands of an expert but can be a disaster, if students are left unattended. Though humanities and art-based interventions can improve communication skills and help inculcate observation skills, their effectiveness in enhancing clinical skills needs more evaluation (Perry et al, 2011). A good case to be chosen should be rather open ended. It must offer an opportunity to explore, challenge reasoning, interpret and draw conclusions. They can be adapted from real life stories for a variety of learning experiences. For example, patient and doctor ‘narratives’ can be used to understand disease and its symptoms, ‘comics’ for creating general awareness in a primary healthcare center, ‘forum theatre’ for ethical dilemmas, ‘poetry’ to evoke empathy. A trial run to see how far the interpretations can go, can be useful in moderating the case as per the audience, the knowledge base of the audience and expectations of the course content. Cases can supplement learning when they form the basic structural format of a teaching session as well as for both formative and summative assessments. Cases can be short when used for a given session and longer when used for a vertical integrated teaching session. New contexts can be added as the student moves vertically up the ladder from phase 1 to 2 and then to phase 3. The same case can continue from phase 1 to 3, getting richer in context and variation. These cases can be made richer by adding ethical dilemmas, historical accounts, debatable issues related to differential diagnosis as these will inspire more practical thinking and reasoning. Cases can integrate clinical contexts with basic sciences. They can offer an ideal platform for preparing SDL modules when facilitated by a teacher and supported by authentic sources of information. They are often a component of hybrid model of self-directed learning. They can be used to give a sense of direction to student, especially during an SDL where we can ask students to explore areas which are very relevant to the actual practice of medicine. In Indian context, the areas that are more relevant to the ‘physician of first contact’, specially the more prevalent diseases and disorders can be the one where SDL can be planned with a case study. It will give students a close to reality experience. The common variations of presentations can be added to enrich the cases. Cases, when given to groups, can be used to see leadership qualities and team spirit. It can be used to inculcate a spirit of camaraderie among students. Thus, simple case study can take into its loop all the five roles required of a competent physician of first contact.

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CONCLUSION Incorporating medical humanities through case studies are likely to promote next level interaction and active learning. When faced with increasing challenges, the discussion is more likely to evolve from one-dimensional approach to a more realistic multipronged approach to solving problems. It can give us the much-needed fresh perspective to solve old problems. Humanities embedded in case studies hold a promise of encouraging out-of-the-box thinking. If the constructivist approach of case studies is equipped with strengths of medical humanities, even simple paper cases will transform to live experiences, more real by virtue of their ability to bring the students closer to a hidden and often missed perspective of human experience.

BIBLIOGRAPHY • Angelo T and Boehrer J. Case learning: How does it work? Why is it effective? Case

Method Website: How to Teach with Cases, University of California, Santa Barbara 2002. Accessed on 20.04.2022. Available from: http://www.soc.ucsb.edu/projects/ casemethod/teaching.html • Borges M, Barbosa R. Cigarette as ‘companion’: A critical gender approach to women’s smoking. Cadernos De Saúde Pública 2008;24(12):2834–42. • Charon R. Literature and medicine: Origins and destinies. Acad Med 2000;75:23–27. • Coles R. The moral education of medical students. Acad Med 1998;73(1):55–7. • Friedman L. See me, hear me: Using film in healthcare classes. Journal of Medical Humanities 1995;16(4):223–28. • Hunter K. Narrative, literature, and the clinical exercise of practical reason. The Journal of Medicine and Philosophy 1996;21(3):303–20. • Leavitt S. Tangles: An illness narrative in graphic form. Virtual Mentor: American Medical Association Journal of Ethics 2014;16(8):652–55. • Modi JN, Anshu Gupta P, Singh T. Teaching and assessing professionalism in the Indian context. Indian Pediatrics 2014;51(11):881–88. • Perry M, Maufulli N, Wilson S, Morissey D. The effectiveness of arts-based interventions in medical education: A literature review. Med Educ 2011;45(2):141–48. • Singh S, Khosla J, Sridhar S. Exploring medical humanities through theatre of the oppressed. Indian Journal of Psychiatry 2012;54(3):296–97. • Smith JA. Keith Haring, Felix Gonzalez-Torres, Wolfgang Tillmans, and the AIDS Epidemic: The use of visual art in a health humanities course. Journal of Medical Humanities 2019;40(2):181–98.

17 Creative Writing

(From Scalpel to Pen: Chaos, Process and Value) Anuradha Joshi Key Points q Creative writing offers an opportunity to foster self-expression and organisational abilities, along with observation and descriptive skills q

Reflective diaries, narratives, essays, poems, storytelling, autobiographies, memoirs, commentaries and anecdotes are some of the tools for creative writing

q

Creative writing skills are relevant to clinical thinking and medical practice

q

Self-regulated and lifelong learning have reflection as an essential aspect, and it is also required

INTRODUCTION Modern medicine, with its advanced technology and managed-care policies, has removed much of what constitutes the art of healing especially the important aspects of doctoring that go beyond the medications prescribed (Mehl, 2007). As we are all aware, there is an interface between the healer and the healed. Our experiences from our training in medical college have been interwoven into our personal and professional lives and have shaped us into the physicians and healthcare professionals that we are today. Such experiences can be presented in the form of creative writing like reflective diaries, narratives, stories, etc. which elicit the real life scenarios, vivid experiences and interactions of healthcare providers with their patients. Creative writings are now a part of teaching–learning methods and are being used to inculcate the importance of humanities in medical education. They usually deal with reflections, reflective diaries, narratives, essays, poems, storytelling, autobiographies, memoirs like medical memoirs, commentaries, anecdotes and much more in field of medicine. Traditional ways of teaching in higher education are enhanced with adult-based approaches (Rankin and Brown, 2016). Adult-based learning enables students to take ownership of their own learning, working in independence using a holistic approach. We are aware that twenty first century is an era of information, technology, knowledge application, innovation, and globalization (Cheng, 2018). In context to this, various creative pedagogical tools are being used to teach values and inculcate humanities in their day-to-day routine; with creative writing being one of those methods. 157

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SCOPE OF CREATIVE WRITING Creative writing is any writing that goes beyond the boundaries of normal professional, journalistic, academic, or technical forms of literature, typically identified by an emphasis on narrative craft, character development, and the use of literary tropes or with various traditions of poetry and poetics. While academic writing classes teach students to write based on the rules of language, creative writing has its core a focus on the self-expression of students. Academic writing includes works of fiction like novels and short stories; and non-fiction like biographies and poems. In the academic setting, training on creative writing is divided amongst fiction and poetry writing. The emphasis is to write in an original style rather than imitate other genres. Any original writing falls within the domain of contemporary writing. Thus, it is more modern name for what has been called as literature. To elaborate further, all the genres of literature are a part of creative writing. Creative writing can technically be considered any writing of original composition. In this sense, creative writing is a more contemporary and process-oriented name for what has been traditionally called literature, including the variety of its genres. A creative writing exercise helps an individual to express his inner self (Forsell et al, 2019). It helps him to sharpen his ability to observe the environment, a vital skill for a physician. It develops the capability to organize his thoughts and describe them in a coherent manner. These ‘soft skills’ are essential for clinical reasoning and hence, to medical practice (Cowen et al, 2016). Traditionally, teaching–learning methods for medical and clinical are incorporated in the syllabus of all medical schools. However, pedagogical approaches for developing the skills of critical thinking, listening and verbal expression, are still in their infancy. These skills are vital for clinical reasoning and doctor–patient communication. Thus, creative writing involves channelling one’s feelings into the written word (Reilly and Langan, 2018). Creative writing helps to provide a link between medical knowledge, one’s own feelings or the affective domain and one’s ability to express creatively (Currier and Zimmerman, 2019). Transforming feelings into a creative piece helps the author and the reader gain a deeper understanding of the subject. Daily encounters of a professional generate complex emotions. These are articulated through creativity, thereby providing an insight into the everyday lives of healthcare workers. This entire exercise provides deeper meaning to everyday existence, and thereby, helps guide future behaviour. It also helps reduce stress and burnout (Reilly and Langan, 2018). Both have become recognized as a key factor in undermining the quality of life of physician.

ROLE OF CREATIVE WRITING AS A TEACHING–LEARNING METHOD IN HUMANITIES Creative writing is no longer solely a province of language and literature classes only. In the 21st century; reflective and creative writing is being recognized as integral to training a medical student. Creative writing can cause wholesome development

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of a medical student. Prior reading and then employing one’s imagination are required to write creatively. Both are important routes to developing empathy in a medical student. Creative writing in the form of reflections, case reports, critiques have been traditionally written by doctors. This forms the basis for subsequent discussion with their peers. Thus, creative writings form a core part of encouraging practitioners to reflect-on, and therefore to learn from successes as well as mistakes, and to share good practice with colleagues. Often there is an awareness of strong feelings associated with a particular experience, further leading to deeper questioning, and thus generating a chain of thoughts (Box 17.1). BOX 17.1: Chain of thought process during creative writing • • • • •

What am I feeling and what are my emotions? Why do I feel like this? What are the consequences of these emotions for me and for others? Are there other situations in my life or my encounters with others when I feel the same? Can I explain why I feel this way?

TOOLS FOR CREATIVE WRITING Some of the tools used for creative writing in medical field and humanities have been enumerated in Box 17.2 and explained further in this chapter. BOX 17.2: Some of the tools used for creative writing • • • • •

Reflective journal or diaries Narratives Essays Poems Storytelling

• Memoirs or medical memoirs • Commentaries • Anecdotes • Autobiographies • Dialogues

Reflective Journal/Diary Reflection is one of the key components of creative writing dealing with how practice is experienced and how professional skills such as critical thinking and independent judgement are acquired by medical professionals (Boud et al, 1985). Reflective writing is one established method for teaching medical students empathetic interactions with patients (DasGupta and Charon, 2004; Rosenbaum and Ferguson, 2005) Reflections can be in the form of reflective journals or diaries, narratives, memoirs. Reflective writing is the process of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of

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self, and which results in a changed conceptual perspective (Boyd and Fales, 1983; Bolton, 1999). Thus, the individual engages his intellect and his feelings to explore these sentinel experiences. This process of reflection lends a new perspective to the experience and may thus, help in solving the so-called ‘messy, indeterminate’ issues. Reflective writing can be in the form of journaling, diaries, narratives, memoirs or medical memoirs. Reflections and the process have been explained in detail in Chapter 20.

Narrative In essence, narrative writing is a form of storytelling (Thompson and Kreuter, 2014). Stories are vital for psychotherapeutic interventions. Narrative writing now has evolved as a stream in bioethics. Patients’ stories tend to be intensely personal. Yet, being complicated and disorganized, it is an art to craft cohesive narratives out of them. Narratives have been used in various media for promoting healthy behaviours for controlling hypertension, quitting smoking, etc. Such patient narratives lead to stronger emotional reactions as the patient identifies himself with the narrator. This in turn, lends a human touch to the educational experience, wherein the patient feels as if he is being listened to (DasGupta and Charon, 2004). This also helps to increase self-awareness among practitioners (Lemal and Vanden, 2010). The basic structure of narrative is given in Table 17.1. TABLE 17.1: Basic concepts of narrative structure with examples of questions useful in exploring these concepts Concept: Illustrative probing questions. Genre: What literary type (or genre) do you think this writing might be described as (e.g. prose, poetry, drama, obituary, prayer, diary entry, legal document, recipe, etc.)? Narrator vs. author: Do we know who the author is? Who is the narrator? Narration: Is the voice of the narrator in the 1st person (I), 2nd person (you), 3rd person (he/she/them)? What is the narrator’s status (e.g. powerful, expert, novice, victim, neutral, biased, involved, distant)? Does the narrator change during the course of the text? Are there multiple points of view (POV) expressed in the narration? Example: Is there a third-person omniscient POV? Is such a POV possible? How would you describe the visual lenses (or focalization) through which you are apprehending the events and characters in this narration? Diction: Is it serious, grandiose, cold/impersonal, pleading, clinical, casual, etc.? Time: When does this story occur? Is it in the past, present or future or a combination? How much time passes in the story? In what order are events described? Are there any flash-backs or flash-forwards? Plot: What happens in this story? Can you recognize a type of story that this narrative may resemble? Have you been exposed to this theme before (e.g. story of quest, chaos, revenge, love, restitution)? Images: What images are conjured up? What metaphors are used? What do you wonder about? Feelings/emotions: What feelings are evoked in this text? Gaps or ‘left out text’: What might be ‘missing’ from the text? Is there anything you want to know more about in this story? Meaning: What meanings do you think the author is trying to convey in this story? Table is based on The Cambridge Introduction to Narrative by Abbott, HP (2008). The Cambridge introduction to narrative. Cambridge University Press.

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Essay Doctors tend to use a lot of medical jargon both in person and in writing. As science, technology and thereby knowledge get more complicated, it is necessary that doctors are able to communicate their work to patients in simple lucid prose. It is necessary to have people who can portray the decision making and thought processes of a doctor, and the inner workings of the medical professions. The style of writing should be tailored to the character of a medical issue (Baruch, 2013).

Poetry One aspect of creative writing is poetry (Cronin and Hawthorne, 2019) which is defined as a literary work in which the expression of feelings and ideas is given intensity by the use of distinctive style and rhythm. A poem is generally written on epiphanies which touch the soul of a medical student or a doctor. Such epiphanies may include witnessing poor doctor–patient encounters, a new patient with cancer or meeting a physician who has committed a therapeutic error. The ethical and moral reasoning that a health professional undergoes while writing a poem helps to develop compassion and empathy in him. As the Stanford physician Abraham Verghese stated, “To hear the voice of the patient preserves our capacity to imagine the suffering of the patient” (Verghese, 1995). Hence, poetry can help make more humane and competent doctors (Kalra et al, 2016; Joshi et al, 2018). An example of a beautiful piece of poetry has been illustrated in Chapter 8.

Storytelling Listening and responding to patients’ stories helps in developing creative writing skills. The stories which patients tell are just first drafts—they need a lot of work with regards to proper articulation of the social, financial and psychological burdens that weave through them. Hence, healthcare providers need to think like creative writers so that the story can be comprehended by the common man. A story is driven by the trio of character, conflict and desire. Complex characters are motivated by inner or outer forces, but impediments interfere in the pursuit of their goals. The characters’ response to these challenges drives the story. Finally, these characters are tested in tough situations, which help to unravel their true natures. Many patients, particularly with distressing symptoms in psychiatry, have such stories to tell. These stories unmask their inner selves, helping the treating doctor to tailor a therapy. A story is propelled by character, conflict and desire. Complex characters want something badly and are driven by inner or outer forces to act. But obstacles interfere with their pursuit. Their response to these challenges not only propels the plot but also provides a charged occasion where characters are tested, allowing their true natures to emerge in finer relief. These larger structural concerns provide a more compassionate prism for understanding those patients who present with distressing symptoms that elude any definable aetiology or represent unconscious expressions of life stresses or secondary gain.

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Autobiographies Autobiographies are also a type of creative writings very commonly used in medical fields like psychiatry and humanities. Autobiographical accounts can generate new understandings about the illness experience. Some medical teachers have used this concept in a very interesting way, like—“Autobiographies of drugs” (Joshi and Ganjiwale, 2015). The latter are designed in such a way as if the drug is speaking about itself to the students. It can either start with narration of some hallmark interesting features related to drug dose, some peculiar pharmacokinetic or specific pharmacodynamic features, with its application in clinics, adverse drug effects of drug or cost of various formulations of the drug available in market. One can even add description of drugs which have an interesting history of discovery and features, e.g. adrenaline, heparin, serotonin, etc. Some interesting phrases can also be added in autobiography of drugs, e.g. “I am your life saver’’ for drugs like adrenaline.

Medical Memoir A medical memoir is a collection of memories that an individual writes about moments or events, both public and private, that took place in the subject’s/person’s life. Medical memoirs depict stories “from a life”, such as events and turning points from the author’s life.

STRATEGIES TO HELP WITH CREATIVE WRITING Some of the strategies which can help in inculcating creative writing skills have been briefed in Box 17.3 and 5 Rs principle of creative writing has been detailed below. BOX 17.3: Strategies to help with creative writing • Write your diary entries (for reflective diaries) immediately after the activity/visit, then reflect and write a comment a few days later. • Explain your feelings in relation to your strengths, capacities, fears, weaknesses and biases. • Suggest alternative actions you might have taken (or might take next time) to improve the activity/visit and make it a better learning experience. • Find questions which you need to think about/ issues which you do not yet understand, but need to understand. • Strike a delicate balance between communicating scientific and social complexities and establishing an engaging voice and style. • A “sophisticated use of language” is critical for physicians to communicate effectively to individual patients or translate technical minutiae into language the public at large can understand.

The 5 Rs of Creative Nonfictional Writing The 5 Rs of creative nonfictional writing include: Write about real life, conduct extensive research, write a narrative, include personal reflection, and learn by reading (Gutkind, 1996).

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Write about real life: Remember that you are writing about real people, real places and real events. Visiting the people and the places you are going to write about will give you the tools necessary to tell an accurate story with well-described artefacts and true-to-life personages. Everything that makes it into your work of creative nonfiction must have happened at some time or another in real life. Never embellish or alter reality. Conduct extensive research: Use every resource available to you to gather information on your subject like medical library, newspaper archives, the internet, interviews, public records, books and magazines, photographs, immersion (visiting the wards or OPDs or place you are writing about). It is also extremely important to ensure your sources are authentic and based on true evidence. Write a narrative: Use the storytelling elements of fiction to create a compelling story with the factual information you have gathered. While a work of creative non-fiction does not have to adhere to the literary techniques and narrative arcs of classic fiction, if you choose to craft your story this way, the standard pattern is: Inciting incident → conflict (internal or external) → climax or turning point → resolution → end of story. Include personal reflection: If not for the addition of personal reflection, there would be nothing to separate a work of creative nonfiction from a long-form newspaper article. The “creative” in “creative nonfiction” comes with the author’s unique voice and opinion on the matters being related on the page. The author should serve as a guide, holding the reader’s hand as they walk through an imaginary museum of well-organized, factual information, and hint at the meaning of this arrangement of facts. In this sense, creative nonfiction relies much more on the personality of the author than fiction. Learn by reading: The creative nonfiction writer should read autobiographies, articles, newspapers, magazines and other nonfiction books to get a taste for how theirs should be formatted and written. Perhaps even reading a novel will help you understand the life and times of the person a little better. By using these tips, you are more than halfway to creating a great work of creative nonfiction. Once you have collected your information, plotted your story and taken a unique angle on the subject, you are ready to begin the hardest part of the process, i.e. writing.

FEW INTERESTING EXAMPLES OF CREATIVE WRITING IN HUMANITIES Individual narratives, aim at sharing their experiences and life details, in fact some can be even used for dark humour when tackling matters of life and death, e.g. ‘This Is Going to Hurt’ (Kay, 2017) is one of the most prolific reflections which depicts the life and times of one junior doctor from a house job in 2004 to a senior registrar post in 2010. It is a type of reflective diary written by Adam Kay. Next example is ‘A Young Doctor’s Notebook’ (Bulgakov, 2012). This is one of the first medical memories to weave fact and fiction in a form that was palatable and intelligible for a popular audience. Here the author describes a young doctor’s

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turbulent and often brutal introduction to his practice in the backward village of Muryovo and the immense burden of responsibility, as he deals with a superstitious and poorly educated people struggling to enter the modern age. ‘Diary of a journey to a faraway galaxy’ (Ferrari et al, 2019a) describes a brief account written by a girl treated with chemotherapy and surgery for an ovarian germ cell tumour in a metaphoric way. ‘Loop: There is no going back: A Graphic Novel by Adolescent Cancer Patients on the Youth Project in Milan’ is a description of the story of the development of a graphic novel (Ferrari et al, 2019b). “What shall I do when I grow up’ is a story about superheroes written by adolescent cancer patients on the Youth Project at the Istituto Nazionale Tumori in Milan, Italy (Gaggiotti et al, 2019). Another set of gripping narratives include nonfiction by Atul Gawande, e.g. “Being mortal” and “Complications: Notes from the life of a young surgeon” (Gawande, 2014). Atul Gawande is a practicing surgeon. In his writings, he displays the challenges and struggles faced by clinicians during ward rounds, dealing with cancer patients in wards, medical and surgical errors. In addition, his memoirs are highly inspirational and riveting when it comes to achieving the power of human dimensions in medicine and ways to deal with family and professional pressures. Overall they represent the power of medicine and literature as an attempt to teach healthcare professionals concrete and effective lessons from the sufferings of self, caregivers and patients.

IMPORTANCE OF CREATIVE WRITING TOOLS IN MEDICAL EDUCATION Evidence suggests that creative writing and narratives affects prognosis in various ways—one of them being positive influence on process of care. They also help in development of compassion, empathy and listening skills. Creative writing acts as a tool in reflective practice and may enable health professionals and family carers to become confident and creative partners in patients suffering from dementia (Bailey et al, 2016). Creative writing also helps to recognise the importance of being able to frame a problem before trying to solve it as well as to be able to stand back from yourself and question your behaviours and attitudes and also helps to view patient problems from multiple perspectives. Creative writing provides students a tool to be more actively involved in their own learning progress. Poetry writing helps link academic knowledge, creativity, and the affective domain. The metaphorical transition embedded in its subtle creation helps assess deeper understanding of the subject and the logical sequence of thought pattern. Poetry writing encourages students to articulate often complex emotions associated with their professional worlds, thereby providing invaluable insights into the everyday lives of healthcare workers. Practice of creative writing helps mitigate stress and sustain a successful practice especially in burnout as the latter has become recognized as a factor undermining physicians’ quality of life. Creative writing also helps to decrease levels of student anxiety in healthcare fields, e.g. pressures of managing work, family and study commitments. Writing reflective diary in medicine serves as a portal of coping

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mechanism (Shapiro et al, 2006). Creative writings like poetry can help patients and palliative care professionals, to seek meaning from and make sense of serious illnesses and losses towards the end of life.

CONCLUSION It is essential for medical students to be able to effectively analyse their own progress and apply theoretical knowledge to practical situations. This will enable them to become strong, independent practitioners. The bottom line is that creative writing provides an opportunity to empathize with ourselves, our life in medical fields, to think from patient point of view in regards to understanding apprehensions, concerns and fears of the patient. Thus, creative writings play a key role in teaching the key principles of humanity to the learners. Creative writing and narratives should be a key part of training to be a medical professional or for that matter any healthcare professional.

BIBLIOGRAPHY • Bailey, C, Jones, R, Tiplady, S, Quinn, I, Wilcockson, J, and Clarke, A. Creative writing

and dementia care:‘making it real’. International Journal of Older People Nursing 2016;11(4): 244–254.

• Baruch, JM. Creative writing as a medical instrument. Journal of Medical Humanities 2013;34(4):459–469.

• Bolton, G. Reflections Through the Looking-glass: the story of a Course of Writing as a Reflexive Practitioner. Teaching in Higher Education 1999;4(2):193–212.

• Boud, D, Keogh, R, and Walker, D (eds) (1985). Reflection: Turning learning into

experience. Routledge Falmer, London. Accessed on 20.04.2022. Available from: https:// craftingjustice.files.wordpress.com/2017/04/david-boud-rosemary-keogh-davidwalker-reflection_-turning-experience-into-learning-routledge-1985-pp-1-165.pdf

• Boyd, EM, and Fales, AW. Reflective learning: Key to learning from experience. Journal of Humanistic Psychology 1983;23(2):99–117.

• Bulgakov, M (2012). Young Doctor’s Notebook. Alma Books. • Cheng, SF. Application of Creative Teaching. Hu li za zhi: The Journal of Nursing 2018;65(6):4. • Cowen, VS, Kaufman, D, and Schoenherr, L. A review of creative and expressive writing as a pedagogical tool in medical education. Medical Education 2016;50(3):311–19.

• Cronin, C and Hawthorne, C. ‘Poetry in motion’ a place in the classroom: Using poetry

to develop writing confidence and reflective skills. Nurse Education Today 2019;76: 73–77.

• Currier, H and Zimmerman, CT. Use of Creative Writing to Illustrate Lived Experiences in Hemodialysis–Dependent Children with Chronic Kidney Failure. Nephrology Nursing Journal 2019;46(3):293–99.

• DasGupta, S, and Charon, R. Personal illness narratives: using reflective writing to teach empathy. Academic Medicine 2004;79(4):351–56.

• Ferrari, A, Veneroni, L, Romani, A, Pagani Bagliacca, E, Gaggiotti, P, Silva, M, Signoroni, S, and Massimino, M. Diary of a journey to a faraway galaxy. Tumori Journal 2019a;105(6):NP32–34.

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• Ferrari, A, Veneroni, L, Signoroni, S, Silva, M, Gaggiotti, P, Casanova, M, Chiaravalli

S, Clerici C, Proserpio T, and Massimino, M. Loop: there’s no going back: A Graphic Novel by Adolescent Cancer Patients on the Youth Project in Milan. Journal of Medical Humanities 2019b;40(4):505–11.

• Forsell, JS, Nyholm, L, and Koskinen, C. Caring in Creative Writing: A Case Study. International Journal for Human Caring 2019;23(1):91–100.

• Gaggiotti, P, Veneroni, L, Signoroni, S, Silva, M, Chisari, M, Casanova, M, and Massimino,

M. “What shall I do when I grow up?” Adolescents with cancer on the Youth Project in Milan play with their imagination and photography. Tumori Journal 2019;105(3):193–98.

• Gutkind, L. From the Editor: The 5 Rs of Creative Nonfiction. Creative Nonfiction,1996;1–14. • Gawande A. Being mortal: Medicine and what matters in the end. Metropolitan Books; 2014.

• Gawande A. Complications: notes from the life of a young surgeon. Penguin Books India; 2002

• Joshi, A, and Ganjiwale, J. Evaluation of Students’ Perceptions Towards an Innovative

Teaching-Learning Method during Pharmacology Revision Classes: Autobiography of Drugs. Journal of Clinical and Diagnostic Research 2015;9(7):FC01–04.

• Joshi, A, Singhal, A, Loomba, P, Grover, S, Badyal, D, and Singh, T. Humanities in Medical Education. Journal of Research in Medical Education and Ethics 2018;8(SI):3–9.

• Kalra, J, Singh, S, Badyal, D, Barua, P, Sharma, T, Dhasmana, DC, and Singh, T. Poetry in teaching pharmacology: Exploring the possibilities. Indian Journal of Pharmacology 2016;48(Suppl 1):S61–64.

• Kay, A (2017). This is going to hurt: secret diaries of a junior doctor. Pan Macmillan, Shaw,

K. Prescribed Reading: Reflective Medical Narratives and the Rise of the Medimoir: An Interview with Adam Kay. Humanities 2018;7(4):130.

• Lemal, M, and Van den Bulck, J. Testing the effectiveness of a skin cancer narrative in

promoting positive health behavior: A pilot study. Preventive Medicine 2010;51(2):178–81.

• Mehl-Madrona, L (2007). Narrative medicine: The use of History and Story in the Healing Process. Simon and Schuster, New York.

• Rankin, J, and Brown, V. Creative teaching method as a learning strategy for student midwives: A qualitative study. Nurse Education Today 2016;38:93–100.

• Reilly, DA, and Langan, S. Ask me about my pearls: Burn care, ethics, and creative writing. AMA Journal of Ethics 2018;20(6):589–94.

• Rosenbaum, ME, Lobas, J, and Ferguson, K. Using reflection activities to enhance teaching about end-of-life care. Journal of Palliative Medicine 2005;8(6):1186–95.

• Shapiro, J, Kasman, D, and Shafer, A. Words and wards: a model of reflective writing and its uses in medical education. Journal of Medical Humanities 2006;27(4):231–44.

• Thompson, T, and Kreuter, MW (2014). Using Written Narratives in Public Health Practice: A Creative Writing Perspective. Preventing Chronic Disease,11, E94. Accessed on 25.04.2022. Available from: https://www.cdc.gov/pcd/issues/2014/13_0402.htm

• Verghese, A (1995). My own country: A Doctor’s Story. Vintage Books, New York.

18 Role of Poetry in Medical Humanities Juhi Kalra Key Points q Poetry can mentor us, the way books cannot! q

Poetry must not be imposed or else it shall lose its charm

q

Poetic inquiry can be a useful tool for qualitative research

INTRODUCTION All boundaries were not made in heaven, be it between science and art, fiction– nonfiction, poem–prose, disease or health. Most boundaries merge at the circumference and have an underlying continuum (Vincent, 2018). Poetry explores this continuum reminding us that we are “human beings” first and then “doctors”. Poetry can be our unique signature! Poetry integrates thoughts and experiences, while at the same time; it has the audacity to break some ossified notions. It thus transcends human boundaries, and uses freedom of expression to travel the real life narrative; we all carry along for life touching events. The versatility of poetry has been experimented as a tool in medical profession, for both doctors and the patients. Rich Furman has used poetry to narrate some personal experiences as well as for qualitative research (Furman, 2004). Though self-indulgent and sentimental, the confession ingrained in poetry is closest to the original and this enormous potential embedded in medical poetry has led it to blossom as a genre per se. Poetry is a popular section in journals like Medical Humanities, the Journal of Medical Humanities, Chest, JAMA, the literary journal—Bellevue Literary Review along with several other journals that are accepting medical poetry for publications (Gee, 1989). The latter was founded by a group of physicians who used creative writing in clinical teaching. Hippocrates Prize for Poetry and Medicine is another proof of its rising recognition in the field of medicine (McNaughten, 2000). Be it a blank verse, free verse, rhymed poetry, an epic, narrative poetry, haiku, sonnet, elegy, ballad, villanelle or the like, if students are allowed to experiment with words, beautiful words of character and wisdom will tell enchanting tales. 167

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POETRY AS AN IMMERSIVE EXPERIENCE Poetry is an amalgamation of creativity, astute observation, analysis and freedom of expression. It reflects an arena for creativity which allows mind to expand and deduct interpretations, thus offering a platform where question and answers turn into aesthetically amicable dialogues, representative of an experience gilded with rich emotional responses. Several Indian doctors have shared their experiences in poems like—“Do you hear me, Ma?” which raises concerns about female foeticide and this poem can be an initiator for an ethics class (Ramalingam, 2015). The poem “डॉक्टर भी इंसान होता है” highlights the stresses in life of a doctor for those who see him only as a machine clad in an apron rather than as a humans (Borker, 2016). The book “inverse medicine” is a collection of poems, as the poetess sees the world around her (Dhaliwal, 2021). Since creative and expressive writing is a worthy cocktail of intelligent quotient and emotional quotient, poetry can complement the existing teaching methodologies (Cowen, 2016). The emotional intelligence thus acquired promotes resilience in health professionals, guarding them against burnout (Olson et al, 2015; Weng et al, 2011). It can enable students to indulge in reflective activities and internalization. The process may help unwind the complexities that envelopes disease, ethical dilemmas, feelings and experiences. It can lend itself to multiple interpretations and yet has a message, center staged.

POETRY IN MEDICAL TEACHING The limitless space offered by poetry can be used to an advantage, provided it is not imposed compulsorily. One must remember that only voluntary participation and facilitation in poetic excursions will lead to a fruitful indulgence. Only when the calling is from the heart, shall poetry retain its charm! So, it is imperative that we introduce our students to the enchantment and let them decide if they wish to embrace its charms or choose another creative or performing art. However, indulgence in a creative art is more likely to bring in a humane transforma­tion than its absence. Though pedagogical tools are often employed for teaching and assessment of soft skills, they have boundaries and limitations. They can be complemented with less formal tools like poetry which can help traverse the complex projections of past present and future to straighten out some of the most difficult and emotionally demanding situations. Poetry can thus till the soil for sowing compassion and empathy in an informal way, without the need for a structured class. Since the poetic space is not a mere void and is vibrant with energy, it carries the potential to nurture creativity and human sensitivity. Its polyglottal context has been used extensively in medicine. The poems “Insomnia,” “Lymphoma,” and “Neurologist focus on health and illness.” The Book of Seventy” offers insights into the problems that arise in geriatric age group as age catches up. An example, worth quoting here is a poem by Alicia Suskin Ostriker “The Surgeon” (Ostriker, 2011). It is about the unexpected death of a lady during surgery, as recalled by the surgeon when he was

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an intern and the deep impact it had on him. This poem can be used for imparting ‘lessons—on how to deal with the life and death situations. Even the subject of mentor and being mentored has been dealt through poetry in “The Ropes” by Kimberly Manning (Manning, 2012). Educators have scouted poetry to improvise the understanding of the scientific content in basic science and health professions courses (Jack, 2015). In one such attempt, poetry has been used in pharmacology to initiate focused thinking and clinical correlation. The students were asked to think about asthma and relate its symptoms with therapy. The order of thinking, pathophysiological correlation and therapeutic options thus explored, revealed its real-time utility during informal teaching (Kalra, 2016). Creative writing has been explored in neurosciences where in students were tutored to write (Petersen, 2020). Opportunities like ‘poetry clubs’, poetry recitation activities, indulging in critical analysis of carefully selected poems can help students enhance their power of self-expression, observation, descriptive, analytical, communication and problem solving skills while oral poetry can sharpen listening and attentiveness. It is claimed that creative arts have an active component and hence are likely to lead to greater engagement and internalization of situations. Just as enacting a role play and writing down the script may help internalize themes better than merely watching, similarly, writing poetry may be even better than listening to poetry or merely reciting on it. For example, creating poetry on a common problem afflicting a community can be an effective way of internalizing the problems of community and subsequently for creating an action plan, provided that students are not left without a trained facilitator. However, the use of poetry in medical education can have its own mental and executional shackles. Though a few individuals may be more creative than others, not all students may feel creative enough. Some may begin to concentrate more on the vocabulary, perfect rhyming, length and structure of the poem, rather than the context. This may defy the very purpose for which it may be used (Threlfall, 2013; Wiseman, 2011). So, it is suggested that like all learner-centred teaching methods, the constructivist incline in poetic indulgence will need skilled facilitation and appropriate planning by faculty to ensure that context is not lost (Lillyman et al, 2011). An encouraging environment by faculty who are willing to take up the pastoral role will be required (Petersen, 2020). This may churn out some artful literary pieces from medical schools in our country where currently the practice is much less prevalent than in medical schools across the globe.

Narrative Competence Through Poetry Poetry is an embodied space for therapeutic alliance where conflicts can be viewed, vulnerabilities and voids observed, prejudices encountered and indecisive moments resolved. It thus becomes a three-dimensional space and a safe ground for learning (Freshwater, 2005). Use of poetry to enhance narrative competence is subjected to criticism also. Critics argue that why burden our students, what additional purpose will poetry

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serve? As a proponent of poetry, however, one can say that “history taking” is like an art where one needs to understand what is said and that which is unsaid, collate the metaphors in patient’s narrative. One needs a congenial, nonjudgmental and trustworthy space. This art of history taking can be honed by poetry. It is seen that those who are accustomed to reading and interpreting poetry, understand metaphors and can read between the lines, better. Poetry reading habits can thus make an individual more competent to understand the real life narrative. ‘Metaphor—far from being a mere literary embellishment—is in reality a key element in the cognitive inferences by which all language users interpret and cope with their experiential world’. (Angelica, 2000, p. 209) ‘Clinical judgment is an interpretative skill where technical decision rooted in scientific understanding, and shaped by ethics, personal characteristics. This too can be fostered by knowledge and practice of the arts and humanities’. (Macnaughton, 2000)

Psychosomatic Encounters in Poetry It is well known that the difficult vocabulary of disease has the key in that which has not been expressed. In context of delving with the roots of disease, the confessions made in poetic spaces, especially in poems with autobiographical elements, paint a more realistic picture than we can envisage through a simple verbal communication. These confessions may be utilized to understand the unexpressed view points and to liberate patients from the pain, blocked thoughts and incongruence that are the cause and consequence of disease. Writing narratives or poetry has been encouraged among terminally ill patients because it acts as a cathartic space that can unfurl the basis of unexplained scientific observations (Hovey et al, 2018). Poetry offers a wonderful space for a dialogue between ‘self’ the ‘disease’ and the ‘environment’. The autobiographical element in them can become therapeutic when a clinician wishes to explore the psychosomatic basis of disease. It can become a useful language of medicine, as good as the books.

For Nurturing Mind Maps Poetry is like a factual mind map where descriptions are entwined with emotional experiences. It can offer a rational sequence in which the mind perceives a given situation or incidence. It is thus very unique in its expression for each individual and may reveal chronological sequences, relevant social norms, myths and ethical dilemmas at a given time and situation. Several patterns may emerge when configuring poems that can be studied, evaluated and analysed. Poetry thus carries the potential of becoming a valuable scholarship for medical professionals who wish to learn about the disease not only through books but through patient-specific perspective. It may reveal new destinations along the journey of uncertainties as it offers small stopovers to composers and readers, alike, where mind can ponder and linger. It can showcase a more real-time perspective than what one sees through a window pane if the teacher and the student do not lose sight of context.

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For Teaching Soft Skills Empathy holds centre stage in medical education but unfortunately, we are still an experimental stage as to have to teach it in an ideal way. There are several components to empathy, like—cognitive, which defines our ability to understand our own thoughts and thoughts of another person; affective, which has an active component of empathy where an affirmation and confirmation of being heard and understood is important. Decline in empathy has been a matter of concern for medical students and has been reported as early as the beginning of clinical posting (Chen et al, 2007). Endeavors which blend cognitive and affective components in medicine can restore the loss. The moment we talk about inclusion of art forms like music, narratives, fiction, graphic medicine, poetry and the like, to enhance aesthetic appreciation, critics often sense a dilution of purpose and scientific sanctity in medicine with inclusion of art forms. This hesitation has rather triggered greater exploration of arts, to find out if this may be true. However on the contrary, participatory activities in humanities like analysis of narrative, poetry writing, enacting a role play have been documented to build relationships, improve understanding of situations through reflection. Also our lack of knowledge about the way these art forms must be applied, the purpose they will solve in medicine can lead to the worst fears coming true. Hence, it is imperative that a good training must be imparted in medical humanities for an efficient facilitation, or else the good intent may be nipped in the bud. Critics may also rightfully say, why play with words? Why twist the facts? Alternatively, the proponents’ admire poetry for ‘poetry’ and also feel it links science and art and completes the circle. It has the power to moderate the overpowering influence of science in our lives that can make us mechanical at times. In the Attitude, Ethics and Communication (AETCOM) module released and adopted by National Medical Commission, the modules namely—What does it mean to be a doctor?, What does it mean to be a patient?, and What does it mean to be family member of a sick patient?, among several others, use recall and reflection. These modules, when well facilitated, can act as opportunities to enhance understanding on either side. Some of these modules can be enriched by inspiring students to write a poem (Medical Council of India, 2018).

Poetry can Offer a Third Space for Interpretation and Reflection Poetry is often regarded as the soliloquy of the mind. It gets converted into colloquy, a dialogue and a conversation, the moment it comes into the public domain and is discussed. It may thus provide solution to the contradictions arising in poet’s mind and in the situation being referred to. Its reflective component provides a platform and opens up the mind, forcing it to delve into alternative thinking. Poetry thus offers a nebulous illusory space, for discourse with disease, patient, therapy and the therapist. It can help to analyze the gaps in a caregiver’s perception and that of the patient. It can help reflect on issues and situations that evoke strong emotional responses that often escape the realm of textbooks and scientific papers like—‘noncompliance’, ‘patient psychology’, ‘near death experiences’, ’trauma’,

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‘grief’, ‘disease’, ‘death’, ‘ethical dilemmas’ and issues surrounding the ‘doctor– patient relationship’. Since poetic space is rich with metaphors, very similar to the metaphors of real life, the poet captures these metaphors from life’s experiences and braids them into meaningful word imagery through deep reflection. Depending on the depth of one’s knowledge and the experience with words, it gathers more nectar. If used judiciously in teaching, poetry can help develop finesse and can carry the fragrance of our culture, thoughts and experiences far and wide. The sensitivity that it awakens when we read or write is like beginning of self-recognition. We realize that there is so much more to life. For a profession like ours, we need this introspection more often.

For Honing Critical Thinking and Professionalism Commentaries on poetry add a new perspective by creating a parallel imagery without bias or fear of judgment. Commentary also offers space for active learning where the words of poet, ventroquilize in our mind, creating a real life image. It can thus help in honing critical thinking skills, interpretive skills and clinical judgment that are essential for acquiring adequate knowledge among students. Poetry may lend more cognitive flexibility and this may play an important role in acquiring professionalism. Professionalism is a dynamic process rather than as prescriptive, it involves acquisition of a range of skills over a period of time through imbibing the right values, ethics, respect and sensitivity for others reflection and introspection (Quirk, 2006). Poetry can enhance intuitiveness and metacognition, both of which are relevant in acquiring professionalism.

POETRY: A QUALITATIVE RESEARCH METHODOLOGY The very fact that poetry is open to derivations, so deciphering it can be a useful tool for qualitative research (Faulkner, 2007). The diversity within the poetry has been likened to a rhizome which proliferates in various directions, making it an open document amenable for discussion, research, deliberation, analysis and critique (Vincent, 2018). As Nachmanovitch (1990, p. 24) said: ‘It takes two to know one’; while interpreting another person’s viewpoint, we understand ours too. In a similar fashion, when transcribing poetry, the poet often internalizes facts presented by another, comprehends and contradicts more clearly and closely. In the process, the one who is analyzing poetry understands himself and the ‘other’, better. The process of writing a commentary on a poem, itself attunes us to lived experiences. Poetic transcripts can add another dimension to the composer’s viewpoint (Ohlen, 2003). Richardson created poetry from words of interviewees. Transcripts were read and reread, sorted out by themes and categorized into large data clumps so that meaning was not lost. He then transformed interview transcripts into poetry by juxtaposing the phrases in the prose and turning them into coherent rhythm of a poem (Richardson, 1992).

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CONCLUSION It must be borne in mind that poetry reading and writing is like evolution of a culture; it builds up over a period of time. Hence, it needs gentle exploration at its own pace. Rushing students into poetic excursions can be as detrimental as a hushed up conversation with a patient where both time and essence are at stake. In haste, one can miss out the metaphors in the interpretive domain of communication. In the wilderness of poetic expanse There were answers Hidden in the backwoods Locked in boondocks At crossroads of science and arts Sometimes screeching with inconsolable scoffs And at other times, soothing, enticing and fragrant with thoughts. Transcripts, commentaries and poetic rhymes Sensing the oblivious world behind Of suffering, disease, struggles and fights Assuaging the metaphors that slid behind Transgressing the forbidden folklore Contending a scholarship in medicine Promising to mentor the dexterous jockey Who knows well his saddle, stirrup, strings… While riding the curriculum horse

BIBLIOGRAPHY • Angelica JC. The metamorphosis of metaphor: from literary trope to conceptual key. Lenguas Modernas 2000; 209–225.

• Borker S. Doctors are also human. RHiME 2016; 3:44–45. • Cowen VS, Kaufman D, Schoenherr L. A review of creative and expressive writing as a pedagogical tool in medical education. Med Educ 2016; 50(3):311–19.

• Daniel C, Lew R, Hershman W, Orlander J. A Cross-sectional Measurement of Medical Student Empathy. Journal of General Internal Medicine 2007; 22(10):1434–38.

• Dhaliwal Inverse Medicine. Self-published: 2021. • Faulkner SL. Concern with craft: Using Ars Poetica as criteria for reading research poetry. Qualitative Inquiry 2007; 13(2):218–34.

• Freshwater D. The poetics of space: researching the concept of spatiality through relationality. Psychodynamic Practice 2005;11(2):177–87.

• Furman R. Using poetry and narrative as qualitative data: Exploring a father’s cancer through poetry. Families, Systems, and Health 2004; 22(2):162–70.

• Gee JP. The narrativization of experience in the oral style. Journal of Education 1989; 171(1):75–96.

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• Hovey RB, Khayat VC, Feig E. Cathartic Poetry: Healing Through Narrative. Perm J 2018; 22:17–196.

• Jack K. The use of poetry writing in nurse education: An evaluation. Nurse Educ Today 2015; 35:e7–e10.

• Kalra J, Singh S, Badyal D, Barua P, Sharma T, Dhasmana DC, Singh T. Poetry in teaching pharmacology: Exploring the possibilities. Indian Journal of Pharmacol 2016; 48:S61–64.

• Lillyman S, Gutteridge R, Berridge P. Using a storyboarding technique in the classroom to address end of life experiences in practice and engage students in deeper reflection. Nurse Educ Pract 2011; 11:179–85.

• Macnaughton J. The humanities in medical education: context, outcomes and structures. Med Humanit 2000; 26(1):23–30.

• Manning KD. The ropes. Ann Intern Med 2012; 156(5):398. • Medical Council of India, 2018. Attitude, Ethics and Communication (AETCOM)

Competencies for the Indian Medical Graduate. Accessed on 27.04.2022. Available from: https://www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf

• Nachmanovitch S. Free play: The power of improvisation in life and the arts. New York: Putnam; 1990.

• Ohlen J. Evocation of meaning through poetic condensation of narratives in empirical phenomenological inquiry into human suffering. Qual Health Res 2003; 13(4):557–66.

• Olson K, Kemper KJ, Mahan JD. What factors promote resilience and protect against

burnout in first-year pediatric and medicine-pediatric residents? Journal of Evid Based Complementary Altern Med 2015; 20(3):192–98.

• Ostriker AS. The surgeon. In: The Book of Seventy. Pittsburgh, PA: University of Pittsburgh Press; 2009.

• Petersen SC, McMahon JM, McFarlane HG, Gillen CM, Itagaki H. Mini-Review–Teaching

Writing in the Undergraduate Neuroscience Curriculum: Its Importance and Best Practices. Neurosci Lett. 2020;737:135302. Accessed on 27.04.2022. Available from: Doi: 10.1016/j.neulet.2020.135302.

• Quirk M. Intuition and metacognition in medi¬cal education: keys to developing expertise. New York, NY: Springer Publishing Company, Inc; 2006.

• Ramalingam S. Do you hear me, Ma? RHiME 2015; 2:39–40. • Richardson L. The consequences of poetic representation. In: Ellis C, Flaherty MG (Eds.). Investigating subjectivity: Research on lived experience. Newbury Park, CA: Sage; 1992. pp. 125–137.

• Threlfall S. Poetry in action (research). An innovative means to a reflective learner in higher education (HE). Reflective Pract. Int Multidiscip Perspect 2013; 14(3):360–67.

• Vincent, A. Is There a Definition? Ruminating on Poetic Inquiry, Strawberries and the

Continued Growth of the Field. Art/Research International: A Transdiscilplinary Journal 2018; 3(2):48–76.

• Weng HC, Hung CM, Liu YT, Cheng YJ, Yen CY, Chang CC, et al. Associations between

emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ 2011; 45(8):835–42.

• Wiseman A. Powerful students, powerful words: writing and learning in a poetry workshop. Literacy 2011; 45(2):70–77.

19 Artwork, Comics and Cartoons Sanjoy Das Key Points q Artwork can be used to reflect patients suffering and disease itself in its proper social context q

Artwork and comics can be used to foster humanities competencies in the learners

q

Comics, cartoons and artwork can be used to overcome healthcare provider’s fatigue

INTRODUCTION Medicine has been recognized as an art. One studies medical science and graduates to the art of healing. In human language of words, there is little scope of expression of feelings. Feelings are better expressed through art. A lot of emphasis has been laid on the character of the healthcare professionals. But how can character be taught? David S. Jones says ‘the arts and humanity can be used to teach empathy, professionalism and other character competencies’. Deciphering artwork is all about understanding feelings of the creator and the perception of the observer. This was probably the origin of cartoons, where the prime observations are exaggerated to catch the attention of the viewer and convey what is meant to be conveyed. Text was added to a series of images, arranged in the form of panels, and was used as a form of narration. This was the origin of comic strips and was used as a means of storytelling that was more expressive and easier to comprehend. The popularity of comic strips, mostly depicting superheroes, slowly percolated into innovative minds; resulting in the creation of cartoons and comic strips that dealt with complex medical subjects like sexual assault, drug abuse, suffering, disease, treatment, death and ethics. This new innovation is now known as graphic medicine.

HISTORY In the 1990s, graphics medicine surfaced and was known as Underground Comics or Comix. Art Spiegelman, Bill Griffith, and Jay lynch were some of the popular underground comic artists (Ray, 2020). Most of their works were self published. Healthcare concerns in the 1960s and HIV/AIDS concerns in the 1980s saw the use of graphic medicine as a tool of expression and awareness. 175

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In 1972, Justin Green published a narrative “Binky Brown Meets the Holy Virgin Mary” (Keith, 2014). In his narrative, Green reveals graphically his obsessive compulsive disorder (OCD). He has narrated his carnal thoughts of the Holy Virgin Mary at the age of puberty and his guilt and fear of God for his obsessive thoughts. In 2010, Sarah Levitt created “Tangles: A story about Alzheimer’s, My Mother and Me”, where he used objects to describe the memory of his mother (Leavitt, 2010). Subsequently, more precise narratives of illness in comic form emerged and these came to be known as Graphic Pathographies (Myers and Goldenberg, 2018). Willaims and Czerwiec (the comic nurse) in 2010 redesigned a website of graphic medicine, launched by a general practitioner Ian Williams in 2007. This redesigned website titled graphicmedicne.org became very popular and soon it developed in to a repository for graphic medicine (https://www.graphicmedicine.org/). The first annual conference of graphic medicine was held in London in 2010 and thereafter in different locations every year. These conferences deal with complex subjects like illness, suffering, medical ethics, medical negligence and doctor–patient relationship. The first book on graphic medicine titled “Graphic Medicine Manifesto” was published in 2015 (Czerwiec, 2015). Graphic medicine is a new sub-genre in India. The University College of Medical Sciences, New Delhi started a Medical Humanities Group in 2009. In addition to many other activities including Augusto Boal’s Theatre of the Oppressed, it launched “Comicos”, an online graphic medicine club. World Comics Con India and Grassroot Comics are organizations that promote self expression on sensitive social issues in graphic form.

WHY COMICS? Comics bring out the aesthetic and thematic aspects of expression in very subtle, yet comprehensible manner. Complex ideas in the form of imagery and text are more easily digestible than mere text. Graphic medicine helps the healthcare professional to imagine himself in the place of the patient, thereby bringing out issues related to patient autonomy, doctor–patient relationship and challenges faced by the healthcare provider (Hansen, 2004). Graphic narratives enhance conveying of difficult to express issues like suffering, pain, death and matters related to medical decision making. Radical and personal disclosures are more clearly projected and help other sufferers and caregivers, while promoting discussions on difficult subjects. As a pedagogic tool in health education, comics provide freedom of reflection in a more critical manner. It is especially helpful for those with poor cognitive skills. It has been presumed that assessment of narratives through graphic medicine is a difficult ball game. But in recent times, assessment through imagery and text has been emphasized akin to assessment of critical reflection (Fig. 19.1).

WHAT IS A COMIC STRIP? Scott McCloud describes a comic strip as ‘a sequence of static images, contained within panels, a staccato rhythm of unconnected moments also known as breakdown, with gaps in

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Fig. 19.1: Assessment of reflections through cartoon strips

between. These gaps are known as gutters where the actual magic and mystery of comics take place’ (McCloud, 1993). In the presence of two consequent images, the human mind assigns a sequence and reads it as a continuous story. The gutters are the spaces where the mind exercises itself to create or imagine what happened in between. There is an active engagement between the creator and the reader. This is why comic is a powerful medium of expression. A comic is neither the image nor the text but something in between, which very often hammers the perception of the reader (Fig. 19.2).

Fig. 19.2: Cartoons decipher variant individual emotions and perspectives

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USING CARTOONS FOR INCULCATING HUMANITIES COMPETENCIES Cartoons and artwork can be utilized for inculcating humanities competencies in students. Well prepared cartoons and comics or comic strips already available can be used to show-case humanities aspects of disease and healthcare. This is surely going to heighten the emotional milieu of the learners. This will help to present disease and the patients’ sufferings in its right social context, by unifying ‘art and science’ of medicine. Artwork also provides reflection opportunities to the learners. Proper use of cartoons, artwork, comics and comic strips help in inculcating reflective practice among healthcare providers. By discussing the same cartoon, cartoon strip, artwork and/or comic in a group will help the learners in a group to draw from different perspectives. Such group discussion focused around an artwork helps in brainstorming (Kasturi and Venkatesan, 2015; Jones, 2014). By designing a cartoon strip themselves, healthcare providers can present their own thoughts. Such designs will provide them a channel to ‘vent out’ their own emotional trauma while dealing with patients having terminal illnesses. In short, this can help the healthcare providers to deal with ‘healthcare fatigue and trauma’. For proper utilization of this aspect of graphic medicine, they must be aware about the methods of designing a comic strip.

DESIGNING A COMIC Tammy Coron has suggested the various steps of writing comics in a simplified manner (Coron, 2015), as detailed below. Start with an idea: It is always the best thing to jot down the idea as soon as it occurs in the mind, even if it is not fully realized. Write the script: Never start drawing the comic as soon as the idea strikes. This is a common mistake. Writing a proper script is one of the most important tasks. Simplicity of language is the key to writing effective comics. It is important to stick to the genre and understand the goals and the main characters in a believable setting. The script should include a beginning, middle and an end. Plan a layout: The layout should be organized before drawing the actual comic. The whole idea is to keep the reader engaged with sustained curiosity. Thumbnails or story boards are interesting tools to draw the reader-in, without revealing what next. Draw the comic: Before starting to draw, enough space should be left for dialogues. Choice of drawing tools is a matter of personal preference. Those with an artistic hand can draw with pencil and later ink and color. Digital artists can use their application of choice. There are numerous such applications available and many of them are free and very user friendly. Based upon personal experience, author recommends use of Adobe Photoshop. Inking and coloring: These can be done by the same or different artists, but both should have clear understanding of the theme of the comic. Color consistency is

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important. The same chamber of a doctor cannot have yellow walls in one frame and blue in another as this will confuse the reader. Lettering: Choice of fonts and their size need special attention. Hand written fonts are sometimes messy and the reader may prefer to ignore the text and just flip through the images. “Blambot Comic Fonts and Lettering” has many free and paid fonts that can be used. However, Comic Sans is a very acceptable font for graphic medicine. Increasing or decreasing the font size can depict shouting or whispering. The shape and appearance of dialogue bubbles contribute a lot in conveying the expression or emotion of the character. These dialogue boxes can be hand drawn or downloaded digitally. Marketing: Now that the comic is ready, it needs to be marketed. By marketing it means that comic should serve the purpose for which it is meant. Using the comic in presentations, publications or even on social media would make it popular.

USEFUL RESOURCES There are many useful resources for creating comics. Some are discussed here.

Books Stan Lee, the creator of Spider-Man, X-Men and Incredible Hulk describes the intricacies of writing comics in his book titled ‘How to write comics’ (Lee, 2011). He has given easy to understand instructions regarding creating concepts, setting plots and writing the script with numerous tips on how to design a comic strip. The book targets beginners as well as advanced comic writers. Adam Clay’s ‘How to draw cartoons—An easy step by step guide’ provides characters, costumes, special effects and numerous ideas about comic creation (Clay, 2010). Christopher Hart, in his book ‘The master guide to drawing anime’ describes step by step creation of characters with various outfits and in different situations (Hart, 2015).

Digital Applications Many online digital applications are available for designing cartoons and cartoon strips (Fig. 19.3). Make Beliefs Comix (www.makebeliefscomix.com) is a free website that allows creation of comics by provision of many characters, settings and objects. Pixton (www.pixton.com) designed by a husband-wife couple is one of the most popular free comic creation applications with numerous layouts, characters, backgrounds, objects and creative options for educators, students and business. Toondoo (www.toondoo.com) is a free comic creation site that is easy to use with many options. Strip Generator (www.stripgenerator.com) is a free online comic strip creator with many unique characters, settings, objects, shapes, speech bubbles and text fonts. Comic for Beginners (www.comicforbeginners.com) is available in both free and premium versions, claiming to be a goldmine for aspiring comic creators. Krita (www.krita.org) is a free and open source digital art studio for concept artists and illustrators. GIMP (www.gimp.org) is a free graphic editor for specialized tasks.

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Fig. 19.3: Online digital platforms for designing cartoons and cartoon strips

Adobe Photoshop is a very interesting application for creating graphic narrations, using one’s own artistic abilities and ideas as well as royalty-free images from the internet (Figs 19.4 and 19.5).

Fig. 19.4: Cartoon strip made using Adobe Photoshop

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Fig. 19.5: Another cartoon strip made using Adobe Photoshop

Lots of resources in the form of vectors, stickman and figures and clipart are available free on the internet and can be used creatively for making comics and other graphic representations (Fig. 19.6).

Fig. 19.6: Vectors, stickman and figures available online

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A combination of simple line diagrams fitted with downloadable emoticons can sometimes be very interesting and meaningful (Fig. 19.7).

Fig. 19.7: Cartoon strip made by using simple line diagrams

HELPFUL TIPS Have a clear storyline: Think of your story and the sequence of events that you would like to present. Mentally highlight the important events that would actually make your story understandable and these are the ones that you cannot miss. Decide the number of frames: The number of frames will depend on the number of events that you propose to present so that continuity is not broken at any point. You may often have to keep space considerations in mind. Addition of a frame or two or deletion of an unimportant frame may be required for maintaining the shape of the entire comic strip without distorting the primary idea. Creative ideas: Graphic medicine is all about creativity and creative ideas often disappear as suddenly as they strike, many times at odd hours. Make it a habit to note down such ideas as soon as they strike so that they can be polished and incorporated later. Be a little funny: It is well known that, even in a painful situation, humor stands out, wailing suffering hilariously. The best man is one who can laugh at himself. Be it serious writing, an essay, an oration or a piece of art, a humorous approach is always appreciated and helps retention.

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Exaggerate: Exaggeration originates from the Latin word “Exaggerationem” meaning exaltation and has been used comics in the form of caricature, hyperbole, farce and slapstick comedy. It is used to describe a word, phrase, individual or situation as better as or worse than it actually is. Use special fonts: Comic book fonts were originally hand-lettered by artists, keeping in mind the size, shape and relevance of the dialogue boxes. Comic sans has been used by many digital comic creators, but many modern fonts are being used today for headings and dialogues for enhancing the tone of the dialogues. Explore font styles like Comica BD, Clementine, Ale and Wenches, Fancy Footwork, Anemie Ace 2, Comic Book Commando and Crimefighter. There are many fonts available on the net for free. So, select a font style before thinking of the font size. Keep it straight and simple (KISS): A comic designer’s goal should be simplicity, going hand-in-hand with exaggeration. Simplicity evokes understanding and appreciation. Do not try to be perfect: “It took me a long time to realize that we are not meant to be perfect …” — Jane Fonda. Perfection is limiting, more so to creative ideas. Do not strive for perfection and give a bit of incomplete space for the reader to ponder over your ideas.

CONCLUSION Cartoons, artwork and comics are very strong medium to heighten the emotions of the healthcare students and they can be used for fostering humanities aspects in the students. They also provide a channel to the healthcare providers to depict their own trauma and fatigue. The hidden potential of cartoons and artwork in inculcating humanities competencies must be trapped fully.

REFERENCES • Clay, A (2010). How to draw cartoons—An easy step by step guide. Arcturus Publishing, UK. • Coron, T (2015). The 8 step guide to creating and publishing your own comic book. Accessed on 27.04.2022. Available from: https://www.creativebloq.com/comics/guidecreate-publish-comic-book-71515975

• Czerwiec, M, Williams, I, Squier, SM, Green, MJ, Myers, KR, Smith, ST (2015). Graphic

Medicine Manifesto. University Park: Penn State University Press. Accessed on 28.04.2022. Available from: https://muse.jhu.edu/book/58781

• Hansen, B. Medical history of the masses: how American comic books celebrated heroes of medicine in the 1940s. Bull Hist Med 2004;78:148–91.

• Hart, C (2015). The master guide to drawing anime. Sixth and Spring Books, NY. • Jones, DS. A complete medical education includes art and humanities. Virtual Mentor (Now AMA Journal of Ethics) 2014;16(8):636–41.

• Kasturi, RR, Venkatesan, S. Picturing illness: History, poetics and graphic medicine. RHiME 2015;2:11–17.

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• Keith, BM ed. Binky Brown Meets the Holy Virgin Mary. Comics through Time: A History of Icons, Idols, and Ideas. ABC-CLIO, USA, 2014;pp. 480–82

• Leavitt, S (2010). Tangles: A story about Alzheimer’s, my mother, and me. Freehand Books, USA. • Lee, S (2011). Lee Stan’s how to write comics. Watson-Guptill Publications, New York. • McCloud, S (1993). Understanding comics. Harper Collins, New York. • Myers, KR, Goldenberg, MDF. Graphic Pathographies and the Ethical Practice of PersonCentred Medicine. AMA Journal of Ethics 2018;20(1):158–66.

• Ray M (2020). Art Spiegelman—The American author and illustrator. Accessed on 27.04.2022. Available from: https://www.britannica.com/biography/Art-Spiegelman

20 Reflections Anil Kapoor Key Points q Reflection is a conscious metacognitive process on one’s past and present experiences which promotes learning and guide for future actions. q

Reflection and reflective narratives are important educational tools to train and assess competencies related to communication, collaboration, ethics and professionalism.

q

Use of prompt to reflect on a ‘disorienting dilemma’ experienced by learners is an effective approach to promote reflective practice.

q

Guidance and constructive feedback from teachers/mentors/peers promote reflection skills.

q

Deeper reflections can improve quality of care, professional growth and therapeutic relationship with patients via fostering humanities.

‘It is not sufficient simply to have an experience in order to learn. Without reflecting upon this experience, it may quickly be forgotten, or its learning potential lost. It is from the feelings and thoughts emerging from this reflection that generalizations or concepts can be generated. And it is generalizations that allow new situations to be tackled effectively’. (Gibbs, 1988) ‘Learning is the process of making a new or revised interpretation and meaning of an experience, which guides subsequent understanding, appreciation and action’. (Mezirow, 1990)

INTRODUCTION Developing a habit to consciously reflect on every clinical experience can significantly promote learning of medical students. Unfortunately, majority of our students fail to practice ‘reflection’. It is observed that medical undergraduates (UGs) do not possess sufficient demonstrable skills of good communication, collaboration, professionalism, ethical behavior or reflect on their experiences, even during the internship. It is difficult to teach and assess these skills through the traditional MBBS curriculum as this requires explicit training of medical UGs in ethical, interpretive, interpersonal and reflective capabilities. Hence, Medical Council of India (MCI) has introduced a new revised competency-based MBBS curriculum from 2019 with 185

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focus to develop the desired competencies before graduation. The term ‘professional competence’ has been defined as ‘the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served’ (Epstein and Hundert, 2002). MCI has also introduced an AETCOM module to teach attitude, ethics, professionalism and communication to address these issues (MCI, 2018). UGs are expected to develop self-directed learning skill and write reports from reflections based on different case scenarios described in the AETCOM module booklet and other clinical experiences.

WHAT ARE ‘REFLECTION’ AND ‘NARRATIVES’? ‘Reflection’ has been defined by many researchers (Box 20.1) (Sandars, 2009). In educational context, reflection can be described as a ‘purposeful conscious metacognitive process of turning back on the thoughts and analyze one’s own (or other’s) experiences/ practices/skills/responses, make sense out of them to link theory with practice so as to promote learning, unlearning and relearning, and bring about desirable changes in decision making and appropriate responses for immediate or future actions for better outcomes; when faced with similar situations’. And, ‘reflective practice’ can be described as a judicious use of reflections while managing complex, ill-defined problems or unpredictable situations. BOX 20.1: Some definitions of reflection Reflection is: • ‘An active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusion to which it tends’ (Dewey, 1938). • ‘A generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to a new understanding and appreciation’ (Boud et al, 1985). • ‘The process of becoming critically aware of how and why our presuppositions have come to constrain the way we perceive, understand, and feel about our world; of reformulating these assumptions to permit a more inclusive, discriminating, permeable and integrative perspective; and of making decisions or otherwise acting on these new understandings. More inclusive, discriminating, permeable and integrative perspectives are superior perspectives that adults choose, if they can, because they are motivated to better understand the meaning of their experience’ (Mezirow, 1990). • ‘A form of mental processing with a purpose and/or anticipated outcome that is applied to relatively complex or unstructured ideas for which there is no obvious solution’ (Moon, 2004). • ‘A metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters’ (Sanders, 2009).

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Reflection is not a linear one-way process. The process of reflective learning usually begins with a sense of inner discomfort following any experience or a dilemma. This is followed by identifying some concerns, receptiveness to new information received from external and internal sources, analyzing the situation from different perspectives including past experiences, identifying lessons learned and making a plan to act and change in behavior, if needed, to be used in future (Boyd, 1983). In order to have good reflections, one needs to consciously control the process of metacognition (thinking about thinking) on past or immediate actions/experiences. One usually reflects after the clinical encounter/event is over (reflection-on-action); with practice one can also develop skills of reflection while going through the event (reflection-in-action) (Schön, 1983). Reflective practice not only increases knowledge and skills but also promote development of necessary attitudes (empathy, care, altruism) and professional growth as a self-directed learner. Medical humanities has emerged in a big way to promote development of these soft skills and ‘narrative medicine’ has come up as an offspring of medicine-andliterature with a goal to develop narrative competence in empathy, reflection, professionalism and trustworthiness for humane and effective medical practice. In the context of medical education, a ‘narrative’ tries to narrate an incidence, an event or a personal experience which has moved the learner; a ‘reflective narrative’ tries to add a critical analysis and make sense out of that experience (Charon, 2006). Narrative medicine can be considered as a ‘medical educational tool’ that is informed by reading, writing, telling and listening stories of illnesses. Rita Charon was the first to use this term in 2000 to refer to ‘clinical practice fortified by narrative competence—the capacity to recognize, absorb, metabolize, interpret, and be moved by stories of illness; thus promotes a healing relationship with patients, colleagues, and the self’ (Charon, 2006). The storytelling provides an opportunity to the learners to release and express their emotions. Practicing the art of narrating (storytelling) experiences around illnesses and suffering of patients, their caregivers and healthcare providers helps them to learn and develop desirable changes in feelings, behavior, respect for cultural diversity, values and formation of professional identity (Arntfield, 2013). Narratives can be structured with a beginning to set the scenario, a middle to unfold the drama and discuss main aspects of the story followed by the end which conveys the important learning message.

MODELS OF REFLECTION Reflections can be done and written in unstructured or structured format. There are many models of reflections, we are describing a few of them here (Gibbs, 1988; Hatton and Smith, 1995; Rolfe et al, 2001; Bishop and Blake, 2007; Pappas, 2010; Menard and Ratnapalan, 2013). In 1984, Kolb described an ‘experiential learning cycle’ with four stages (Fig. 20.1). To begin with, a learner first actively participates in any event with difficult or complex situation (Stage 1: Concrete experience), followed by active reflection on that experience where she/he analyzes and identifies one’s own reaction to that experience, gaps in knowledge/skills, learning needs

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Fig. 20.1: Experiential learning cycle (from Kolb, 1984)

(Stage 2: Reflective observation) and tries to make sense and internalize the new insights developed and plan changes to be made in professional practice (Stage 3: Abstract conceptualization). The learner then tries to practice the new learning in similar situations in future to cope with complexity and changes in practice (Stage 4: Active experimentation). This cyclic process gets repeated leading to increase in learning and modification in behavior and practices with every new experience. In 1988, Gibbs described a ‘reflective cycle’ (Fig. 20.2), a six-stage model with a structured approach (Gibbs, 1988) as follows:

Fig. 20.2: Gibbs reflective cycle (from Gibbs, 1988)

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Stage 1: Description of the event. Describe the experience/situation you are reflecting on—what and where was the event, what was its context, who were other people involved, what everyone including you were doing, what was your part in it and what was the final outcome? Stage 2: Feelings. Express your feelings—why you are still thinking about that experience, your feelings at the start of the event, how the total event made you feel, how the actions of other people affected your feelings and how your feeling is affected by the final outcome of it. Stage 3: Evaluation. Evaluate the whole experience/situation to make a valuejudgment. What was good and/or bad about it; and why? Stage 4: Analysis. Breakdown the whole experience/situation into smaller components. Analyze every component and everyone’s actions one by one separately. Stage 5: Conclusion. Try to make ‘sense’ based on stages 1 to 4 above after analyzing the issues related to the experience/situation from different angles. What new learning and insight you have developed as a result of your own as well as other people’s actions leading to the final outcome of the event. Stage 6: Action plan. Think and make a plan for what would you do, if you encounter similar situation again—would you act in the same way or differently? In 2001, Rolfe et al described another simple approach for reflective writing, based on Borton’s developmental model (1970) under three parts: What happened? So what? What next? (Bishop and Blake, 2007.) The learner begins by describing the problem/situation that she/he has experienced and is reflecting on (What happened?), followed by analyzing the observations about the experience and what does it mean to oneself in terms of feelings and concepts which need to be developed or challenged to be changed (So what?), finally concluding by lessons learned, making a plan about how she/he intends to apply new concepts/learning and what she/he would change under similar situation next time (What next?). In contrast to narrative, this is more of formal and academic writing. One needs to focus more on ‘so what’ and ‘what happened’ should be as small as possible. It will be useful to quote relevant references in ‘so what’ and ‘what next’ which helped to develop new insight and which will be used in future. Peter Pappas from Portland University, Oregon, USA in 2010 had proposed a model of taxonomy of reflections based on Bloom’s taxonomy for cognitive domain (Table 20.1). Using this model, reflection can be utilized as a guiding process for developing higher-order thinking skills! And it can also be used as a tool for formative assessment of students/learners. Sample questions which will be useful to promote students’ reflective ability based on the level of taxonomy are given below. 1. Remembering: What was the activity/task assigned? What was the deadline to complete it? Did I finish in time? 2. Understanding: Did I understand all the parts of the activity/assignment and how they were linked with each other? Did I respond to all parts of the given

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TABLE 20.1: Peter Pappas model for taxonomy of reflection (based on Bloom’s levels) Levels of taxonomy

Expression statement

Pappas questions for reflection

6. Creating

Try to combine or reorganize smaller ‘What should I do next? What is my pieces into a new pattern, structure plan/design?’ or construct

5. Evaluating

Try to make judgments based on ‘How well did I do? What worked? recommended criteria and standards What do I need to improve?’

4. Analyzing

Try to break material/experience into ‘Do I see any patterns or relationships smaller pieces; determine how these in what I did?’ pieces correlate with each other and to the whole construct or purpose

3. Applying

Try to carry out or use a procedure ‘When did I do this before? Where through execution or implementation. could I use this again?’ Try to extend the procedure to a different setting

2. Understanding

Try to construct meaning from verbal, ‘What was important about what I written, or graphical messages did? Did I meet my goals?’

1. Remembering

Try to retrieve, recognize, and recall ‘What did I do during the experi­ence?’ relevant knowledge/experience from long- or short-term memory

activity/assignments? Do I see where this activity/assignment fits in with what I am studying? 3. Applying: How was this activity/assignment similar to previous ones in this subject or other subjects in terms of content, process or outcome? Where could I apply this knowledge or skill in my life? 4. Analyzing: Were the actions, skills or strategies I used effective for completing the activity/assignment? Are there ways to modify them and apply to other activities/assignments? What were the outcomes of the approach I used? Was my approach time-efficient? Do I need to reorganize or modify the steps in my approach? 5. Evaluating: What am I learning and how is it important for me? How am I progressing towards developing the desired competence as a learner? Did I use my knowledge and skills effectively in the given activity/assignment (e.g. eliciting history from a patient, examination of patient, assist or perform any procedure under supervision, etc.)? In what areas have I developed competence? What areas need more focus and practice for improvement? 6. Creating: What changes should I make in my approach and practice to improve my knowledge and skills? What more resources should I use to improve my weak areas. What skills should I practice more often to develop competence? What help should I seek from my peers and teachers to improve my knowledge and skills? How can I modify my skills for practice in future to further improve the outcomes in my professional life? Is there any training course I need to undergo?

WHAT IS THE PURPOSE OF REFLECTIONS? Reflections help in learning, unlearning and relearning! Following repeated experiences, we tend to develop some assumptions and beliefs about ourselves

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Fig. 20.3: Concept map on how reflection promotes transformative learning

and others and also develop our own approaches (use of knowledge and skills) of managing clinical problems and complex situations. These are stored in our memory as ‘mental models’ (Sandars, 2009). Occasionally, these mental models get challenged in subsequent experiences when we do not get the expected response or outcome as we used to get earlier under similar situations. Here, reflection activates metacognitive process leading to revision and changes in previous mental models. Sometimes these changes are dramatic and associated with strong emotional reactions like happiness, sadness, anger, etc. leading to significant shift in perspectives and our practices. The process, whereby any experience challenges and modifies the previously formed mental model and/or forms a new mental model which facilitates the learner to give up old practices, adopt new changes, develop new skills and start new practices in future encounter/situation, is known as ‘transformative learning’ (Fig. 20.3). Reflection for learning: Experiential learning occurs by having exposure to various kinds of experiences; but not always! It needs to be interpreted correctly by processing—comparing and relating with previous experiences and develop new meanings, expand or change the existing knowledge. Reflection to develop ‘therapeutic relationship’: People often say ‘My half of the illness is relieved after seeing my doctor’! This signifies the importance of good and effective doctor–patient (and their care providers) relationship on patients’ sense of wellbeing, satisfaction, compliance of medication and recovery. Besides having good knowledge and skills, a good doctor needs to recognize and understand the differences in personal beliefs and values of self, patients and their caregivers. These differences may sometimes produce strong emotional reactions which can influence decision-making and actions. Accordingly, care of the patient and outcome may vary when the doctor is unhappy or angry as compared to that when doctor empathizes with patient or when patient does not have trust on treating doctor.

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Reflection for ‘professional growth’: Doctors come across a variety of patients and situations including difficult and very complicated ones. Over years of practice, they develop the ‘expertise’ to manage them by ‘reflection-in-action’ during every encounter by integrating their knowledge and skills acquired through their habitual practice of ‘reflection-on-action’ on earlier encounters. ‘Reflection-before-action’ with a particular learning goal for managing complex scenarios followed by reflectionon-action (with or without guidance) can promote deeper, self-directed, lifelong learning; thus, help to improve decision-making, problem-solving and academic performance and develop professional practice (Sandars, 2009).

WHAT IS NOT REFLECTIVE WRITING? One needs to practice the skills to analyze, evaluate and create (Bloom) new insight and perspectives from the process of reflection. Hence, it will be useful to know what does not comprise ‘reflection’. Likewise, simple description of the situation or experience, conveying information, instructions, argument, straight forward decision (e.g. something is good or bad, right or wrong), simple problem-solving using recall (e.g. calculating Body Mass Index) will not be considered as reflection (Bishop and Blake, 2007).

BARRIERS AND GUIDE TO PROMOTE REFLECTIVE PRACTICES There are many perceived barriers for practicing reflections as a learning tool and many possible approaches to promote reflective practices among medical faculty and students (Box 20.2). BOX 20.2: Barriers and approaches to promote reflections Possible barriers for practicing reflections as a learning tool • Students are not formally trained what reflection is, how to reflect and its benefits and role in lifelong learning and professional growth. • Lack of critical thinking on experiences by the students. • Students lack interest and motivation to practice reflection. • Students may feel it is wastage of time as it is not included in assessment. • Teachers may find it difficult to read and provide feedback to reflections, thus demotivating students to pen down reflections. • Teachers themselves may not be trained about the concept of reflection and how to practice, teach and assess it. • Lack of explicit recommendation of use of reflection as a learning tool in traditional MBBS curriculum. Approaches to promote reflective practices among medical faculty and students • Faculty development for teaching and practicing reflections and serve as role models; conduct workshops with hands-on exercises. • Sensitize students to the importance of reflection in improving the learning, communications, better patient care and professional growth. • Incorporate formal sessions to teach students in form of workshops, provide handouts of reading materials, group exercises to reflect and share and get feedback. • Use reflections and portfolios for formative assessment to motivate students. • Share and publish good experiences from respective institutes.

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HOW DO I REFLECT ON MY LEARNING EXPERIENCES? It will be prudent to practice any one model for reflection; Rolfe’s model is simple and easy to practice. After going through any experience, try to think about it as soon as you are relatively free and unlikely to be disturbed or at the end of the day before going to bed. Put aside your mobile and any other distracters. Sit down and think about all the new experiences you had in the day—did you come across any ‘disorienting dilemma’ (Mezirow, 1981), i.e. situation which was complex, unexpected, surprising, difficult, challenging, confusing, generated doubts, or which had unusual outcome. Select any one to reflect and start silent brainstorming. Try to compare it with your older experiences under similar situations, analyze, make sense out of it and pen it down in first person using pronouns like ‘I’, ‘me’, ‘we’ in the statements. Here is a framework of questions which can be followed for deeper and critical reflections. What happened? What happened during the experience? How many persons were involved and what everyone did including me? What was the outcome of this experience; whether it was as expected or different and/or unexpected? So what? Did I have similar experience in past or was it a new/different kind of experience? Did I or someone miss something in understanding, communication, ethical issues, eliciting history or clinical examination, interpretation of findings or laboratory reports or treatment, etc.? How this affected the outcome of the experience? What are my feelings (thought process) about ‘myself’ and ‘others’ (patient, patient’s relatives, other doctors, nursing staff, any other healthcare professional involved in patient care, etc.) involved in this experience? Do I feel like crying/happy/sad/ worried/angry/guilty/anxious/shocked/surprised/moved/inspired, etc.? If yes, then why? Whether this experience strengthens or contradicts and challenges my old beliefs and assumptions? Why and how? Whether I need to change my beliefs and practices for future? In short, try to describe ‘disorienting dilemma’, conflict, challenge, or issue of concern that may include different perspectives, explore alternative explanations, and challenges to old assumptions, if any. What next? What knowledge and/or skills I already have and what new knowledge and skills I need to know/develop to address such situations? How and where will I get the required knowledge and skills? What resources do I have or need for the same? Do I need to buy/practice something? How much time and practice will I need to learn/master it? Do I need to take guidance and feedback from peers and/ or teachers? If yes, identify that person and fix a meeting. What actions will I do differently as compared to my last experience? Make a list of action plans to fill in the gaps in existing knowledge, skills, attitudes, communications, professionalism and ethics to further develop the desired

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competencies. Then act on it; seek guidance and feedback from peers and teachers to clarify doubts, if any. Discuss, read, revise and practice newer skills till you feel confident; then perform them under supervision and undergo assessments and ask for feedback to document the learning of those skills. Try to reflect similarly and make sense out of every experience. Intermittently, read your reflections and try to revise them further for deeper learning. Over a period of time, you will be surprised to find that your thought process, beliefs, assumptions keep on changing leading to changes in your clinical approach and practices. A ‘reflective thinking framework’ is available from ‘Library and Learning Services Study Guide’ at http://docplayer.net/storage/78/78140889/1587233964/2aSDcnQBB03hf NG7ouwCqQ/78140889.pdf which can also be used for writing one’s reflections. Exercises on ‘reflective writing’ can be done using some prompts given by the teacher. Once we develop a habit of reflection and get a good amount and variety of experiences, we can also do ‘reflection-before-action’ and ‘reflection-inaction’ during new encounters/situation in future. This will help us to analyze the situation from different perspectives and choose the best possible action in the given context. We can also write reflections as narratives like storytelling. This can further enhance the learning in communication and affective domain. Try to write in details the flow of events or experience (Who? What? When? Where? Why? And How?), use dialogues, keep it interesting, easy to read, enjoyable and may even build suspense for the reader. If appropriate, try to add relevant sensory details (see, hear, touch, smell, taste), thoughts and feelings. Ensure that grammar and spellings are correct. Avoid negative attitudes, sarcasm, foul language or emotional outbursts. A peerreview may be done for feedback and refinement. As we expect our students to practice writing reflections, it will be prudent for our faculty also to learn, practice and write reflections on their own day-to-day experiences and how to improve them in future! Common areas for self-reflection for faculty in addition to those described for students are—preparation of lesson plan for lectures, conducting the practical or bedside teaching or assessment of students, preparing exam papers, conducting exams, research related activities and publications, attending or conducting faculty development programs/workshops, meetings within or outside department, revision in curriculum with implementation of newer elements like foundation course, early clinical exposure, integrated teaching, designing MCQs and case based questions, AETCOM, online teaching, use of workplace based assessment, etc. They can also develop their portfolios by collecting evidence for change in their perceptions, knowledge and behavior and be the role models for the students.

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EXAMPLES OF WRITING NARRATIVES AND REFLECTIONS Example 1: Narrative style I was attending medicine OPD as an intern with my unit head. An elderly man, about 75 years, walked in slowly holding his son from left hand with tremors in right hand. Sir greeted him with a smile and asked him to sit down and tell his problem. He was known case of parkinsonism, his face was looking dull, and suddenly he started crying while telling his problems. Sir put an arm around his shoulder, patted him gently and looked into his eyes without saying a word; and asked his (patient’s) son to give him water. Sir asked him about his daily routine and social activities “How are your children doing and how do you spend your time? How much time do you watch TV?” He stopped crying and started talking and sir kept on listening to him. Sir told him “You should do exercise for 10 minutes daily in sitting and lying posture (as he was having difficulty in walking), sit out in balcony for half an hour, watch comedy serials and play Ludo with grandchildren”. Soon, he was looking lively and I could see a little smile on his face when he left with his prescription, thanking and blessing sir! After he left, sir told us “His wife died a few months ago and so he feels lonely, there is nobody to sit and talk with him. His sons look after him but are too busy to sit and chat with him. He comes here every 2 weeks just to talk and I listen to him. I have given him antidepressant but he will need time to come out of grief reaction”. It was a new learning for me that some patients need attention and to be heard patiently to vent out their feelings. Gentle behavior, showing concern and kind gestures and a couple of minutes can heal the patient inside out! It reminded me that we may not cure the disease but we can always empathize and support them emotionally. We need to treat the person and not the disease only!

A ‘critical incident’ has been shared below, from author’s own experience; first as a narrative followed by reflective writing (Rolfe model) for the readers to get the feel of both the styles on a single experience. Example 2: Narrative style This incident happened during my first year of PG, while I was attending ward round of my friend’s unit. My friend presented a case “Sir, this 17-year-old girl is referred from casualty about half an hour ago in altered sensorium with diagnosis of ‘functional’ (hysterical) unconsciousness with no past history of any disease. On admission, I tried a ‘swab of liquor ammonia’ over her nostrils. At that time, she responded to commands, opened her eyes and showed her tongue. I have sent the laboratory tests and started intravenous dextrose with saline (DNS) as advised by R3 (third year PG). Her BP is normal; but now she is not responding to verbal commands”. No relative of girl was present at that time to elicit further history. Sir started examining her gently— pulse, touched her forehead by the back of his hand, eyes, neck rigidity, planters, deep tendon reflexes, heart, and chest. Suddenly he paused and started sniffing over her face and observed her breathing. I was a bit confused as to what he was doing! He asked both of us to check for any smell in her breath. Both of us tried but could not perceive any smell. Sir said, “Stop DNS, start normal saline, find her relatives, transfer her to ICU immediately and do the blood sugar by glucometer and inform me at the earliest; catheterize and take a urine sample for sugar and ketone. This is not functional! This looks like DKA (diabetic ketoacidosis)”. (At that time, we had only 1 glucometer, that too in ICU.) Before leaving he told us, “Go out of this room, take some deep breaths, come back and check for smell in her breath. There is ketone smell in it”. As an obedient student, we did exactly the same. After three attempts, I was able to make out that there was some smell in her breath and after 5 attempts I was pretty sure about it! She was shifted to ICU, her blood sugar was recorded ‘high’ by glucometer and urine showed presence of sugar and ketones. She was treated for DKA; and recovered in few days. This was an eye-opener experience for me. The manner and gentleness in which sir examined her impressed me! It hardly took him 2 minutes to diagnose DKA, that too in absence of a reliable history! A little casual approach or missing a finding can lead to wrong diagnosis; and patient will be wrongly treated and may even die. I realized the significance of thorough general examination including smell in breath, in true sense! Now onwards, I will be extra careful in attending and labelling functional to any unconscious patient. I cannot afford to miss anyone of them!

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Example 3: Reflective writing (Rolfe model) What happened: One day, I saw a young 17-year-old girl who was referred from casualty to female medical ward in altered sensorium with diagnosis of ‘functional’ (hysterical) unconsciousness and prescription of IV dextrose normal saline. On admission, she had responded to inhalation of ‘liquor ammonia’. However, our consultant who came for the round refuted the diagnosis of ‘functional’ as he could smell ketone odor in her breath and shifted her to ICU immediately. She was diagnosed as DKA (diabetic ketoacidosis), responded well to treatment and was fully conscious next day! She gave history of increase in thirst, appetite, frequency of urination and generalized weakness for last 1 month. So what: Before this particular incidence, I had experienced many such adolescent girls presenting in altered sensorium as functional and treated them by painful pressure over sternum or ‘apply a swab of liquor ammonia’ over nostrils; its inhalation used to give the miraculous results—they used to hold breath for few seconds, followed by becoming restless, opening eyes and responding to verbal commands when they could not hold their breath any longer! However, this young girl did not respond well. Why? Because she was not functional; this was my first experience of DKA diagnosed bedside just by sniffing the breath of patient. I started feeling sorry about this patient! If she is in DKA, it means she has type 1 diabetes mellitus and would require insulin injection lifelong. I thought “the reason for deterioration of her sensorium after admission was probably due to DNS infusion which would have raised her blood glucose further. She had a high risk of mortality and she may even face difficulty in getting married”. Personally, this experience made me feel guilty, changed my old belief that all young females presenting with unconsciousness of short duration are functional (sorry for this gender bias). It sensitized me to develop empathy towards such young females presenting with altered sensorium. I realized the need to elicit proper history, perform thorough clinical examination and think of other possibilities (differential diagnosis) before saying ‘functional’ for any patient. What next: I will be humble and try to empathize with unconscious patients. I will elicit proper history, perform thorough clinical examination and rule out other possibilities before labeling ‘functional’ and applying swab of liquor ammonia over nostrils for any patient. I will check for ketone smell in breadth during bedside examination of patients especially with altered sensorium. And, I will never make fun of functional patients.

ASSESSMENT OF NARRATIVES, REFLECTION AND REFLECTIVE PRACTICES Since the reflection is a complex cognitive activity, its assessment needs more of qualita­tive tools. Attempts have been made to assess reflection through verbal communications (face to face) or self-assessment questionnaires or Rubrics and by reviewing their learning portfolios. However, students need to be trained for writing ‘learning portfolio’ to record and document their experiences, achievements and pieces of reflections on them as evidence to prove that new learning is happening. This portfolio can comprise of collection of a variety of documents and contents in paper or electronic form (e-portfolio) about record of participation, achievements, professional development with documented evidence and reflective writing, e.g. assignments, project work, concept maps, drawings, case presentations done, critical incidents, patient management plan, seminar presentations, journal club and review of articles, self-assessment, feedback from teachers on written and/or clinical assessments like mini-clinical evaluation exercise (mini-CEX), direct observation of procedural skills (DOPS), research activities (short-term studentship from Indian Council of Medical Research, etc.), field work, attending patients in camps, papers presented in conferences, papers published; also patients’ discharge tickets and procedures done under supervision during internship, along with reflections on all these

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experiences (Ahmed, 2018). These may be supported by relevant photos/videos (while practicing clinical skills or group work). Appropriate consent should be documented and confidentiality of patients/participants should be maintained. Quantitative and qualitative assessment of these portfolios can be done to find out evidences for improvement due to experiential learning and progress in development of competencies of communication, professionalism, attitude, self-assessment and reflection; appropriate feedback can be useful for further improvement. A word of caution here, deeper reflections can expose the vulnerability of learners; hence it is important for teachers to maintain the confidentiality for any sensitive issues. Also, once students are aware that their portfolios will be assessed, they may not give the real picture and may add certain things to create bias for the assessor. Hong Kong Polytechnic University developed a 16-item self-rated questionnaire to examine the extent to which learner engages in reflective thinking in disciplines of health sciences (Kember et al, 2000). This instrument contains four scales: (1) Habitual action, (2) understanding, (3) reflection, and (4) critical reflection; each one of them has four contributory items measured using a 5-point Likert scale. It can be used as a diagnostic tool to determine the effect of teaching and learning on reflective thinking of learners pursuing courses which have a professional practice component. This is done by repeatedly subjecting the learners to this instrument—first, soon after joining course to assess normal baseline study patterns, then intermittently during the course (once a year) and finally near the completion of course. Changes in the mean of each of 4 scales can be reasonably attributed to changes in reflective practices due to the course and its teaching–learning environment. Counseling needs to be provided to those who do not show any improvement in reflective practices. It can also be used to compare groups of students who are subjected to different teaching–learning conditions or courses, e.g. undergraduate and postgraduate students. Groningen Reflection Ability Scale (GRAS), a 23-item self-rated scale, was developed by University of Groningen, The Netherlands, to measure the personal reflection ability of physicians and medical students (Aukes et al, 2007). It comprises 10 items on self-reflection, 6 items on empathetic reflection and 7 items on reflective communication. Another rubric, the ‘REFLECT’ (reflection evaluation for learners’ enhanced competencies tool) was designed by Warren Alpert Medical School, Brown University, USA (Wald et al, 2012). It provides a ‘prompt’ in form of a scenario or situation on which students have to select their own patient-experience which relates to the given prompt and write a narrative reflection which is then qualitatively analyzed and categorized out of four reflective capacity levels—nonreflective habitual action, nonreflective thoughtful action, reflective, and critically reflective; last one further subcategorized as transformative reflection, and learning and confirmatory learning. A ‘reflective practice questionnaire’ has been developed by Department of Humanities, Rocky Vista University (Rogers et al, 2019). It consists of 40 questions on 6-point Likert scale to measure reflective capacity addressing reflection-on-action, reflection-in-action, self-appraisal, reflection with others, desire for improvement,

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confidence in general and in communication skills, handling uncertainties, stress while interacting with patients and job satisfaction. The model of taxonomy of reflection developed by Peter Pappas (2010) described earlier can also be used as a tool for formative assessment followed by constructive feedback to the learners.

CONCLUSION Reflection in medical education is a multidimensional construct developed by analyzing the cognitive-emotional and metacognitive processes in medical practice. Teaching methods of narrative medicine can transform practice by improving the skills of empathic interviewing, ethics, professionalism, reflection, writing narratives, self-awareness, creating and sustaining healing and healthy relationships with patients, their care providers and colleagues, thus fostering medical humanities. We need to train our faculty about reflection and reflective narratives as a teaching–learning tool to promote integration of theory and practice and transfer of learning. And, faculty need to sensitize their students to reflection, various models for reflection, provide conducive environment and goals for reflective exercises to integrate new learning with current knowledge, give assignments to write reflections using prompts to document lessons learned, assess them and provide constructive feedback and follow-ups and motivate them to apply reflective learning in clinical practice (Aronson, 2010). This can be best achieved by making reflective practice as a part of the curriculum as already incorporated in the new CBME curriculum for medical undergraduates by MCI, which has been replaced by National Medical Commission (NMC) in 2020. This in turn will promote development of competencies related to communication, collaboration, professionalism and ethics and transform the Indian Medical Graduates as caring and responsive physicians of first contact.

BIBLIOGRAPHY • Ahmed MH. Reflection for the undergraduate on writing in the portfolio: Where are we

now and where are we going? Journal of Advances in Med Educ and Professionalism 2018; 6(3):97–101.

• Arntfield SL, Slesar K, Dickson J, Charon R. Narrative medicine as a means of training medical students towards residency competences. Patient Education and Counseling 2013; 91(3):280–86.

• Aronson L. Twelve tips for teaching reflection at all levels of medical education. Med Teach 2011;33:200–5.

• Aukes LC, Geertsma J, Cohen-Schotanus J, Zwierstra RP, Slaets JP. The development of a scale to measure personal reflection in medical practice and education. Med Teach 2007;29:177–82.

• Bishop G, Blake J. Reflective practice: A Guide to Reflective Practice with Workbook: For

postgraduate and post experience learners. Working Paper. University of Huddersfield, Huddersfield, UK 2007. Accessed on 17.04.2022. Available from: http://eprints.hud. ac.uk/id/eprint/19114/

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• Boyd E, Fales A. Reflective Learning: Key to Learning from Experience. Journal of

Humanistic Psychology 1983;23(2):99–117. • Charon, R. Narrative Medicine–Honoring the Stories of Illness. Oxford University Press 2006. • Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002; 287:226–35. • Gibbs G. Learning by Doing: A guide to teaching and learning methods. Oxford Centre for Staff and Learning Development at Oxford Brookes University. London (Kindle Version 2013) 1988. Accessed on 20.04.2022. Available from: https://thoughtsmostlyaboutlearning. files.wordpress.com/2015/12/learning-by-doing-graham-gibbs.pdf • Hatton N, Smith D. Reflection in teacher education: Towards definition and implementation. Teaching and Teacher Education 1995;11:33–49. • Kember D, Leung DYP, Jones A, Loke AY, Mckay J, Sinclair K, Tse H, Webb C, Wong FKY, Wong M, Yeung E. Development of a questionnaire to measure the level of reflective thinking. Assessment and Evaluation in Higher Education 2000; 25(4):382–95. • Library and learning services study guide. Reflective Writing. Accessed on 18.04.2022. Available from: http://docplayer.net/storage/78/78140889/ 1587233964/2aSDcnQBB03hfNG7ouwCqQ/78140889.pdf • Medical Council of India. Attitude, Ethics and Communication (AETCOM) Competencies for the Indian Medical Graduate 2018. Accessed on 16.04.2022. Available from: https:// www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf • Ménard L, Ratnapalan S. Teaching moment: Reflection in medicine: Models and application. Canadian Family Physician 2013;59(1):105–7. • Mezirow J. A critical theory of adult learning and education. Adult Education Quarterly 1983;32(1):3–24. • Mezirow J. Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning. Jossey-Bass, San Francisco, CA, 1990. • Pappas P. (2010). A Taxonomy of Reflection: Critical Thinking For Students, Teachers, and Principals (Part 1). Accessed on 26.01.2022. Available from: https://peterpappas. com/2010/01/taxonomy-reflection-critical-thinking-students-teachers-principals.html • Pappas P. (2010). The Reflective Student: A Taxonomy of Reflection (Part 2). Accessed on 26.01.2022. Available from: https://peterpappas.com/2010/01/reflective-studenttaxonomy-reflection-.html • Rogers SL, Priddis LE, Michels N, Tieman M, Van Winkle LJ. Applications of the reflective practice questionnaire in medical education. BMC Med Educ 2019;19:47. https://doi. org/10.1186/s12909-019-1481-6. • Rolfe G, Freshwater D, Jasper M. Critical reflection in Nursing and the helping professions: A user’s guide. Basingstoke: Palgrave Macmillan 2001. Accessed on 17.04.2022. Available from: https://my.cumbria.ac.uk/media/ReflectiveModelRolfe.pdf • Sandars J. The use of reflection in medical education: AMEE Guide No. 44. 2009;31:685–95. • Schön, D. The reflective practitioner: How professionals think in action? New York: Basic Books,1983. • Wald HS, Borkan JM, Taylor JS, Anthony D, Reis SP. Fostering and evaluating reflective capacity in medical education: Developing the REFLECT rubric for assessing reflective writing. Acad Med 2012;87:41–50.

21 Teaching Medical Humanities: Global Learning Toward Local Caring Rakesh Biswas, Vivek Podder, Aditya Samitinjay Key Points q Medical education and practice are at the crossroads driven by evolving societal requirements and clinical complexity. q

Doctor–patient relationships are increasingly threatened into bitter spats rather than the transforming healing experience they were originally meant to provide.

q

Medical humanities has the potential to bridge the current divide and should be introduced into the curriculum in a manner that cannot only improve student learning outcomes but also patient healing outcomes.

q

This chapter share’s practical experiences of a clinical patient centred learning ecosystem where a solution (working prototype) has made a beginning to integrate humanities and science toward improving student learning outcomes and patient healing outcomes.

INTRODUCTION Most doctors begin their teaching journeys either as interns or postgraduate residents or as newly minted faculty and some are fortunate to become part of a teaching learning ecosystem even as medical students and remain lifelong medical students. This chapter traces the learning journeys of a few medical students, now faculty, who have navigated their regular patient centred workflows utilizing medical humanities as a tool to not only enable improvement of their own learning outcomes, but also established empathic relationships toward improved healing outcomes for their patients. The chapter uses quotes compiled from the past publications of these medical students, now faculty. In the next few paragraphs, we illustrate through our past published quotes, the role of individual patient stories and the empathy it generates to strengthen the human doctor–patient bond as one of the key features of medical humanities. In the words of one such student, we quote: ‘As medical students, when we finished the basic sciences and started clinics, we immediately noticed a pleasurable difference as we no longer had to cram dull theory. The patient was our greatest teacher of medicine, as much as the dead body had been in anatomy’. 200

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‘The best way to learn was interviewing patients and getting to the depths of the story, which in most cases would yield the diagnosis. It was a detective game and the clues had to be meticulously elucidated. This is where our teachers played a part. They showed us how to elicit these vital clues’. ‘We learnt not only how to hunt for information but also to love our patients. It was great to collect their stories and reflect on them over our textbooks. That was the first time we experienced our books coming alive. While our contemporaries were collecting stamps, coins, or peoples’ autographs, we started collecting people, live people, who were not long dead characters of a novel but would greet us from bus stops or on morning walks. Interacting with them we experienced vitality flowing like a river in and out of our lives’ (Biswas, 2003). In the words of another medical student, we quote: ‘During third year of medical school, my doctor a cardiac surgeon named Dr DPS told that we need to do this surgery soon because of severe transvalvular aortic pressure. We took our time to manage the cost of the surgery and also took into consideration an unexpected education gap from my medical school. Finally, after a decade of the stressful journey, my operation was done successfully’. ‘During this journey, I realized the importance of love, compassion, touch, and empathy. Now whenever I clerk any patient in the hospital and during my BMJ elective in India, I look at them and realize: ‘Yes, I know how it feels to be a patient and what patient might be expecting from me like I realized being a patient once.’ I can make a connection of empathy and love with the patients and can understand that within every human being there is a physician inside who knows only to love and care humanity’ (Podder, 2018). And another student: ‘A friendly, hand-on-the-shoulder chat with several PGs there, gave me a profound insight into their lives, into how they practice medicine and what their aspirations were. Almost all of them had their own governing principles, almost all of them had an awareness and insight into what was happening and why it was happening. A common theme emerged– their desire to learn and be curious was not being met largely due to a deference to authority. Months and years of indifference can render the best of us inhuman, indifferent, and stoic. On some days, even I find myself detached and indifferent. However, now that I’m a young consultant myself, with a few independent powers in clinical decision making, I get back on my feet quickly. However, for PGs and junior doctors, it may not be the same—out-of-the-box thinking is shunned, curious questioning is castigated, uncanny ideas are discarded. Consequently, young enthusiastic minds may not see the light of the day and retort to a system of learning that does not breed curiosity, but rather indifference’. ‘I firmly believe, humanities are a direct manifestation of scientific temperament, and our prime focus should be on encouraging a sound scientific temperament and an attitude of healthy scepticism’ (Samitinjay, 2022).

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WHY DO WE NEED HUMANITIES IN THE MEDICAL CURRICULUM: CURRENT PROBLEM STATEMENT ‘The job of the human being (in the digital age) is to become skilled at locating relevant valid data for their needs. In the sphere of medicine, the required skill is to be able to relate the knowledge generated by the study of groups of patients or populations to that lonely and anxious individual who has come to seek help’ (Sir Muir Gray, 2001). Medical humanities drive us to ‘study humans so that the patient is not just seen as a disease comprising a mass of signs and symptoms but is also recognized as a person with a story of his own. Such an approach not only fosters a better doctor–patient relationship but also more often than not brings out a lot of hidden clues to the diagnosis’ (Biswas, 2003). It is increasingly noted that ‘there is a current disintegration of medical education and practice globally and medical student and faculty engagement in learning is often confined to rote memorization driven by an arcane curriculum that promotes plagiarism and diminishes scholarship. Increasingly medical education has become disconnected from patients who continue to suffer due to lack of student and faculty engagement with them in a broader empathic meaningful manner’ (Sarbadhikary, 2021). ‘The top-down compartmentalized structure of medical education and practice in which future health professionals were very often simply expected to learn and memorize the structure of their chosen field of medicine (and then appl y it for patient care) has been recently challenged by the evidence-based healthcare, complexity in healthcare and the health informatics movements that have organically grown bottom up since the last few decades’ (Biswas, 2008). ‘Not knowing, the chaos of real-life clinical questions, a healthy scepticism, appreciation of the rapid turnover of information and the realization that active and interactive learners learn, are the energies that fuel problem-based learning in the aforementioned bottom-up movements’ (Armstrong, 2004).

Why—Medical Humanities From PGI at Chandigarh to Manipal, Pokhara, Nepal in 1999 was a dream journey and medical humanities became a vital tool to interpret that dream over the next few years of stay. Life in pristine rural Nepal challenged all our presumptive urban training. Quoting from our personal view at that time: 'In these remote villages there is education, which unlike ours teaches wisdom. It teaches us to gather and grow food and to cook it if necessary. It teaches us to live harmoniously with nature and not plunder it to the hilt, a glowering testimony of which today, is our cities we proudly display. Concrete jungles of human misery, a coexistence of the rich in high rises and others in slums … people who couldn’t make it to the top. Our cities were signposts of development, and we wanted the developing world such as those pristine rural villages to reach similar status.' For the first time “a global cancer of poverty was starkly apparent, engulfing all of us in the developed first world, cut off from that rural remote village aka the third world. A village, we hope still exists, somewhere replete with lush green forests

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and inaccessible mountain passes warding off people … who cut forests to build roads and lay the foundation for a gradual infiltration … of more people from our world which is already struck by the disease. A disease … born in our patronizing outlook, that gave us the license to meddle with the affairs, of the first self-sufficient village our predecessors destroyed with their reformist attitude (Biswas, 2002). The need for medical humanities will be further highlighted through the narrative by two student members of our team (Chandra, 2013). Narratives from Indian medical students (authors SC and TB) touch upon the key roadblocks a medical student faces in identifying and developing these skills in India as well as their potential reward (Box 21.1). BOX 21.1: Narrative of medical students highlighting importance of humanities in medical education Teaching modules and textbooks are not sufficient to teach a medical student how to be a good physician. We learn by observing our peers and seniors, but our most important teachers are our patients. My conversation with my first patient was more of a viva voce examination, punctuated with abrupt pauses—my voice was trembling, and I was trying hard to remember all the “questions” as per the training manual. Suddenly, I looked up to find my attending standing there. A legend in the hospital, his presence made me feel even more embarrassed at my apparent ineptitude. Instead of ridiculing me however, he gently taught me an important lesson—“Talk to the patient as you would to your own family member or friend. Extend them the same courtesy, and also the same level of comfort. You will learn ‘what’ to ask as you grow as a physician, so do not worry about that aspect. Right now, focus on ‘how’ you will interact with him”. Emboldened and enlightened, I went back to my patient and proceeded to ‘talk to him’ rather than merely ‘taking a case’. Not only did I finish taking a complete history in a shorter time than anticipated, I also gleaned some important information, which he had not shared with the resident. This helped me consider a new differential. Over the years, I have had many such physician and patient encounters teach me the value of compassion, empathy, trust and the value of empowerment and inclusion for the patient in the decision-making process. These values enhance my personal and professional growth.”

Similarly, on our patient centred teaching learning front, we found that contrary to what generalizable randomized controlled trial data projected, every individual was unique and had unique life trajectories and medical humanities driven students were best suited to unearth these trajectories as documented in their published personal histories of our patients. Medical humanities transformed the personal history taking from a mere recording of the patient’s habits to recording of his entire life story details (Biswas, 2003). Following up on our aforementioned lecture strategy toward integrating medical humanities with medical knowledge, we created lectures using a blend of science and fiction as illustrated in “the story of glomerular injury” (Fig. 21.1—slides borrowed from the lecture previously published in a medical humanities novel), where one can see how a visual of the happenings of 9/11 appear to have been lifted straight away from

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Fig. 21.1: Slide showing blend of science and fiction

a cartoon in Harrison’s Textbook of Medicine and in the lecture, one gathers the entire fictional depiction of how the micro-world story of glomerular injury is also played in the macro-world inhabited by embodied humans (Biswas, 2009). Embracing the aforementioned medical humanities driven data capture tools it gradually becomes apparent that present day outcome-based research deals less with patients as individuals than as populations. Evidence-based medicine struggles to apply the fruits of population-based research to individuals who are often not as predictable as linear quantitative research would like them to be (Biswas, 2007). Soon after this, we conceived the first conceptual model for our current medical humanities driven teaching–learning ecosystem and published it as “user driven healthcare” in 2008. In the same paper we addressed the current global medical education “risk of training a generation of doctors who, while skilled in study interpretation and statistical methods, may fail to recognize and develop the complex reasoning skills necessary for sound clinical judgment.” Again, quoting Armstrong, ‘The biggest challenge for medical education facilitators has been keeping it patient-centered. It has been noted that residents and medical students often struggle with a format where the primary focus is the patient and is question driven and where the emphasis is in large part on process and skill acquisition rather than finding ‘the right answer’. This takes them out of their cultural comfort zone of didactic and contentfocused education where not knowing is traditionally frowned upon. It requires that they become comfortable saying they do not know and embrace this as a positive phenomenon, which will over time, drive their desire to know and keep up to date in a world of medicine where the only constant is change’ (Armstrong, 2007). ‘To inculcate the traits required of a good physician, the mere mastery of theoretical concepts and clinical skills is not enough. The horizons of medical syllabi need to be expanded

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to incorporate the shift in healthcare paradigms. A flexibly structured and adaptive program that focuses on creating a strong balanced foundation rather than merely completing pre-set syllabi is of immense benefit to both the trainee physician and society in general’ (Chandra, 2013).

OUR PAST AND CURRENT EVOLVING SOLUTIONS TO THE PROBLEM In this section we shall share how we tried and are still trying to teach and learn about humans as persons with disease rather than just diseases and how there is still a large unexplored area left that needs to be covered to optimally integrate medical education with practice. With this chapter we hope to even stimulate more and more medical students to join us in our current endeavour.

How—Medical Humanities These skills can be inculcated by integrating disease related general knowledge with humanities particular knowledge of the individual patient’s life (Fig. 21.2) (archived by us in the super course lecture series hosted by university of Pittsburgh library) is an example of a typical exam question on chronic myeloid leukaemia (Biswas, 2008). We tried to resolve this disease dehumanization, decontextualization problem in medical education in our lecture based large group teaching sessions by placing them side by side with normal signs and symptoms as illustrated in Fig. 21.3 (archived

Fig. 21.2: Integrating humanities with disease-related general knowledge

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Fig. 21.3: An attempt to resolve disease dehumanization problem

by us in the super course lecture series hosted by university of Pittsburgh library), that begins the lecture on CML with the disease-based question paper and moves on to the patient as a person or humanities story (Biswas, 2008). More of these series of humanities driven lectures that we took at that time are archived in the webpage–https://sites.pitt.edu/~super1/faculty/lecturers. htm#Rakesh Biswas. We have further shared these lectures as chapters in our book on narrative medicine and we quote below from few of these to illustrate how we were able to utilize these patient-centered experiences as teaching tools. The haematology lectures were shared as a chapter titled, “Hematology: The river within”, where disease-related general knowledge were interspersed with the personal stories of the patients along with river poetry. The chapter tried to highlight the power of personal experience and its role in enhancing the engagement of the learner centred experiences as teaching tools. Not only are ‘patient as person’ stories transferring factual information, but they also highlight the limitations of textbook general knowledge. The “failure of the textbook” is common enough to warrant a discourse about the limitations of knowledge as much as a discourse about the impact of success and failure in medical care on the individual. We believe that this format of teaching promotes deeper insight in the learner and instils a sense of “always being humble” as a health professional.” A sample from the patient narrative in the chapter is quoted as: ‘I returned to work at the end of March 1993, part time, wearing a wig, on the day that my short-term disability insurance ended.’ ‘The song of the river ends not at her banks but in the hearts of those who have loved her...’ (Chaudhuri, 2011) The same patient in the above mentioned medical humanities lecture also worked with us later as an author and associate editor of our journal (accessible from https://

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www.igi-global.com/journal/international-journal-user-driven-healthcare/41022) and even addressed our work in a global TEDx conference along with our students (accessible from https://www.youtube.com/watch?v=76AVUQOK9LM). She subsequently wrote an integrative medical humanities article with some of our students who had by then become US based faculty of hemato-oncology and informatics. Before we move on to describe how we have currently built on a slowly growing working model of medical humanities education using windows of opportunity offered even in the current formative assessment curriculum, we shall take a quick look at how it all began since one of us started our teaching career a few decades ago. A solution to the above problem statements, we recognized was “user driven healthcare” that is a spontaneously evolving “medical humanities” learning ecosystem to answer multidimensional information needs of individual patients and clinicians through concerted collaborative learning between multiple online users and stakeholders, primarily patients, health professionals and other actors in a care giving collaborative network across a web interface.’ We postulated that, “User-driven healthcare (UDHC), using medical humanities narrative tools can integrate the experiences of illness, the disease management and the social context in ways that are supportive to every learning stakeholder. It can create a venue to share the many narratives of a particular individual’s disease and illness. For each and every individual patient that suffers, it is possible to electronically document her/his clinical encounter with the entire social network that supports her/his healthcare. This persistent documentation in individual personal case reports made accessible after deidentification to all stakeholders (that include innumerable patients and caregivers) would serve as a valuable learning resource that may enable improved decision-making utilizing meaning derived from multiple dimensions of the clinical encounter (Biswas, 2008). Utilizing the UDHC approach, medical humanities in effect became our “discovery tool’ of new knowledge arising from different types of experiences ranging from the implicit knowledge in narratives through to the explicit knowledge that is formalized in the published peer reviewed literature and translated into clinical knowledge (Martin and Biswas, 2013). We began the medical humanities UDHC movement, grounded organically from 2008 and kept publishing our results from time to time. The backbone of the system is formed by the ‘virtual volunteer physician’ network who cater to the cases, consisting of experienced physicians along with medical students. The system links them to patients in the vast underrepresented rural areas through data inclusive of the patients’ narrative of their problems, workups by local practitioners and relevant investigation reports sent directly by patients or with the help of local social workers. While, one arm of the network focuses on improved patient care to the underserved rural population of India, the impact on medical students is an equal if not greater function of the UDHC system. The students enjoy a ringside view of the entire process of decision making in healthcare complete with its good and bad outcomes that raise in them the necessary emotions and empathy that promotes

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an integrative approach to learning through appreciative inquiry, rather than the prevalent textbook memorization approach (Bera, 2013). The idea of sharing and learning around patients has been alive since the beginning of medicine when physicians would present their cases to a large audience to primarily learn from the inputs of other physicians (Price, 2013). From this interchange many published their cases naming themselves after the disease problems they solved. In this way, case reporting became a gainful activity not only in terms of scientific advancement toward patient benefits but also as an important instrument of physician fame. Figure 21.4 (downloaded from our previous publication accessible from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4587042/) shows how UDHC has adapted this tradition in the UDHC blended learning model. Beginning in 2012, The British Medical Journal (BMJ) have initiated a patientcentered learning model also known as a global-health case-reports elective for medical students around the world (accessible from https://casereports.bmj.com/ pages/bmj-case-reports-student-electives/). This initiative is offered in collaboration with the institution where the first author serves as a faculty and the elective program has followed him over three institutions from 2012 to 2022 and has been attended by students from France, US, UK, India, China, Nepal, and Bangladesh many of whom have published case reports with a strong medical humanities content where they have exemplified our medical humanities vision of global learning toward local caring (Shah, 2016; Webb, 2018; Podder, 2019; Samitinjay, 2020). From 2015, our medical humanities driven UDHC network gradually began developing a model of person-centered health research through a ‘citizen science

Fig. 21.4: User-driven healthcare blended learning

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model’ where the public can become informed and responsible shared decisionmakers who help prioritize, initiate, design, organize and participate in health research. UDHC was also promoting a clinical research foundation that would target needs of the local population through observation and engagement of interested citizens in a collaborative learning atmosphere. We have begun to train ‘patients, their primary caregivers, and all interested citizens’ in the essential elements necessary to understand medicine beginning with anatomy to explain their diagnosis with examples and by introducing them to medical students and other patients who can take the time to explain options for their medical future. This “Medical humanities” research around individual humans is very different from the current dominant paradigm of ‘population-based research’ because we treat each and every patient as a research project; a perspective which would not be achieved through the traditional population-based lens. This research does not focus on scaling or generalization for population statistical outcomes, but is content to benefit one individual at a time (as long as it is done with the support of current best evidence and ethics). The returns for the physicians and researchers in this program are in terms of learning and in being able to find the resources to meet their patient’s needs. Although their learning points are gathered and shared as ‘case reports’ publications; the emotional satisfaction one derives in meeting the needs in an impossible situation is difficult to share in words” (Purkayastha et al, 2015). Our healthcare learning ecosystem is currently based offline in the Kamineni Institute of Medical Sciences, and this offline base keeps shifting with the various university locations in India, where lead author is based for a variable period of years. The online component of this blended learning ecosystem began on email groups, and then shifted to social media groups such as “Tabula Rasa”. It currently exists in WhatsApp groups with a global audience of medical students and physicians. Over the last decade, we have adopted an evidence-based, medical humanities approach that enables utilizing the best available evidence toward optimizing care for individual patients. Our individual patient requirements have led us to adopt a blended learning platform to enable an informational support for our patients. It also helps medical students to have a platform to help patients locally while learning from global experts in an online ecosystem and we recognize this as a subset of UDHC due to the strong offline component and hence call it a “Case based blended learning ecosystem—CBBLE” (Podder, 2018). This also allows opportunities for formative assessment of humanities competencies.

WORKING PROTOTYPE OF HEALTH HUMANITIES INTEGRATION TO THE MEDICAL FORMATIVE ASSESSMENT CURRICULUM We have tried to built-in an ecosystem by connecting community patient healthcare requirements to student learning outcomes toward peer review assessment. There are two pivotal interconnected nodes that are at the centre of this learning and caring ecosystem—the patient at home in the community connected to teaching hospital, through a chain of health professionals starting with medical students at home in

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their community as well as their teaching hospitals and their faculty coordinator. We are exemplifying the same here through a real life encounter. Illustration from recent real time student–teacher–patient learning workflow A patient in touch with a community connected hospital in Narketpally, Telangana (2000 km from her place of residence in Bengal), gets in touch with the telehealth physician and coordinator of the hospital at Narketpally through a WhatsApp text query, seeking help for her son and this patient is referred for a detailed narrative timeline to a medical student currently locked down at a distance of 1000 km from the same patient. The conversation between parents and faculty coordinator is presented in Box 21.2. BOX 21.2: CBBLE: Example of a conversation between healthcare team and patient The telehealth physician faculty coordinator receives a text message from one of his longdistance patients who had even made a 2000 km journey in the past to be evaluated for her spondyloarthropathy symptoms and this time she needed consultation for her son and below are the deidentified verbatim text messages in Hindi (to provide a feel of the real manner in which this actually evolved): [5/13, 6:00 pm] Patient Spondyloarthropathy, 30 years old female: Hum ... (location) se [5/13, 6:00 pm] Pt Spondyloarthropathy, 30 years old female: Mera bacha 8 saal ka hai [5/13, 6:01 pm] Pt Spondyloarthrpathy, 30 years old female: Sir wo bar bar toilet karta hai [5/13, 6:03 pm] Pt Spondyloarthrpathy, 30 years old female: Test Karwaya koi infaction nhi hai [5/13, 6:04 pm] Pt Spondyloarthrpathy, 30 years old female: Sir kya problem ho sakta hai [5/13, 6:05 pm] Pt Spondyloarthrpathy, 30 years old female: Par isko constipation ka problem hai The faculty coordinator replied one hour later: Humare student doctor aapko phone karenge detail mein jaan ne ke liye.

The medical student proceeds to gather the history from the patient and prepares a brief case report with the patient requirements and shares it with the global case based blended learning ecosystem CBBLE network from which the patient requirements are further shared in various other global forums by other interested health professionals, both for learning more about the problem presented as well as helping the patient (Box 21.3). This patient data was further utilized in a monthly summative assessment module for the same batch of students to test their competencies in patient care related to clinical problem solving through empathic patient data capture and continuity of communication. The monthly summative assessment module was part of a question paper of the month for the entire batch of 2017 (accessible from: https://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthlyassignment.html?m=1). Student SM’s answer is available online around the patient question in Q5B (accessible from: https://drsaranyaroshni.blogspot.com/2021/05/assignmentpatient-centred-learning.html?m=) where they are derived from standard theory of

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BOX 21.3: Subsequent action taken by the medical student The faculty coordinator immediately posts this requirement below onto the global CBBLE WhatsApp group (a global group of medical students and faculty health professionals with 200 members): [5/13, 7:21 pm] FC: Anyone here who would like to take a telephonic history from the mother of an 8-year-old child with frequent urination and then share the deidentified details here for analysis? [5/13, 7:22 pm] FC: Mother's language is Hindi. Within minutes there were a few interested medical students texting the faculty coordinator and he chose the earliest person and within one and a half hours that student had telephoned the mother and made a summary of the patient's problem representation which was again circulated by the FC into the global CBBLE as well as other health professionals groups, and the subsequent inputs into the patient problem have all been captured by the same student SM in her e-logbook. The same student SM was instrumental in arranging a tele-counselling with one of the psychiatry department faculty members from her Medical College in Narketpally from 2000 km away and the patients’ health outcomes currently appear to be evolving to everyone's satisfaction.

clinical problem solving but very interestingly she makes a mention of the child’s problem again in Q10 which is about sharing her learning experiences of the month, where she presents artwork collected from the patient and also goes on to describe many more patients where she was a part of the data capture process for our CBBLE. Although the question paper for the month of May 2021 which she answered above was not meant to test empathy competencies (unlike that of April 2021 accessible here: http://medicinedepartment.blogspot.com/2021/04/medicine-paper-forapril-2021-bimonthly.html?m=1) yet she also managed to display her empathy competencies in her answer to Q10. Gradual integration of traditional with competency driven curricula in a ‘Medical Humanities’ patient-centered learning framework The definition of competency for a health professional is: “habitual, consistent and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflections in daily practice for the benefit of the individual being served” (Epstein and Hundert, 2002). We would like to bring our attention to the last part of this excellent definition, “benefit of the individual being served,” which reminds us again of the fact that the patient is the primary beneficiary of medical education. The solution to the problem is to think of online formative assessments as a process of active learning by the medical student that puts the patient at the center of his learning portfolio. For example, if someone is to learn thyroid pathology and is to be assessed for it, then the learner needs to share what active patient-centered efforts she has undertaken in that process. Generally, the process begins in understanding the life events of that real human being with the thyroid pathology and then capturing the palpable and investigational data acquired from that person’s body with that pathology (Podder, 2018).

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CONCLUSION This chapter shared the personal teaching and learning journeys of the authors that is a humble attempt toward utilizing “Medical humanities” as a tool to integrate medical education and practice. Medical humanities tools of “narrative medicine” when merged with tools of information communication technology can get multiple online users to drive patient healthcare outcomes as well as health professionals learning outcomes. This rapidly growing phenomenon has been previously described as user-driven healthcare and both these tools are likely to further evolve and refine toward better healthcare education and healing outcomes.

BIBLIOGRAPHY • Armstrong EC. Morning POEMs (Patient Oriented Evidence that Matters): Teaching point-of-care, patient focused evidence-based medicine. Accessed on 16.08.2007. Available at: http://www.fammed.washington.edu/ebp/media/stfm-9-03-morningpoems.doc.

• Bera K, Seth B, Biswas R. Conversational learning among medical students: harnessing the power of web 2.0 through user driven healthcare. Ann Neurosci 2013;20(2):37–38.

• Biswas R, Dhakal B, Dhakal G, Das R, Nagra J. Medical student narratives for understanding disease and social order in the third world. Eubios Jl Asian Intl Bioethics 2003;13(4):139–42.

• Biswas R, Martin C, Sturmberg J, Shankar R, Umakanth S, Shanker, Kasthuri AS. User

driven healthcare–Answering multidimensional information needs in individual patients utilizing post EBM approaches: A conceptual model. Journal of Evaluation in Clinical Practice 2008;14:742–49.

• Biswas R, Umakanth S, Shetty M, Hande M, Nagra JS. Problem based self-directed life-

long participatory learning in medical educators and their audience: Reflective lessons learnt from a lecture series. Journal of Education Research 2009;3(4):294–310.

• Biswas R, Umakanth S, Strumberg J, Martin CM, Hande M, Nagra JS. The process of evidence-based medicine and the search for meaning. J Eval Clin Pract 2007;13(4):529–32.

• Biswas R. Chronic Myeloid Leukemia Lecture; 2008. Accessed on 01.02.2022. Available from: https://sites.pitt.edu/~super1/lecture/lec35161/001.htm.

• Biswas R. The birth of poverty. British Medical Journal (UK), 2002; 325:51. • Biswas, R. Always a medical student. BMJ 2003;326:030241. Accessed on 29.09.2022. Available from: https://www.bmj.com/content/326/Suppl_S2/030241.

• Chandra S, Price A, Biswas T, Bera K, Biswas R. User Driven Learning: Blending the

Best of Clinical Medicine and Humanities to Infuse ‘Joy’ into the Medical Curriculum. International Journal of User-driven Healthcare (IJUDH) 2013;3(3):122–27.

• Chandra S, Price A, Biswas T, Bera K, Biswas R. User Driven Learning: Blending the Best of Clinical Medicine and Humanities to Infuse “Joy” into the Medical Curriculum. Int Journal of User-driven Healthcare 2013;3(3):116–21.

• Chaudhuri A, Young J, Martin CM, Sturmberg JP, Biswas R. Hematology: The River

Within. In: Biswas R, Martin C (Eds.). User-driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies. Hershey, PA, USA: Medical Information Science, 2011;pp. 16–33.

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• Epstein RM, Hundert EM, Defining and assessing professional competence. JAMA 2002;

287(2):226–235. • Martin CM, Biswas R, Joshi A, Sturmberg JP. Patient Journey Record Systems (PaJR): The Development of a Conceptual Framework for a Patient Journey System. In: Biswas R, Martin C (Eds.). User-Driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies. Hershey, PA, USA: Medical Information Science, 2011;pp. 75–92. • Podder V, Dhakal B, Shaik GUS, Sundar K, Sivapuram MS, Chattu VK, et al. Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment. Healthcare 2018; 6:78. • Podder V, Price A, Sivapuram MS, Biswas R. Middle-aged man who could not afford an angioplasty. BMJ Case Rep. 2019;12(3):e227118. Accessed on 29.09.2022. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453268/pdf/bcr-2018-227118.pdf. • Podder V. A patient becomes a medical student; 2018. Accessed on 31.01.2022. Available from: https://www.kevinmd.com/blog/2018/03/patient-becomes-medical-student. html • Price A, Biswas T, Biswas R. Person-centered healthcare in the information age: Experiences from a user driven healthcare network. Eur Journal of Pers Centered Healthcare 2013;1(2):385–93. • Purkayastha S, Price A, Biswas R, Jai Ganesh AU, Otero P. From Dyadic Ties to Information Infra­struc­tures: Care-Coordination between Patients, Providers, Students and Researchers: Contribution of the Health Informatics Education Working Group. Yearbook of Medical Informatics 2015;10(1):68–74. • Samitinjay A, Karri SR, Khairkar P, Biswas R. Traumatic subdural haematoma: integrating case-based clinical judgement with guidelines. BMJ Case Rep 2020;13(9):e233197. Accessed on 29.09.2022. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7476468/pdf/bcr-2019-233197.pdf. • Samitinjay A. IoB–Internet of Behaviors and Emotional Connections; 2021. Accessed on 01.02.2022. Available from: https://adityasamitinjay.blogspot.com/2022/01/iobinternet-of-behaviors-and-emotional.html • Sarbadhikari SN, Priyadarshini B, Kutikuppala LVS, Jodavula S, Mukherjee S, Krishna V, et al. Scholarship of Integration and the future of Medical Education and Research (MER) In: Adkoli BV and Ray A (Eds). Medical Education Research: Theory, Practice, Publication and Scholarship. Notion Press: Chennai, India, 2021;pp. 353–68. • Shah BS, Yarbrough C, Price A, Biswas R. An unfortunate injection. BMJ Case Rep. 2016. Accessed on 29.09.2022. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4785487/pdf/bcr-2015-211127.pdf. • Webb E, Vanan NK, Biswas R. Empirical treatment of tuberculosis: TB or not TB? BMJ Case Rep. 2018. Accessed on 29.09.2022. Available from: https://www.ncbi.nlm.nih. gov/pmc/articles/PMC6047727/pdf/bcr-2018-224166.pdf.

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Implementation and Assessment 22. Medical Humanities and CBME Curriculum: Opportunities and Challenges 23. An Outline of Structured Curriculum of Medical Humanities in Indian Context 24. Assessment in Medical Humanities

22 Medical Humanities and CBME Curriculum: Opportunities and Challenges Shaista Saiyad Key Points q Introduction of medical humanities in undergraduate medical curriculum will help in laying foundation for learning of hidden curriculum especially soft skills. q

q

Introduction of competency based curriculum and AETCOM will provide immense opportunities to foster humanities competencies in Indian Medical Graduates. Challenges are multifaceted, right from convincing the stakeholders to lack of adequate manpower.

INTRODUCTION Our traditional medical curriculum was totally scientific and evidence based (Cate J et al, 2000). However, it has been realized that medicine, in addition to science, is an art too. We require ‘humane’ doctors, who can combine evidence-based scientific knowledge with kindness, compassion and understanding on patients, as patients are after all humans. The problems related to real patients are not only related to mere scientific fact, but also often related to social, cultural, religious and spiritual factors. Time has come to address these factors too, for a competent Indian Medical Graduate. Introduction of humanities in undergraduate medical curriculum, promises to lay foundation for teaching these neglected areas of curriculum (Shapiro et al, 2004; Lancaster et al, 2002). Humanism is considered to be one of the strongest pillars of professionalism. Medical humanities is the application of the techniques of teaching soft skills related to humanities to medical practice. Medical humanities has been defined by Evans as an integrated, interdisciplinary, philosophical method to making students learn and interpret human experiences of illness, disability and medical intervention.

COMPETENCY BASED MEDICAL EDUCATION (CBME) CURRICULUM IN CONTEXT TO MEDICAL HUMANITIES Competency based medical education (CBME) curriculum has been proposed by experts because there was realization that healthcare professionals could not effectively manage health problems of patients and community as they had gaps in key competencies related to soft skills like medical 217

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humanities. Competency based medical education is an outcome-based approach to design the implementation, assessment and evaluation of a medical education program using a defined frame work of competencies (Frank JR et al, 2010). Here the ultimate output is fixed as acquisition of certain defined competencies covering the aspects of knowledge, attitude, skill as well as social values including humanities. CBME is such an effective strategy where all the domains are given equal impor­ tance right from planning and through implementation, assessment and evaluation. Main goal is ‘good basic physicians’ who can confidently handle common health problems efficiently in a holistic and humane manner. It is an approach to preparing future doctors for practice that is organized around outcomes or competencies derived from societal, patient and needs of all healthcare stakeholders needs. Inclusion of medical humanities (MH) in CBME is about coming out of all the enclosures of all the earlier defined curriculum types. Very vital component of CBME is inclusion of ‘attitudinal’ domain which deals with attributes of humanities like empathy, communication, compassion, ethics, moral values, etc. Inclusion of these soft skills will ensure holistic and humane patient care.

INTEGRATION OF MEDICAL HUMANITIES IN CBME CURRICULUM Since there were lacunae in traditional medical curriculum, in terms of lack of attributes of humanities, ‘humanization’ of undergraduate medical education was need of the hour. Communicating effectively and empathetically with patients and their relatives has been visualized as a core area of the revised curriculum. Integration of medical humanities in CBME can provide much needed cultural competency to doctors. Cultural competency is the ability of doctors to demonstrate clinical competence towards patients with diverse values, beliefs and feelings. It can provide pivotal role in helping share of future doctors as compassionate doctors and reflective human beings.

Opportunities The main goal of undergraduate medical education programme as suggested in the latest Regulations on Graduate Medical Education (MCI, 2019) is to create an “Indian Medical Graduate”(IMG) having required knowledge, skills, attitudes, values and responsiveness, so that he or she may function appropriately and effectively as a physician of first contact of the community while being globally relevant. The new curriculum is more learner centric, patient centric and has new components like cultural competency and disability competency, making it wholesome curriculum. The result is a competency based curriculum which conforms to global trends. To bridge the big competency gap between doctors and patients, MCI has rolled out competency based medical curriculum as well as ‘attitude, ethics and communication’ (AETCOM) module (MCI, 2018), aimed at integration of all three domains for competent IMGs. According to AETCOM module, students would be able to learn about humanities through art, music, literature and cinema. This

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would help students understand the broader socioeconomic framework and cultural context within which healthcare is delivered. Suggested themes include: The history and culture of diseases; the history of modern medicine in the Western world and in India; the political economy of medicine in India; representing the doctor—a study of selected fiction, artworks and films; questions of gender, caste, minority, sexuality; patient issues; death and dying in India; the art of practice; sociology; family structure; socioeconomic aspects, poverty; health seeking behaviour; and health beliefs. Main aim of including humanities in medical curriculum is to bridge the gap between doctors and patients. It is supposed to be longitudinal modular program, spanning across whole of undergraduate medical studies with a goal to integrate ‘art’ and ‘science’ of medicine. Competencies are not achieved overnight; but gradually over a period of time as learner progress along a development path (Fig. 22.1). When students enter undergraduate medical studies, they are in stage 1: Unconscious incompetence. Students are incompetent and they are not aware that they are incompetent. As the medical studies progress, students enter stag 2: Conscious incompetence. Students gradually start becoming aware that they are incompetent. If appropriate teaching–learning and assessment methods are used, then comes stage 3: Conscious competence. Students become competent, but they are consciously competent. Last stage is stage 4: Unconscious competence. Students become highly competent without any effort. Automaticity is the key word in stage 4. Highest opportunities of making students learn MH lies in stage 2 and stage 3. Appropriate molding of students occurs in stage 2 and stage 3. If medical humanities and other soft skills are introduced in these stages, students can internalize various attributes of attitudinal domain, including medical humanities. Stage 4 is the actual behavioral changes that occur in students due to development of appropriate beliefs, attitudes, awareness of thoughts and reactions to patients and situations leading to complete automaticity.

Fig. 22.1: Conscious competence learning matrix

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Standardizing undergraduate medical education through integration of MH into curricula has potential of addressing health needs of society. USA, United Kingdom and Australia have adopted medical humanities in their medical curriculum. Many workshops, ‘Theatre of the Oppressed’ have been organized periodically by The Medical Humanities Group at University College of Medical Sciences, Delhi for exploring various aspects of medical humanities (Gupta et al, 2013). Introduction of MH modules in many foreign universities has shown beneficial effects on improvement of knowledge, skills and attitudes among medical students (Spike JP, 2003; Macnaughten J, 2000). Gurtoo et al, (2013) in their study have also concluded that acceptability and feasibility of MH curriculum was encouraging in terms of leaning. Medical students in preclinical years are highly motivated, receptive and these attributes of students can be exploited to mould them to learn various attributes of humanities. Awareness, knowledge and attitude of undergraduate students can be improved by implementation of MH curriculum early in curriculum (Saiyad M et al, 2019). Looking at the success of introduction of medical humanities curriculum at various institutions, there appears to be great opportunity in implementing medical humanities in CBME curriculum in India. According to a study by Petrou L, it was recommended by students that humanities should be preferably introduced in first year most and final year least (Petrou L et al, 2021). MH can also be offered as elective for interested students during their undergraduate medical study. NMC has rolled out electives’ module (MCI, 2020) for undergraduate medical students in India. This can be an excellent opportunity for offering electives related to MH to undergraduate students.

Challenges It has been documented that there is a three-decade lag period between acceptance and actual implementation of CBME. Medical humanities has largely remained as a part of ‘hidden curriculum’. Students are supposed to learn this vital domain by themselves as there is no formal training on this aspect. Hence, students try to ‘catch’ it via role models or by trial and error. Due to these limitations of current or traditional medical curriculum, introduction of medical humanities will be a great challenge for all the stakeholders. Application of MH to medical education and practice is complex and requires formal training, diligence and discussion. Training of such huge number of faculty is a challenge in itself. It will take a long time to effect a transition from the present to a completely competency based curriculum which includes MH, because the very concept is so new and so different that it will require a lot of understanding to even motivate support. There is a requirement to train the entire faculty in these concepts so as to motivate them to accept after critically reflecting. Resistance to change and resistance to faculty development will be big challenge. There is always a tendency of faculty of slipping back to ‘teach as we were taught’, and so there is need for longitudinal programs for faculty development.

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Students must have a willingness to join the change in thoughtful discussion, should accept the personal responsibility for learning, be ready for frequent assessments. MH modules should be prepared taking care of validity, reliability, appropriateness as well as feasibility. If prepared and applied inappropriately, it can lead to demotivation of students as well as faculty and can cause reduction in educational content. All modules should be validated for robustness. Module development will be time consuming and shall need expertise and very sound knowledge about the subject. Bringing uniformity across the nation will be a mammoth task and also the most essential to keep entire nation together, otherwise all efforts will go waste and medical services will suffer. Deciding what needs to be changed and all that which needs to be retained would be another challenge. The sole purpose is to improve the defects in system rather than changing it altogether. Other challenges likely to be faced while implementing these modules would be convincing the stakeholders, capacity building, consensus building, motivating students into becoming self directed learners and formulating and using appropriate assessment methods. One of the biggest challenges would be lack of trained faculty, planning of logistics and administrative support. To ensure a reasonable pace of implementation would be another challenge. Stepwise approach should be used for implementation, so that the problems can be modified early in the course of implementation. Too swift a pace can hamper the process. A very sound planning is needed. Teaching–learning methods serve as vehicles for achieving outcomes. For MH, selecting appropriate teaching–learning methods would be another challenge as neither the faculty nor the students have been exposed to newer methods of learning MH. Also, teaching–learning methods should be aligned with outcomes, objectives and assessment. As we already know, assessment drives curriculum, so the assessment tools used for assessment of MH should be valid, reliable, feasible and having high educational impact. Vital aspect of assessment of MH would be benchmarking of specific competencies and modalities for assessment of attainment of development milestones. Several institutions which have been using teacher-centered approaches will have challenges of introducing innovative, learner-centered approaches. The challenge of developing relevant tools for monitoring and evaluating the implementation of MH as well as assessment tools for the learner competencies would be a challenge. Challenges are multifaceted, right from convincing the stakeholders like faculties, administrators, students, the policy makers to lack of adequate manpower. Shankar PR has described various enabling and inhibitory factors for implementation of MH curriculum (Shankar PR, 2020). • Travellators (enabling factors) for implementation of MH curriculum are trained faculty, favorable educational environment towards MH, good and efficient Information technology structure and diverse, talented student body. • Speed breakers (inhibiting factors) are large number of students, traditional architecture of colleges, lack of separate department of Medical Education and language barriers in MH implementation (Table 22.1).

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TABLE 22.1: Challenges in implementation of MH curriculum and their possible solutions Challenges

Possible solutions

Training of large number NMC has already initiated Faculty Development Programs for sensitization of faculty members and implementation of MH curriculum as a part of new CBME curriculum. Also, faculty should be encouraged to undergo various workshops, CMEs, conferences specially designed for training in MH Students’ readiness

Students would need sensitization and awareness regarding MH curriculum before its implementation. There are plenty of opportunities for self-directed learning in new curriculum, which students will readily welcome for learning MH. New age students are multitalented. Involvement of drama, music, literature, photography, movies in MH curriculum would give them wide scope of self-directed learning

Pace of implementation

Phasewise longitudinal implementation of MH curriculum has been suggested for adequate exposure of students to all elements of MH

Lack of adequate faculty

Common pool of interested faculty can be created as MH does not fit into a single discipline. Also, guest faculty from other disciplines like psychology, arts, etc. can be included

Language problems

Since MH involves artistic approaches, local languages should also be included specially for dramas, literature, role plays, etc.

Integration of disciplines

According to a study, students preferred integrated approach for studying MH, some opting for vertical learning throughout (Petrou L et al, 2021). Interdiscipline integration—MH is new in our medical colleges but ‘Humanities’ as such has been part of nonmedical curriculum since long. Inviting expert faculty form psychology, arts can be of immense help, in addition to medical faculty (Shankar PR, 2020). Such interdisciplinary integration will be beneficial for medical faculty as well as student.

Sustenance of new curri­culum after implementation

For implementation and evaluation of new CBME as well as MH curriculum there should be a separate department of Medical Education, dedicated exclusively for quality assurance and maintenance

PLANNING FOR IMPLEMENTATION Inclusion and implementation of MH competencies and curriculum within the framework of CBME curriculum will require robust planning, as CBME curriculum implementation in India is in its infancy currently. Stakeholders, faculty and students are already skeptical about the ways and means of introducing and implementing CBME curriculum in their institutions. Identifying humanities competencies and then including them in phase-wise manner for longitudinal development within the framework of CBME curriculum will be a mammoth task. This mandates the utilization of feasible and result-oriented planning strategies. First planning strategies will be to address the challenges via Force Field Analysis (FFA) for proposed change thus helping in addressing the anticipated change (Fig. 22.2). According to FFA, forces facilitating inclusion of MH in context to CBME are more than forces against. Next in the line will be designing a stakeholder matrix at the institutional level to get bird’s eye view regarding implementation and evaluation of medical humanities in CBME (Fig. 22.3). According to stakeholder matrix, appropriate steps can be taken to facilitate inclusion of MH in curriculum. According to new proposed curriculum, key

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Fig. 22.2: Force field analysis for inclusion and implementation of MH competencies within CBME framework

Fig. 22.3: Stakeholder matrix for inclusion and implementation of MH competencies within CBME framework

players are supportive, which is the biggest advantage for implementation of MH curriculum. Having conducted a FFA and designed a stakeholders matrix as per institutional set-up, the next step will be to design and make operational the strategies on-field for overcoming the challenges being faced for smooth implementation. Faculty development as identified is the foremost strategy for addressing most of the challenges. All the stakeholders shall have to be engaged in order to ensure a smooth implementation of MH in CBME in the future. It will require continuous training and

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fulfilling updating needs of all the stakeholders so as to solicit support, innovation and active contribution. The new program should be evaluated meticulously and continuation or complete implementation of the program will depend on the actual outcome of this evaluation. There are many more challenges which might surface up during the implementation phase. Meticulous planning, regional task forces, strong support from the council and political will can ease the implementation challenges. Every college should have a MH cell with interested, trained and motivated faculty as designated members as well as external experts. There could be sessions throughout the year at regular intervals by faculty well versed in humanities via structured modules. If internal faculties are not enough, external faculty can be invited initially till internal expertise is available.

CONCLUSION Introduction of CBME curriculum in India has provided immense opportunity to include and introduce humanities competencies within the framework of CBME curriculum. Inclusion and integration of medical humanities in competency based medical education curriculum would help our medical system to churn out holistic and humane doctors proficient in ‘art of doctoring’. However, meticulous planning is required for identification of these competencies, designing curriculum, planning for teaching methods and finalization of assessment strategies.

BIBLIOGRAPHY • Carr, SE, Noya, F, Phillips, B, et al. Health Humanities curriculum and evaluation in

health professions education: a scoping review. BMC Med Educ 2021;21:568. • Cate, TJT, De Haes, JCJ M. Summative assessment of medical students in the affective domain. Medical Teacher 2000;22(1):40–43. • Frank, JR, Mungroo, R, Ahmad, Y, Wang. M, De Rossi, S, Horsley, T. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Medical Teacher 2010;32(8):631–637. • Gupta, S, Agrawal, A, Singh, S, Singh, N. Theatre of the Oppressed in medical humanities education: the road less travelled. Indian Journal of Medical Ethics 2013;10(3):200–203. • Gurtoo, A, Ranjan, P, Sud, Ritika, Kumari, A. A study of acceptability and feasibility of integrating humanities based study modules in undergraduate curriculum. Indian Journal of Medical Research 2013;137(1):197–202. • Lancaster, T, Hart, R, Gardner, S. Literature and medicine: evaluating a special study module using the nominal group technique. Medical Education 2002;36(11):71–76. • Macnaughton, J. The humanities in medical education: context, outcomes and structures. Medical Humanities 2000;26(1):23–30. • Medical Council of India (2018). Attitude, Ethics and Communication (AETCOM) Competencies for the Indian Medical Graduate. Accessed on 29.09.2022. Available from: https://www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf. • Medical Council of India (2019). The regulations on graduate medical education, 1997 – Part II. Accessed on 29.09.2022. Available from: https://www.nmc.org.in/

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ActivitiWebClient/open/getDocument?path=/Documents/Public/Portal/Gazette/ GME-06.11.2019.pdf. • Medical Council of India. (2020). Module on electives for the undergraduate medical education program. Accessed on 29.09.2022. Available from: https://www.nmc.org.in/ wp-content/uploads/2020/08/Electives-Module-20-05-2020.pdf. • Petrou, L, Mittelman, E, Osibona, O, et al. The role of humanities in the medical curriculum: medical students’ perspectives. BMC Med Educ 2021;21:179. • Saiyad SM, Paralikar SJ, Verma AP. Introduction of Medical Humanities in MBBS 1st Year. Int J Appl Basic Med Res 2017 Dec; 7(Suppl 1):S23–26. • Shankar PR. Medical humanities in Medical Colleges in India: Travellators and speed breakers. Arch Med Health Sci 2020;8:112–19. • Shapiro, J, Morrison, E, Boker, J. Teaching empathy to first year medical students: evaluation of an elective literature and medicine course. Educ Health 2004;17(1):73–84. • Spike, JP. Developing a medical humanities concentration in the medical curriculum at the University of Rochester School of Medicine and Dentistry, Rochester, New York, USA. Academic Medicine 2003;78(10):983–86.

23 An Outline of Structured Curriculum of Medical Humanities in Indian Context Rajiv Mahajan, Tejinder Singh Key Points q Though students caught humanities competencies from role models, that leaves much to chance. q

Medical humanities competencies must be taught to the students during undergraduate training.

q

Opportunities must be created to apply these concepts and principles during internship period.

q

A comprehensive, institutional curriculum must be designed for the purpose.

INTRODUCTION As stated in previous chapters in this book and as stressed in next chapter, medical humanities is not a single entity. It is a construct formed with amalgamation of many roles and generic competencies, viz. professionalism, interpersonal skills, ethics, communication skills, altruism, empathy, along with knowledge of social factors involved in patient care. Most of these competencies per se are related to attitudes and behavior of a person and in medical professionals they are ‘caught’ by observing the role models during training, as part of hidden curriculum. But with changing paradigm, the call for teaching these humanistic qualities is growing louder, as learning from hidden curriculum leaves much to chance (Mahajan et al, 2016). The need and ways of designing and implementing such a curriculum has been well established in earlier chapters in this book. A longitudinal curriculum for attitudes, ethics and communication skills in the form of AETCOM module for medical undergraduates in India has been implemented by Medical Council of India (MCI, 2018). MCI has also allotted time period for teaching professionalism and ethics to medical undergraduates during foundation course. Foundation course competencies 4.1 to 4.15 relates to sensitization of professionalism, ethics, cultural competencies, time management, stress management and interpersonal relationship—in short many competencies related to humanities, and as such sensitization to the medical humanities itself. During foundation course, seven hours have been dedicated to understanding disability competencies—a very important aspect of medical humanities (MCI, 2019a). Before moving ahead, let us recapitulate briefly the related curriculum components mentioned in earlier chapters. 226

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Communication Skills Communicator is one of the five roles of Indian Medical Graduate (IMG). The key communication competencies expected from IMG include: building rapport with people; awareness of professional roles and responsibilities of a physician; history taking and clinical examination skills; counseling skills: explaining diagnosis and prognosis, breaking bad news, communicating news of terminal illness; ability to maintain proper documentation in healthcare. Further AETCOM module has four generic communication competencies and five modules for communication; spread longitudinally over undergraduate medical training (MCI, 2018). The module implemented effectively will lead to inculcation of attitude, ethics and communication competencies in IMG.

Professionalism Medical professionalism is ‘a (normative) belief system about how best to organize and deliver healthcare, which calls on group members to jointly declare (profess) what the public and individual patients can expect regarding shared competency standards and ethical values and to implement trustworthy means to ensure that all medical professionals live up to these promises’ (Wynia, 2014). Altruism, accountability, duty, excellence, honor, integrity and respect for others are some of the important attributes of professionalism (O’Sullivan et al, 2012). MCI has identified ‘professionalism’ as one of the five roles of IMG. Ethics is also one of the core components of medical professionalism. AETCOM module will definitely help to reinforce professional values in IMG. Details of professionalism are in Chapter 7 and of altruism, empathy and attitudes in Chapter 8 of this book.

Medical Sociology Medical sociology is related to the study of social causes and consequences of health and illness (Cockerham and Scambler, 2010). It is important for medical graduates to understand the social perspective of health and disease. Medical sociology is an important curricular focus for IMG as it helps in identification of the critical role that the entire social and cultural spectrum, including customs, norms, social attitudes, beliefs, and cultural diversity plays in determining the health of individuals, groups and the larger society. Details of medical sociology are in Chapter 11 of this book.

DEDICATED MEDICAL HUMANITIES CURRICULUM Though curricular components of ‘medical humanities’ are found scattered in various modules; it is pertinent to collate all these piecemeal activities, refine them and develop them into specific medical humanities curriculum for our needs, for the needs of IMG. Assimilating these specific medical humanities competencies with the existing curriculum, making way for integration with various competencies highlighted in different modules will be next challenging job for smooth and effective implementation.

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Considering ‘medical humanities’ a construct, generic competencies, subcompetencies and their phase-wise acquisition has been detailed in this chapter.

Generic Medical Humanities Competencies The generic competencies as related to medical humanities have been described in Box 23.1. As evident from Box 23.1, healthcare professional must be competent to understand the role of other members of a healthcare team while providing healthcare and must give due consideration to social, cultural and psychological aspects of the disease as well as healthcare.

Identified Subcompetencies The competencies related to various components of medical humanities, viz. communica­tion skills, professionalism, and medical sociology has been documented in previous chapters in this book. Having identified generic competencies of medical humanities (Box 23.1); some of the essential subcompetencies, for undergraduate training program has been delineated in Table 23.1. As medical humanities curriculum must be a comprehensive, longitudinal curriculum, the subcompetencies have been identified to be acquired in a phase-wise manner over the entire period of medical undergraduate training. As evident from Table 23.1, efforts can be made to integrate the teaching–learning activities of many of the medical humanities subcompetencies with the AETCOM competencies, thus making time-issue an insignificant excuse for implementing the curriculum in medical undergraduate training. Though the subcompetencies have been identified phase-wise so as to have a longitudinal program; it can well be used to design an elective program under competency based undergraduate curriculum for medical training in India (MCI, 2019b). BOX 23.1: Generic medical humanities competencies • Apply core concepts and skills from humanities discipline, viz. literature, sociology, ethics, altruism in understanding patients’ problems. • Apply core humanities concept for improved patient care with a team-based approach, with due consideration to the role of each healthcare professional in the team. • Develop multicontextual approach to patient care, with consideration of psychology of patient, care providers and other family members in their social and cultural perspectives. • Develop skills to provide patient care with due consideration to cultural diversity and social norms.

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TABLE 23.1: Phase-wise subcompetencies for medical humanities and their possible integration with AETCOM competencies Phase

Subcompetency Subcompetencies number

Integration with AETCOM competencies*

Phase 1 (preclinical)

MH 1.1

AETCOM competency 32 —

MH 1.2

MH 1.3

Phase 2 (paraclinical)

Demonstrate ability to critically analyze the AETCOM role of professionalism, ethics and com­ competencies munication skills in patient care 3–7, 23, 27, 28, 30

MH 2.1

Demonstrate ability to critically analyze the role of medical sociology and cultural diversity in patient care Demonstrate ability to elicit history from patients in a respectful and nonjudgmental manner Demonstrate ability to understand the health needs of persons with varied abilities Demonstrate sensitivity to visualize disease and health in community setting’s perspec­ tives

AETCOM competency 19

Demonstrate ability to understand the psycho­logical needs of patients and relatives of chronic illness Demonstrate ability to respect patients’ privacy and confidentiality Demonstrate ability to understand and give due consideration to the personal preferences of the patient Demonstrate ability to use poetry, music, narra­tives, reflections to depict patients’ sufferings

—

Integrate and apply the principles of medical humanities in improving patient care out­ comes under supervision Demonstrate ability to balance the personal and professional life Demonstrate ability to break bad news to patients in a sensitive manner Demonstrate ability to handle patients’ and caregivers’ burn-out in patients with chronic diseases

—

MH 2.3 MH 2.4

MH 3.1

MH 3.2 MH 3.3

MH 3.4 Internship

AETCOM competency 1 (H)

MH 1.4

MH 2.2

Phase 3 (clinical)

Demonstrate ability to handle cadavers with respect and dignity deserved Demonstrate ability to critically analyze the importance of medical humanities in patient care Demonstrate ability to delineate the attributes of a good healthcare professional

MH 4.1

MH 4.2 MH 4.3 MH 4.4

*Pages 78–82 of AETCOM module (MCI, 2018)

—

AETCOM competency 10 —

AETCOM competencies 24, 25 AETCOM competency 52 AETCOM competency 40

AETCOM competency 41 AETCOM competency 35 —

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Teaching Tools and Methods Various teaching methods which can be used to inculcate these competencies have already been explained in previous chapters in this book. Briefly, teaching of medical humanities cannot be conducted by methods delivering knowledge components only, viz. didactic lectures, integrated lectures, seminars, etc. The acquisition of medical humanities competencies will need specific methods promoting experiential learning. The expected qualities, which the teaching methods used for teaching medical humanities must have, have been highlighted in Fig. 23.1. As evident from Fig. 23.1, no one teaching method is going to have all such qualities, so multiple teaching methods must be used for inculcating medical humanities competencies. The teaching methods usually used are—role plays, theatre, cinemeducation, case studies, case diaries, reflections, narratives, comics, artwork and cartoon, demonstrations in small group; besides interactive lectures for delivering knowledge components. The assessment methods for assessing these competencies have been detailed in next chapter.

Fig. 23.1: Expected and required qualities of teaching methods used for inculcating medical humanities

DEVELOPING INSTITUTIONAL CURRICULUM OF MEDICAL HUMANITIES Learning objectives for each phase-wise subcompetencies documented in Table 23.1 must be framed and aligned with teaching methods and assessment methods for developing an effective institutional curriculum for medical humanities. Curriculum can be easily implemented by integrating with delivery of AETCOM module and by making use of some of the time allotted for the same. MCI framework of designing learning objectives from competencies and aligning them with teaching methods and assessment methods can be used for framing institutional curriculum of medical humanities. An example with one subcompetency has been depicted in Table 23.2.

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TABLE 23.2: Institutional curriculum framework for medical humanities—exemplified Subcompetency Learning objectives number MH 1.1

Core/ noncore

Discuss the importance Core of cadavers in medical education Helps to dispose of Core tissues daily after work Covers the cadavers Core properly after work

Domain Proficiency Teaching Assessment of learning level method method C

K

A

SH

A

SH

Interactive lecture Small group teaching

MCQs Direct observation

C: Cognitive; A: Affective; K: Knows; SH: Shows how; MCQs: Multiple choice questions

Using same framework, an institutional curriculum can be designed. Efforts must be made to deliver as well as assess this curriculum as part of the regular teaching in the department and clinics.

CONCLUSION Medical humanities competencies should be inculcated during undergraduate training. The same can be fostered by making it a part of routine departmental and clinical teaching and integrating them with AETCOM competencies. The curricular concepts and principles of medical humanities can be delivered to students in the form of longitudinal program, covering internship period, when students actually are involved in patient care, though under supervision.

BIBLIOGRAPHY • Cockerham W, Scambler G. Medical sociology and sociological theory. In: Cockerham W (Ed.) The New Blackwell Companion to Medical Sociology. Oxford, UK: Wiley-Blackwell 2010; pp 1–26.

• Mahajan R, Aruldhas BW, Sharma M, Badyal DK, Singh T. Professionalism and Ethics: A

proposed curriculum for undergraduates. Int Journal of App Basic Med Res 2016;6:157–63.

• Medical Council of India (2018). Attitude, Ethics and Communication (AETCOM)

Competencies for the Indian Medical Graduate. Accessed on 17.12.2022. Available from: https://www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf.

• Medical Council of India (2019a). Foundation Course for the Undergraduate Medical Education Program. Accessed on 19.12.2022. Available from: https://www.nmc.org.in/ wp-content/uploads/2020/08/FOUNDATION-COURSE-MBBS-17.07.2019.pdf.

• Medical Council of India (2019b). The regulations on graduate medical education,

1997–Part II. Accessed on 18.12.2022. Available from: https://www.nmc.org.in/ ActivitiWebClient/open/getDocument?path=/Documents/Public/Portal/Gazette/ GME-06.11.2019.pdf.

• O’Sullivan H, Van Mook W, Fewtrell R, Wass V. Integrating professionalism into the curriculum: AMEE Guide No. 61. Medical Teacher 2012;34(2):64–77.

• Wynia MK, Papadakis MA, Sullivan WM, Hafferty FW. More than a list of values and desired behaviors: A foundational understanding of medical professionalism. Academic Medicine 2014;89:712–14.

24 Assessment in Medical Humanities Rajiv Mahajan Key Points q

Medical humanities can be assessed indirectly through assessment of its constituent components and major attributes only.

q

Assessment in medical humanities is a longitudinal, developmental process.

q

Formative assessment and feedback are the major components in assessment of medical humanities.

q

Direct observation and subjective assessment are core elements of assessment in medical humanities.

Assessment is said to drive learning. It directs and guides learning. It is often said— whatever is not assessed is not possessed. Field of medical humanities is no exception to the rule. Medical humanities is not a ‘single’ term in itself; rather it is amalgamation of medical sciences with philosophy, sociology, psychology, history, literature, theatre and arts, empathy, culture, and more importantly with ethics, communication, and professionalism in medical context. It is the unison of clinical skills with soft skills (Joshi et al, 2018). Traditionally, when we talk about integration, we are talking of integrating subjects. But we also need to integrate knowledge and skills with attitudes and communication in given context, and medical humanities is the perfect conceptualization of this integration. Medical humanities can safely be regarded as a construct in itself, with a goal to develop ‘humanistic physicians’. Unarguably, the wider scope of opportunities presented by medical humanities and a greater need for including these components in the competency based model; calls, not only for integrated and interactive methods to teach the finer concepts but also for adopting robust and comprehensive assessment methods.

WHY TO ASSESS? Most of the issues related to ‘unprofessional physician behavior’ are related to conduct and attitude of the physicians and not related to lack of clinical competence. Though many efforts have been undertaken to teach and assess clinical competencies, little progress has been made to teach humanities to the medical students and no such efforts are visible to assess such soft skills. 232

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Without adopting robust methods to assess medical humanities; teachers and students will have no benchmark to gauze for the learning that has happened. Moreover, in the absence of assessment, learning of medical humanities skills will be low on the priority list of the students. Additionally, in due course, assessment results will give feedback to the program evaluators too.

WHAT TO ASSESS? Medical humanities, a buzz word, though appears ‘simple and straightforward’ at the face value; is laborious to learn, is protracted to teach and is ambiguously stretched to assess. At this stage, one must keep in mind that medical humanities being an umbrella of soft skills cannot be assessed directly; but through assessment of its different spokes only; with a caution that one must avoid the temptation of an atomizing it so much that it becomes difficult to reassemble these spokes into a meaningful concept. As medical humanities is amalgamation of varied skills as said overleaf (Dhaliwal et al, 2019), assessment methods have to be adopted to assess—communication skills, professionalism, ethics, empathy, altruism, trustworthiness, honesty, cultural sensitivity, social awareness (Holmboe, 2016) (list is long but not exhaustive) and clinical competence of the physician should make the cornerstone of the assessment (Fig. 24.1).

Fig. 24.1: Important attributes of humanistic physicians which need to be assessed

As we do not have the luxury of having one tool which will assess all the components, a mix of various tools or assessment toolbox will provide better opportunities by complimenting and supplementing the tools (Singh and Modi, 2013). Since ‘humanistic physician’ is an outcome of interplay of all these attributes with overlapping relationships; it stands to reason that assessment would not be a mere sum-total of the assessment of these attributes. Rather, the relationship will

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run in multiplication and absence of one attribute is likely to render the assessment value of humanistic physician as ‘nil’ (Box 24.1). However, it is clarified that this is only a notional concept and the intention is not to arrive at some value. For example, a physician who is very good in communication skills but is indulged in unethical practices will still score zero on assessment scale for medical humanities. Similarly, an empathetic physician lacking attributes of professionalism will be rendered nil on humanistic scale. BOX 24.1: Assessment of medical humanities as interplay of various attributes HP = CC × ComS × P × E × Emp × H × Alt × T × CS × SA HP: Humanistic physician; CC: Clinical competence; ComS: Communication skills; P: Professionalism; E: Ethics; Emp: Empathy; H: Honesty; Alt: Altruism; T: Trustworthiness; CS: Cultural sensitivity; SA: Social awareness

WHEN TO ASSESS? The best way to assess medical humanities is to have a longitudinal observation, generously mixing the ongoing assessment with formative feedback. The key concept here is longitudinal observation by multiple assessors over multiple settings. Two important points are worth discussion here. 1. The skills are always context specific, meaning performing one skill satisfactorily does not mean that the other skill can also be performed satisfactorily (or assumed to be performed satisfactorily). Same applies to different attributes of humanities, which are separate clinical and soft skills in their own right. This literally means that each and every soft skill/attribute needs to be assessed. As this cannot be done during end-of-the-term summative assessment; the need to have continuous assessment or in-training assessment is reinforced. 2. Continuous assessment provides better opportunities to improve upon the learning by having continuous monitoring and feedback. Timely mid-course corrections can be applied, thereby promoting longitudinal development of the students in the field of medical humanities. But at the same time, if assessment of humanities will contribute nothing towards at-the-term-end summative assessment, then teaching–learning in the field will be ignored. As such, assessment of humanities must have both formative and summative components (Mahajan et al, 2016).

HOW TO ASSESS? Almost all of the attributes of medical humanities are either soft skills in their own right or are related to soft skills. Some points are worth pondering here. These soft learning skills do not allow themselves to be ‘objectively’ assessed, but has to be assessed with lot of ‘subjectivity’, and this feature can draw a lot of

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criticism from the torch-bearers of objective assessment. Before we discard subjective assessment as unreliable, consider that neither subjectivity is biased nor objectivity means reliability. Objectivity (or subjectivity for that matter) simply ensures measurement and reliability ensures decision-making (Cassidy, 2009; Singh, 2012). It is argued that we should stop using these terms altogether (Munro and Jeremy, 2019). A number of reputed institutions in all parts of the world are looking back at the beneficial effects of expert subjective judgments now. There are ways and means to counter subjectivity by increasing the number of tasks, assessors, and occasions. Subjective expert judgments made after prolonged observation are considered more reliable than snapshot objective assessment (Modi et al, 2014). Like other soft skills, assessment should be based upon direct observation and mainly through formative assessment. Ludwig W Eichna (1980) has famously remarked that we are training a group of physicians who have never been observed. As such, direct observation, formative assessment, regular feedback and monitoring should make the cornerstone of training and assessment of humanities in medical education to undergraduate and postgraduate medical students. Thirdly, assessment in humanities should not be a stand-alone exercise. Assessment should be intercalated as a component of programmatic assessment at the macro-level and even for one assessment test; it should be incorporated along with assessment of other skills/competencies and not as separate entity at microlevel. This means that there should not be a separate assessment test or station for assessment of medical humanities, for students can deceive the assessors by modifying attitude, communication, ethics, honesty, etc. for better show-off during such separate assessments or separate stations. Accordingly, assessment of medical humanities should be made a part of on-going assessment, by incorporating the ways to observe the attributes of medical humanities at established stations. In a nutshell, assessment of medical humanities should be programmatic, subjective assessment focusing affective and communication domain, based upon direct observation providing feedback opportunities for formative assessment laced with monitoring for promoting longitudinal development of the students (Fig. 24.2). Though the assessment of medical humanities will be mainly related to affective and communication, yet knowledge component should not be ignored. Knowledge of principles of communication is as important as communicating with someone.

TOOLS FOR ASSESSMENT As assessment of medical humanities focuses mainly on the assessment of soft skills pertaining to affective and communication domains, the tools used will be same as used for other soft skills, and at the same time, the assessment of knowledge domain should not be ignored, as mentioned above. Workplace-based assessment (WPBA) and its tool-kit, with its explicit advantage of ‘direct observation by experts’ and ‘inbuilt feedback options’ will be the most authentic assessment for medical humanities (Singh and Modi, 2013). As stressed above, a programmatic assessment incorporating multiple tools for assessment of each level of Miller’s pyramid, with continuous formative assessment having ample feedback opportunities and

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Fig. 24.2: Important characteristics of assessment of medical humanities

continuous monitoring and mentoring resulting in longitudinal development of the students should be designed (Fig. 24.3). Many tools, mostly used for WPBA, are available in the kitty for assessment of medical humanities like: Mini-clinical evaluation exercise (mini-CEX), objectivestructured clinical examination (OSCE), case-based discussion (CBD) or chartstimulated recall, multisource feedback (MSF), portfolios, discussion of critical incident reports (CIRs), students’ narratives and reflections (assessment for learning) and multiple choice and short answer questions (for assessment of knowledge component) (Singh and Modi, 2013). Mini-CEX involves direct observation of an actual clinical encounter of a student with patient, where evaluation is done on seven core clinical skills—medical interviewing, physical examination, professionalism, clinical judgment, counseling, organization/efficacy and overall clinical competence (Hejri et al, 2017). For its use for assessing medical humanities, encounters focusing on medical interviewing, professionalism, counseling can be arranged as even otherwise not all skills may be assessed in a single encounter of mini-CEX. Advantage with mini-CEX includes immediate and contextual feedback. Critical incident reports are experiences of learners in the form of short narratives, focusing on the most critical professional conduct and experiences. As such, CIRs

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Fig. 24.3: Programmatic assessment and tools used for assessment of medical humanities for longitudinal development of the learner. MSF: Multisource feedback; CIR: Critical incident report; mini-CEX: Mini-clinical evaluation exercise; PMEX: Professionalism mini-evaluation exercise; OSCE: Objective-structured clinical evaluation; CBD: Case-based discussion; MCQs: Multiple choice questions; EMQs: Extended matching questions; SAQs: Short answer questions

are suitable for assessing ethics, values and attitudes, and professional development. CBD reflects the trainee’s level of experience and provides ample opportunities for structured feedback and improvement. In OSCE, stations can be arranged in a manner so as to have assessment of ethics, empathy, communication skills and professionalism (Mattick and Bligh, 2006; Modi et al, 2016). Stand-alone stations for assessment of these components will not serve much purpose, as stated overleaf. In case of stand-alone and separate stations, just to assess various components of medical humanities, there are chances of students disguise the good attitude and communication thus befooling the assessors. There are also the chances of Hawthorne’s effect being implied under such circumstances. A solution to circumvent this problem is to use MSF for assessment of humanities components at the workplace itself. MSF is a questionnaire-based assessment method in which students are evaluated by patients, peers, nursing staff, and faculty on key performance behaviors. One caution while using MSF for assessment of humanities is that the instruments that are developed to assess humanities components must be tested to ensure that they are reliable, valid, have a good generalizability coefficient (Ep2 = 0.70), and examine variance in ratings to understand whether ratings are attributable to how the students perform and not to factors beyond their control (e.g. gender, age, or setting). Students’ portfolios, a process-oriented tool helps in longitudinal development of the students by providing opportunities for formative and summative assessment, feedback, and reflections. It also helps in inculcating self-directed learning skills in the students and can be specifically used for assessment of humanities components

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too. Students’ narratives and reflections as a tool for assessment for learning of medical humanities have been explained in detail in other chapters in this book. For assessment of ‘knows’ and ‘know-how’ areas, MCQs can be suitably designed.

SPECIAL TOOLS FOR SPECIFIC COMPONENTS Some of the special tools for assessment of specific components of medical humanities are: Professionalism mini-evaluation exercise (P-MEX), Jefferson scale of empathy (JSE), and Kalamazoo consensus statement (KCS) checklists for assessment of professionalism, empathy and communication skills, respectively. Although assessment of professionalism is part of mini-CEX, it fails to categorize precise behaviors to be observed in pragmatic situations. For more detailed and specific assessment of professionalism, P-MEX is a useful tool. P-MEX assesses four important factors of professionalism, viz. doctor–patient relationship, reflection, time management and interprofessional relationship. It is a 24-item, structured, observation instrument, with a four-point rating scale for each item as—unacceptable, below expectations, met expectations and exceeded expectations. Additionally, there is space for recording of unprofessional behavior. The rater assessment is discussed with the trainee, and the form is paced in the learning portfolio, thus helping in longitudinal professional development. The P-MEX instrument is available from: https://journals.lww.com/academicmedicine/ Fulltext/2006/10001/The_Professionalism_Mini_Evaluation_ Exercise__A.19.aspx The JSE is a content-specific, context-relevant psychometric instrument specifically designed to measure empathy. It was developed by Centre for Research in Medical Education and Healthcare. It has three versions: Medical students (S-version), health professions (HP-version), health professions students (HPS-version). S-version can be used to assess empathy in medical students. JSE is a 20-item instrument rated on seven-point Likert scale (1 = strongly disagree; 7 = strongly agree). Half of the items are positively worded and directly scored, and the other half are negatively worded and reverse scored. Administration through paper format and online administration, both are available; though, huge cost involved is a hindering factor. JSE questionnaire is available from: https://www.jefferson.edu/university/skmc/research/researchmedical-education/jefferson-scale-of-empathy.html. Accordingly, some other suitable, specific, reliable and valid scales like Toronto empathy questionnaire, multidimensional emotional empathy scale, or Griffith empathy measure can be used for the purposes of assessment of empathy (Neumann et al, 2015; Spreng et al, 2009). The Kalamazoo consensus statement includes seven evidence-based ‘essential elements’ or tasks, of effective physician–patient communication and provides skill competencies for each element. Kalamazoo essential elements communication checklist includes seven core communication competencies and 24 subcompetencies, rated using categorical ratings—done well, needs improvement, not done, not applicable. The instrument was minimally modified using global ratings on a Likert scale (1 = poor to 5 = excellent) and is known as Kalamazoo essential elements communication checklist—adapted. Third checklist—Gap-Kalamazoo

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communication skills assessment form has four versions, viz. clinician/faculty, patient/family, peer facilitator, and self-assessment and is used for 360° assessment of communication skills. This form has nine dimensions and contains Likert scale, forced-choice, and free-text fields, enabling it to provide absolute and relative scores for each aspect. These three instruments have been used in undergraduate, graduate, and postgraduate medical education and other healthcare education programs for assessment of communication skills. KCS is available from: https://osu-lp-preceptor. osu.edu/system/block_resource_items/resources/000/ 000/013/original/ Kalamazoo_Essential_Elements_of_Communication_%28new%29__08-04-2017. pdf?1502201510. The Kalamazoo instrument has been used for assessment in attitude, ethics and communication (AETCOM) module released by Medical Council of India also. A 28-item self-report altruism scale for adults is available for self-assessment of altruism specifically. A 32-item cultural diversity self-assessment instrument for specifically assess cultural diversity on five-point Likert scale (1 = almost never true; 5 = almost always true) is also available (Lee et al, 2003). An account of the assessment tool and the specific component/domain of medical humanities they assess have been briefed in Table 24.1. TABLE 24.1: Assessment tool and the component/domain of medical humanities assessed Assessment tool/instrument

Component/domain assessed

MCQs, SAQs, EMQs

Cognitive domain (K, KH)

Portfolios, CBD

Cognitive domain (KH)

OSCE, mini-CEX, MSF, CIR

Psychomotor and affective domain (S, D)

P-MEX

Professionalism

JSE

Empathy

KCS checklists

Communication skills

Altruism scale for adults

Self-assessment of altruism

Cultural diversity self-assessment instrument

Cultural diversity

MCQs: Multiple choice questions; SAQs: Short answer questions; EMQs: Extended matching questions; CBD: Casebased discussion; OSCE: Objective-structured clinical evaluation; mini-CEX: Mini-clinical evaluation exercise; MSF: Multisource feedback; CIR: Critical incident report; PMEX: Professionalism mini-evaluation exercise; JSE: Jefferson scale of empathy; KCS: Kalamazoo consensus statement; K: Knows; KH: Know-how; S: Shows; D: Does

ISSUES WITH ASSESSMENT Though we have plethora of instruments and tools to assess medical humanities, but all these instruments are component-specific and as such provide indirect evidence of construct of medical humanities and cannot assess medical humanities directly. The issue is compounded with the fact that the definition of medical humanities varies and is component-driven itself. The contribution made by each component is unknown and no component can be said to be more important than the others. Absence of even one attribute can render total global ratings of medical humanities as nil.

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Faculty training in assessment of medical humanities for—the ways to incorporate it in on-going assessment process, developing a feedback culture and longitudinal monitoring—is an issue in itself. Reliability of older tools like MCQs or OSCE is inbuilt in the tool itself but for newer tools/methods, reliability depends upon the assessor and the way it is being used. Thus, faculty training plays a crucial role for authentic and reliable use of these instruments. Another issue is with the use of patients/family rater scales. The feedback provided and as such ratings given by patients/family are mostly outcome-driven and not process-driven. Under such circumstances, the ratings given by patients/family will largely depend upon the fate of the patient and not on the care and humanistictouch provided by the resident/student and will not truly reflect the assessment of humanistic components. There is still long way to go to adopt teaching–learning of medical humanities proper in medical curriculum and incorporating a robust assessment system.

BIBLIOGRAPHY • Cassidy S. Subjectivity and the valid assessment of pre-registration student nurse clinical learning outcomes: Implications for mentors. Nurse Education Today 2009;29(1):33–39.

• Dhaliwal U, Singh S, Singh N. Promoting competence in undergraduate medical students

through the humanities: The ABCDE paradigm. RHiME 2015;(2):28–36. • Eichna LW. Medical school education, 1975–1979: a student’s perspective. New England Journal of Medicine 1980;303(13):727–34. • Hejri SM, Jalili M, Shirazi M, Masoomi R, Nedjat S, Norcini J. The utility of mini-Clinical Evaluation Exercise (mini-CEX) in undergraduate and postgraduate medical education: protocol for a systematic review. Systematic Reviews 2017;6(1):146. • Holmboe E. Bench to bedside: medical humanities education and assessment as a translational challenge. Med Edu 2016;(50):275–77. • Joshi A, Singhal A, Loomba P, Grover S, Badyal D, Singh T. Humanities in Medical Education. J Res Med Educ Ethics 2018;8(1):S3–9. • Kalamazoo (2017). Essential Elements Communication Checklist. Accessed on 17.12.2022. Available from:https://osu-lp-preceptor.osu.edu/system/block_resource_ items/ resources /000/000/013/original/Kalamazoo_Essential_Elements_of_ Communication_%28new%290,8-04-2017.pdf? 1502201510. • Lee DY, Lee JY, Kang CH. Development and validation of an altruism scale for adults. Psychological Reports 2003;92(2):555–61. • Mahajan R, Aruldhas BW, Sharma M, Badyal DK, Singh T. Professionalism and ethics: a proposed curriculum for undergraduates. International Journal of Applied and Basic Medical Research 2016;6(3):157. • Mattick K, Bligh J. Teaching and assessing medical ethics: Where are we now? Journal of Med Ethics 2006;32(3):181–85. • Modi JN, Chhatwal J, Gupta P, Singh T. Teaching and assessing communication skills in medical undergraduate training. Indian Pediatrics 2016;53(6):497–504.

• Modi JN, Gupta P, Singh T. Teaching and assessing professionalism in the Indian context. Indian Pediatrics 2014;51(11):881–88.

Assessment in Medical Humanities

241

• Munro E, Hardie J. Why we should stop talking about objectivity and subjectivity in social work? The British Journal of Social Work 2019;49(2):411–27.

• Neumann DL, Chan RC, Boyle GJ, Wang Y, Westbury HR. Measures of empathy: Selfreport, behavioral and neuroscientific approaches. In Measures of personality and social psychological constructs. Academic Press 2015;257–89.

• Singh T. Student assessment: Issues and dilemmas regarding objectivity. Natl Med Journal of India 2012;25(5):287–90.

• Singh T, Modi JN. Workplace-based assessment: A step to promote competency based postgraduate training. Indian pediatrics 2013;50(6):553–59.

• Spreng RN, McKinnon MC, Mar RA, Levine B. The Toronto Empathy Questionnaire: Scale development and initial validation of a factor-analytic solution to multiple empathy measures. Journal of Personality Assessment 2009;91(1):62–71.

• Thomas Jefferson University. Jefferson Scale of Empathy. Centre for Research in Medical Education and Healthcare. Accessed on 17.12.2022. Available from: https://www. jefferson.edu/university/skmc/research/research-medical-education/ jefferson-scaleof-empathy.html.

Index ABCDE paradigm 

76 AETCOM module  66, 227, 229 Affective domain  11, 75 Altruism 73 Altruism scale for adults  239 Anthropology 152 Artwork 178 Attitude 70 Autobiographies 162 Bayer Institute for Healthcare Communication E4 Model  50, 51 Burnout  11, 26 among caregivers  33 among postgraduates, residents and clinicians  29 among teachers  27 dimensions 26 in medical students  31 models 27 Calgary-Cambridge observation guide  50, 51 Case based learning  152 Case studies  150 introduction of  150 limitations 154 stepwise approach for using  151 tools 152 Cinemeducation 117 challenges 122 introduction of  118 role in teaching humanities  119 Clinical empathy  72 Cognitive domain 11 empathy 73 Comic strip  176 Communication 20 barriers 49 competencies  54, 55 effective 49 interpersonal 50 models 50–52 non-verbal  21, 49 verbal 21 Communication skills  20, 49 assessment of  56 faculty training  57 need for training  50 teaching methods  54 training 53 training in India  53 transfer to workplace  57 Compassion  10, 21, 73 Confidentiality  79 breach in  81 disclosure principles of  83 foundations of  79

Consequentialism 80 Creative writing  157 5 Rs of  162 as a teaching–learning method 158 examples of  163 introduction of  157 strategies to help with  162 scope of  158 tools for  159 Critical incident reports  67, 236 Cultural diversity self-assessment instrument 239

Depersonalization 

11, 26 Designing a comic  178 Dignity  19, 79

Empathy 

10, 19, 21, 42, 72 Empathy-altruism hypothesis  73 End of life  90 distressing symptoms at  92 End of life care  90 education for  98 elements of  91 Ethical code  12, 79 Experiential learning cycle  187, 188

Graphic medicine 

153, 175 history of  175, 176 introduction of  175 Groningen Reflection Ability Scale  197

Health 105

Healthcare 16 Human touch  41

Indian Medical Graduate 

goal 74 roles of  22, 74, 101 Informed consent  20, 63, Interpersonal communication  50, 139 skills 49

Jefferson scale of empathy 

17, 20, 22, 50, 52

238

Kalamazoo consensus statement  Leadership skills 

18, 130 Learning environments  129 Lifelong learner  19, 74, 101, 139

Medical humanities 

3, 12, 200 assessment of  232 cell 7 curriculum 227 definitions  4, 5, 125

243

52, 238

244

Humanities in Medical Education

history 6 in context of CBME  217, 218 institutional curriculum  231 integration with CBME curriculum  218 introduction of  3 need of  10, 202 planning for implementation of  222 purpose of training in  12 role models  147 role plays for inculcating  130 subcompetencies 228 teaching tools  230 tools for assessment of  235 Medical memoir  162 Medical professionalism  62, 227 attributes of  64 Medical sociology  101 assessment of  110, 111 introduction of  101 role in medical education  107 scope of  103 teaching–learning approaches  109, 110 theories 104 undergraduate curriculum  108, 109 Miller’s pyramid  56, 235 Mini-CEX  196, 236 Multisource feedback  236

Narratives 

152, 160, 186, 195 assessment of  196 Narrative competence 169 medicine 187

Patient-centered clinical method 

50, 51 Poetry 161 a qualitative research methodology  172 as an immersive experience  168 in medical teaching  168 narrative competence through  169 psychosomatic encounters in  170 Portability and Accountability Act, 1996  20 Portfolios  66, 196, 236 Privacy 78 governing laws  86 major categories of  79 Probity  19, 20 Professional 62 Professional competence  63, 73, 185 Professionalism  62, 227 elements of  63 introduction of  62 mini-evaluation exercise  238 tools for assessment of  67 Professionalism and ethics  62 assessment of  67 curricular opportunities  66 teaching—rationale 64 teaching—operational aspects  65

Reasoning skills 

12, 204 Reductionist approach  4 Reflection-before-action  192 Reflection-in-action  187, 192 Reflection-on-action  187, 192 Reflections  159, 185 approaches to promote  192 assessment of  196

barriers 192 definitions  186 models of  187 purpose of  190 Reflective cycle 188 diary  159, 164 journal 159 practice  164, 186 practice questionnaire  197 Retrospective reasoning  129 Role models  142 characteristics of  143 real life examples  146 types of  144 Role plays  126 advantages of  131 assessment of students using  132 for inculcating medical humanities  130 guiding principles  129 introduction of  126 issues with  133 planning and execution of  127 playing role plays  127 significance of  129 tips for executing  128 types 127 use of  131 Rust out  35

Sciences 3

analytical 3 humanities 3 normative 3 SEGUE framework for teaching and assessing communication skills  50, 52 Social constructionism 105 determinants of health 106 Sociology 102 role in graduate medical education  107 Storytelling 160 Stress 25 coping with  34 Stress and burnout  25 assessing 34 System-based practice  17

Theatre 136

conventional theatre  136 forum theatre  138 incorporation in CBME  140 liberatory theatre  137 pedagogical theatre  137 propaganda theatre  137 role in medical humanities  138, 139 traditional theatre  136 types 136 Theatre of the oppressed  7, 137, 140, 153, 220 Three-function model  50, 51 Transformative learning  191 Traumatic deidealization  11 Trigger films  119

Unethical practice  12, 234 Workplace-based assessment 

235