TOOLS FOR FACULTY AND STAFF | MEDICAL HUMANITIES
Teaching Medical Humanities
in an Internal Medicine Residency Program
A rise in medical humanities activities is changing traditional
views of the role of the arts in medical education. The
term “medical humanities” refers to the use of humanities
and arts-based teaching materials in the medical setting (1). It
includes such disciplines as writing, literature, religion, ethics,
history, philosophy, film, and social and cultural anthropology.
Humanities education has traditionally been important for
cultivating observational skills as well as in understanding
human nature and its predicaments (2). It encourages an
understanding of the physician’s role in human health and
illness. In addition it can teach compassion, empathy, and
communication, skills that are particularly relevant for young
physicians exposed to the suffering of others.
At some medical schools, efforts to integrate medical
humanities have resulted in the creation of extensive curricula,
including lectures, panels and small group discussions, and
electives (3). Ironically, these activities virtually disappear as
medical students advance to graduate training. Despite the
fact that residency spans a critical period for the development
of attitude and practice patterns, medical humanities is rarely
a focus of residency training programs in the United States.
Burn-out rates are currently as high as 76% in internal medicine
residency programs while burned-out residents are significantly
more likely to report providing suboptimal care and feeling
career dissatisfaction. These statistics suggest that medical
humanities may prove critical during the training period when
stress, 30-hour shifts, and inadequate leisure time are prevalent
and can potentially result in poor patient care (4).
California Pacific Medical Center (CPMC) performed a
study of resident attitudes toward medical humanities, initiated
a curriculum, and then evaluated residents’ perceptions of the
curriculum before and after implementation. The curriculum
consisted of two noon conferences and two journal clubs
(Figure 1). The curriculum evaluation occurred from October
2004 to September 2006. Eighty-one percent of housestaff
responded to the pre-curriculum survey and 76% to the post-
curriculum survey. According to the survey, residents felt
medical humanities were an important aspect of medical
education that improved patient care delivery through
communication, the physician-patient relationship, end-of-life
issues, delivery of bad news, self-reflection, and moral and
professional development. Residents chose an average of “4”
on a five-point Likert scale on both the pre-curriculum and
post-curriculum surveys for questions addressing these concepts
(1 = strongly disagree, 5 = strongly agree).
Intern and resident responses were compared. Before
the curriculum was implemented, interns (compared with
residents) wanted more than four medical humanities
noon conferences per year (p = 0.05). In contrast, after the
curriculum was implemented both interns and residents
6 Academic Internal Medicine Insight
believed two conferences per year were appropriate. Also,
after the curriculum was in place, a significant number of
residents as compared to interns agreed with one or multiple
statements that medical humanities “is an important part of
medical education” (p = 0.05), “balances the technological
focus of modern medicine” (p = 0.003), and “helps improve job
satisfaction” (p = 0.05).
Female and male resident responses were also compared.
In the pre-curriculum survey women were more likely than
men to believe focusing on the medical humanities would
improve patient care delivery through enhancing self-
reflection (p = 0.02) and moral/professional development (p =
0.02). After the curriculum was introduced, significantly more
women than men disagreed with the statement that more
scheduled learning time should be devoted to science and
clinically-based topics rather than humanities topics (p = 0.01).
In addition, more women than men agreed that teaching in
the medical humanities helped balance the technological focus
of modern medicine (p-value 0.03).
The CPMC study suggests residents believe medical
humanities are an important part of medical education;
however male and female residents have differing opinions
on how medical humanities education affects patient care
delivery, its utility in an era of technology-focused care,
and the amount of learning time that should be devoted
to medical humanities as compared to science-based topics.
Residents, as compared to interns, differ in their opinions
of whether teaching in the medical humanities balances the
technological focus of care and improves job satisfaction.
According to survey results, two noon conferences per year will
likely suffice for the medical humanities curriculum and will
not disrupt scientifically-oriented education. Female housestaff
in particular did not believe additional scheduled learning time
should be devoted to more science or clinically-based topics.
The findings are significant for a number of reasons.
First, professionalism is a core competency of the Accreditation
Council for Graduate Medical Education. Various definitions
of professionalism have appeared in the medical literature,
including the description of a moral and social responsibility of
the physician (5-6). Residents believe teaching in the medical
humanities can reinforce these aspects of medicine particularly
because of the impact on moral and professional development.
This finding has greater meaning in light of a recent study
that found disciplinary action among practicing physicians by
medical boards to be strongly associated with unprofessional
behavior in medical school (7). Interestingly, another study
published in The New England Journal of Medicine (NEJM)
identified five attributes of excellent attending physicians;
two were attributes that may be best conveyed via medical
humanities education: stressing the importance of the
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 FIGURE 1: Study Curriculum and Other Ideas
Name/Institution
Noon Conferences
The field of medical humanities and its relevance to medical education were described; historical examples provided (i.e., the works of Leonardo da Vinci,
Vesalius, and William Carlos Williams); housestaff/attendings shared personal artwork, writing, or the writing of well known authors, and discussed the role
of humanities in their lives.
Housestaff and attending physicians described or read memorable moments in training (written in advance); examples included a needlestick from a dying
HIV patient, shifting attitudes toward one’s white coat through the years, and a eulogy for a difficult patient.
Journal Clubs
Housestaff and attending physicians met informally at a local restaurant to discuss articles (New Yorker essay on average doctors, Harvard Business Review
article addressing women’s ambition).
Other successful events since study completed:
In advance, housestaff/attendings chose one to two poems out of the anthology Body Language: Poems of the Medical Training Experience and described
how they resonate with their own patient encounters.
At start of conference, housestaff/attendings spent 10 minutes writing about an experience that reminded them of why they went into medicine. Then they
shared stories and discussed.
TV Medicine: presented data on coma and code outcomes on television versus real life; held interactive discussion of media influence on patient perceptions
of medical care stimulated by several clips from the TV shows Scrubs and Grey’s Anatomy.
Interns/residents/chief residents/attending physicians (10 total) were given the option in advance of choosing a poem out of Body Language to read
or writing about a memorable patient encounter (most were about death/dying) to share at the conference. (Alternative: for a lighter variation, have
participants share funny patient stories.)
Reflection Evenings: Residents and attendings met at the house of one of the associate program directors. Events have included:
• Asking participants to discuss one thing they liked about how they have changed since residency started and one thing they disliked.
• Discussing prompted by essays on the process of becoming a doctor.

physician-patient relationship in one’s teaching and teaching the pressing need to augment medical knowledge are realities
the psychosocial aspects of medicine (8). of residency training, residents felt that spending time on
Several differences in responses between sexes were medical humanities is valuable. Furthermore, the study suggests
evident in the NEJM study—which may be important medical humanities can contribute to educational efforts in
information for medical educators in light of rising numbers professionalism, complement biomedical education for increasing
of female medical student graduates. Approximately one- numbers of female physicians, and enhance job satisfaction.
half of US medical student graduates are now women. For
AUTHORS
three consecutive years (2005-2007), more than 65% of CPMC
internal medicine residents have been women. These results Neeta Jain, MD
may support a prior finding that women are more likely than Chief Resident
men to engage patients as partners in their care in a patient- Department of Medicine
centered approach as “female physician’s communication styles California Pacific Medical Center
tend to be sensitive not only to patients’ biomedical concerns
but also to their emotional concerns” (9). Paul Aronowitz, MD
The data show that a significant number of senior Program Director
housestaff believe teaching in the medical humanities helps Department of Medicine
improve job satisfaction. Prior studies show physicians who are California Pacific Medical Center
satisfied with their work have patients who are more satisfied Continued on page 15
with their care and have greater levels of trust and confidence
in their physicians. Physician job satisfaction appears to be
inversely related to physician turnover, yet associated with
patient adherence to treatment regimens while dissatisfaction
with increased physician health problems (10).
The implications of this relatively small study may be
broad. The finding that residents believe teaching in the
medical humanities is an important part of medical education
is significant. While heavy patient care responsibilities and

Academic Internal Medicine Insight | 2008 | 6:1 7


FIGURE 2: Clinical Guideline Review:
Questions to Consider
Do older adults present differently than younger adults?
Should the diagnostic approach vary for different age groups?
Are there risk stratification tools available for older adults?
Does treatment or treatments in older adults differ from younger adults?
What is the role of supportive therapy?
What preventative interventions should be employed?
Older patients with multiple conditions also tend to
have varying attitudes about the risks and benefits of certain
therapies, and measures of quality of life may be more
important than traditional clinical outcomes. In a 2000 study,
when offered individualized decision making about treatment,
fewer patients chose the guideline-indicated treatment than
those who typically would be recommended treatment (5). To
remedy this disconnect, guidelines should encourage informed
decision making by clinicians in concert with patients, taking
into consideration patient preferences, quality of life, and
treatment regimens that encourage patient adherence.
Considerations related to pay-for-performance measures,
which provide financial incentives to health care providers
for achieving specified performance targets, also should be
evaluated when assessing the value of clinical guidelines for
older Americans. Critical questions arise regarding whether
pay-for-performance would encourage clinicians to “dissuade
clinicians from caring for individuals with multiple chronic
diseases…or lead to unfair and inaccurate judgments of
physicians’ care for this population” (4). However, arguing
that patients receiving complex treatment should be exempted
from pay-for-performance metrics would not foster an
improvement in care for these individuals. (Figure 2)
In response to this concern, the Association of Specialty
Professors (ASP) has received a $250,000 grant from Atlantic
Philanthropies (USA), Inc., to improve the care of older
adults through the augmentation of guidelines or quality
improvement metrics with content appropriate for the
increasing number of elderly patients cared for by internists.
This funding complements the ASP project, “Integrating
Geriatrics into the Specialties of Internal Medicine: Moving
Forward from Awareness to Action,” funded by a $2.6 million
grant from the John A. Hartford Foundation. Under the grant,
these clinical policies will be produced and endorsed by 11
internal medicine specialty societies. For more information
about the Atlantic Philanthropies, please visit www.
atlanticphilanthropies.org.
ASP anticipates this project will have several important
outcomes. Experts from each of the specialty societies will
review and augment 44 clinical guidelines, policies, or quality
improvement metrics with recommendations relevant to the
growing elderly population. Once created, these new policies
can be disseminated through specialty society websites and
Academic Internal Medicine Insight | 2008 | 6:1
educational materials made available to the societies’ physician
members to influence the care delivered to elderly patients by
internists.
AUTHOR
John R. Ashworth
Project Coordinator
Alliance for Academic Internal Medicine
REFERENCES
1. Anderson G, Horvath J. Chronic Conditions: Making the Case for Ongoing Care. Robert Wood
Johnson Foundation’s Partnership for Solutions; 2002. Online. http://www.partnershipforsolutions.
org/DMS/files/chronicbook2002.pdf. Accessed January 16, 2008.
2. United States Centers for Medicare and Medicaid Services. Program Information on Medicare,
Medicaid, SCHIP, and Other Programs of the Centers for Medicare & Medicine Services: June 2002.
Online. http://www.cms.hhs.gov/TheChartSeries/downloads/sec3b_z.zip. Accessed January 15, 2008.
3. Tinetti ME, Bogardus Jr., ST, Agostini, JV. Potential pitfalls of disease-specific guidelines for
patients with multiple conditions. N Engl J Med. 2004;35:2870-2874.
4. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older
patients with multiple comorbid diseases: implications for pay for performance. JAMA.
2005;294:716-724.
5. Protheroe, J, Fahey, T, Montgomery, AA. The impact of patients’ preferences on the treatment of
atrial fibrillation: Observational study of patient based decision analysis. BMJ. 2000;320:1380-1384.
Teaching Medical Humanities
in an Internal Medicine
Residency Program Continued from page 7
REFERENCES
1. Shapiro J, Rucker L. Can poetry make better doctors? Teaching the humanities and arts to
medical students and residents at the University of California, Irvine, College of Medicine. Acad
Med. 2003;78:953-957.
2. Montgomery K, Chambers T, Reifler DR. Humanities education at Northwestern University
Feinberg School of Medicine. Acad Med. 2003;78:958-962.
3. Krackov SK, Levin RI, Catanese V, et al. Medical humanities at New York University School of
Medicine: An array of rich programs in diverse settings. Acad Med. 2003;78:977-982.
4. Shanafelt TD, Bradkey KA, Wipf JE, Back AL. Burnout and self-reported patient care in internal
medicine residency program. Ann Intern Med. 2002;136:358-367.
5. Whitcomb ME. Medical professionalism: Can it be taught? Acad Med. 2005;80:883-884.
6. Wynia MK, Latham SR, Kao AC, et al. Medical professionalism in society. N Engl J Med.
1999;341:1612-1616.
7. Papadakis MA, et al. Disciplinary action by medical boards and prior behavior in medical school.
N Engl J Med. 2005;353:2673-2682.
8. Wright SM, Kern DE, Kolodner K, et al. Attributes of excellent attending-physician role models.
N Engl J Med. 1998;339:1986-1993.
9. Levinson W, Lurie N. When most doctors are women: What lies ahead? Ann Intern Med.
2004;141:471-474.
10. Brown S, Gunderman RB. Viewpoint: Enhancing the professional fulfillment of physicians. Acad
Med. 2006;81:577-582.
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