Exploring the medical humanities

When we read alone and for pleasure, our defences are down—and we hide nothing from the great characters of fiction. In our consulting rooms, and on the ward, we so often do our best to hide everything, beneath the white coat, or the avuncular bedside manner. So often, a professional detachment is all that is left after all those years inured to the foibles, fallacies and frictions of our patients' tragic lives. It is at the point where art and medicine collide, that doctors can re-attach themselves to the human race and re-feel those emotions which motivate or terrify our patients.... Every contact with patients has an ethical and artistic dimension, as well as a technical one.¹

This vivid urging that doctors embrace the “point where art and medicine collide” proclaims both the now familiar ethical dimension of the clinical encounter and also a more recently acknowledged creative or “artistic” one. This recognition is welcome as far as it goes, but focusing on the resensitising of medical practitioners risks overlooking the possibility that the collision of art and medicine might affect the nature of medical practice itself. These two emphases correspond to two conceptions of what are coming to be known as the medical humanities: an “additive” view, whereby an essentially unchanged biomedicine is softened in practice by the sensitised practitioner and an “integrated” view, whereby the nature, goals, and knowledge base of clinical medicine itself are seen as shaped by the understanding and relief of human bodily suffering. This more ambitious view entails that the experiential nature of suffering be brought within the scope of medicine's explanatory models, if necessary by reappraising those models.

The perspective of the practitioner is crucial in framing explanations for the problems which medicine exists to address—patients' experience of illness, disability, and suffering. The medical humanities explore how the humanities, traditionally concerned with recording and exploring human experience, engage with specific experiences of patients, doctors, health, illness, and suffering. An integratedconception of the medical humanities carries this engagement through to the perennially important question: What is medicine for? It affirms medicine's unique character as a form of human self exploration, recognising that in medicine our material and our experiential natures are irreducibly fused; our bodily tissues and our personal values unite in constituting those experiences of illness and suffering which send people to their doctors. Medicine's objects—its patients—are also self reflecting subjects who, together with the doctor, actively form and transform the clinical encounter, the central arena of medicine.²

As the General Medical Council has suggested in Tomorrow's Doctors,³ engagement with the humanities might offer several benefits, including fostering clinicians' abilities to communicate with patients, to penetrate more deeply into the patient's wider narrative, and to seek more diverse ways of promoting well being and reducing the impact of illness or disability. For chronic illness in particular (where biomedicine offers only a partial response) clinical medicine seems likely to serve its patients best by incorporating into their treatment an appreciation of individual patients' experience. This might help to avoid overprescribing (or occasionally underprescribing) and overdependence. Again, a narrowly causal view of how people become ill in the first place is inadequate to understanding the role of psychosocial factors in aetiology and how they fuse with physical factors. Hence a more “narrative” understanding of illness might be important diagnostically as well.⁴

Although the promise of these benefits is plausible, they need to be shown convincingly, and this remains to be done. But producing the evidence also needs a richer conception of what kinds of evidence are pertinent to clinical assessment,⁵ requiring qualitative studies to refine as well as to apply this conception. In short the medical humanities stand in need of investigation and elaboration both conceptually and empirically. This is a real challenge, but one that must be undertaken.

It would most effectively be facilitated by a forum dedicated to this kind of inquiry and to serious discussion of the need and scope for engaging with the humanities in medical education and professional development—as Tomorrow's Doctors urged. In many ways, the position of the medical humanities resembles that of medical ethics 20 years ago, when its modern form emerged in Britain as an absorbing academic discourse but not yet the integral part of medical education and practice that it has now become. The medical humanities have a pressing need for a “one stop shop” in the form of a journal.

As advertised in this issue, the BMJ Publishing Group is to launch just such a journal, Medical Humanities. As well as offering a forum for the medical humanities in general—in which qualitative empirical studies and original creative writing will also be welcome—the new journal will explore the integrated conception of the medical humanities and the prospects for an extended understanding of medicine's own explanatory models. In doing so it will offer a distinctive British and European voice in a discourse that is presently only fragmentarily developed in the United States and is now emerging as a genuinely international inquiry.