A New Way of Teaching Humanities in Medical School: Critical Medical Humanities

Abstract

Purpose

This study investigates medical students’ experiences with a pre-clerkship critical medical humanities (CMH) curriculum that emphasized power, privilege, and inequities in healthcare.

Methods

Twenty-six third-year medical students at a semi-rural US medical school were interviewed in Fall-Winter 2023. Semi-structured interviews explored students’ reflections on the curriculum’s impact, and narrative analysis was used to identify key themes. Validation strategies included reflexivity, triangulation, and analysis of disconfirming cases.

Results

The results revealed 4 themes. First, students valued humanities learning but noted limitations of the classroom setting. Second, the facilitated self-reflection uncovered implicit biases and encouraged critical perspectives on medical knowledge. Third, despite a belief that the humanities were important for future practice, participants deprioritized them in favor of science courses. Finally, learning about diversity and equity concepts was perceived to be limited in racially homogenous groups.

Conclusion

The CMH curriculum encouraged critical thinking and cultural humility, though its full impact was constrained by systemic and cultural tensions in medical education prioritizing scientific knowledge. Embedding health humanities learning into clinical contexts and providing faculty development to address diversity and equity challenges may enhance curricular outcomes. Institutional support and national guidance are needed to align health humanities curricula with broader educational goals.

Introduction

Health humanities (HH) as a scholarly and teaching field, in academic medicine and elsewhere, is changing: a more traditional HH approach is evolving towards critical medical humanities (CMH). The more traditional approach to HH focuses on the human connection. It aims to illuminate and enlighten medical practice, striving to develop empathetic, patient-centered, reflective, and self-aware physicians. Educational outcomes of interest have included empathy,^1–3 patient-centeredness,^4,5 reflection, ⁶ and self-awareness or wellness.^7–9 In contrast, CMH focuses on social knowledge and, as Kumagai and Lypson note, “a reflective awareness of the differences in power and privilege and the inequities that are embedded in social relationships … and the fostering of a reorientation of perspective towards a commitment to social justice.” ¹⁰ Educational outcomes of interest have included structural competency, ¹¹ critical awareness, ¹² and knowledge of health equity via “critical consciousness, structural competency, and cultural humility.” ¹³ Both approaches share the end goal of improving humanistic practice, the goal of HH since its beginnings.^14,15

Unlike other areas of medical education, there is no broad agreement about the purposes of HH curricula. ¹⁶ Recent literature reflects this discordance: Carr et al ⁵ found no fewer than 6 major focus areas for HH education: knowledge acquisition; mastering skills (eg, observation and reflection); relational aims, including perspective taking; personal growth and activism; wellness and self-care; and critical evaluation. Especially given that most schools of medicine have minimal required HH curricula, ¹⁷ the heterogeneity in purpose is striking. Evidence of traditional (eg, relational aims) and CMH approaches (eg, critical evaluation) are found within these widely ranging focus areas. We suspect that although most medical schools include some HH curricula, few are explicit or purposeful about the philosophy that underlies their curriculum, whether it be the traditional approach, CMH, or something else. The AAMC's Foundational Role of Arts and Humanities in Medical Education report¹⁸ is emblematic: it does not identify underlying philosophies and is agnostic about taking a CMH versus a more traditional approach.

In response to the pandemic and consequent broad social recognition of persistent health inequities in the United States and globally, we initiated a humanities curricular reform project, which resulted in a shift from our historically traditional curriculum to a modified CMH curriculum. A discussion of our process, the resulting curriculum, and some initial challenges are reported elsewhere. ¹⁹ To apply CMH approaches, we implemented new framing concepts, such as social construction and critical consciousness. The social construction framing supports learning about medicine as shaping and being shaped by its cultural circumstances and history, especially in relation to medical racism, gender and illness, disability, and implicit bias. The social construction frame also emphasizes societal influences on health and embodiment, providing an important link to concepts in our school's health system science curriculum. ²⁰ Additionally, the new humanities curriculum introduces students to visual thinking skills, narrative medicine, and theoretically informed instruction in doctor-patient communication. Medical ethics continues as a signature element of the curriculum, ²¹ but is reframed by the curricular emphasis on context and social justice concerns. Other curricular elements include the cultivation of resilience in the face of emotionally challenging aspects of clinical care and focused discussions on topical issues such as abortion, artificial intelligence, weight bias, and trust in healthcare. Our learning objectives and curricular goals blend a traditional emphasis in professional identity formation and approaching patients as whole persons with more critical objectives related to power, privilege, and intersectional elements of the social determinants of health.

The present qualitative study explored students’ lived experiences of a weekly required CMH preclerkship curriculum, examining in particular students’ perceptions of the teaching of CMH topics such as cultural humility and critical consciousness.

Methods

Context

This study draws on qualitative data from students at a semirural medical school in the Mid-Atlantic region of the United States, where the academic medical center provides tertiary care for a largely white and rural catchment area. The school has a longitudinal HH curriculum throughout undergraduate medical education. The 18-month preclerkship phase includes 4 required HH courses, each of which meets weekly in a 2-hour session for a total of ∼120 contact hours. Students are broken into small groups of 8 to 10 learners, and discussion is led by a faculty facilitator using a standardized guide developed by content experts who run the courses. During required clerkships (just over 12 months), the students meet biweekly in small groups to debrief, using humanities concepts and tools. In their final year, students take a month-long HH selective (topics and faculty vary). Across the longitudinal curriculum, faculty facilitators rotate from course to course. Uniquely, all elements of the HH curriculum are required for all students rather than being offered as a pathway or elective courses. The present study focused on the preclerkship phase and included students who participated in the inaugural year of the new curriculum, academic year 2021 to 2022. This study was approved as exempt by the Penn State College of Medicine IRB (study ID 00018082).

Participants and data collection

All 141 third-year medical students were invited via email to participate in an interview. Up to 2 follow-up emails were sent to nonresponders. Twenty-six medical students agreed to participate and completed interviews in the Fall-Winter of 2023. Interviews were conducted via videoconference with a trained interviewer who relied on a semistructured interview guide. Each interview explored the participants’ experience with the preclerkship HH curriculum with questions such as “Cultural humility is a process of being open, self-aware, egoless, and incorporating self-reflection when interacting with diverse individuals, groups, or communities. What are your thoughts about how cultural humility was taught or addressed in the Humanities curriculum?—Was it effective, ineffective? How so?” The full semistructured interview guide is provided in Supplemental Appendix A. Interviews ranged from 46 to 118 min and were audio-recorded and transcribed verbatim. Each participant received a $20 gift card upon completion of the interview.

Qualitative data analysis and validity

We used an applied narrative analysis as our qualitative data analysis method, ²² specifically thematic content analysis, utilizing open coding and constant comparisons.^22,23 One analyst (RLV) was an experienced medical educator and qualitative researcher who helped design the preclerkship HH curriculum. The second analyst (JS) was a public health professional with a background in qualitative research who conducted the interviews and had no association with the HH curriculum. A codebook with definitions and example quotes was developed through an iterative process of reviewing transcripts, applying a draft codebook to novel transcripts, revising the codebook, and so on. The final codebook contained 56 independent codes. The 2 analysts, as well as the larger research team, participated in this iterative process. Ultimately, the 2 analysts applied the finalized codebook independently to all 26 transcripts, achieving a kappa of 0.96 after discussing disagreements (kappa 0.77 before discussing disagreements). Data saturation was judged to have occurred after coding analysis of 15 interviews. Coding continued after saturation to refine existing codes and to explore nuance between and among codes.

Strategies for validation included engaging in reflexivity about researcher bias, triangulation, and exploring negative or disconfirming data. ²² During data collection and analysis, we tried to be aware of what we, as researchers, brought to the research. Our research group had a range of experiences that informed our analysis, including being students, faculty, and administrators in a college of medicine. We are all women, and all but one of us is white. At the outset, we acknowledged our perception that HH generally and CMH in particular were an important part of a medical school curriculum. The reporting of this qualitative study conforms to the COREQ guidelines (Supplemental Appendix B). ²⁴

Results

Using narrative analysis, we identified 4 themes that yielded substantial insights into medical students' perceptions of the humanities curriculum. We include here brief quotations from the interviews that illustrate these themes especially well.

Theme 1: Participants identified HH learning as helpful knowledge for practice; however, some participants felt the classroom context was limiting.

When discussing the impact of HH small-group learning, participants especially noted the practical elements that positively affected their thinking and behavior during clerkships, such as classroom discussions about diverse cultural attitudes toward infant sleep. Being required to run through scenarios that involved a variety of patient populations in a preclerkship small-group setting helped participants think concretely about how they would handle various clinical situations. In this way, most participants identified that their prior HH learning had provided a good knowledge base for clerkships.

… I do feel like my cultural humility was definitely improved from the humanities because it brought from my subconscious into my consciousness level of thinking the ways in which certain populations have been impacted in medicine specifically, and why it would influence the way that they seek care, or how [adherent] they are, or what kinds of questions they're more likely to ask. And I've seen that even clinically as I've gone through clerkships at this point, I could be aware of why certain populations would be more hesitant, or why they'll have specific questions about medications or testing that they may need, why it would be indicated. (Interview 11)

A few participants reported that the classroom context of the HH curriculum was limiting because of the “distance” (Interview 3) between the concepts and the reality of patient care. However, the preclerkship HH coursework provided a helpful foundation that was important for the real-life experiences that followed.

I would say the most impactful was not the in-class learning. I do appreciate the humanities courses. They definitely built a good foundation, but the most impactful was when I got onto the floors and actually had to interact with patients. So whether it was using a translator or having patients just respond saying, “I can't do that, I can't do what you're recommending,” because of cultural reasons, I think those have been the most influential. But then again, I don't think I would've had as good as a learning experience [in clerkships] had I not had some foundational knowledge of how to cope with that from the [preclerkship] courses. (Interview 8)

Theme 2: Humanities learning opportunities challenged participants to question their beliefs and assumptions.

Subtheme 2.1: Participants questioned themselves: Who they were and what they believed to be true.

Many participants reported that the HH curriculum prompted them to “really reflect on ourselves” (Interview 13) and that this often resulted in a realization of their own implicit bias. Participants were “surprised” (Interview 16) and “taken aback” (Interview 1) by what they discovered about themselves and reported being motivated to “work through it… and [be] more aware.” (Interview 24). In this way, the HH curriculum challenged their beliefs and assumptions about themselves.

I think it definitely showed that I do have implicit biases. I was like, “oh, there's no way I'm going to have implicit biases on the one where we were looking at people with disabilities [because my family member has genetic disease causing developmental delay].” But then, it still showed that I did, and I was really taken aback and it made me kind of think more about it. So, you always have to be aware of these things and try to overcome them no matter how good you think you are being. (Interview 1)

Subtheme 2.2: Participants adopted a newly critical approach to medical and scientific knowledge, realizing that it can have embedded bias.

Some participants reported that the HH curriculum prompted them to question their previously held assumptions about the infallibility of science, which included that science was “true and real and raw” (Interview 16) and perfectly, accurately representative of reality. The curriculum also prompted participants to question what—and how—they were learning in biomedical sciences, for example, the limitations of a pattern recognition approach.

I guess if I had to say one thing, it would be, I always look at medicine and be like, this is fact, this is rooted in truth and science and there's no room for humans to sort of mess that up or to exert our biases on it because it's science and that's true and real and raw, but I think that the discussion about the different spirometry results, it's like, oh, it just sort of made me think about all the ways that humans can impact this thing that is seemingly like truth. (Interview 6)

Theme 3: Participants reported feeling stressed and overwhelmed with adapting to medical school in general and being successful in their biomedical science courses in particular, which led them to deprioritize HH learning.

Most participants reported that they tended to deprioritize their HH courses in favor of their biomedical science courses, which was reinforced and encouraged by the stated and unstated priorities of medical education and the credentialing process. Participants concurrently indicated that they felt the HH curriculum was important to becoming a great doctor; the problem was that everything else was important in more immediate ways (eg, passing a science course).

Humanities was kind of the bottom of my list in pre-clinicals for importance. It was like the organ blocks and anatomy were the top, and then humanities and health systems were kind of the bottom. And then all the other, we had to do a couple hours on site each week. And there was a lot of other stuff that kind of got in the way. So having an assignment to do for humanities [On Tuesday] or read something … it'd be done Monday night and as quick as possible so that you have time to do other stuff … So I guess the importance of it in the whole curriculum, well, I think it's important and it can make us better doctors. The division of time, there's just a lot more pressing things I felt. (Interview 9)

Theme 4: Participants reported that they did not learn as much about diversity and equity concepts when they were in racially homogenous groups.

Participants commented frequently on their own small groups and what they heard about their peers’ small groups. Many participants reported that having students from a wide array of backgrounds who were engaged in the discussion and willing to share their perspectives and experiences was an important—even essential—component of a positive small-group learning experience. Some participants worried about discussing a concept (eg, medical racism) that they had not experienced and believed that hearing from peers who had personally experienced the concept was essential. When participants discussed outward markers of diversity, they focused almost exclusively on race, and made negative judgments about groups based on a lack of externally visible diversity markers.

I think in terms of talking about cultural humility in [location], it's kind of hard because my class is primarily white. Most of the facilitators in our group were white. I remember having one, maybe two people of color in my group … I don't know if that's anything the humanities curriculum can really do [anything about] or if that's just a consequence of where we are geographically. Yeah, where we are. I think that was a shortcoming, just that we were talking about a lot of these experiences that a lot of us didn't really have and we weren't talking about it … Not that we have to always talk about it from personal experience, but I think sometimes those things are more meaningful when you talk about them in concrete ways rather than these abstract things that we, as people who don't really experience those things, bring to the table. (Interview 4)

This preference for learning directly from individuals affected by racism or other biases was sometimes acutely experienced by these individuals as a burden:

Sometimes, going, again, from the perspective of being a minority in a lot of these classes, I felt like there is this unspoken responsibility that's placed on whoever identifies with the population you're talking about, and you feel this pressure that everyone's looking to you to say something about it. […]. We feel this unspoken responsibility to speak about it, even if no one is saying it. And without that [input from the minority] … everyone wants to play a devil's advocate. And in certain classes, I chose to not say anything at all and see where the conversation went, just to get rid of the feeling that “I have to be teaching this class, because I'm the one who identifies with this.” So I think, without people knowing [it], they were creating this feeling of, “Oh, you identify with this, you should be contributing the most to this discussion.” And that feeling was not just with me. When I spoke with others, it was like, “Yeah, you end up teaching in a way.” And sometimes, that gets exhausting, because it's not my job to teach. (Interview 3)

Additional evidence of the themes can be found in Supplemental Appendix C.

Discussion

Overall, we found that participants appreciated HH learning as a foundation for clinical practice, highlighting its role in fostering cultural humility and improving patient interactions, but noted limitations in the classroom contexts that weakened the effectiveness of the curriculum. These findings align well with the Cultural Historical Activity Theory (CHAT), which has roots in the work of Vygotsky ²⁵ and later Engeström, ²⁶ and describes any human activity in terms of an “activity system.” This theory has recently been applied to the field of medical education.^27–30 The components of the activity system include a subject who is engaged in activity towards an object, or purpose of the activity, to achieve a desired outcome. Although the subject may be an individual person, CHAT emphasizes that their activity is always mediated by the culture and environment in which they are embedded, that is, the activity system. The components of the activity system that mediate the activity include the community; tools, which can be physical or abstract; rules, both written and unwritten; and division of labor, which distributes the work among various roles in the community. ²⁶ Figure 1 depicts these components of an activity system using a triangle. The lines and arrows between each component signify that each of the activity system components connects with, and can potentially conflict with, other components. CHAT is a good theoretical match for our data: both CMH and CHAT are grounded in critical theory—a framework for analyzing society, culture, and power dynamics—and CHAT helps to explain the tensions we found between and within the themes.

Figure 1.

Humanities education in medical school, analyzed through the lens of Cultural Historical Activity Theory (CHAT).

Figure 1 displays the components of the medical education activity system. An analysis of those components exposes several tensions within the system. Importantly, in our study, medical students (subject) perceived the clinic (tool) to be where humanities knowledge was enacted (Theme 1). Our data suggested that students perceive the importance of nonscientific ways of knowing and being (object and outcome). And yet, participants repeatedly described scientific knowledge and science courses as taking priority over everything else (the rule that they were unconsciously following). This tension helps explain Theme 3, where participants articulated contradictory ideas, namely that they tended to deprioritize HH while simultaneously believing that it was very important and would make them better doctors. It may also help explain Theme 2, where participants were surprised to discover that science was fallible (contrary to their previously held rule regarding the primacy of scientific knowledge).

Students seemed to believe that learners from majority backgrounds learned from students in specific underrepresented groups (division of labor). This expectation places an emotional and intellectual burden on learners in minoritized groups and has been well-described previously as the “conscripted curriculum.” ³¹ Since the conscripted curriculum is “premised on the presence of people whose social identities confer a particular form of experientially based expertise,” ³¹ the student perception seemed to be that small-group learning was completely dependent upon who was in the room. Theme 4 suggests that participants do not learn as much when in racially homogeneous groups, indicating that our learners have unwittingly and unfortunately endorsed the conscripted curriculum. There are facilitation strategies that small group faculty can take to combat the conscripted curriculum,^31,32 however, our data suggest that application of those strategies was uneven and often unsuccessful.

The formal HH curriculum was enacted entirely in a preclerkship small-group setting (tools). However, students reported that meaning making was largely delayed until they were immersed in their clinical clerkships (another tool) several months later. In Theme 1, addressing what they took away from the HH curriculum, most students discussed what they had learned in the context of their clerkship experiences, and some students explicitly noted the limitations of the classroom environment. It was difficult for the participants to understand the benefits of the HH curriculum until they were immersed in clerkships. This tension is aligned with transformative learning, which suggests that a disruptive context, such as clerkships, is an essential component of learning.^33–35 Thus, preclerkship HH curricula might be thought of as 2-step transformative learning processes, where content groundwork is laid in a preclerkship setting and the disruptive environment occurs later.

Our study had limitations, including that the study was conducted at a single institution with a long and well-known history of commitment to HH learning in medical education, and thus the participants may not be representative of medical students from other institutions. Additionally, it is a majority white institution in a semirural, suburban area. Given the wide heterogeneity of medical school structure, culture, and emphasis, the results from the present study should be applied to other schools cautiously. Finally, because qualitative research involves a subjective decision-making process that may be influenced by researchers’ theoretical perspectives, prior experiences, and analytical assumptions, there is the possibility for researcher bias in data interpretation and analysis. To address this, we engaged in numerous strategies to minimize and bracket our bias, enumerated in Supplemental Appendix B. Strengths of the study include an interdisciplinary team, rigorously developed and applied qualitative methods, and a studied curriculum that is required for all students and longitudinal.

Implications

This study has numerous implications. Overall, we found that institutional support, small-group facilitator training, and expanded approaches in the clinical context are crucial to the success of HH curricular goals.

On a macro level, the CHAT analysis clarified the importance of context and implicit rules in medical education, especially when HH is involved, because so much of HH learning exists in tension with the rules, tools, and community members in medical education. As such, strong institutional support is essential for HH programs to be successful. Additionally, a CMH approach to HH may support students in identifying and interrogating the unwritten rules, allowing them to be better able to uncover assumptions about medical education and practice.

CMH approaches necessarily address historical discrimination, implicit bias, and inequity in medicine, culture, and society, aligning them with efforts by students and organizations in academic medicine to show respect for all people.^36,37 Unfortunately, these issues often elicit the conscripted curriculum, ³¹ and many facilitators do not know how to disrupt this damaging pattern. ³⁸ Significant faculty development is needed to set small-group facilitators up for success with educational materials that challenge implicit cultural and professional rules. Training facilitators thoroughly and longitudinally is a challenge in academic medicine, as is finding facilitators with a disposition to engage in material that often challenges their own professional training and rule-based understanding of professional values.

Another implication is related to the timing of HH curricula. Our data suggests a limitation of the preclerkship small-group setting: the disruptive environment of clerkships appeared necessary for students to solidify their prior HH learning. However, the priorities and curricular structure of medical education makes it easier to slot HH learning into preclerkship courses and a final year devoted to electives. Such a structure creates conditions in which HH courses do not violate educational rules about the primacy of scientific knowledge and clinical experience in students’ educations. However, our data suggests that it is important to overcome the logistical challenges of clerkships, HH practitioners, and the structure of medical education to embed HH learning into the clinical milieu.

HH curricula are unique in medical education. Unlike the basic sciences, where there is broad agreement about their purpose, there is no broad agreement about why schools of medicine should use scarce circular time on HH. Concurrently, our data show that students perceive HH as an essential component of their medical education, setting them up for success treating patients as whole persons in the clinical environment. Yet our CHAT analysis revealed that HH are fighting an uphill battle against many unwritten rules of medical education. To address tensions that limit the effectiveness of HH learning, practitioners and students alike would benefit from clear recommendations from national organizations about the purpose of HH curricula in medical education.

Conclusion

This study suggests that while medical students value CMH learning as foundational to clinical practice, significant structural and contextual barriers limit its effectiveness. Students recognized the importance of HH education for developing cultural humility and improving patient interactions, yet consistently deprioritized it due to competing academic demands and institutional priorities favoring biomedical sciences. The CHAT framework revealed fundamental tensions within medical education that undermine humanities learning, particularly the disconnect between preclerkship classroom contexts and clinical application.

Our analysis highlights the need for stronger institutional support of the HH curriculum, comprehensive faculty development, and integration of HH learning into clinical settings. Without addressing these systemic challenges, HH curricula will continue to operate at a disadvantage. Medical leaders and educators must reconcile these tensions to fully realize the potential of HH learning in physician formation.