The Development of the Department of Medical Humanities at The Brody School of Medicine at East Carolina University
by Loretta Kopelman

The Department of Medical Humanities at The Brody School of Medicine at East Carolina University was one of only nine programs selected to be featured by Academic Medicine in an 1989 issue devoted to "Teaching Medical Ethics." Portions of what follows are adapted from this and other of my writings on Medical Humanities. Most recently, I was asked to describe our program for its 2003 October issue.

The Brody School of Medicine at East Carolina University, situated in a rural, medically underserved area at an established state university, graduated its first class in June 1981. During 1978, I was hired to begin the medical humanities program as a section within the Department of Pediatrics. The program grew with the new school, becoming an independent program in 1982 and a department in 1984. The term "medical humanities," as applied to this program, indicates our interest in any humanities discipline that may have a relationship to medicine. Our emphasis, however, is philosophy (including ethics), history, law and literature.

The program grew quickly because the dean and many of the senior faculty wanted to integrate humanities into medical education. Some of the basic science and clinical faculty had taken bioethics courses, so there was fertile ground in which the program could grow. There are now seven full-time faculty in our department. We have had several visiting professors join us as our faculty obtain release time for research and other projects.

The development of a humanities department in a medical school presents unusual challenges. The East Carolina program has been fortunate because it was encouraged by the school's deans and the basic science and clinical faculty. Currently, the program provides 55 contact hours with medical students in the required curriculum; our fourth-year elective courses are well subscribed (about half of the members of the graduating class take one or more); and we have programs for residents, fellows, basic science Ph.D.s and faculty.

Early Crucial Decisions In the first year of the program, 1978-79, five crucial decisions were made with the support of the dean or the curriculum committee.

1. To begin humanities courses in the preclinical required curriculum as a base to build on in the clinical years. This decision arose after a debate about where humanities teaching would be most effective. Some argued that we should integrate humanities teaching entirely into the other existing courses. However, because medical humanities teaching, principally teaching of ethics and philosophy, involved what was to most of the students unfamiliar methods of inquiry, integration would have been difficult unless there had been time beforehand to teach students these methods of analysis. Moreover, continuity, essential to this teaching, would have been extremely difficult to establish by means of lectures or seminars scattered here and there in a variety of courses.
   
   The program has been allotted 20 required contact hours for the first-year course, 24 for the second-year course, and 8 to 10 hours in the third year, for a total of 52-54 required contact hours. Most of the initial efforts of the medical humanities program were dedicated to developing these required courses.
   
   
2. To develop a humanities program that would have continuity from year to year throughout undergraduate and residency training without sacrificing research time of the faculty. Even in the first year, the program expanded beyond what one person could handle. Fortunately, a site visit from the Institute on Human Values in Medicine helped to convince the dean to hire another person in medical humanities. We sought the best person we could find no matter what his or her field, so long as the candidate had a doctorate in a humanities discipline. We screened applicants not only for the quality of their academic qualifications, but also for indications that they could work well with medical students and faculty.
   
   When our continued growth required more faculty, careful documentation of our teaching, service, and research activities helped make the case for such additional staff. At present, we have seven full-time faculty members, four of whom have been granted tenure and promoted to full professor by the medical school. Five of us have a Ph.D. in philosophy and two a Ph.D. in history (one of our historians also has a law degree). We also include in our activities literature, drama, and social policy, other humanities disciplines. Physicians and basic science faculty are involved in all aspects of our program. Holding time for research, as we built our program, enabled us to publish articles in scholarly journals, which enhanced our standing in the medical school.
   
   
3. To arrange for program faculty to team-teach the courses with clinical faculty. Many members of the clinical faculty were eager to support and participate in a medical humanities program, and some helped from the first week to build the program. For example, the section head of Hematology-Oncology sought me out the first week to say he wanted to make the program a success and help in any way he could. Team-teaching has proved to be a useful strategy for a variety of reasons. It keeps each course focused on the large number of issues that are important to the practice of medicine, provides a means for faculty development for everyone involved, gives the students contact with physicians who see medical humanities as important, allows the clinicians to show the students why the theoretical discussions matter, and increases our support from the faculty. Team-teaching is arranged by mutual agreement; some of us have worked with the same clinical faculty members for years. We learn from each other in our conferences, classes, and committees. Most of us enjoy the different perspectives made possible by an interdisciplinary program. Many of the faculty who have worked with us are members of the ethics committees at our teaching hospital. In short, team-teaching promotes mutual faculty development. All of our courses and seminars, however, have at least one instructor whose primary area of specialization is medical humanities and who is a member of our department.
   
   
4. To show the importance of the medical humanities programs and courses by the way in which they were constructed and situated in the curriculum. Two crucial ways in which the importance of our program was shown were to make some of the courses required and to grade them as other courses were graded. The chair of the Department of Medicine argued for this arrangement by saying that it would encourage the school and the students to take medical humanities seriously. We established two required courses in the preclinical years and then integrated the rest of the program into the required clinical services and into elective courses during the fourth year.
   
   When our program began, there were few medical school courses to use as models. We had to address basic issues and problems of format, topics, and readings, a difficult but exciting process. We found that seminars were effective, supplemented by occasional plenary sessions with invited patients or other guests. Our guests have included physician-poets and physician-authors, patients who were dying, patients who were participating in clinical trials, and patients who were unable to afford medical care. Whenever we have a patient as a guest, we also have the patient's physician attend. These sessions are usually informal, with students asking many questions.
   
   To keep seminars from becoming unwieldy and formal, we split the sessions and teach in groups of 10 to 12 students. Weekly readings (of no more than two hours, or ten pages) are varied, and many come from leading medical journals. Using these readings as a basis for critical discussion, along with readings in theory, shows the students the importance of the moral and social issues of health care, how they arise in practice, and how to read medical literature more critically. Evaluation, using letter grades as do the other courses, is based on short essays, examinations on the readings (in the first year), and class participation.
   
   
5. To focus primarily upon teaching a method of inquiry rather than merely imposing answers to questions devised by the faculty. Students need tools for identifying and working on the kind of problems identified in the program's courses and encountered in medical practice. In our courses, we encourage the students to challenge any view and to formulate and defend positions that differ from the faculty's if they wish. Shortly after I arrived, I wrote the following statement of our program's philosophy.

Humanities disciplines have as their goal broadening our perspectives, fighting dogmatism, and developing critical thought and judgment. In fostering creativity of thought and rigorous examination of methods, problems, and results, the humanities and the sciences are entirely compatible. The difference is that the results of science can (in principle) be tested empirically, while those of humanities are not entirely subject to empirical resolution. It is important to have students recognize this, but equally important for them to see that this does not mean rational discourse in the humanities is not possible. Rather, rational discourse plays as essential a role in the humanities as it does in the sciences. Therefore, the humanities program tries to show students how important, but nonempirical claims, may arise in medical conflicts. Accordingly, substantive problems are presented in terms of important alternative solutions (and their strengths and weaknesses) in order to develop the critical skills needed to evaluate claims that cannot be resolved entirely through empirical means. Developing these critical skills is valuable in itself and also allows the systematic integration, enrichment, and review of their own concerns. The approach is interdisciplinary, but to win the respect of the students and faculty, any humanities subject must be presented as a rigorous academic discipline. Emphasis is placed on the ethical and social policy problems that arise in the practice of medicine, concerns which, owing to expanding technology, have become very complex.

I should perhaps add, first, we believe that approaching the problems in the way just described also fosters empathy. There are various routes to compassion, one being to get to know and identify with other people. Hence, we have found it valuable to have the students meet some of the patients afflicted with the problems we discuss. Another way to foster empathy is the critical assessment of one's own views and limitations, including trying to see the problem from "the other side." This attempt to see things from different perspectives has been an important part of our evaluation of the students in the various medical humanities courses. The students write short papers in which they must select and defend a thesis, but identify what they view as major limitations of their positions. Students are often surprised to learn how evaluative concepts and assumptions are woven into most "hard" scientific and "objective" medical decisions.

We also try to offer students the tools to evaluate moral claims. This requires teaching them that to put forth one's opinion as moral, one must be willing to justify it in a certain way. That is, one must be willing to seek clarity in stating the problem and all relevant information, to defend choices with reasons, and to reconsider views in light of new data. Seeking a moral defense of one's position also requires that one is not being egotistical, but will apply the reasons to all, universally and impartially, even to oneself (The Golden Rule expresses this). One must seek to assess one's reasons critically in relation to other relevant considerations such as legal, social, or religious traditions or other stable views about how we should act or what we should be. It also requires a willingness to be sensitive to moral conflicts or problems, beliefs about what is compassionate, and the feelings, preferences, or rights of others. As in using the scientific method, this method of moral reasoning is a goal we seek, and none of us should claim with certainty that it has been reached. For example, we cannot be certain we have all the relevant data or that the "factual" assessments are uncolored by what we expect or want to find. This method of moral or practical reasoning may be taught and used in medical practice by centering it around the following questions:

1. What is the moral problem?
   
   
2. Are there other or better ways to view it?
   
   
3. What data are relevant? Are you using the best information? How good is your data?
   
   
4. What are the options?
   
   
5. What are the likely consequences of the different options?
   
   
6. What rights, duties, or values are important? If there is a conflict, what is the weightiest consideration?
   
   
7. What are the weaknesses of your view?
   
   
8. How would you want to be treated in these circumstances?

The following approaches to evaluation have been most useful to us:

1. We have the students respond anonymously to a standardized short-answer questionnaire given by the dean's office.
   
   
2. We have the students anonymously write short essays during the last class period about what they like, dislike, and wish to see changed in the course.
   
   
3. We solicit comments from the students who are serving as officers of the class being evaluated.
   
   
4. We discuss the courses among ourselves as faculty members, both program faculty and the many other faculty who work with us.
   
   
5. We watch our students to see how well they improve in their ability to structure and discuss issues critically.

Based on what we learn from evaluations of the program and on what we judge will keep interest high, we try to vary our readings, topics, and teaching methods each year or even more frequently. We often discuss such changes among ourselves and with those with whom we team-teach. We work with both basic science and clinical faculty to try to integrate our topics in a timely and useful manner in relation to their programs. We have been fortunate that they have been so cooperative and enthusiastic; their warm response has been essential in winning the respect of our students for the program.

This program has been an interdisciplinary collaboration of many individuals. I am deeply grateful to my current colleagues John C. Moskop, Ph.D., Todd L. Savitt, Ph.D., Kenneth DeVille, Ph.D., J.D., Janet Malek, Ph.D., Mary Ellen Wojtasiewicz, R.N., Ph.D., and Fabrice Jotterand, Ph.D., and those of the past, David Resnik, J.D., Ph.D., John K. Davis, Ph.D., J.D., Joel J. Shuman, Ph.D., Willem A. Landman, D.Phil., Carl Elliot, M.D., Ph.D., Jeffrey Kahn, Ph.D., M.P.H., and Reidar Lie, M.D., Ph.D., who have worked hard on all aspects of the teaching, research, and service programs. All in the program are grateful to the many clinicians who have taught them so much and enriched the program.