MEDICAL HUMANITIES AT MICHIGAN STATE UNIVERSITY

Andrew D. Hunt, M.D. Howard Brody, Ph.D., M.D.

s recently as the mid-l960s, scholarly A activity in the field of medical ethics was practically nonexistent; and little activity that deserved to be called “medical humanities” was taking place except in long-established but academically isolated departments of history of medicine. In November, 1981, a meeting convened by the Society for Health and Human Values for directors of medical humanities programs in medical schools drew representatives from almost 70 programs (out of approximately 120 medical schools in the U S ) . While many of these programs focused almost exclusively on medical ethics, others have brought other humanities disciplines, including history, literature, philosophy, reli- gious studies, art history, and law into the mainstream of medical education, stimulating in the process a new wave of scholarly research marked by the appearance of several vigor- ous new journals such as the Journal of Medi- cine and Philosophy.

The development of the Medical Humani- ties Program at Michigan State University reflects in some ways this nation-wide trend; in other ways it reflects some peculiar local factors of an innovative medical college lo- cated on the campus of a land-grant university with a history of encouraging interdisciplinary research. This article will describe the back- ground against which medical education was begun at Michigan State; the eventual forma- tion of a formal program in medical humani- ties; and finally some of the program’s recent activities and accomplishments. 0 1982 by The Regents of the University of California 0272-342 5/82/07/008 1 + 0716 00.50

Michigan State University entered the field of medical education during a period of excite- ment and ferment. Western Reserve University had revised its curriculum from top to toe with a view to patient-oriented interdisciplin- ary pedagogy and more effective student learning (1). The University of Kentucky, in the establishment of its new medical school, had included departments of community medi- cine and behavioral science, believing learn- ing in these fields to be essential for students in a public institution mandated to provide physicians for its largely rural population (2). Stanford University, in preparation for con- solidation of its medical school on the Palo Alto campus, and with an educational empha- sis on producing academically oriented phy- sicians, had devoted five years to planning a new educational program emphasizing free time, student choice, interdisciplinary labora- tories for learning basic science, and continu- ous behavioral science involvement (3). Miller (4) and his followers had begun significantly to influence medical education through the adaptation of educationally sound principles to medical student teaching, leading to estab- lishment at the University of Illinois of its Center for Educational Development, which became a model for institutions aspiring to significant research and reform in medical education. The Association of American Medi- cal Colleges was going through a self-limited phase of interest in medical education as a process. It had sponsored a number of two- day institutes on various phases of education

and relevant administrative issues, was strongly encouraging the formation of new medical schools, and was urging their leaders to ex- ploit the flexibility provided by newness in the interest of innovation.

While the Civil Rights movement had only just begun, and the student activism of the late ’60s had not yet occurred, some public disaffection with overspecialized and poorly distributed medicine was being expressed, there was talk of reviving family practice, and a nation-wide shortage of physicians had been officially declared ( 5 ) . Federal legislation was enacted to assist new schools, and the W.K. Kellogg Foundation established the funding of new “two-year” medical schools as their highest priority. Michigan State was one of the universities to whom a grant was given by that foundation.

Michigan State, with 40,000 students, large colleges of natural and social sciences, a dis- tinguished College of Veterinary Medicine, a School of Nursing, large departments of bio- chemistry, physiology, pathology, and anatomy already serving multiple colleges and pro- grams, and a Land Grant-driven momentum toward socially relevant educational, research, and service programs, had, in 1964, been actively planning for the advent of medical education on its campus, and was receptive to considerable risk-taking as it entered this treacherous arena.

The development of curriculum and insti- tutional ambience at Michigan State has been complex, filled with idiosyncratic factors, and is an interesting story whose full telling is in- appropriate here. Suffice it to say that the College of Human Medicine was a two-year, preclinical program for the first two years after admitting its first class in 1966, and the students admitted in the fall of 1968 were the first to be granted the M.D. degree in 1972. During these early years, the newly recruited faculty became involved in extraordinarily intense discussion and debate, with some

degree of direction provided from the dean’s office and curriculum committee. Assuming that factual curricular content would automa- tically accrue through the usual departmental contributions, the college concentrated on basic principles and process.

Basic principles included the idea that the behavioral and social sciences were as basic to medical education as the natural and physi- cal; that in this public institution, legislatively mandated toward community service and the state’s need for more physicians in areas of shortage, much clinical learning should occur in community settings; and that peda- gogical research and innovation were where this school, at least in its formative years, should invest much of its scholarly energy. Accordingly, the departments of anthropol- ogy, sociology, and psychology, through joint administrative arrangements with the College of Social Sciences, were included within the executive structure of the College of Human Medicine, as were the traditional basic science units through arrangements with the College of Natural Science. Adminis- trative arrangements with community hospi- tals in several Michigan communities were made to provide sites for clinical clerkships, and the Office of Medical Education Research and Development (OMERAD) was established in close cooperation with the College of Edu- cation. Later, an Office of Health Services Education and Research (later still the Depart- ment of Community Health Science) was estab- lished to develop an analogous strength in the area of health services.

The process issues developed around be- havioral characteristics deemed appropriate in physicians. Physicians constantly need to expand their knowledge on their own: hence self-learning should be deliberately fostered, preferably as the main way in which informa- tion is acquired. Problem-solving, further- more, is the mode within which most medical activity occurs, and likewise was defined as

HUNT, BRODY 83

an area that should attract major curricular attention. Finally, the skills of interpersonal relationships, communication and interview- ing skills as applied behavioral science, should be given special attention. Accordingly, an educational method involving preceptors and small groups, specially developed paper cases, replete with reading lists, stop-think questions and learning objectives, was developed and called “focal problems” (6). Techniques for use of closed circuit television and programmed human models in the teaching of interpersonal relationships and interviewing emerged from practices developed earlier in the College of Education. These college-wide educational sequences, then, were designed to foster, in addition to problem-solving and self-learning, an attitude of sharing rather than competition, recognition of the interaction between behav- ioral and natural scientific phenomena, and constant awareness of the primacy of the patient in the medical transaction.

Interlocking with the interdisciplinary col- lege-wide educational program are the more traditional departmental offerings at the usual preclinical and clinical levels. While some tension, usually constructive, is maintained between the two pedagogical approaches, a precarious peace is maintained by continuous involvement of the dean’s apparatus, relevant faculty committees, and the students them- selves, who, through membership on college committees and independent activity, have considerable influence on curriculum. Indeed, an alternative approach eschewing all formal lectures, and with all learning taking place within the focal problem format (now known as Track 11) was generated through student activity in 1973, and is elected by about 30% of each class.

This, then, is a new medical school deliber- ately and systematically developed to enlist the resources of the university to the end purpose of “producing” medical graduates schooled not only in the biological, behavioral,

and clinical sciences of medicine, but also accustomed to self-learning and the analytical intellectual exercise of integration and pro- cessing of data in the interest of the needs of individual patients. While compromises have had to be made with the real world, not only within the college itself, but also with external reality in the form of the accreditation process, a more than usually fertile soil was prepared for the later planting of a formal Medical Hu- manities Program.

Indeed, the process began quietly, and almost unrecognized. During the fall aca- demic term of 1969, a distinguished medical historian and humanist, whose husband was recruited as a visiting professor elsewhere on campus, was given a medical school appoint- ment jointly with the Department of Philoso- phy, and this arrangement continued for the next nine years. She interacted with faculty, arranged informal elective courses with stu- dents, made rounds with clinicians, and re- ported periodically on her own work, in a fashion which sensitized our academic com- munity to humanistic issues in medicine and to the relevant gaps in our program. The chair- man of our Department of Pediatrics, alerted to significant unexplored ethical issues in the community hospitals with which we worked, started a series of ethics conferences in collab- oration with two members of the Department of Philosophy. These conferences ultimately became approved for continuing medical education credit, and continue to this day on a monthly basis. A medical student decided to acquire a doctorate in philosophy coinci- dently with his medical education. He has since become prominent in the field of medi- cal ethics, has qualified in family practice, and has joined our faculty as the program’s assis- tant coordinator. During the 1976-77 academic year, the chairman of Radiology, personally interested in philosophy and ethics, sponsored a series of monthly seminars open to all mem- bers of the university community, consisting

84 MOBIUS

of scholarly presentations in such fields as ethics, philosophy, philosophy of science, history, and religious studies.

By the fall of 1976, then, the elements of a program in the humanities as they relate to health and medicine, and involving a wide segment of the university community, were in place, and the idea of formalizing it led to a request for a consultation visit by the Insti- tute on Human Values in Medicine. The visi- tors’ report recognized the extent of relevant activities at Michigan State, and urged the establishment of a formal program utilizing the style of joint administration of depart- ments by several colleges (described above) that was initially used to involve the biological and social science departments in the medical college. Teaching and research assignments in shared departments like biochemistry and anthropology are negotiated according to academic needs and funding sources. Such arrangements provide a multitude of resources to the health professional colleges nor normally available in the traditional medical school, and render useless the usual disciplinary cal- culations of “full-time faculty” in departments so shared. The report, then, suggested that similar arrangements be negotiated for the humanistic disciplines such as philosophy, history, and English.

The medical humanities program which took root, then, was to exploit this adminis- trative style in the interest of the humanities, not only in the College of Human Medicine, but also in the other health professions schools at Michigan State; namely, osteopathic medi- cine, nursing, and veterinary medicine. Further- more, “curriculum” was interpreted to in- clude the entire span of university-based health professions education including both prebaccalaureate and postgraduate phases of the process. The author of this paper, then in the process of disengaging as dean of the College of Human Medicine, was selected as coordinator of the program, and, in partial

preparation for this task, enrolled in a National Endowment for the Humanities seminar on ethics in medicine in the summer of 1977.

The first year of the program was largely devoted to consolidation of activities, and the preparation of an application to the NEH for a pilot grant that focused primarily upon the value-laden aspects of gerontology, at the general university level. Two courses, one for lower-division students and entitled “Grow- ing Old in America,” and another for juniors, seniors, and graduate students called “Aging and Human Values,” were proposed, and with funds from the grant, implemented. These courses were given for two successive years during the grant period and, from the standpoint of enrollment, content, and stu- dent evaluation, were deemed successful. While details are inappropriate here, the ad- ministrative arrangements are important, since they set the style for further program development. The courses were “team taught” by faculty members from such departments as history, art history, biology, philosophy, liter- ature, cultural anthropology, and pediatrics. Grant funds, processed through the program, were paid, pro rata, to relevant university departments, through a process of negotia- tion for released time for the involved faculty members. By this means faculty resources from essentially any department of the uni- versity, including the medical school, can be mobilized for specific purposes, without the development of a new department of medical “humanists.” “Aging and Human Values,” after expiration of the grant, was “picked up” by the College of Arts and Letters, and made permanent. Other initiatives stemming from that grant, namely, elective courses in medi- cine and nursing, have also continued.

Beginning in the fall of 1978, a series of nine presentations on medical ethics was offered in the fall quarter to medical students on an elective basis. These were in the form of case presentations, panel discussions, or

HUNT, BRODY 85

lectures. Student and faculty response was such that this series has become required of first-year human medicine students. Faculty participation is by clinicians, philosophers, lawyers, nurses, and ministers, with film showings and debates sometimes used to illus- trate relevant issues.

By the time of the termination of the pilot grant, in June 1980, a beginning had been made. Core personnel consisted of the coor- dinator, an assistant coordinator (half-time from the department of philosophy), a full- time secretary, and two graduate assistants- one from the College of Human Medicine, and charged with the organization of the hospi- tal-based ethics conferences, and one from philosophy, whose duties include develop- ment of on-campus seminars and the editing of the quarterly Medical Humanities Report, circulated to a wide audience of university faculty and practicing physicians. A friendly benefactor donated the furnishings for an elegant reading room and library, and has annually provided funds for both the news- letter and for periodic outside speakers of dis- tinction four or five times each year.

However, the real goals had by no means been met, and first steps in achieving them became the basis for our second application to the NEH for an implementation grant. It is our considered opinion that medicine is dogged by a fundamental fallacy; namely, that it is primarily a “science.” While the so-called “art” of medicine is periodically invoked as a companion to its “science,” it has been a weak partner indeed, and gets but little atten- tion in most medical schools. While the idea that medicine is fundamentally an exercise in humanistic behavior, with science one of its most powerful tools is not new with us, we feel strongly that the humanities need to be incorporated within the central curricular content, rather than at the periphery.

A new and seminal work on the philosophy of medical practice rejects the notion that

medicine is fundamentally a “science” but also avoids the vagueness of labeling it an “art” (7). Medicine is instead viewed as a skill or craft that involves the application of general scientific facts to individuals for pur- poses of healing. What counts as a “right” healing action, by this formulation, is inti- mately bound up with what is “good” for the individual human being involved. Hence the value and ethical dimensions can no more be separated from medical practice than can the biological sciences (7) .

However, the traditional benchmark of academic success-the accumulation of re- quired contact hours-seemed inappropriate to us in view of the already incapacitating plethora of curricular content. Rather we would strive to introduce humanities objec- tives and evaluation strategies into existing programs and exercises, with a view to their becoming accepted and recognized as funda- mental to much of the medical decision-making paradigm. Since the grant has been funded for but four months, accomplishments cannot yet be reported, and we are limited to describ- ing the current state of planning.

The grant, specifically focused on teaching of medical ethics, funds one and one half full- time equivalent philosophers, to be distributed between human and osteopathic medicine and nursing, and commits the university to making these positions permanent at the end of the grant period. It also provides for a full- time person skilled in evaluation, and a num- ber of graduate assistants, secretarial time, and relevant consultations. Included in the funding, also, is part-time released time for one important clinical faculty member from each of the involved colleges.

The program includes an intensive study of the three curricula, and the planning of faculty development sessions, with full educational involvement occurring by the third year. With a wide array of clinicians under continued supervision by professional philosophers,

86 MOBIUS

teaching of the ethical and value-laden moie- ties of clinical decision-making should become part and parcel of much student learning in clinical settings.

Strategies at the preclinical level are most advanced in planning in the College of Human Medicine, where intense involvement within the focal problem sequence has begun. During the past year the organization of these problem- solving exercises has moved toward decision analysis, with emphasis on calculation of probabilities, decision trees, and patient- derived utilities. Concepts of autonomy and patient participation in the decision-making process, then, become inextricably linked to a proper intellectual treatment of such exer- cises, and the Humanities Program is involved in developing these aspects. In addition, dur- ing the winter quarter, 1982, the Humanities Program is responsible for developing and administering the focal problems.

Much focal problem teaching occurs in groups of ten students with physician and behavioral science preceptors. It is impracti- cal for the Medical Humanities Program to provide a trained philosopher for the meeting of each group; hence a major effort is the train- ing of existing faculty to handle in-depth ethi- cal discussions, and the preparation of detailed discussion guides to assist the process. While a few ethics questions have been inserted into the more clinically oriented focal problems, such as anemia, hypertension, and altered consciousness, for the winter 1982 sequence four cases have been especially developed on the theme, “Terminal Care and the Value of Life.” These cases raise issues including brain death, rational refusal of life-prolonging treat- ment, and the just distribution of health care dollars in society.

Similar methods (case examples with de- tailed discussion leader’s guides) are being used to increase the ethics content in the Col- lege of Nursing courses. In nursing an addi- tional wrinkle is encountered with the recent popularity of “values clarification” exercises

in nursing education, with these often being confused with ethics teaching. We intend to use such exercises as a jumping-off point, to demonstrate that however important it is to clarify the values one already does hold, the true task of ethics is to reflect critically on values one rationally ought to hold.

Movement of this teaching out of the class- room and into hospitals and clinics will be logistically difficult, given the scattered com- munity sites used for student teaching. A prom- ising beginning was made in fall quarter, 1981, when students enrolled in the third-year Lansing medicine clerkship were required to do an “ethics write-up” of one patient they cared for during this 12-week in-hospital expe- rience. This clerkship exercise currently requires close participation of the program staff; further development will be required to transfer responsibility for such an exercise to community-based faculty at a distance from the university.

With a little luck, then, medical ethics should be fairly well integrated into the health pro- fessions curricula by the end of these three years of NEH support, and there should be assured funding of indefinite continuation of this teaching. What, however, about the other humanities?

The decision largely to limit required humanities participation in the four years of medical and nursing school to ethics was made both because of recognition of where most of our strength lies, and because of a feeling that the thought process of ethical log- ical reasoning would be more naturally and easily welcomed by our health professions educational establishments than would his- tory, literature, or religious studies. This is not to say that these disciplines have been overlooked. A monthly seminar on the history of medicine, given by a member of the History Department, and regularly attended by a small group of interested people, is available to medical and nursing students, and relevant departmental offerings in other disciplines are

HUNT. BRODY 87

theoretically available as electives. One of our medical students, for example, has been doing graduate work in history on an elective basis. A new development in winter 1982 is a litera- ture and medicine elective developed within the Department of Family Practice, where short stories and plays will be used to illus- trate the concept of the family life cycle and the interpersonal conflicts peculiar to each stage of family development.

Earlier in this paper, our concept of the continuum of medical education from college freshman to medical school graduation was mentioned. While obviously Michigan State premedical students apply to medical schools all over the country, the largest cluster of admissions to all four of our health profes- sions colleges is comprised of our own gradu- ates. For example, a course highly recom- mended for premedical students is “Moral Problems in Medicine,” given by the Philoso- phy Department, and highly subscribed to by juniors and seniors planning on attending one of our health professions colleges. For the past two years, the English Department has offered a course called “Literature in Medi- cine,” which is beginning to find favor with premedical students and advisors. The pro- gram has made a list of a surprisingly large number of courses either having to do with humanities as they relate unambiguously to medicine, or emphasizing philosophical or otherwise humanistic considerations of sci- ence. There is now considerable sentiment, on the part not only of our program staff, but also of relevant university officials, in developing a humanities-rich premedical major that could be offered as an alternative to the traditional highly competitive science-bound track.

The program’s ability to influence such a wide range of educational levels is in part due to our joint administrative and shared-time arrangements with a variety of departments, already described. In addition, however, the administrative focus of the program itself and

its governance are significant. While the dean’s office of the College of Human Medi- cine is the lead point of the troika, the deans of nursing and osteopathic medicine share the basic administrative responsibility with the College. Furthermore, the Policy Board, which is responsible for fundamental direction vis-P- vis educational emphasis, future planning, and funding policies, is composed of repre- sentatives not only from the three health pro- fessional colleges, but also from Veterinary Medicine, Arts and Letters, Natural Sciences, and Social Science, with specific representa- tion from Political Science and the Depart- ment of Humanities. This group, articulate and debate-prone, which meets minimally on a quarterly basis and more often if necessary, is a strong force against encapsulation of medical humanities within the medical and nursing schools and in maintaining our credi- bility within the greater university.

Additional educational activities include a strong program in continuing medical educa- tion. The program coordinator is chairman of the Michigan State Medical Society’s sub- committee on content in medical ethics, as a result of which we give a well-attended four- hour seminar at each annual scientific meeting of the society. We are, furthermore, invited several times a year by county medical socie- ties to provide for CME credit programs.

With Lansing as the state capital, proximity to state government promotes frequent com- munication with legislators, some of whom have become interested in medically related ethical issues. Members of the program, there- fore, have been active as members of various legislative task forces, one on a thus far unsuc- cessful effort on behalf of Michigan’s version of living-will legislation, another on the devel- opment of a statutory base for standards for hospice care.

We have been strong supporters of the locally developed hospice program. Our pro- gram has become one means through which physicians are available to provide medical

88 MOBIUS

care for the patients, all of whom are in home care. One of the program’s assistant coordi- nators, a member of the Department of Family Practice, takes his turn on call, and arranges for other members of the department to par- ticipate.

The foregoing teaching and service activi- ties naturally assume the lion’s share of atten- tion at a publicly funded university; but schol- arly research has not been neglected. This past year saw the publication of a revised text- book on medical ethics and a new textbook on nursing ethics by program staff and asso- ciate faculty, as well as a number of journal articles and papers presented at national meet- ings. Traditional humanists are being reassured that entry into the medical arena for teaching and service functions does not mean an end to meaningful scholarship; instead the medi- cal world provides new issues for analysis and the opportunity for new forms of interdisci- plinary research.

In conclusion, the Medical Humanities Pro- gram at Michican State has emerged in the context of the unique administrative style of the university and of the way medical educa- tion developed there. By being able to utilize faculty of the university-based departments in the various humanities through released time arrangements, an unusual wealth and diversity of experienced teachers are available without the necessity of creating a new depart- ment. Basic university-provided core support for the program has been supplemented by two NEH grants, the acceptance of which included the commitment to continue perma- nently a considerable segment of the activities and faculty expansion included in the grants. The result has been steady progress in the teaching of medical ethics in the medical and nursing schools, a considerable activity in continuing medical education, and continu- ing expansion of medically related offerings in the humanities at the undergraduate level, with the possible emergence of an alternative humanities-rich premedical major. Additional

activities such as participation in legislative task forces and in the local hospice program have also been described. Finally, the free- dom to indulge in exercises beyond those to which one is usually constrained by public funds, resulting in much of the program’s excellence and “tclat,” has been made possi- ble by the regular donations of a very special benefactor. 00

REFERENCESlFOOTNOTES

1. Williams G. Western Reserve’s experiment in medical education and its outcome. New York: Oxford University Press, 1980. 2. Willard WR. The development of the medical school as a community resource. Am J Pub Health 1964; 54:

3. Stowe LM. The Stanford plan: an educational con- tinuum for medicine. J Med Ed 1959; 34:1059-1069. 4. Miller GE. Teaching and learning in medical school. Boston: Harvard University Press, 1961. 5. United States Public Health Service: physicians for a growing America. Publication N o . 709, Washington, D.C., 1959. 6. Jones JW., Ways PO. Focal problems: a major curricu- lar commitment to problem based small group learning. In Hunt AD, Weeks LE (eds.), Medical education since 1960: marching to a different drummer. Michigan State University Foundation and W.K. Kellogg Foundation, 1979. 7. Pellegrino ED, Thomasma DC. A philosophical basis of medical practice. New York: Oxford University Press, 1981.

1041-1 048.

Andrew D. Hunt, M.D. Dr. Hunt is coordinator of the Medical Humanities Pro- gram at Michigan State University. At present, he is at Stanford University on sabbatical leave as a visiting pro- fessor of pediatrics. He is also president of the Society for Health and Human Values.

Howard Brody, Ph.D., M.D. Dr. Brody is assistant professor in Family Practice and assistant coordinator of the Medical Humanities Program at Michigan State University School of Medicine.

Requests for reprints: Andrew D. Hunt, M.D., Medical Humanities Program, Michigan State University, East Lansing, Michigan 48824.