Footprints of Medical Humanities in the Emergency Department: The Balance of the Arts and Sciences

Fatimah Lateef, FRCS (A&E), MBBS, FAMS (Em Med)*

 

*Correspondence to: Fatimah Lateef, FRCS (A&E), MBBS, FAMS (Em Med)

Senior Consultant, Dept of Emergency Medicine, Singapore General Hospital

Core Faculty, Emergency Medicine Residency, SingHealth

Professor, Duke NUS Graduate Medical School, Yong Loo Lin School of Medicine, National University of Singapore and Lee Kong Chian Medical School, Nanyang Technological University

Director, SingHealth Duke NUS Institute of Medical Simulation (SIMS)

Faculty, Duke NUS Global Health Institute.

Copyright
© 2024: Fatimah Lateef. This is an open access article distributed under the Creative Commons Attribution   License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original   work is properly cited.

Received:  18 April 2024

Published: 01 May 2024

DOI: https://doi.org/10.5281/zenodo.11121447

Abstract

Medical Humanities (MH) represents an interdisciplinary field that comprises of humanities, social sciences and the applications of the arts in medical education, research, innovation and medical practice. The Humanities includes the arts, eg. literature, history, music, philosophy, poetry and narratives, theatre, drama and the performing arts, painting and drawing, as well as many more, that ca be integrated into the science of Medicine. The spectrum is wide and the applications continue to broaden. Emergency Medicine is a specialty which is extremely fast moving, hectic, robust and very dynamic. It is not easy for one to envision how MH can be integrated into the practice of Emergency Medicine.

The author shares how the use of various methodologies such as story-telling, narrative creation, painting, visual thinking, drama and role-playing to enhance understanding and inculcation of MH principles and elements, can be incorporated into emergency patient care delivery ( eg. history taking, explaining treatment, getting informed consent) training and education of Emergency Physicians (EPs), uplifting communications, professionalism and identity as well as research and innovation work.

In the end, it is about making the work of EPs more meaningful, work-life balance achievable and the formation of impactful human relations with their patients and colleagues. It will also value add to their comprehension of their professional identity in a medical world which spans a multitude of specialties.

Key Words: Medical humanities, arts, narratives, visual thinking, emergency medicine, professionalism.

Introduction

Medical Humanities (MH) represents an interdisciplinary field of medicine that comprises of humanities, social sciences and the applications of the arts in medical education and medical practice. The area of arts would include literature, history, music, philosophy, poetry and narratives, theatre, drama and the performing arts, painting and drawing, as well as many more. (1-3) (Table 1) The spectrum is broad, almost all encompassing and will highlight the intersection between humanity and health. Afterall, the practice of Medicine does require a deep understanding of humans; in its study, approaches, execution, communications, decision-making and many other aspects of practice. MH can help frame the various aspects of medical practice and can be applied academically as well as experientially. With MH, medical practitioners can discover the elements critical to the care of a patient as a ‘whole’ person; not as a system of parts or a case. (3-7) 

Despite having been around for many decades, MH is still less known, less recognized and less established in the conscious practice of many, amongst the healthcare fraternity. (2,3) In fact the definition of MH continue to remain controversial, without a universal consensus. If adequately reviewed and assessed, there are many elements of MH embedded in the day to day practice, but healthcare providers tend to be less aware of these. In more recent years, MH has begun to be thrusted forwards, with its spectrum and practice being revisited, reviewed and reapplied in various specialties of  Medicine. The applications of MH have thus expanded. The elements of MH can value add to medical related domains, enhance the way tasks are executed, strengthen communications with patients, as well as upliftment in many more areas of healthcare delivery. The power of MH is that it can help us understand more of our lives and that of others, especially the people we interact with.(7) It can be included in teaching thinking, listening and learning skills, to contribute towards a well-rounded experiential curriculum.(8) The use of MH to showcase humanistic methodologies in medical competencies and tasks execution is, in principle, a positive and value-adding initiative. However, many will ask, where, in an already busy and tight curriculum should it be introduced. For example, practitioners and medical students may feel that getting them to understand more of the history of medicine, is a distraction rather than a necessary intervention. This is the part that needs to be addressed to get buy-in. The ideas is to integrate MH and not expand any existing curriculum.

With increasing awareness and application of MH today, the main thrust will be to enhance the quality and value of care delivery. MH can help doctors to: (7-13)

• Enhance their patient- doctor relationship
• Inculcate and strengthen their humanistic skills
• Deepen understanding of the different stages of care delivery, especially from the patients’ perspectives
• Understand further about the social issues/ adaptive issues in patient care
• Reduce stress and burnout incidence, thus closely linked to their well-being and psychological wellness
• Enhance their ability for reflection
• Enhance their levels of curiosity
• Improve communications skills and
• Generate humility

The bottom-line is how all these can help doctors/ healthcare staff connect with their patients and manage themselves better. It is about integrating humanities into the natural sciences. It is about the power to transform our beliefs and action to become more meaningful. MH can help us in the positive transformation of our appraisal of the clinical interaction, as well as both our personal and professional values.

MH is about caring for people besides just treating the disease. Medicine delves in natural sciences, evidence-based practices, biomedical training, technical decision making and diagnoses. The part on addressing values of people may not be apparent, thus the integration of MH will help in reflection and analysis. (14, 15) The experiences depicted through MH can also help in inculcation of observation skills and reflective practice. Patients have an identity, an inner life, their histories, personal and social relationships, culture and their social contexts as well as individualized capacity for disease handling and tolerance. We have to appreciate this.   

Table 1: Spectrum of Humanities which can be applied to Medicine

History Arts The Classics Civics Geography, Musicology Drama Literature Language and Narrative Sociology, Social studies Anthropology Culture Poetry Religion

Others: Philosophy, Politics

Medical Humanities and Emergency Medicine (Table 2)

Emergency Medicine is strategically positioned between the community and the rest of the hospital. At the point of entry into the Emergency Department, patients are facing a spectrum of acute issues (eg. acute medical conditions and diagnoses, pain , discomfort, anxieties, concerns and  a whole multitude of problems, which need tending to, in a variety of ways). They may feel vulnerable, fearful and at risk. In the ED, fast thinking, rapid execution of stabilization and management without having too many details available, is the norm. It is fast paced, involves dealing with life and death situations, resuscitation and breaking serious news. This is where EPs come into the picture to take charge, reassure patients, make the accurate diagnosis, and deliver empathetic, relevant technical care, perform the appropriate procedures and always remaining confident, efficient and effective. (16-19) Every point of contact can represent  an opportunity for EPs to practice and execute elements of MH ( eg. humanistic approaches, ethical, proper communications, professionalism etc). This is where we can see arts and Medicine ( the science) “collide”. MH may also be the reason why despite all the challenges EPs encounter at work, they continue to strive in the delivery of genuine care for patients. Taking this further, MH can synergistically help in the push to improve acute care delivery in the VUCA (vulnerable, uncertain, complex and ambiguous) environment of the ED. (16, 20, 21) (Table 2)

Table 2 summarizes where MH can be integrated in EM: in the areas of emergency patient care delivery, training and educational programmes, in professionalism and communications initiatives as well as research/ innovation. The list is not exhaustive. Various forms of combination and permutation of integrating the arts via the spectrum of methodologies continue to be explored.

Emergency Physicians (EPs) would not have had time to establish any long term relationships with their patients, who present acutely. It thus becomes imperative for one to ask, “Is there time for application of MH?” in such a high stress and busy environment. This is exactly where we need the incorporation of MH elements. However, it is easy to overlook these, especially against the background of a hectic ED. With all the ambiguities and challenges in the ED, the incorporation of MH has the potential to make EPs more comfortable in handling these. Application of MH in the ED can be unique but still relevant and crucial. It has the potential to be therapeutic and cathartic. It can help curate experiences to be less traumatic and painful for both EPs and their patients. MH can also help nurture the growth of the EP and contribute towards their levels of satisfaction, appreciation and joy at work. The elements of MH is not exclusive to EPs. In any patient -doctor interaction it can help practitioners to understand their patients better, as well as, for themselves to be better understood. MH can help in entangling the disease from the social, cultural and other elements involved. This does not mean complete dissociation of the disease from all these other elements, but more of appreciating and understanding that there is a bigger, adaptive picture in our patients and the decisions they make, as well as their receptiveness to treatment and advice. Thus, the incorporation of MH elements and principles can certainly commence in the ED. (22, 24) (Table 2)

In a busy ED, EPs often forget to examine and reflect on the emotional dimensions of some of these experiences which can be very profound, despite being laced with uncertainties and anxieties. These experiences will resonate in different ways for each EP. They will experience deep insight, reflection, self-realization and connection with others. They will deepen the understanding of themselves, their emotional triggers, strengths and weaknesses. This is also where metacognition (ie. the link between emotions and critical thinking) is highly applicable in the very dynamic and emotionally charged environment of the ED. (17, 24, 25)

 

Table 2: Application of Medical Humanities in Emergency Medicine

Please view attached pdf to view table 2

(consider impact on patients and emergency physicians)

 

Techniques and Methodologies

The practice of creative arts can help in the engagement of EPs’ faculties: eg. sight, hearing, imagination and can support our learning, reflection, critical thinking etc. It encourages expression of ideas and sharing of lived experiences. It is extremely dynamic, exciting and will continue to grow. Thus, the utilization through various modalities can be explored:

1.Narratives and Stories

The formal way of integrating narratives is to have a blueprint for creative writing and stories on how elements of MH can be weaved in to make sense and impact EPs and patients. Some subdivide narratives to add structure to their plans. Some examples are: (2, 4, 26)

Moral narratives: explores the moral-ethical relationships between EPs and individual patients and how they view their illness as well as make decisions

Care narratives: deals with patients perspectives on the technical medical decisions which EPs share with them as well as being aware of the bigger adaptive elements which impact them (eg. social, financial, religion, cultural elements)

Taking these one step further, it is possible to explore how narratives can be integrated with scientific evidence for education, best retention and learning in general. It should also be decided if we are using the narratives approach as for its referential or evaluative function, as this will help better curation and execution. Essentially the use of narratives can help with meaning-making, memory boxing, development of professional identity, reflective practice and also inculcation of empathy and compassion. (26, 27)  

Narratives can be used to organize memories that can be shared in conversations. Our brain encodes experiences to form memories. They reflect realism, sequence of events, chronological order of situations and even flash-backs. These may come from our patients and colleagues and will remain dynamic and stimulating, bearing in mind the honest , open conversations we have with them are a priviledge.  Specific narratives can help inculcate cultural competence. In the practice of Medicine, taking the “HIStory” is essentially listening to the patient’s story or narrative. From one narrative or story, a second story can be generated due to our minds cross-linking these. Paralleling techniques such as this can help enhance believability. As EPs we can explore patients’ rationale and decisions by listening to their stories and life experiences which have impact on their view of illnesses. The language used is also paramount. Choice of words and phrases can have different effects on patients. (26-29)

Finally, in today’s practice, we must not lose sight that digital narratives and archiving offer yet another avenue for MH work to be platformed, stored and shared. 

2.Visual Thinking Strategies

Visual literacy is very helpful for EPs at the frontline where patients with acute problems may not be able to directly share information or converse adequately. Its like a form of training our eyes, hearts and mind.The astute observation skills can assist in picking up signs relevant to diagnosis. Patients non-verbal communications cues such as their facial expression, tone of voice and body language are also very important to be observed in order to get the ‘full picture ‘ of the patient. (7, 30) 

Visual thinking strategies is something that can be taught. For example, when looking at an image, person or picture, the following questions can be posed to stimulate one to think:

1. What is this image/ picture all about? What is going on in the picture?
2. Can you explain further, based on the inputs in a. above ( taking the concept and idea deeper)  and
3. Any stories that you can link to the image?

It can be useful in strengthening observation skills, which is required in Medicine. Clinical observation is more than a cursory glance. It is where visual information is integrated with cognitive knowledge in an aesthetic reasoning process that can generate meaning. (24)

Here, one gets to practice their observation, thinking and even listening skills. Without realizing it, this simple activity can help EPs reach out to patients and families better. They get used to deconstruction of an image or idea with subsequent analysis. It requires practice to inculcate the astute observation skills so that with time it becomes easier to recognize the cues and clues in our patients, combining both verbal and non verbal communications as well as watching for congruency. It is using visual metaphors in the whole embodiment. It can also help strengthen our visual diagnostic skills and capabilities. These help us connect with our patients, understand heir perspectives, make comparison between different patients and understand their wishes and hopes better. 

3.Drama, Theatre and Plays

This involves re-creation and re-enactment of scenarios and cases which have learning value. The use of shorter snippets work better for busy EPs and ED staff, compared to longer productions or full play. The cases which are based on real experiences can be very powerful as a learning tool, but they will have to be anonymized. Hypothetical scenarios can also be created and drafted. Staff can help act out these scenarios or Standardized Patients can be used. Partnerships with arts organizations and groups can be very useful as professional actors can depict emotions and other values very well and these are the elements that can uplift performances as well as the learning value and impact on the audience. (31-36)

4.Musicology

Music therapy is quite known to many. The collaborative efforts by musicians with EPs can certainly result high quality, orchestrated pieces of work, not only sweet to our ears but making meaningful emotional connections. Initiatives whereby vital signs “bleeps” or even heart sounds of critically ill patents are pieced into musical format and shared with family members can be cathartic. EPs who managed the patient can resurrect their memories when they listen to such pieces and this often can bring forth closure and better management of their emotions. (4, 11, 20) 

5,Reflection

Various forms of reflection are relevant, such as self reflection, ‘reflection in practice’ and ‘reflection on practice’. Reflection is like grooming our hearts and minds. We can reflect on our vulnerabilities, clinical skills and capabilities as well as the depth of our human experiences. (37)

Depth of reflection by EPs has been shown to have some impact on their stress levels, burnout rate, collegiality, people management, work-life balance, managing shift hours and negotiation of dynamic work environment. Reflection also affects how we make decisions, communicate, break bad news and share critical information with patients. With reflection and MH, it helps EPs understand the differences and inequalities in people’s lives. Through reflection, EPs “go through”  emotions ( as they experience and explore), which at times can be layered and complex, but still very human. These may span social, psychological, cultural and humanistic domains. (12, 37-39)

 

Conclusion

The use of MH can help develop a more holistic approach towards illness and health in the ED. With the fast paced and robust dynamics in EM, MH can offer “front row seats” for human emotion experiences, observation and management. It can impact the work-life balance of professionals such as EPs. This is linked to their occupational health and in turn, affects their execution of patient-centric practice, leadership and self esteem at work. It can also enhance critical thinking, active listening, communications skills ( difficult conversations), tolerance for uncertainty and maintenance of psychological safety in the ED. MH can co-exist with the rigors of a hectic ED practice and contribute towards a more wholesome outcome for both patients and EPs. The use of narratives, paintings, case scenarios, photographs, role-plays etc can serve as learning modalities for both individuals as well as group learning. It uplifts our human-to-human interaction and formation of collegial alliances.

The relevance of creative energies brought about through integration of MH in the ED, is really necessary as EPs care for their patients and continue to enhance the value and meaning of their work, despite how challenging the situation may be. The footprints of MH in EM practice will continue to be established more clearly I the coming years. This is provided we give it a chance. 

 

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