Medicine and the Liberal Arts

Lecture by Professor Pericles Lewis, President, Yale-NUS College
11th Asia Pacific Medical Education Conference
University Cultural Centre, National University of Singapore
17 January 2014

Ladies and gentlemen,

I am honored to be presenting at the 11th Asia-Pacific Medical Education Conference here in Singapore. I will be speaking today about the relevance of a broad liberal arts and science education for future medical practitioners and researchers, and also, more specifically, about the ways that the study of humanities subject matters may be of particular benefit for a medical education.

I would like to begin by clarifying the term liberal arts. In its traditional sense, going back to Latin, and in modern American usage, the liberal arts include both the arts and sciences, or to use a more contemporary division of knowledge, the humanities, the social sciences, and the natural and computational sciences. In particular, the American liberal arts approach, which we are adapting at Yale-NUS College here in Singapore, emphasises broad preparation in a variety of disciplines, followed by in-depth specialisation in one (or sometimes two) major subjects. It differs from the traditional British model of education, which is common in Singapore and many other former colonies, first of all in that students at liberal arts institutions are not required to declare a major until after a year or two of university study. A related point is that in a liberal arts degree, the amount of time devoted to specialisation in a subject matter is typically about half of the four-year course, whereas in traditional British degrees a large majority of the time at university is devoted to specialisation.

There are a number of reasons why I believe that a liberal arts and sciences approach is relevant today. First is its encouragement of flexibility of thought: a student who has had some exposure to a range of disciplines will, if well-trained, develop the ability to approach a problem from many different angles, and ideally also to branch out across traditional disciplinary boundaries. A second feature of liberal arts and sciences education is its emphasis on small classrooms, early exposure to laboratory research, and active learning. Rather than absorb information in a large lecture hall and reproduce it on a written examination, the student is encouraged to articulate his or her learning in small classes, with direct contact with a professor, and to engage in real research, which is assessed through continuous assessment rather than a single exam. This has cognitive benefits and also, I believe, social benefits, as the student learns how to express disagreement or come to reasoned consensus with peers and with the instructor. Finally, in the 21st century, liberal arts education should inculcate an understanding of cultural differences. This is highly valuable in a world dominated by globalisation and multiculturalism. The ability to work with others of different backgrounds is important for everyone, and perhaps especially for medical professionals.

Traditionally, in Singapore, as in much of the British Commonwealth, medicine is an undergraduate subject. Starting about a century ago, however, Yale and other leading medical schools in the United States began treating medicine as a graduate subject, normally pursued after a BA or BSc degree. The American system of medical school admissions, including the MCAT test, assumes that a student entering medical school will have a certain amount of “premedical” knowledge, but allows for students to study a variety of subjects at the undergraduate level. More recently, with the creation of the Duke-NUS Graduate Medical School, this model of Graduate medical education has taken root in Singapore. While it is clearly more resource-intensive than the alternative, it has certain advantages, particularly in that it allows students to develop more fully and have a wider range of general knowledge before specialising in medicine. It also encourages the development of medical research, as students with an undergraduate science degree and a graduate medical degree will be in a better position to pursue original research than those with only an undergraduate medical degree. You are the experts on medical education, so I leave further discussion of this question to you, but I would like to apprise you of some developments in the system for admission to medical school used in the United States.

A recent committee, chaired by Robert Alpern, Dean of the Yale School of Medicine, and sponsored by the American Association of Medical Colleges and the Howard Hughes Medical Institute, reviewed the requirements for admission to medical schools, as well as the scientific education provided within medical schools. The report, titled “Scientific Foundations for Future Physicians”, makes a number of points that are relevant to liberal arts and science education.

First of all, although it is a relatively small part of the report, I would like to note that the report emphasises the importance of a broad-ranging undergraduate education as a background for medical study.

“This report stems largely from the concern that premedical course requirements have been static for decades and may not accurately reflect the essential competencies every entering medical student must have mastered, today and in the future. The competencies for premedical education need to be broad and compatible with a strong liberal arts education. The work of the committee is based on the premise that the undergraduate years are not and should not be aimed only at students preparing for professional school. Instead, the undergraduate years should be devoted to creative engagement in the elements of a broad, intellectually expansive liberal arts education. Therefore, the time commitment for achieving required scientific competencies should not be so burdensome that the medical school candidate would be limited to the study of science, with little time available to pursue other academically challenging scholarly avenues that are also the foundation of intellectual growth.”

The basic source of concern is that the long list of courses students have in the past been expected to take as part of their premedical education is out of date in three respects: 1) it reflects bodies of knowledge that may not be the most relevant for current medical practitioners; 2) it focuses precisely on the idea of bodies of knowledge rather than on the development of particular competencies; and 3) as indicated in the above quotation, it tends to make the undergraduate degree primarily a “pre-professional” pre-medical degree rather than focus on the broader talents that an education in the liberal arts and sciences can promote.

I will spend most of today’s talk speaking about the broader role of the liberal arts and particularly the humanities in the education of future physicians, but I would like to touch briefly on the nature of undergraduate science education.

The AAMC_HHMI report calls for students entering medical school to have the following competencies:

  • apply quantitative reasoning,
  • understand process of scientific inquiry,
  • knowledge of basic principles of physics, chemistry, and cellular and evolutionary biology

I have somewhat shortened the details of the scientific principles that pre-medical students need to have mastered. I would like to suggest today that not only pre-medical students, but all students who complete an undergraduate degree, should be able to apply quantitative reasoning and understand the process of scientific inquiry. In somewhat lesser depth, I think they should also have at least some exposure to the principles of physics, chemistry and biology, even if they are majoring in literature or economics or sociology. It seems to me that every well-educated citizen should have at least some familiarity with the way science works in order to be capable of understanding public policy debates and making reasonable decisions about their own health. It is over half a century since CP Snow wrote about the two cultures in Britain, and it remains the case that in most advanced countries, most educated citizens remain profoundly ignorant of the nature of scientific inquiry

Conversely, I think it is equally important that future doctors and future scientists have some significant exposure to the humanities and social sciences. On this chart, which summarises the Yale-NUS College curriculum, you will see that all of our students take some combination of the courses marked in white, that is courses that introduce them to the humanities, to philosophy and political thought, to social institutions, and also to the nature of scientific inquiry and to the habits of quantitative reasoning. I would like my graduating students, including the artists and the political scientists, to understand the basics of evolutionary theory. I would like every student to be able to look at a graph in the newspaper and make some sense of it and to ask intelligent questions about the difference between causation and correlation.

The faculty of Yale-NUS College, who are distinguished teachers and accomplished researchers from all the major fields of the humanities, social sciences, and natural sciences, have come together over the past eighteen months to try to answer the question “What must a young person learn in order to live a responsible life in this century?” The result is our common curriculum. In many American universities, while students are required to distribute their courses among a variety of fields, they are allowed to take any course they like within that field. The result is a number of courses designed for non-majors, which are often chosen by students on the basis of how easily they can fulfil breadth requirements. Instead, we have designed a set of courses that all students take. This means that they share a common language and a common set of knowledge, which they take with them into their more advanced studies within a particular major. While some American colleges and universities offer a similar core curriculum, many of these focus almost exclusively on the great books (i.e. the humanities) and in particular on the great books of the West. By contrast, our curriculum is broader in two ways: it introduces students not only to the great books but also to crucial ideas in science, math, and social science. And it introduces them not only to the great books of the West but also to major works of Asian cultures. We think that this broader education will prepare our students well for the 21st century, and for work and life in a globalised world where they will need to draw both on the eternal questions asked by literature and philosophy and on the most current scientific and historical research.

It is perhaps obvious enough why a future doctor needs to know something about quantitative reasoning, scientific inquiry, and physics, chemistry and especially biology. In the remainder of my talk, I would like to discuss why the study of the humanities may also benefit future medical professionals. In the broadest sense, I think that the study of human cultures, their greatest accomplishments and their worst atrocities, is important for any person — it is a way of understanding better the human condition. But I will focus today on the benefits for doctors in terms of understanding of their patients through literature, observation through the study of art and the history of art, and confronting ethical problems through the study of philosophy.

The basic study of the humanities differs from that of the sciences because science tends to focus on repeatable experiments and causal laws. In general, if a scientific experiment or observation is valid, it should be reproducible.

Humanistic study focuses instead on what is unique in human experience, for example, the particular individual, or work of literature or art, or historical episode. Because humans live in the context of history, much of our cultural experience is changed by historical circumstances. While we share the same biology as the ancient Greeks or Chinese or the inhabitants of the Indus Valley civilization, we have not only very different technologies, but also a different understanding of our environment, different moral perspectives, and access to the products of previous generations of human beings. As a result, even though we can find patterns in human activities, and such patterns are the focus of the social sciences, many human activities, like a painting, or a poem, or a battle, or a political movement, are essentially unique.

The philosopher RS Downie has suggested the implications of this uniqueness in terms of doctors’ relationships to their patients, and the value of literature for improving that relationship:

“Understanding from a whole person perspective requires two things: knowledge of the person’s biography (or extended case history) and some imaginative sympathy with the biography… Whereas the medical and social sciences develop understanding of disease processes and typical behaviour, literature can remind us that what is scientifically typical occurs in unique forms in individual patients.”

The study of literature can help us to develop the imaginative sympathy of which Downie writes. It also can help us understand the cultural background of others — another form of imaginative sympathy. For a Western male, for example, literature may help to understand the experience of an Asian female. But more broadly, the study of literature allows us to enter into the thoughts of others, whatever their race or gender, and see the world as others see it.

More specifically, there have been many great authors who have written about medical issues, in particular the condition of being ill and facing one’s mortality. I am thinking for example of Thomas Mann’s The Magic Mountain and Virginia Woolf’s “On Being Ill”. There are also many great writers who were doctors, such as Anton Chekhov and William Carlos Williams, and they sometimes have a particularly acute insight into the lives of their patients or the social structure of their times. Just to give one famous example of a writer facing illness and death, I would like to quote John Donne’s Meditation 17:

“No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.”

I think this theme of facing one’s mortality, and understanding the suffering of a patient, has generated some of the greatest works of literature, and surely the study of it would be a good background to medical practice.

A number of colleges, universities, and medical schools have offered life drawing classes for medical or pre-medical students because drawing, especially of course drawing of human anatomy, helps develop the skills of observation and understanding of the human body. I would also like to suggest that the appreciation of art and the history of art can help to develop some of the human sympathy that Downie attributes to literature.

My colleague Tom Duffy of the Yale Medical School has written a very moving article, “Portraits of an Illness”, about a patient of his who was himself an artist and who underwent chemotherapy. The patient, identified as Aaron, drew at least 15 self-portraits during the course of a 37-day hospitalisation for leukaemia.

“The first self-portrait I reproduce here was drawn on the second day of Aaron’s chemotherapy treatment.

“The second self-portrait, tenth in the series, shows Aaron near completion of his initial course of chemotherapy, suffering a rash secondary to a drug allergy.

“At the end of the second course of chemotherapy, he is hairless and sunken, and visibly depressed.”

As Duffy stresses, chemotherapy is a particularly isolating treatment because of the need to limit visits in order to avoid infection. Aaron’s self-portraits give us some idea of his experience over the course of his 37-day hospitalisation. He lived for an additional year after completion of the treatment but then died after a relapse.

Duffy comments:

“It is easier to discuss the details of chemotherapy and blood counts than to enter the dangerous, precarious, painful, mysterious, and fertile regions that Aaron’s portraits depict. One cannot examine his portraits without being compelled to try to understand what it is like to look at death, and what is necessary to help accompany a patient on that journey. Aaron’s gaze in each of his portraits is an invitation, a command, to witness him and his suffering. To gaze not upon his leukaemic cells and all the complicated data of his illness. It is to gaze into his person, even his soul, as he fought for his life. It is his legacy that we extend that gaze to all of the patients in our care.”

These are a distinct and moving recent set of drawings, but I think the broader implication is that the study of art, and particularly art depicting illness or medical procedures, can help the physician to understand the journey of his or her patients.

A number of medical schools require students to take a course in medical ethics, and there is now a growing movement of cross-cultural medical ethics. I believe this is an essential part of medical education, but I would also like to suggest that the broader study of philosophy can help to develop a future physician’s ethical understanding.

Aristotle and Confucius, who lived about a century apart and in Greece and China respectively, both emphasised virtue as a key part of ethics, and in that sense they are quite relevant to the current movement in philosophy known as virtue ethics. Broadly speaking, Aristotle emphasises that the highest virtue is contemplative and rational whereas Confucius places more emphasis on the duties one owes to one’s family. Arguably, these two philosophers inspire much in the Western and Chinese philosophical traditions and possibly also in the broader cultures of the West and China. In terms of medical ethics in particular, Aristotle, who was the son of a doctor, tended to emphasise the virtuous path as a mean between two extremes, and he often drew on medical analogies to express this idea. Likewise he compared a good legislator to a good doctor. Although Confucius has less to say about medicine, he too emphasises virtue as a mean between extremes. What they both share is the notion that the best doctor ultimately treats not only the patient’s body but also the soul, and that knowledge of what we might call psychology and care for the patient must be combined with technical skill.

Clearly no physician, or any other individual, will have an in-depth knowledge of quantitative reasoning, scientific inquiry, physics, chemistry, biology, literature, art, and philosophy. There is a need to specialise at some point. But I hope that my talk today has suggested why a broad liberal arts and sciences education can be an excellent preparation for a career as a physician or medical research scientist. I would also like to add that there is much for liberal arts educators to learn from medical education. Most recently, I would like to mention that the Yale-NUS College course in quantitative reasoning draws on the TEAM LEAD model developed at Duke-NUS Graduate Medical School, which uses a “flipped-classroom” model in which students study materials in textbooks and online before coming to class and use classroom time for hands-on, team-based projects.

In closing, I would like to share with you the vision statement of Yale-NUS College:

A community of learning,
Founded by two great universities,
In Asia, for the world.

Our hope is to create a close community in which living and learning are intertwined, drawing on the strengths of our two founding partners, Yale and the National University of Singapore, here in Southeast Asia and educating students for service not only here in Asia but throughout the world.

Thank you.