Medicine as interpretation: the uses of literary metaphors and methods

Humanities mini-course curricula for midcareer health professionals at the Penn State Milton S. Hershey Medical Center

The field of medical humanities has traditionally focused on medical students and, more recently, on premedical undergraduates. Comparatively little formal humanities pedagogy has been dedicated to midcareer health professionals. To address this lack, the Department of Humanities at the Pennsylvania State University College of Medicine and the Milton S. Hershey Medical Center designed eight annual humanities mini-courses for faculty and staff throughout the college and medical center.These mini-courses fell into four categories: reading, reflection, and discussion; creative expression; technology; and ethics. They were geared toward midcareer health professionals who were seeking new intellectual and creative stimulation and variety in daily routine. They also provided humanities faculty the opportunity to devote attention to topics that capitalize on their professional training and that interest them personally.Participants indicated a high degree of satisfaction with the mini-courses for four principal reasons: (1) learning the tools and methodologies of a new discipline or domain other than biomedicine, (2) using their minds and training in uncustomary ways, (3) forming new alliances with colleagues (which served to lessen the sense of professional isolation), and (4) enjoying a respite from the stressful flow of the workday. Humanities faculty facilitators provided more mixed responses but agreed that conducting the mini-courses had been a positive overall experience.Although this article provides a foundational framework for the development of a humanities mini-course series, the authors encourage others to replicate these curricula in other medical settings as an important step toward a robust pedagogy designed for midcareer health care professionals.

Reflexivity and metapositions: strategies for appraisal of clinical evidence

According to Sackett, evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. In this article, clinical reasoning is depicted as multilayered processes of evidence construction by means of social interaction and human interpretation. A basic set of knowledge is the doctors initial capital at the onset of the individual encounter. This is a necessary, but insufficient, presumption for the elaboration of clinical knowledge required to solve the particular problem. A diagnostic conclusion may appear to constitute the most obvious part of knowledge. Yet the formulation of hypotheses and the choice of adequate strategies for the pursuit of evidence are perhaps even more significant dimensions of clinical knowledge. Potential biases affect the ways in which evidence is gathered and used. When clinicians are not committed to appraising the evidence constituting the foundations of their enterprise, quality assessment of clinical practice becomes casual and unreliable. Reflexivity implies having a self-conscious account of the production of knowledge as it is being produced. From metapositions, critical questions can be asked and sometimes answered. Evidence-based practice in the original sense requires that doctors reflect upon their own positions as knowers, in the process of situated knowing, where certain rhetorical spaces rule.

A introdução das artes nos currículos médicos

A capacitação profissional apropriada no campo da infecção pelo HIV/Aids prevê que tratamento e cuidados sejam oferecidos de maneira adequada, ética e humanizada. A preocupação com esta capacitação tem acentuado a discussão sobre como a formação médica pode integrar a aquisição de excelência técnica e traços humanistas. Assim, a Educação Médica passa a incorporar o desafio de adequar-se, para providenciar aos médicos, produtos finais de seus currículos, uma formação humanista e humanizadora. As Humanidades, em específico as Artes, são disciplinas que classicamente cumprem esta função. Postula-se e discute-se que elas sejam introduzidas nos currículos médicos, seja pelo seu valor intrínseco, fonte de experiência estética e conhecimento, seja para facilitar a execução de objetivos mais amplos dentro desses currículos.

Lessons From Literature: Caring, Interpretation, and Dialogue

There can be little doubt that nursing, like other arts and sciences, is experiencing an "interpretive turn" (Hiley, Bohman, & Shusterman, 1991). As part of this more global "turn," the curriculum revolution has spurred nurse educators to critically examine their schools, curricula, and everyday practices as teachers and propose alternative pedagogies where appropriate. I argue that what is now being developed as nursing humanities is a valuable approach to interpretive pedagogy which challenges, stimulates, integrates, and develops students' thinking and understanding of the lived experience of patients/clients in ways that more traditional scientific and behaviorist approaches to nursing education are unable to do. In creating courses or learning experiences using nursing humanities, it is essential to attend to both content and pedagogical approach as being inseparable. Ignoring the former will produce no more than a pleasant chat, while ignoring the latter will result in mere "metaphor counting" or rote learning of "what the book, story, or poem means." Nurse educators have used literature to help illuminate health and illness issues in the past, but unfortunately, this has been viewed as an essentially marginal approach. While novels, stories, poems, and other literature can certainly be used in almost any nursing class, I believe that nursing humanities is such a rich seam of pedagogical and critical possibility that it merits development of specific courses and options within all of our nursing courses and programs.

Is medicine hermeneutics all the way down?

Several recent publications have suggested that hermeneutics, the method of literary criticism, might prove to be useful in medicine. In this essay I consider this thesis with particular attention to the claim that medicine "is hermeneutics all the way down". After examining an anti-positivist critique of positivist medicine and arguing that hermeneutic interpretation involves a more radical critique of modern medicine, I examine the supposed consequences of hermeneutical universalism: relativism, skepticism and antirealism which further evaluation reveals to be only potential consequences of hermeneutics. A brief discussion of phronesis and of the possible "texts" of medicine concludes the article.

Clinical interpretation: the hermeneutics of medicine

I argue that clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts. The literary critic reading a novel, the judge asked to apply a law, must arrive at a coherent reading of their respective texts. Similarly, the physician interprets the 'text' of the ill person: clinical signs and symptoms are read to ferret out their meaning, the underlying disease. However, I suggest that the hermeneutics of medicine is rendered uniquely complex by its wide variety of textual forms. I discuss four in turn: the "experiential text" of illness as lived out by the patient; the "narrative text" constituted during history-taking; the "physical text" of the patient's body as objectively examined; the "instrumental text" constructed by diagnostic technologies. I further suggest that certain flaws in modern medicine arise from its refusal of a hermeneutic self-understanding. In seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject--the living, experiencing patient.

The voices of the medical record

The medical record, as a managerial, historic, and legal document, serves many purposes. Although its form may be well established and many of the cases documented in it 'routine' in medical experience, what is written in the medical record nevertheless records decisions and actions of individuals. Viewed as an interpretive 'text', it can itself become the object of interpretation. This essay applies literary theory and methodology to the structure, content, and writing style(s) of an actual medical record for the purpose of exploring the relationship between the forms and language of medical discourse and the daily decisions surrounding medical treatment. The medical record is shown to document not only the absence of a consistent treatment plan for the patient studied but also a breakdown in communication between different health professionals caring for that patient. The paper raises questions about the kind of education being given to house staff in this instance. The essay concludes with a consideration of how such situations might be more generally avoided.