“Ah! Bach!” and other Confessions of a “Humanities in Medical Education” Cynic, Converted

From the 4/16/2021 newsletter

Director’s Corner 

“Ah! Bach!” and other Confessions of a “Humanities in Medical Education” Cynic, Converted

Adina Kalet, MD MPH

In this Director’s Corner, Dr. Kalet admits to her own early arrogance about the introduction of the humanities in medicine and challenges us to find a rich and inspiring way forward using a character and caring framework …

Did you know that M*A*S*H, the comedy-drama television series that ran on CBS from 1972 to 1983 and based on a movie of the same name, is one of the most highly rated US television shows in history? For the few who are unfamiliar, this remarkable ensemble piece told the fictional story of the 4077th Mobile Army Surgical Hospital, in Uijeongbu, South Korea, during the Korean War (1950–53). It ran for eleven seasons, spanning the final years of the Vietnam War and into the Cold War. There were 256 thirty-minute episodes. It was a literal modern War and Peace. As does most great art, M*A*S*H grappled with the most controversial political and humanistic issues of all times. The theme song, “Suicide is Painless,” is an indicator of how deeply philosophical the writing was, and how accessible the insights. In my estimation, it is the best medical drama ever written and performed. To each his/her own, right? 

For me, a child of the 1960s and 1970s, M*A*S*H was formative. I wanted to be “Hawkeye” Pierce. Even though he was a womanizing, sarcastic, sometimes cruel practical trickster, he was also an artfully skilled, lifesaving, courageous, compassionate, and empathic physician and colleague. I was drawn to his deliciously complex character - both in the theatrical and philosophical sense - and strong moral presence. In one of my most memorable episodes, Hawkeye gives seduction advice to Walter “Radar” O’Reilly, the eerily perceptive, dewy-eyed, camp administrative savant, farm boy from Ottumwa, Iowa. Hawkeye coaches him on how to fake his knowledge of classical music to win the affections of a nurse (nurses were all women) in camp by saying “Ah! Bach!” with a dreamy look and expressive hand motions. The superficiality of the gesture has me on the floor laughing even now. Will they stop at nothing to get the girl into bed?

This represented how I felt, as a medical student and resident about the rather clumsy early efforts made by medical educators in the 1980s to seduce medical students into self-awareness through incorporating the “arts and humanities” into medicine. 

Not every humanities experience is meaningful for medical students 

Curricula which required engagement with selected works of art to view or read without much guidance or structure, felt like a manipulative and superficial ploy to get me to feel something I did not (or would not) and do something I could not yet do. I am not proud of this; I know now I was wrong. I was young and insecure. But it is still a common point of view of trainees. 

As Art Derse shares in his history of the humanities in medicine at MCW I, too, have occasionally heard students say, “I didn’t come to medical school to read poetry (insert: write stories, look at art, or watch movies).”  I think that these students are right and, yet, deeply wrong. 

They are right because medical training is hard enough and – given the great variation in how each of us prefers to access our own humanity, empathy and compassion – being required to engage with a particular work of art is too vague. Students who hold this view are deeply wrong because they misunderstand the point of the exercise. 

I personally have great difficulty connecting with poetry. For me, it is hard work and, therefore, not entertaining enough. But, of course, I now know I must do the hard work to reap the most profound lessons the humanities have to offer. And it is almost impossible to do this work on our own. We need facilitators and guides. The work of art is just the “trigger” for reflection, a starting point to get oneself to challenge assumptions, see the wart’s, face the fears. This is both hard work and not guaranteed to lead to the intended learning. 

“If you haven’t read Thomas Mann’s Magic Mountain you should not be allowed to be a physician!” 

I heard this repeatedly from one of the most erudite and revered clinicians in my department in New York City in the 1990s. What he meant to communicate was that physicians should read great literature in order to develop empathy for and access to the deepest, most complex and conflictual aspects of the “illness experience.” But what he said and represented, sounded crude, insensitive and, frankly, terrifying to my modern ears. Would this powerful man really limit access to the profession based on this one book? I believed he would. I tried to talk with him about it many times. He dismissed my concerns and was openly derisive when I insisted that we focus on skills building and personal reflection as a path to ensuring all physicians have the communication skills – including empathy – to elicit the patient’s story and to build a therapeutic rapport. He absolutely despised any mention of Standardized Patients (SPs). He felt – without any direct experience, by the way - that using professional actors trained to portray patients, assess trainees’ communication skills, and provide them feedback was “fake” and manipulative. 

Given his great love of using the arts to instill empathy, this perplexed me. In my experience, SPs are highly disciplined artists willing to engage with our trainees to ensure that all patients have caring and competent physicians.  He also dismissed my choices of “great” literature, which ran more toward Toni Morrison, Alice Walker, Margaret Attwood, Jamaica Kincaid, Alice Munro, Marilynne Robinson, Tillie Olsen, Virginia Woolf, than toward Thomas Mann (as of a month ago, I have yet to get past page 300 of Magic Mountain. I am still struggling, though). And this was the leader of our Humanities in Medicine program. 

Initially, I rebelled. We needed more than simply a trigger for deep thought that was unguided and self-congratulatory.  Over the years, with many pedagogical advances and an openness to a broader range of humanities, my view has softened. My colleague was a man of his times; what other choice did he have? But we must make other choices, expand the canon, and make use of the humanities to open our minds and hearts. Not easy.   

So, where do we begin?

This past Sunday morning, my husband left the New York Times on the table opened to the Op Ed entitled “A Once-in-a-Century Crisis Can Help Educate Doctors.” I “girded my loins,” ready for a diatribe, another “humanist” telling us in medical education what we must add to an already overwhelming experience of medical training. 

But I was relieved. In this piece, Molly Worthen, a historian at UNC-Chapel Hill who writes about higher education, points out that the pandemic has given us an opportunity to transform medical education because it has forced health professionals and medical schools to look beyond the particulars of modern medicine and think more broadly about how we prepare doctors. She says, and I agree, that COVID has provided us “a pilot project to demonstrate that the humanities are an essential part of what a medical education should be — not just a luxury, but foundational.” 

She celebrates the strides we have made away from the early “humanities in medicine” days of museum visits and the “great novels,” as we move toward a true integration of the humanities at many medical centers and in many programs. The humanities force practitioners to be clear eyed even as they evaluate seemingly empirical data. “Humanists take evidence so seriously that they emphasize viewing it from multiple vantage points and recognizing one’s own limited perspective.”  

Worthen finishes, reminding us all of where we began our medical journeys days, years, or even decades ago. She says our students “grasp intuitively that medicine is not a science but an art that uses science as one of many tools.” 

Embracing Ambiguity

There is so much work to do. In this and in the last issue of the Transformational Times, we have highlighted the many ways these efforts are happening at MCW and beyond. Despite this, there is no clear path to integrate the humanities into medicine. Yet, maybe not knowing exactly how, yet embracing, the ambiguity of that task will bring us closer. Maybe that is the point. Ah! Bach!

In his own way, even Hawkeye knew that the humanities were important while working in the M*A*S*H unit. He once told an interviewer that he brought every single book ever written in English with him when he was sent to Korea. How? Well, he responded, “I brought the dictionary. I figure it's got all the other books in it.” Not a very high brow answer for a man named after Benjamin Franklin and nicknamed after a character from James Fenimore Cooper’s The Last of the Mohicans. I can’t say I agree with everything Hawkeye said, but this, at least, was right on target.  

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.