Literature in medical school: why, how, and if
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Do literature courses in medical school make better doctors? Will the doctors be more sensitive, display more empathy? If so, how is this achieved? And what is the evidence it does so?
Since 1980 many educators have supported the integration of humanities coursework into medical school curricula. One widespread claim has been that literature can inculcate values in future doctors that conventional biological sciences do not provide. As long ago as 1983, physician and medical educator Dr. Stephen L. Daniel summarized this point of view when he wrote that “The humanist is trained to know and teach the richness of the human spirit rather than serve the worldly needs of his fellow men,” and therefore “is in a privileged position to help medical students discover what patients’ values might be.”1 More recently Dr. Lester D. Friedman concurred, writing that “the inclusion, discussion, and analysis of imaginative works of art within the [medical] curriculum encourage students to consider how their emotions—a gateway to their compassion and empathy—can best be incorporated into their practices, allowing them to be both better healers and richer individuals.”2
For most of its defenders, the promotion of humanities courses in medical schools will help the student to cultivate empathy. Thus Anderson and Schiedermayer propose that the humanities encourage “students to become more sensitive, effective, and caring as doctors.”3 This argument is not solely made by physicians: certain narrative theorists have also argued that the analysis of fictional representations of illness can enhance a medical practitioner’s treatment of patients.4
What I want to draw attention to in these claims is not the enthusiasm they express, but to the tenuousness of their evidence in harnessing that enthusiasm. Not only do the benefits of teaching literature in medical school seem to be taken for granted, but the claims for this often seem to imbue literature with a power that amounts to clerical rather than critical insight.
As Rita Felski has argued in The Uses of Literature, difficulties arise whenever critics try to force a necessary causality between literary forms and larger political [or social] effects.5 This caution applies well to the claim that literature can help create better doctors by first creating better people. I think a middle ground is possible; literature (or the humanities) is a more critical and intellectual undertaking than a mere celebration of the human spirit, and my purpose here is to propose an orientation that emphasizes narrative complexity and historical particularity in place of moral or deterministic reasoning.
For the literary and cultural critic George Levine, what we can learn from literature is not transcendent, moralistic, or instrumentalist. “Literature, (if not also literary criticism),” he writes, “resists systemization, tests our abstractly conceived ideas into the rich texture of experience, and is more concerned with the singular than the general.”6 Levine’s emphasis on the uniqueness of the literary object recalls Felski’s assertion that our “engagements with [literary] texts are extraordinarily varied, complex, and often unpredictable.”7 Both of these descriptions could be applied to the experience of a doctor treating patients: they stress the singularity of the individual case, the complexity and unpredictability of the encounter, and in so doing resist the tendency to seek a magic bullet either medical or humanitarian in the course of treatment.
As several scholars have described, the similarities between a patient’s story and a literary narrative can invite us to treat fictional stories about doctors and patients as model case studies.8 Fictional cases also allow for deeper insights into the background, context, and personal experience of illness than actual clinical encounters. While a patient’s story was once a normative part of a doctor-patient encounter, our current system of data collection and impersonal diagnostic testing has moved the story to the margins of the encounter. The doctor-patient relationship has suffered from this tilt and one corrective effort seems to be the inclusion of literary fiction in medical education. And yet that inclusion is often undermined by the understanding of literature and the humanities as a morally contagious practice that makes doctors more empathic and better at providing care.
A brief look at two doctor-patient encounters in novels can demonstrate the range of interpretative possibilities to which I have been referring. My first example is from Charlotte Bronte’s Villette (1853). Heroine Lucy Snowe—evasive, anxious, and unforthcoming about the roots or sources of her anxieties—is repeatedly interviewed by her friend John Bretton, a physician. The doctor-patient interviews in this novel do not teach transferable skills—how to listen to a patient, how a patient might experience a particular illness. But they do expertly frame the shaping powers of a particular culture and setting on a fragile subject. Dr. Bretton’s diagnoses emphasize the growing preference for scientism over states of emotion, a perspective underscored by the gender and class relations in the novel and in mid-Victorian society. As he says at one point to a nervous Lucy, “I look upon you now from a professional point of view, and I read, perhaps, all you would conceal – in your eye, which is curiously vivid and restless: in your cheek, which the blood has forsaken; in your hand, which you cannot steady.”9 Dr. Bretton favors physical symptoms over Lucy’s story, which he repeatedly interrupts, redirects, and dismisses (and this exchange thus serves as a mark in the nineteenth-century’s gradual turn to scientific registers over personal perception). To me, the unfamiliarity of the medical advice and approach in this novel comprises its constructive example: instead of treating it as a universalized expression of patient suffering, good or bad doctoring, or the abstracted rewards transmitted by a great novel, its jarring and unfinished course of treatment (Lucy is never diagnosed, and, arguably, never cured) is meaningful for its portrayal of idiosyncrasy, social difficulty, and communication malfunctions. If real clinical encounters increasingly are reduced to sites of data collection and impersonal diagnostics, then rich examples of clinical challenges remind us not only of the cultural contingencies of any medical interview, but of the influence of personality on medical thinking and treatment. Literary study’s attention to the mediation of representation thereby directs us to the complex workings of subjectivity and social relations, and shows how the story of illness is shaped by these factors.
The doctor-patient pairing in my second example—Henry James’s The Wings of the Dove—also features an unnamed illness and a medical relationship more notable for its nuanced social interactions than its empirical information. Heroine Milly Theale has a mysterious and ultimately fatal condition. Her physician, Sir Luke Strett, shows a curious disregard for the language and methods of diagnostic medicine. In their first meeting Milly is struck by his willingness to let her lead the conversation. Rather than probing her with instruments or asking for a medical history, he offers a “great empty cup of attention” for her to fill as she wishes. Later she reports that Sir Luke “knows all about me, and I like it.”
The substance of the doctor-patient relationship in Wings of the Dove, then, is relational instead of informational. The discussions between Sir Luke and Milly are cryptic, as is her illness and even the method of her death. However for physician and narrative critic Rita Charon, perhaps today’s most committed advocate of literature in medical school, the narrative ambiguity of this novel can be translated into decisive answers. In the course of her article on The Wings of the Dove, Charon decides what is wrong with Milly, she locates the “narrative truth” of the novel, she seeks to understand “the heart of the story,” its “final authority,” and explains why James writes the novel in the first place.10 These solutions to the mysteries of the novel typify an instrumentalist approach to fiction and what it can offer to a student or a student doctor. In a footnote to her article, Charon asserts that “it is useful for physicians to follow in fine detail Milly’s interior dialogue . . . This passage exquisitely describes a patient’s hearing what she has determined to hear. . . . This passage confirms a growing understanding among medical doctors who study medical discourse that the patient’s interview of a physician is as crucial in allowing truth to emerge as is the doctor’s interview with the patient” [my emphasis].11
By converting Milly’s interior thoughts to guidelines for physicians, Charon diminishes what is literary about the text: she infers instead that literature is a coded form of something real, and that in turn it has a practical application to actual medical practice. This process thereby dispenses with the novel’s particular context (late-Victorian London), and treats its enigmatic heroine—so much the product of her age—as an associative type for contemporary doctors.
So finally, if medical students are asked to read fiction as part of their coursework, it seems reasonable to propose that they should understand why and how fiction is different from empirical knowledge. While literature can spark our identification and figure imaginative bridges to current or personal experience, this does not seem to be its most provocative offering: if we are reading literature in order to find or confirm our own reality—especially a reality that leads to diagnostic medicine—then we are treating its imagined texture as a code to be translated away from narrative and social contexts and into the purely familiar or instrumental. This process may not be so different from the arguments that see the humanities as a tool for making us better people. In both cases the effort aims for an application of the literary text to life, rather than an effort to understand its original context, and its (perhaps deeply unfamiliar) rendering of the complexity of social interaction, truth values, and the mutability of what we in any culture decide is real.
- Stephen L. Daniel, “Humanities and Medicine: A Question of Relevance,” in The Crisis in the Humanities: Interdisciplinary Responses, ed. Sarah Putzell-Korah and Robert Detweiler (Potomac, MD: Studia Humanitatis, 1983, 91-103) 91; 94.
- Lester D. Friedman, “The Precarious Position of the Medical Humanities in the Medical School Curriculum,” Academic Medicine 77.4 (2002) (320-322): 320.
- R. Anderson and D. Schiedermayer, “The art of medicine through the humanities: An overview of a one-month humanities elective for fourth-year students,” Medical Education 37 (2003) (560-562): 560.
- See for instance Rita Charon, “Literature and Medicine: Origins and Destines,” Academic Medicine 75.1 (2000) (23-27) and “Narrative Medicine: A Model for Empathy, Reflection, Profession and Trust,” Journal of American Medical Association 286 (2001) (1897-1902); Arthur W. Frank, The Wounded Storyteller: Body, Illness, and Ethics (Chicago: University of Chicago Press, 1995).
- George Levine, The Realistic Imagination: English Fiction from Frankenstein to Lady Chatterley (Chicago: University of Chicago Press, 1981) 177.
- Felski 8
- See for instance Rita Charon, “Literary Concepts for Medical Readers: Frame, Time, Plot, Desire,” in Teaching Literature and Medicine, ed. A.H. Hawkins and M.C. McEntyre (New York: The Modern Languages Association, 2000) (29-41); Byron J. Good, “The Narrative Representation of Illness” in Medicine, Rationality and Experience: An Anthropological Perspective (New York: Cambridge University Press 1994) (135-65).
- Charlotte Brontë, Villette, ed. Margaret Smith and Harold Rosengarten (New York: Oxford University Press, 2008) 248.
- Rita Charon, “The Great Empty Cup of Attention: The Doctor and the Illness in The Wings of the Dove,” Literature and Medicine 9 (1990) (105-124): 106, 106, 117, 117.
- Charon “Great Empty Cup,” n 25, 123-4.
TABITHA SPARKS, PhD, is an associate professor of English at McGill University in Montreal, Quebec (Canada), where she specializes in the nineteenth-century British novel, literature and medicine, Victorian cultural studies, and narrative theory. She is the author of been chapters. She is also a member of the Narrative Medicine Research Group at McGill, which has published articles in Genre and Literature and Medicine.
Highlighted in Frontispiece Spring 2014 – Volume 6, Issue 2