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Recent attention to racial disparities in law enforcement, highlighted by the death of Freddie Gray, raises questions about whether medical education adequately prepares physicians to care for persons particularly affected by societal inequities and injustice who present to clinics, hospitals, and emergency rooms. In this Perspective, the authors propose that medical school curricula should address such concerns through an explicit pedagogical orientation. The authors detail two specific approaches-antiracist pedagogy and the concept of structural competency-to construct a curriculum oriented toward appropriate care for patients who are victimized by extremely challenging social and economic disadvantages and who present with health concerns that arise from these disadvantages. In memory of Freddie Gray, the authors describe a curriculum, outlining specific strategies for engaging learners and naming specific resources that can be brought to bear on these strategies. The fundamental aim of such a curriculum is to help trainees and faculty understand how equitable access to skilled and respectful health care is often denied; how we and the institutions where we learn, teach, and work can be complicit in this reality; and how we can work toward eliminating the societal injustices that interfere with the delivery of appropriate health care.

Categories are essential to doctors' thinking and reasoning about their patients. Much of the clinical categorization learned in medical school serves useful purposes, but an extensive literature exists on students' reliance on broad systems of social categorization. In this article, the authors challenge some of the orthodoxies of categorization by combining narrative approaches to medical practice with the theoretical term "intersectionality" to draw students' attention to the important intersecting, but often overlooked, identities of their patients. Although intersectionality applies for all patients, the focus here is on its importance in understanding and caring for marginalized or disadvantaged persons.Intersectionality posits that understanding individual lives requires looking beyond categories of identity in isolation and instead considering them at their intersection, where interrelated systems of power and oppression, advantage and discrimination are at play and determine access to social and material necessities of life. Combined with narrative approaches that emphasize the singularity of a person's story, narrative intersectionality can enable a more robust understanding of how injustice and inequality interrelate multidimensionally to produce social disadvantage.The authors apply this framework to two films that present characters whose lives are made up of numerous and often-contradictory identities to highlight what physicians may be overlooking in the care of patients. If the education of physicians encourages synthesis and categorization aimed at the critically useful process of making clinical "assessments" and "plans," then there must also be emphasis in their education on what might be missing from that process.

Slow medical education borrows from other “slow” movements by offering a complementary orientation to medical education that emphasizes the value of slow and thoughtful reflection and interaction in medical education and clinical care. Such slow experiences, when systematically structured throughout

Since the emergence of the field in the 1970s, several trends have begun to challenge the original assumptions, claims, and practices of what became known as the medical humanities. In this article, the authors make the case for the health humanities as a more encompassing label because it captures recent theoretical and pedagogical developments in higher education such as the shift from rigid disciplinary boundaries to multi- and interdisciplinary inquiry, which has transformed humanities curricula in health professions. Calling the area of study health humanities also underscores the crucial distinction between medicine and health. Following a brief history of the field and the rationales that brought humanities disciplines to medical education in the first place-the "why" of the medical humanities-the authors turn to the "why" of the health humanities, using disability studies to illuminate those methodologies and materials that represent the distinction between the two. In addition, the authors make note of how humanities inquiry has now expanded across the landscape of other health professions curricula; how there is both awareness and evidence that medicine is only a minor determinant of health in human populations alongside social and cultural factors; and finally, how the current movement in health professions education is towards interdisciplinary and interprofessional learning experiences for students.

It would be unusual to find a current medical school administrator or faculty member who has not heard the phrase "literature and medicine" or who does not know that literature is taught in various forms-short stories, novels, poems, essays-at many points in the curriculum at U.S. medical schools. Yet the phrase is used in slippery if not elusive ways, with no clear referent common to all who use it. This article focuses on three theoretical and pedagogical uses for literature in medical, health professions, and interprofessional education: close reading, ethical or moral inquiry, and drawing illustrations. Summaries of these approaches are provided, followed by demonstrations of how they might work in the classroom by using the story "Blankets," by Native American writer Sherman Alexie.Close reading requires reading slowly and carefully to enrich an initial encounter with a text. Ethical or moral inquiry turns to literary representations to challenge readers' assumptions and prejudices. Literature offers rich, provoking, and unusual depictions of common phenomena, so it can be used to draw illustrations. Although each approach can be used on its own, the authors argue that reading closely makes the other two approaches possible and meaningful because it shares with the diagnostic process many practices critical to skilled interprofessional caregiving: paying attention to details, gathering and reevaluating evidence, weighing competing interpretations. By modeling a close reading of a text, faculty can demonstrate how this skill, which courts rather than resists ambiguity, can assist students in making ethical and compassionate judgments.

From the poetry of William Carlos Williams, the novels of Walker Percy, and the short stories of Anton Chekov to the contemporary essays of Atul Gawande, physicians' contributions to literary genres have been significant. This article explores the specific form of confessional writing offered by physicians during the past half century, writing that often exposes medical error or negative feelings towards patients. A history of confessional practices as a legal tool, as religious practice, and as literary genre is offered, followed by analyses of selected confessional writings by physicians, many of them found in clinical journals such as Journal of the American Medical Association, Annals of Internal Medicine, and the Lancet. The authors of the narratives described here are engaged in several or all elements of the confessional sequence, which may offer them some resolution through the exposure and acknowledgment of their shared humanity with their patients and their expression of regret for any harm done.

In this essay, I explore medical humanities practice in the United States with descriptions offered by fifteen faculty members who participated in an electronic survey. The questions posed focused on the desirability of a core humanities curriculum in medical education; on the knowledge, skills, and values that are found in such a curriculum; and on who should teach medical humanities and make curriculum decisions regarding content and placement. I conclude with a call for a renewed interdisciplinarity in the medical humanities and a move away from the territorial aspects of disciplinary knowledge and methods sometimes found in medical humanities practice.

To examine perceptions of the formal, informal, and hidden curricula in psychiatry as they are observed and experienced by (1) attending physicians who have teaching responsibilities for residents and medical students, (2) residents who are taught by those same physicians and who have teaching responsibilities for medical students, and (3) medical students who are taught by attendings and residents during their psychiatry rotation.From June to November 2007, the authors conducted focus groups with attendings, residents, and students in one midwestern academic setting. The sessions were audiotaped, transcribed, and analyzed for themes surrounding the formal, informal, and hidden curricula.All three groups offered a similar belief that the knowledge, skills, and values of the formal curriculum focused on building relationships. Similarly, all three suggested that elements of the informal and hidden curricula were expressed primarily as the values arising from attendings' role modeling, as the nature and amount of time attendings spend with patients, and as attendings' advice arising from experience and intuition versus "textbook learning." Whereas students and residents offered negative values arising from the informal and hidden curricula, attendings did not, offering instead the more positive values they intended to encourage through the informal and hidden curricula.The process described here has great potential in local settings across all disciplines. Asking teachers and learners in any setting to think about how they experience the educational environment and what sense they make of all curricular efforts can provide a reality check for educators and a values check for learners as they critically reflect on the meanings of what they are learning.

The humanities offer great potential for enhancing professional and humanistic development in medical education. Yet, although many students report benefit from exposure to the humanities in their medical education, they also offer consistent complaints and skepticism. The authors offer a pedagogical definition of the medical humanities, linking it to medicine as a practice profession. They then explore three student critiques of medical humanities curricula: (1) the content critique, examining issues of perceived relevance and intellectual bait-and-switch, (2) the teaching critique, which examines instructor trustworthiness and perceived personal intrusiveness, and (3) the structural/placement critique, or how and when medical humanities appear in the curriculum. Next, ways are suggested to tailor medical humanities to better acknowledge and reframe the needs of medical students. These include ongoing cross-disciplinary reflective practices in which intellectual tools of the humanities are incorporated into educational activities to help students examine and, at times, contest the process, values, and goals of medical practice. This systematic, pervasive reflection will organically lead to meaningful contributions from the medical humanities in three specific areas of great interest to medical educators: professionalism, "narrativity," and educational competencies. Regarding pedagogy, the implications of this approach are an integrated required curriculum and innovative concepts such as "applied humanities scholars." In turn, systematic integration of humanities perspectives and ways of thinking into clinical training will usefully expand the range of metaphors and narratives available to reflect on medical practice and offer possibilities for deepening and strengthening professional education.

Context A study of medical students’ perspectives on derogatory and cynical humour was published in 2006. The current study examines residents’ and attending doctors’ perspectives on the same phenomenon in three clinical departments of psychiatry, internal medicine and surgery. Methods Two focus groups were conducted in each of the three clinical departments, one with residents and one with attending doctors, during the 2006–07 academic year. Seventy doctors participated, including 49 residents and 21 attendings. The same semi-structured format was used in each group. Questions focused on characterisations of derogatory and cynical humour along with motives and rules for its use. All focus groups were audiotaped and the tapes transcribed. Each transcript was read independently by each researcher as part of an inductive process to discover the categories that describe and explain the uses, motives and effects of such humour. Results Three categories that appeared in the first study with medical students – locations for humour, the humour game, and not-funny humour – emerged as virtually identical, whereas two others – objects of humour and motives for humour – were more fully elaborated. Discussion Discussions of derogatory and cynical humour should occur in any department where teaching and role modelling are priorities. In addition, the tenets of appreciative inquiry and the complex responsive process, particularly as they are used at the Indiana University School of Medicine, offer medical educators valuable tools for addressing this phenomenon.

There is currently little knowledge or understanding of medical students' knowledge and attitudes toward the poor. Teaching hospitals bring students face-to-face with poor and uninsured patients on a regular basis. However, an overview of the research available suggests that this contact does not result in students' greater understanding and empathy for the plight of the poor and may, in fact, lead to an erosion of positive attitudes toward the poor. A basic understanding of justice suggests that as the poor are disproportionately the subjects of medical training, this population should enjoy a proportionate benefit for this service. Furthermore, medicine's social contract with the public is often thought to include an ideal of service to the underserved and a duty to help educate the general public regarding the health needs of our nation. In their discussion, the authors situate medical students' attitudes toward the poor within larger cultural perspectives, including attitudes toward the poor and attributions for poverty. They provide three suggestions for improving trainees' knowledge of and attitudes toward the poor-namely, increasing the socioeconomic diversity of students, promoting empathy through curricular efforts, and focusing more directly on role modeling. The authors argue that service learning, especially efforts that include gaining detailed knowledge of a particular person or persons, coupled with critical reflection, presents a very promising direction toward achieving these goals. Finally, they posit an agenda for future educational research that might contribute to the increased efficacy of medical education in this important formative domain.

The use of simulation and standardized patients in medical education is firmly established. In this "point-counterpoint" format we debate not their important function but the extent to which they are used to establish "evidence" for trainees' empathic communication skills beyond their surface manifestations. We also question such issues as the power dynamics implicit in simulation when patients are not really worried or dependent but rather students who are under the evaluative surveillance gaze, often relying on formulaic and superficial behaviors associated with good communication. We offer educative experiences in narrative domains as opportunities to develop the habits of thinking and authentic feeling often absent in evaluative-based simulations.

The literature consistently reports that sexual harassment occurs with regularity in medical education, mostly in clinical settings, and most of it goes unreported. Reasons for nonreporting include the fear of retaliation, a reluctance to be viewed as a victim, a fear that one is being "too sensitive," and the belief that nothing will be done.We wanted to examine with greater concentration the stories women students tell about sexual harassment, including what they count as sexual harassment, for more or different clues to their persistent nonreporting.We used focus groups to interview 30 women students at 5 U.S. medical schools. We used systematic inductive guidelines to analyze the transcribed data, linking to and building new theoretical frameworks to provide an interpretive understanding of the lived experiences of the women in our study.Consistent with previous literature, most of the students interviewed had either witnessed or observed sexual harassment. We selected 2 theoretical lenses heretofore not used to explain responses to sexual harassment: 3rd-wave feminist theory to think about how current women students conceive sexual harassment and personality theory to explain beliefs about nonreporting.Medical educators need new ways to understand how contemporary women students define and respond to sexual harassment.

In this essay we link the rationale for the medical humanities with radical hermeneutics, a move that infuses the medical humanities with incredulity and suspicion. This orientation is particularly important at this historical moment, when the evidence-based and competency blanket is threatening to overpower all aspects of medical education, including the medical humanities discourse itself. Radical hermeneutics works relentlessly against the final word on anything, and as such, it provides a critically provocative way of thinking about doctors, patients, illness, health, families, death--in short, the experience of being human. We use three literary examples to illustrate the complex, contradictory, perplexing, and disturbing questions related to a life in medicine: Rafael Campo's "Like a Prayer," Irvin Yalom's "Fat Lady," and Richard Selzer's "Brute."

Introduction Upon designing and implementing a literature course on family values for Year 4 medical students, we found that while the supposed benefits of literary inquiry were to lead students to a deeper understanding of difficult issues such as illness and violence in the family, many of our students were unable to engage critically with the course material. This, we believe, was a result of their resistance to confronting issues such as inequality and oppression. This paper is an attempt to theorise student resistance to difficult, unruly subjects they encounter in a literature class, particularly those surrounding race, gender, social class and sexual identity. Methods We modify some of the expansive claims made by narrative medicine and put forth a new pedagogical and curricular approach to the uses of literature in medical education. Results We found that many students resisted course material and corresponding discussions, especially those related to sexual identity and non-traditional family values, male−female relationships and white racism. Discussion To reduce student resistance, we pose a more critical approach to narrative inquiry in medical settings that may deepen students' willingness to imagine what it is like to be someone who is suffering, and to work against oppressive social structures that sustain such suffering. Thus, we recommend moving narrative inquiry beyond a focus on the self and the patient in that individualised, circumscribed relationship and into a collective process involving the social, political, cultural and economic conditions that affect health and well-being.

Background: A well-known phenomenon among U.S. medical students known as pimping, or the pedagogical device of questioning students in the clinical setting, receives virtually no attention in medical literature. Purpose: Identifying 4th-year medical students' relevant knowledge and attitudes about pimping may help educators understand the range of beliefs about pimping and the role it plays in the socialization process into the medical community. Methods: Over a 2-month period, 11 fourth-year medical students at a Midwest medical school were asked 6 open-ended questions focusing on pimping as understood and experienced in the clinical setting. Investigators individually analyzed the interview data using qualitative methods to characterize students' experiences and recurring ideas and concepts. Results: All students noted the hierarchical nature of pimping, viewing it as a tool for attendings or residents to assess students' levels of knowledge. Although some students experienced malignant pimping, humilia...

The topic of developing professionalism dominated the content of many academic medicine publications and conference agendas during the past decade. Calls to address the development of professionalism among medical students and residents have come from professional societies, accrediting agencies, and a host of educators in the biomedical sciences. The language of the professionalism movement is now a given among those in academic medicine. We raise serious concerns about the professionalism discourse and how the specialized language of academic medicine disciplines has defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors subsumed under the label of "professionalism." In particular, we argue that the professionalism discourse needs to pay more attention to the academic environment in which students are educated, that it should articulate specific positive behaviors, that the theory of professionalism must be constructed from a dialogue with those we are educating, and that this theoretical and practical discourse must aim at a deeper understanding of social justice and the role of medicine within a just society.

Literary inquiry has been a part of the curriculum at many North American medical schools for more than 30 years. Ostensibly its original purpose was to “humanize” the overstuffed, science-based curriculum. Since then, other rationales for its place in the curriculum have appeared, including, among others, translating critical reading skills to “reading” the patient, obtaining moral knowledge, and acquiring patients’ perspectives on illness. In this article, I use my experiences in a literature and medicine class for fourth-year medical students to examine how they construct “family”—the medium in which most medical care is delivered—through their readings of Pat Conroy's novel, The Prince of Tides. Throughout the article I return to assumptions of how literature is supposed to “work” on medical students as they read this novel, showing how the culture of medical education, particularly its curriculum practices, has installed ways of reading and methods of analysis that oppose literature's potential offerings. Beyond the selection of texts, I address issues surrounding the epistemological, pedagogical, and ideological undertaking of literary inquiry in the medical curriculum.

The Human Values in Medicine Program (HVM) at the Northeastern Ohio Universities College of Medicine is composed of 120 required hours in medical humanities, social sciences, and behavioral sciences. In addition to a required HVM month in the fourth year when the bulk of the course work is completed, students can also choose from lectures, seminars, and short courses during the first, second, and third years. The broad goal of the HVM program as originally conceived was for students to use the content and skills of the humanities disciplines to reflect on their own and others' values, and to appraise their role in the patient-physician relationship, both in the community and in the larger culture. During the past several years, a cultural studies orientation has also been included, particularly the practice of critical analysis aimed at identifying the inequities and injustices within the doctor-patient relationship, in medical training, and in health care access and delivery in the U.S. and beyond. Current program development includes standardizing a bioethics curriculum for all students and developing a required fourth-year course that all students take during their HVM elective month.

The author proposes a theoretical orientation for cultural competency that reorganizes common curricular responses to the study of culture in medical education. What has come to be known in medical education as cultural competency is theoretically truncated and may actually work against what educators hope to achieve. Using Giroux's concept of insurgent multiculturalism, she suggests that the critical study of culture might be a bridge to certain aspects of professional development. Insurgent multiculturalism moves inquiry away from a focus on nondominant groups to a study of how unequal distributions of power allow some groups but not others to acquire and keep resources, including the rituals, policies, attitudes, and protocols of medical institutions. This approach includes not only the doctor-patient relationship but also the social causes of inequalities and dominance. Linked to professional development efforts, insurgent multiculturalism can provide students with more opportunities to look at their biases, challenge their assumptions, know people beyond labels, confront the effects of power and privilege, and develop a far greater capacity for compassion and respect.

Since its publication in 1978, Samuel Shem's The House of God has sold over two million copies in over 50 countries. While it has remained popular among medical students, its value as a literary text to promote critical reflection on self and profession continues to be unrecognized in professional spheres. In spite of the ongoing conditions in medical training that prompted Shem's satirical novel, The House of God continues to evoke negative responses from academic medicine and has even been dismissed as "dated." This article examines the novel, its reception by academic medicine, and the relevance of its satire through an analyses of articles, reviews, and letters, along with Shem's observations on the novel and its controversies. Finally, the future of The House of God is proposed.