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Students of medicine: broadening their studies.

Over the last 30 years, a growing desire for students of medicine to broaden their studies has emerged, notably in the humanities. This accompanied a culture change: increasing awareness of the limitations of the biomedical model of medicine with a realization of the need for an approach encompassing not just the patient’s symptoms and signs but their interaction with the patient’s life and environment. The age old twinning of medicine and literature characterized by Apollo, the Greek god of medicine and poetry, slowly fell apart through the scientific revolution, described by Snow as a ‘two culture’ dichotomy in 1959. This declaration inspired a new look at the way science, especially medicine, is performed and led to a recognition of a need to reconnect these disciplines. A slow but steady revival of interest in the humanities in medical education has occurred, looking at everything from the history, philosophy and ethics surrounding medicine to studies as diverse as arts and literature. In this editorial, we seek to look at the methods and evidence behind teaching of one of these: literature. This change happened most notably in the USA with an increasing use of literature teaching within medical schools, with approximately one-third teaching literature to students in 1994. Similarly, in the UK, an increasing number of literary options have evolved after publication of Tomorrow’s Doctors in 1993. This created ‘special study modules’, an optional part of the undergraduate curriculum where students are encouraged ‘to study in depth in areas of particular interest to them’, often only loosely related to medicine. An increasing number of humanitiesrelated intercalated degrees, where students take a year out in their undergraduate training, are available, although not all these have literature content. Why is literature thought to be good for medical students and doctors? It has been suggested that it will foster ‘increased empathic understanding, development of complex interpersonal skills and a greater appreciation for the art of medicine’. Another view, proposed notably by the psychiatrist Coles, views literature merely as a tool for teaching medical ethics—with ‘stylistic analysis being clearly subordinate to questions of character and action’. Recently, there has been a convergence of these views, espoused by Charon in her concept of ‘Narrative Medicine’. Narrative medicine can be seen as an evolution of the two previous views: a model for understanding the stories of patients and the competence to ‘absorb, interpret and respond to stories’. Although not directly related to the study of literature, Charon proposes that this is easiest for students of literature and suggests literature as a method to start the practice of narrative medicine. A recent review in the New England Journal of Medicine explains the concept well. Narrative medicine is just one of the many ways in which literature is used in medical teaching. There are numerous other techniques used worldwide in both undergraduate and postgraduate teaching—from creative writing to classical literary criticism, book groups, role play, poetry workshops, film and theatre studies. The evidence to support a positive effect of literature on clinicians is thin: this may be due to a lack of definition. Given the variety of the courses on offer, there is no consensus on what teaching ‘literature’ is. The courses differ in their length, content and assessment. At the other end, it is not clear which outcomes should be measured, as there appears to be no clear idea what literature is trying to improve. Our literature search did not find any trials comparing a group studying literature to a control group. A few case reports have originated from universities including literature either as a required component: Oslo and Chicago being two of many examples (issue 10 of volume 78 of Academic Medicine lists many of the US courses). In the UK, Birmingham and Nottingham Medical Schools offer special study modules in literature studies and Kings’ College London has a well-regarded masters programme. Reports from these courses are generally very favourable, concluding that the students had a better