ORIGINAL ARTICLES AND REVIEWS
Medical humanities in healthcare education in Italy: a literature review
Laura FieschiI; Maria MatareseII; Ercole VelloneIII; Rosaria AlvaroIII; Maria Grazia De MarinisII
IScuola di Dottorato in Scienze Infermieristiche, Università di Roma Tor Vergata, Rome, Italy
IIUniversità Campus Bio Medico di Roma, Rome, Italy
IIIUniversità di Roma Tor Vergata, Rome, Italy
ABSTRACT
OBJECTIVE. The introduction of medical humanities (MH) in undergraduate medical education in Italy has been an issue of debate since the 90's and few years later it was extended to other healthcare degrees. The aims of this Italian literature review, after considering the international scene, are: to evaluate the extent to which the interest in this subject has gradually developed throughout the country; which professional groups have contributed to the debate; to identify which theoretical constructs led to the introduction of MH in undergraduate medical education; to identify whether a clear and shared definition of MH exists in Italian literature; to verify what kinds of MH experiences have been accomplished in Italy.
MATERIALS AND METHODS. A comprehensive literature search was conducted, including electronic databases, bibliographies, manual sorting of articles in paper format, congress proceedings.
RESULTS. The analysis of the chosen articles underlines that, however limited, Italian literature does not present a very different picture from the international scene. It emerges that teaching MH is believed to be an important feature in undergraduate education of healthcare professionals who intend to propose a bio-psychological-social approach to care, in spite of the difficulty to measure its short and long term effectiveness. The lack of a multidisciplinary, multi-professional approach is also evident.
CONCLUSION. Further research aiming to implement the quantity and quality of MH studies in the curricula of undergraduate healthcare education is desirable.
Key words: medical humanities education healthcare professions
INTRODUCTION
An exclusively technical-scientific approach to education is more and more considered inadequate for the 21th century doctor. Any clinician who wishes to be fully prepared to understand and tackle many of the inevitable future problems cannot avoid the concept that the aim of medicine is always the investigation of diseases and should always keep in mind that the patient is a human being. To neglect this simple but founding element would give rise to an increasingly wider gap and would make the already difficult communication between doctors, patients and society impossible.
For many years, in the past, medical and philosophical studies had been combined into a single faculty - facultas artistarum. The students who graduated in medicine also achieved a degree in medicine and philosophy. The faculties were separated in the 19th century. It was established, however, that before beginning their medical studies, the students were to attend a two year course of philosophical studies which could provide the future physician with adequate knowledge of the general problems and a solid education to the rules of rational thought. Logic and moral philosophy represented the two fundamental pillars of their acquisition of a firm methodological training and the set of values on which they could found their future professional behaviour [1]. The complete separation of the two faculties took place during the period of Italy's unification into a single state, when the faculty of medicine ceased to have any link with the so-called spiritual sciences and was transformed into a purely naturalistic faculty. The movement, which in the United States beginning from the 50s-60s supported the need to integrate the typically scientific subjects of medical education with medical humanities (MH), developed with the spreading of anthropological medical research [2] on the meaning of illness and treatment, on the need to place the patient, intended as a human being, at the centre of all the process of care. This led to the crisis of the biomedical model, concept which had already been described and criticized by Engel [3]. Humanistic education, considered by many authors necessary for the spreading of a patient-centred culture of care and not only on his objective symptoms, has been regarded from the beginning as complementary, not in opposition to scientific education. In 1951 HB Van Wyck [4] dealt with the issue of medical doctors' education in a conference in Canada concluding that he hoped the teaching of sciences and humanities would be duly integrated; in 1976 in an editorial of the Journal of the Royal College of General Practitioners, it is stated: "We believe that the choice between the arts or science represents a false and dangerous dichotomy. In many aspects of the doctor/patient relationship, the knowledge and understanding of drama, literature and philosophy can greatly help understanding" [5].
What is certain is that from the 70s onwards MH in the USA have been gradually but widely introduced in the curricula of the faculties of medicine and since then many other English speaking countries have followed their example [6, 7], thus recovering those humanistic roots already present in the ancient university tradition. The arguments in favour of this trend can be summarized in the concept according to which scientific education, which refers to a positivistic-reductionist paradigm, has mainly a biomedical perspective and does not allow the physician to acquire the necessary skills to help him satisfy the patients' global complex health needs [8].
"Laughing is contagious! We must take care of the person as well as the disease" says Patch Adams, the protagonist of the much contested film bearing the same title, starring Robin Williams.
The study of humanistic subjects and artistic forms such as philosophy, ethics, literature, theatre, cinema, figurative arts and music have become practical didactic experiences in many medical schools and also, since the 90s, in nurse training courses [9-11] in order to limit the risks of the standard and undifferentiated response of "technological and scientific medicine". By introducing MH, the educators' aim was to foster the achievement of aptitudes and modes of behaviour indispensable for the realization of the so-called "humanistic medicine"; this is characterized by an empathic and holistic approach, ranging from the development of communicative and relational skills to the acquisition of more involving ones based on compassionate care; from the achievement of decision making to problem solving skills; from the ability to observe and interpret signs and symptoms to reflection and socializing skills etc. [12]. However, after almost a century of debate, a clear and shared definition of MH has not yet been reached: "What are medical humanities?" asks in 2004 Jill Gordon [13], honorary associate professor at the University of Sydney, although the introduction of medical humanities into the faculties of medicine in Australia dates back to 2004; Martin Evans, professor of humanities in medicine and co-director of the Centre for Arts and Humanities in Health and Medicine of Durham University, writes an article in 2007 entitled "Medical humanities: stranger at the gate, or long-lost friend?" [14] in which he speculates on the meaning given to this expression and on the relationship between medical humanities and philosophy; Howard Brody, director of the Institute for Medical Humanities (University of Texas) in 2009 writes on Journal of Medical Humanities that, although a set of courses of medical humanities had already been introduced into the curricula of medicine in the USA back in the 60s and 70s, to give an exact definition to MH still remains a challenge [15].
The main techniques through which MH have an impact on medical education [7] seem to concern the exposure of the students to "simulated experiences" (based on literature, films, plays etc.) in which they engage the difficult task of understanding and interpreting the significance of complex human situations; their active participation in the artistic process moreover allows the students to explore more deeply into emotions and feelings thus widening their own horizons of thought [12].
Few articles in international literature report empirical studies concerning the impact of MH on medical education in terms of knowledge, attitudes and behaviour. Mostly all of the available studies suffer from methodological "weakness" [16] concerning the teaching/learning issue and leave many questions unsolved about the possible correct employment of MH in medical education and their contribution to the care quality offered to the patient.
It is uncertain whether the students who participate in MH activities will actually become "better" doctors and whether their patients will receive better care. One of the most generally feared risks in recent years is that this lack of evidence of effectiveness might discourage the educators from making a constant and integrated use of MH in the curricula of the faculties of medicine.
A review of Italian literature was considered useful in the current variegated situation of MH on the international scene in order to assess to what extent the interest in this issue has developed in time and which professional categories have participated in the debate; on which theoretical constructs the proposal of introducing MH in medical and health care professional (HCP) education is founded; whether a clear and shared definition of MH exists in Italian literature; moreover we intend to understand what kind of MH experiences have been accomplished in the Italian faculties of medicine.
METHOD
The research covers the period between the publication of the first retrieved article and the first six months of 2011.
Research strategies as complete as possible have been adopted:
- electronic databases;
- bibliographies;
- manual sorting of articles in paper format;
- congress and conference proceedings.
The main international data bank were searched: CINHAL, Medline, PsychINFO, Education Research. The research was carried out using the free terms "medical humanities" and the term Ital* using the Boolean operator AND for the fields Title and Abstract. The term Ital* was subsequently cancelled and the limit of the language of publication (Italian) was inserted. The research was also carried out through Google Scholar to verify the existence of further publications or "grey literature". In the same way a research was carried out in the Ilisi data base (data base of the Collegio IPASVI in Rome which offers the possibility to research and consult index cards of the articles published in the main Italian nursing magazines), also using "education" as indexation category.
On Italian on-line magazines, in the sites where this modality can be used, the research started by using "medical humanities" as key word, since the Italian translation was not considered satisfactory and it is not generally used. Other terms used to express similar concepts were subsequently identified.
As for paper format magazines, manual consultation of the archives was carried out in libraries, selecting the articles on the basis of their titles and abstracts, where present. A further phase of selection allowed us to eliminate all the inappropriate material, thus defining a posteriori the criteria of inclusion and exclusion, which are summarised as follows:
- we limited our research to Italian medical or nursing magazines which publish topics pertaining to the education of physicians and healthcare professionals;
- we included only articles containing in their title, abstract or text the following key words - besides MH: human sciences, humanities, humanism, narration, autobiography, art, cinema, film, literature, poetry, provided they were associated to health professions;
- we excluded reviews and letters to the magazines. Editorials were not excluded from the review since in this phase of the debate on MH they contribute to define their theoretical and pedagogical assumptions;
- we included articles taken from conferences and/or congresses;
- we excluded articles based on the experience of patients and their family.
Thus, the main magazines of the sector which are currently in circulation were identified: Medic - Metodologia didattica e innovazione clinica; L'Arco di Giano; Janus, Medicina: Cultura, Culture; Tutor; International Nursing Perspectives; and Medicina Narrativa. It was not possible to consult the magazine Rivista per le Medical Humanities, which has been published in Italian since 2007 in the Ticino Canton (Switzerland), as it was only available in one library on the national territory.
RESULTS
Ninety-eight articles were found in all. After a careful reading and after completing the selection of publications on the basis of the criteria of inclusion/exclusion, 60 articles were included in the review.
The distribution of the articles in the journals was:
- Medic - Metodologia didattica e innovazione clinica: 14;
- Tutor: 20;
- Medicina Narrativa: 2;
- Janus: 6;
- L'Arco di Giano: 10;
- International Nursing Perspectives: 3;
- Nursing Oggi: 1;
- Atti convegni: 4;
- Total: 60.
The time distribution of the publications is represented in Figure 1.
Contributions to the debate on MH mainly come from doctors, followed by philosophers. Few articles were written by nurses, pedagogists and psychologists and an anthropologist has contributed with two articles. No contribution was given by any other health professionals.
The profession of the 71 authors was:
- doctors: 33;
- nurses: 9;
- philosophers: 7;
- pedagogists: 4;
- psychologists: 2;
- others/non specified: 16;
- Total: 71.
The majority of articles found is represented by theoretical contributions to the debate and by articles of discussion, variously supported by analyses as well as theoretical, historical and anthropological argumentations: 5 of them are editorials, there are 6 articles describing training experiences, 4 articles reporting results of empirical research and one literature review.
In the field of MH there is quite a vast area of literature dedicated to narrative medicine (NM), to the use of narration as a contribution to self-training in the social context, but also as an integral part of health treatment (autobiographies, autopathographies, diaries). This review has taken into consideration only the articles related to the use of NM in the education of health professionals.
Following Zannini and Visioli's [17] definition which describes the relationship between humanities, narrations and illness narratives as: "the large container of humanities (which include the so-called "human" disciplines) includes narrations which in turn include illness narratives", we have examined together MH and NM literature. While the articles analysing theoretical constructs deal with MH in general, those specifically concerning educational proposals or descriptions of experiences refer to precise forms in the narrative field.
As far as the theories and constructs at the basis of MH are concerned, the analysed articles point out that their theoretical foundation reveals a crisis of the existing model of treatment, which is based on the concept of disease. Consequently, the articles point out the need for a change in treatment paradigm which is not only biological but bio-psycho-social and patient-centred. Many authors underline the importance of the relationship with the patient, with the background of the person considered as the subject rather than as the object of treatment, in order to reach a shared attribution of meaning of the disease. In this way, the competence behind the medical act is not only based on fundamental biological and clinical informations but also on the "subjective" knowledge of the patient's real experience [18-23]. MH, in the same way as NM, can create the right conditions for a different relationship between physician and patient, which should resemble a partnership [18-24] aiming at the achievement of an effective therapeutic alliance. Going into the detail of NM, Parizzi [25] states that "It is not a new fashion, but the rediscovery and reaffirmation of the role and primary task of being a doctor, which implies listening, attention, respect, sympathy, sharing, participation, empathy". Some authors point out that it is not a technique, but it is rather a cultural outlook of consideration and attention depending on the mental attitude of the professional [25-27].
Some authors underline the need to move away from educational models mainly oriented towards "technicality and the omnipotence of medical science" [20, 28], in favour of models responding to the real health needs of the individual and of the whole community, taking into consideration both the changes of the citizens' needs, and the different social-economic conditions.
All authors agree that any contrast between evidence-based medicine and narrative-based medicine does not exist, on the contrary the humanistic and scientific-technological approaches should be complementary, thus harmonizing the gap between "science of nature" and "science of the spirit".
The definitions of MH found in Italian literature can be subdivided into two fundamental classes: one identifies the fields of knowledge which MH introduce in syllabuses and the other is of a teleological kind.
As far as the former is concerned, many authors agree with Cattorini [27], according to whom MH refer to different disciplines and practices going from medical psychology to literary criticism, from health anthropology to the history of health and to ethics, but also religion, theatre, figurative arts, music, law, philosophy, sociology [18, 19, 21, 24, 28-40] and more in general "all the arts and reflections on arts and man and on man's knowledge" [41].
As for teleological definitions, four different functions of MH can be found:
1. development of an empathic attitude;
2. development of interpretative abilities;
3. understanding and self-care;
4. acquisition of ethical sense and of responsibility.
Development of an empathic attitude
There is an agreement concerning the role MH have in improving an emphatic attitude and in preparing undergraduate students to a therapeutic relationship which gives importance to the experiences, the needs and problems of every single patient. By educating to values such as understanding, tolerance, respect, "it is possible to help undergraduate students to learn from their emotions, to help them become experts in humanity" [23, 26]. Narration and understanding is fundamental in the relationship between doctor and patient [27], where "understanding" is referred to the sciences of the spirit and to the person, to meanings and values, rather than to the "explanation" of a causal relation, which concerns the sciences of nature [32, 36, 42, 43].
Development of interpretative abilities
According to several authors, MH have the function of providing students with interpretative abilities of events linked to health/disease experiences, through the retrieval of the history of patients, which goes far beyond their clinical history. The acquisition of narrative competences makes it possible for them to understand the dialogic aspect of narration in clinical interviews and in drawing up the case history, in contrast with the monological approach of an objective exam on the patient [40]. The confusion or the manner in which the patient gives his narration of events may provide a careful listener with relevant elements for the interpretation of the clinical case and of the features of the pathology of that particular patient, his/her experience and the reasons behind the long duration of some pathologies [44, 45]. Drawing up a case history and clinical reasoning, which are fundamental in the diagnostic process, require hermeneutic abilities which can be developed through the study of MH, since the interpretation of a text requires the same abilities as the interpretation of signs, symptoms and of the care needs of the patients [19, 31].
Understanding and self-care
MH and narration are considered by some authors understanding and self-care instruments which can help students develop a reflexive attitude, contributing to increase the abilities to analyse one's emotions and behaviour, which are factors of protection against the appearance of anxiety, frustration and burn-out [17, 26, 37]. Books, short stories, films offer precious opportunities as they can evoke emotions, reflections, memories, connections to one's experience, allowing, at the same time, to keep that emotional distance which makes the analysis and re-elaboration of one's experiences possible. Through narrations it is possible for readers to discover and transform their own feelings and actions [22, 46]. Some authors [25, 40, 45] support that the re-elaboration of one's experiences through reading prepares doctors and nurses to a direct relationship with the patient, leading them to investigate on the sense and meaning of illness and, in a broad sense, to face it also from an existential point of view, before having to treat them concretely and responsibly in their various professional contexts. Moreover, through literature, it is possible for students to approach the problem of death, which is currently almost ignored in the Faculties of Medicine, except for the assessment of death ascertainment which is taught in the courses of Legal Medicine [44].
Acquisition of ethical sense and of responsibility
MH can provide "a historical-epistemological framework in which the ethical-social and ethical-economic dimensions of medicine can find a definition and a composition" [39, 47]. Having deep-rooted human values can help future professionals to adjust to an uncertain and constantly changing social-health context, as well as contribute to the ability to rationalize economic resources, to understand the social representations of diseases, which vary in indifferent ethnic and religious groups [22, 30]. MH would greatly contribute to the formation of a highly professional behaviour (professionalism) which requires, besides specific knowledges, the ability to tolerate ambiguity, to observe one's own thoughts, to give integrated judgement to clinical problems and to recognize one's own mistakes [48]. The cinema and literature "help us point out the growing weight of economy on our health systems and the equity problems connected to the access to health services" [49]. Moreover, they can offer cultural instruments which can be of use in case of doubts and can represent a guide when making professional decisions and in the acceptance of their limits [42, 50].
MH offer undergraduate students instruments to understand the experience of illness and, consequently, a guide in the formulation of ethical assessments in order to adopt the most suitable clinical behaviour towards a patient. Literature guides the doctor's attention to focus on the ethical dimensions of diseases and of medicine, recalling the sense of responsibility and the pact of mutual trust [22]. A particular aspect of MH is dealt with in the article by Borghi and Pennacchini [51] who, recalling some concepts on the comparison between medical knowledge and biotechnological knowledge [20], tackle the issue of technical humanities, defined as a series of philosophical reflections on the meaning and purpose of science and technology, which should contrast the spreading of reductionist attitudes. As far as this matter is concerned it is interesting to indicate the positions of Spinsanti [49] and Trabucchi [45], who warn against the trivialization of some positions which reduce MH to the role of humanising medicine or mitigating the coldness of a technological approach not supported by the deep knowledge of the person's history and his/her disease. If so, MH risk being reduced to medical amenities.
As for the modalities of teaching MH and their introduction into the curricula of undergraduate students attending the faculty of medicine, there are few guidelines, while many authors underline the possible risks of the lack of adequately planned courses.
Several authors [23, 36, 37, 47, 52] point out a discrepancy between decrees and ministerial guidelines, which provide clear indications on the teaching of humanities, and universities, where the programmes of the courses are often fragmentary and inadequate.
Corbellini [47] believes that before introducing MH teaching, it is necessary to declare the epistemological premises from which to start as far as the statute of knowledge and medical practices are concerned. Vettore [23] adds that it is not enough to simply conform to the new curricular systems, but it is necessary to adopt suitable pedagogically grounded educational methodologies. An interdisciplinary approach, in which different disciplines do not simply coexist, but interact, is desirable [27, 43], since "without a theoretical foundation on the connection between medicine, clinical education, narration and science, MH are bound to be merely juxtaposed to the current biomedical practices". Some authors bring up the issue of planning, underlining the need to define the goals of a training project in the field of humanities and emphasizing the importance of an accurate preliminary work of research and selection of the material [22, 53].
According to Malacrida [33], "the red thread running through MH teaching might start from virtue ethics which is based on the forming of the character, habits, attitudes of care givers. Then it might develop into care ethics, based on values such as empathy, sympathy, trust not simply considered as feelings but as a search for solutions to value conflicts. It might also include the ethics of the principles of autonomy, dignity, vulnerability, distributive justice, which allows a point of contact between deontological theory and utilitarian theory".
As for the final aim of our review, related to MH educational courses, we refer to the 6 articles which describe educational experiences and to the 4 empirical studies we found. The description of these experiences contain propositions and educational suggestions which include the introduction of literature, the cinema and reflexive writing as learning tools.
Some authors share the opinion that "the most suitable educational setting for this kind of didactic activities is a small group, since it is easier to activate reflections and interpretations, free expression and exchange, therefore, the circularity of experiences" and they underline the role of tutors who should preside over the phases of this process [17]. As for the best period in which the training co urses should be held, some suggest that they should take place during the first years, while others believe that MH should accompany students throughout the whole course of their studies [48].
The articles dealing with the use of the cinema for educational purposes all agree it offers great educational potentialities thanks to its great power of suggestion and its evocative capacity to stir emotions. Depending on the available time or the specific aims one wishes to reach, it is possible to show some scenes or entire films which creates greater involvement and enhances the ability of observation and interpretation [53]. Some learning tools can be exploited to sustain and complete the film vision: reviews, film ratings, grids for analysis which could be handed out before and/or after the film projection; a brainstorming activity could be helpful; moreover, some questions or a questionnaire could help the students to reflect about the proposed situation and to conduct the debate; furthermore, it is possible to leave the students some time to write down their individual reflections followed by a small group debate. A feedback questionnaire can report the students' degree of appreciation on the course: this should allow the teacher/educator to make possible adjustments in future decisions [37, 54].
Among the reflection activities, Garrino [55] suggests keeping a diary is a significant educational means from the methodological point of view since it obliges to reflect upon one's own experience. According to the phenomenological-existential approach, a written record helps us to memorise and to make use of our experience, to investigate a feeling or give a meaning to our knowledge as well as providing a critical revision of our behaviour and our role in relation to the patient's expectations and questions.
Some authors bring up the problem of training educators. According to Zannini [48], they should be identified as "people who make learning easier", on whose competence little has been invested so far [37]. It is necessary to consider carefully the role of "teachers, their specific competence, their ability to deal with experts in other fields, but also their ability to use analogies and metaphors" [22]. As far as the use of films for educational purposes is concerned, it is essential for educators to be specifically prepared so that they can optimise their educational effectiveness, avoiding a mere instrumental use of films which would be an end in itself [53]. If the teacher is not a health professional, the possible risk of losing sight of the necessary connections to clinical practice is underlined, as this would make the intervention abstract and less effective [21].
Three articles deal with the specific aspect of writing as a reflective practice and the use of diaries in the training of clinical tutors in the degree course in nursing [56-58]. The importance of MH also in continuing education is highlighted by some authors [31, 61]. Two articles [59, 60] concerning medical education describe the educational process in seminars on clinical ethics deliberation. These courses made use of literary passages and film clips, followed by sessions of debate and in-depth analysis. Torsoli [19] and Albano [62] hope that, like in many other countries, Departments of Medical Education will be established also in Italy, but this has currently taken place only in very few Universities.
The educational aims of the several courses where MH and NM are taught include:
- the development of clinical reasoning abilities and the understanding of human beings [63];
- the development of literacy skills and narrative competence training [48, 64];
- the enhancement of the ethical and sympathetic dimension of diseases [27, 53];
- the understanding of pain [65, 66];
- the development of emotional and relational abilities [25, 54];
- the development of listening skills and the ability to form relations with the patient [23, 32].
Several methods of using literature are described in the selected articles: readings of extracts or entire classic and/or contemporary works, followed by a comment session and guided discussions in small groups, with the elaboration of a final report and a written text containing personal reflections [22, 63, 65]; elaboration of stories re-written or re-read from the point of view of other characters [64]; the use of diaries [51], autobiographical writing and text analysis [48].
Only 4 articles report the results of empirical researches. In 3 of them the didactic methodology was based on film projections, while in the fourth several techniques were followed (films, psycho-social-plays, autobiographies and photolangage).
The educational aims of the courses were multiple:
- to assess the impact of the use of films and documentaries on the education of undergraduate medical students [28];
- to guide undergraduate medical students to in-depth analysis of several issues (medical models, communication, pain, isolation, mental diseases, right to treatment) within a laboratory of communication skills [66];
- to provide nursing students with elements for a general approach to pain management [65];
- to help undergraduate medical students control their emotions [67].
Owing to the variety of teaching and evaluation methods, it is not possible to summarise them here and only some common features will be pointed out:
- almost all authors underline the need to clearly define the educational aims and that expert educators/tutors should preside over the phases of the course;
- awareness of working in an interesting, yet still unexplored field;
- several articles emphasize the difficulty to evaluate the effectiveness of MH courses.
The latter point has given rise to many considerations, in particular concerning the risk of using quantitative methods to assess their educational effectiveness, since not all learning outcomes are objective and thus measurable. There are other important aspects such as the evaluation of the process, the ability of self-evaluation and also the students' and tutors' appreciation of the course [17, 68, 69]. Even with the awareness of the difficulties and limits of evaluation in the pedagogical field, where "there still remains a certain amount of confusion between educational experience and reflection on the experience itself, which is the very essence of research", and where - due to reasons of ethical nature - it would be inappropriate to resort to a control group in setting up the research, it is however necessary to identify describers of educational quality which make it possible to monitor and assess the innovations presented in time [66]. In this research the evaluation papers, filled in annually at the end of the training period by the clinical tutors, have been used as indicators of the effectiveness of the educational intervention. The results show that students gradually improved their ability in forming more open relationships with patients and in understanding the psychological relevance of problems besides becoming more prepared to being exposed to the patients' pain and suffering. Leone et al. [67] in their study report very detailed methodologies concerning data analysis. Besides considering students' evaluation of the experience, they used quantitative methods of analysis of the participants' verbal and non-verbal communication rating video-taped students interactions.
All the educational experiences where students' appreciation was assessed report a positive evaluation. The fact that the courses were not compulsory might make this be considered a bias in sampling. Zannini [48], on the contrary, reports some criticism from the students concerning MH teaching, which would not be able to develop concrete abilities and, although stimulating, is perceived as irrelevant for their future profession. Moreover, MH are sometimes considered too involving and intrusive and consequently students indicate that the best way to integrate them into their curricula is through elective courses.
CONCLUSIONS
The analysis of the selected articles shows that, however limited, Italian literature does not substantially differ from the international scene. It emerges that the introduction of MH represents an important element for educators who wish to propose a different model of care other than the bio-medical one, in spite of the awareness that it is difficult to measure its effectiveness in the short and long period. Moreover, the lack of a multidisciplinary and multiprofessional approach risks to confine the experiences to restricted and limited areas instead of involving all the faculties of medicine in which declared objectives and teaching practices should find appropriate and coherent relations.
As for the distribution of research in time, there is no evident increase in the number of these studies, which in fact affect a small part of the academic world. Within this group there is no network of educators and tutors who shared their experiences, which instead remain limited to a small number of universities.
The only contribution, although very small, of non-medical health professionals to the current debate comes from nurses.
As for results, even after 15 years between the first and latest research, there is no consolidation of knowledge supported by significant results.
Further research is needed to fill the above mentioned gaps: it is desirable first of all to carry on with new experiments in order to implement the quantity and quality of the studies on MH in the curricula of degree courses of health professions. In our opinion, it would be necessary to develop programs of pedagogical research supported by well-structured protocols, which include above all modalities of monitoring and long and short term result evaluations, identifying the most suitable indicators in order to assess the selected learning aims.
Moreover, the planning of MH courses still presents open issues, such as:
- whether MH teaching must be offered as compulsory courses, inserted in the core curriculum, or as elective courses students can choose to attend;
- in which phase of degree courses MH might be introduced (before clinical instruction, at the beginning of an internship, throughout the whole course of studies);
- whether to insert MH also in continuing professional education;
- which professional figures should undertake teaching MH and how to train educators.
REFERENCES
1. Binetti P, De Marinis MG. La prospettiva pedagogica nella Facoltà di Medicina. Roma: SEU; 2002.
2. Good BJ. Narrare la malattia. Lo sguardo antropologico sul rapporto medico-paziente. Torino: Edizioni di Comunità; 1999.
3. Engel GL. The need for a new medical model. A challenge for biomedicine. Science 1977;196(4286):129-36.
4. Van Wyck HB. The role of the humanities in medical education. Can Med Assoc J 1951;64:254-60.
5. Editorial. The arts as aids to learning J Royal Coll Gen Pract 1976;26:555-9.
6. Kuper A. Literature and medicine: A problem of assessment. Acad Med 2006;81:128-37.
7. Perry M, Maffulli N, Willson S, Morrissey D. The effectiveness of arts-based interventions in medical education: a literature review. Med Educ 2011;45:142-8. DOI: 10.1111/j.1365-2923.2010.03848.x
8. Cooper RA, Tauber AI. New physicians for a New Century. Acad Med 2005;80:1086-8.
9. Darbishire P. Understanding caring through arts and humanities: a medical/nursing humanities approach to promoting alternative experiences of thinking and learning. J Adv Nurs 1994;19:856-63. DOI: 10.1111/j.1365-2648.1994.tb01161.x
10. Wainwright SP, Williams C. Culture and ageing: reflections on the arts and nursing. J Adv Nurs 52(5):518-25. DOI: 10.1111/j.1365-2648.2005.03620.x
11. Dellasega C, Milone-Nuzzo P, Curci KM, Ballare JO, Kirch DG. The humanities interface of nursing and Medicine. J Prof Nurs 2007;23:3:174-9. DOI: 10.1016/j.profnurs.2007.01.006
12. Ousager J, Johannessen H. Humanities in undergraduate medical education. A literature review. Acad Med 2010;85:988-98. DOI: 10.1097/ACM.0b013e3181dd226b
13. Gordon J. Medical humanities: to cure sometimes, to relieve often, to comfort always. Med J Aust 2005;182(1):5-8.
14. Evans H. Medical humanities: stranger at the gate or long lost friend? Med Health Care Philos 2007;10:363-72. DOI: 10.1007/s11019-007-9079-x
15. Brody HJ15. . Defining the medical humanities: Three conceptions and three narratives. J Med Humanit 2011;32:1-7. DOI: 10.1007/s10912-009-9094-4
16. Stern DT, Jordan JC, Bruder A, Packer B, Sole A. Teaching humanism Perspect Bio Me 2008:51(4):495-507.
17. Zannini L, Visioli S. Narrazione e medical humanities. Tutor 2004;4:26-32.
18. Editoriale. Alcune ragioni per un insegnamento delle humanities agli studenti di medicina. Medic 1999;7:5-8.
19. Torsoli A. Salute ed educazione medica: esigenze di qualità. Tutor 2001;1:11-6.
20. Canestrari B. Sapere medico e sapere biotecnologico a confronto. Medic 2002;10:214-6.
21. Zannini L. Per una pedagogia narrativa e interpretativa nella formazione degli operatori sanitari. L'arco di Giano 2003;37:123-38.
22. Binetti P. Modi e modelli della formazione medica. Medic 2004;12:18-25.
23. Vettore L. Luci ed ombre dei nuovi curricula della facoltà di medicina. L'arco di Giano 2009;61:203-20.
24. Editoriale. Letteratura umanistica e curriculum degli studi medici. Medic 1996;4:65-6.
25. Parizzi F. La medicina narrativa. L'arco di Giano 2009;61:165-73.
26. Bert G. La medicina narrativa nella formazione dei professionisti sanitari. In: Gentile AE, Luzi I, Razeto S, Taruscio D (Eds). Convegno Medicina narrativa e malattie rare. Istituto Superiore di Sanità. Roma 26 giugno 2009. Atti. Roma: Istituto Superiore di Sanità; 2009. (Rapporti ISTISAN, 09/50). p. 61-6.
27. Cattorini P. A qualcuno piace umano. Narrazione, etica e medicina: il caso del cinema. In: Gentile AE, Luzi I, Razeto S, Taruscio D (Eds). Convegno Medicina narrativa e malattie rare. Istituto Superiore di Sanità. Roma 26 giugno 2009. Atti. Roma: Istituto Superiore di Sanità; 2009. (Rapporti ISTISAN, 09/50). p. 69-85.
28. Fognini G, Duca P, Casazza G. Medicinema: la formazione del medico e il contributo della decima musa. Considerazioni su di una sperimentazione didattica. Medic 2005;13:50-6.
29. Editoriale. Umanesimo e umanità clinica. Medic 2000;8:113-4.
30. Editoriale. Educazione medica: alcune implicazioni di un approccio bio-psico-sociale e umanistico. Medic 2002;10:174-6.
31. Delvecchio G, Gandini T, Barberis L. La qualità nella formazione continua. Tutor 2001;1:46-53.
32. Russo MT. Il ruolo delle scienze umane nella formazione del medico. Tutor 2001;1:82-94.
33. Malacrida R. Il medico umanista trova il suo master. Janus 2002;5:68-72.
34. Spinsanti S. Narrazione letteraria e MH. Janus 2002;5:135-41.
35. Binetti P. Le Scienze Umane nella educazione medica: literacy skills e communication skills negli anni della formazione di base. Medic 2004;12:41-53.
36. Federspil G. Le Humanities e il ragionamento clinico. Medic 2004;12:27-36.
37. De Marinis MG, Pascarella MC, Binetti P. Leggere per "essere": l'uso della letteratura nella formazione infermieristica. Int Nursing Persp 2005;5:73-9.
38. Giardina S. Il futuro ha un cuore antico: riflessioni sulla storia della medicina. L'arco di Giano 2006;50:75-88.
39. Consorti F, Basili S, Rizieri M, Mancuso R, Mannucci A, Martinelli F, Martini A, Mezzanotte V, Mezzapesa M, Mogini V, Murrali P, Napoli V, Nocioni M, Pendolino M, Piccolo A, Pietropaoli N, Pofi R, Poli E. Tra evidence based medicine e narrative based medicine: l'importanza del confronto. Tutor 2009;9:9-17.
40. Virzì A, Bianchini O, Dipasquale S, Genovese M, Previti G, Signorelli MS. Medicina narrativa: Cos'è? Medicina Narrativa 2011;1:9-13.
41. Delvecchio G. Humanities in medicina. Tutor 2008;3:142-50.
42. Antiseri D. Conosciamo solo tramite la Scienza? A che cosa servono l'Arte e la Letteratura. Medic 1996;4:109-14.
43. Galli G. Il rapporto medicina - scienze umane in un'ottica multidisciplinare. Medic 2001;10:45-9.
44. Cagli V. Letteratura, arti e medicina narrativa. Tutor 2004;4:19-25.
45. Trabucchi M. Malattia, letteratura, medicina narrativa. L'arco di Giano 2010;65:107-20.
46. Russo MT. Nursing e letteratura: una proposta formativa per il dialogo tra generazioni. Int Nursing Persp 2002;2:175-82.
47. Corbellini G. Ambiguità delle medical humanities. L'arco di Giano 2003;36:63-6.
48. Zannini L. Medicina narrativa e medical humanities. In: Gentile AE, Luzi I, Razeto S, Taruscio D (Eds). Convegno Medicina narrativa e malattie rare. Istituto Superiore di Sanità. Roma 26 giugno 2009. Atti. Roma: Istituto Superiore di Sanità; 2009. (Rapporti ISTISAN, 09/50). p. 15-25.
49. Spinsanti S. Lo schermo di Ippocrate. Janus 2002;7:66-70.
50. Galli G. La malattia e la salute tra oggettività e interpretazione. Medic 2004;12:37-40.
51. Borghi L, Pennacchini M. Medicina high-tech e technical humanities. L'arco di Giano 2009;61:165-73.
52. Giarelli G. L'insegnamento delle medical humanities in Italia. Janus 2008;30:22-5.
53. Parizzi F. L'arte filmica come strumento formativo. Tutor 2008;3:158-63.
54. Garrino L. L'utilizzo dei filmati per lo sviluppo della competenza emotiva nella relazione di cura: una proposta formativa. Tutor 2007;7:100-6.
55. Garrino L. L'utilizzo dei diari nella formazione infermieristica: analisi della letteratura. Tutor 2007;7:94-9.
56. Gargano A, Garrino L, Lombardo S. Le immagini della formazione: narrazioni sull'apprendimento. Tutor 2002;2:124-30.
57. Gregorino S. Considerazioni sulla formazione tutoriale tra pratiche riflessive e scrittura. Tutor 2007;7:90-3.
58. Madrussan E. La rielaborazione dell'esperienza clinica attraverso i diari: breve ricognizione di un percorso formativo. Tutor 2007;7:86-9.
59. Dordoni P. La deliberazione in etica clinica: logica di un percorso formativo. Tutor 2002;2:44-50.
60. Dordoni P, Casati S. Per una competenza etica dei comitati di bioetica: esperienza formativa nel seminario di Costagrande. Tutor 2004;4:33-8.
61. Garavaglia M. L'educazione medica: basta una laurea per essere medico? L'Arco di Giano 2002;34:27-31.
62. Albano MG. Il ruolo dell'educazione medica nelle scienze umane. Medic 2004;12:54-6.
63. Torsoli A. A course of humanities as part of the undergraduate medical curriculum at two Rome Universities. Medic 1998;6:70-1.
64. Bert G. Punti di vista, aspetti pragmatici della narrazione. Medicina Narrativa 2011;1:27-36.
65. De Marinis MG, Matarese M, Tartaglini D, D'Innocenzo A, Binetti P. Un approccio didattico al problema del dolore nel diploma universitario per infermiere. Nursing Oggi 1999;3:38-41.
66. Binetti P, Bruni R. Il cinema tra formazione e terapia. Tutor 2004;4:90-101.
67. Leone D, Vegni E, Vescovo A, Moja EA. Emotions in clinical practice: questions from an experiential pilot education progam with medical students. Tutor 2010;3:136-42.
68. Nordio S. Continuare a discutere di educazione medica. Competenze e performance. L'Arco di Giano 2004;42:91-121.
69. De Marinis MG. Ri-formare e rinnovare. Int Nursing Persp 2010;10:1-4.
Address for correspondence:
Laura Fieschi
Scuola di Dottorato in Scienze Infermieristiche
Università di Roma Tor Vergata, 00173 Rome, Italy
E-mail: laura.fieschi@gmail.com
Conflict of interest statement
There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.
Received on 10 August 2012
Accepted on 27 September 2012