Summary of the impact

The field of medicine has become more complex and morally demanding as it faces the challenges of technological advances, changing social attitudes and financial constraints, all dramatically highlighted in the recent Francis Report. These challenges require a profession with independent judgment and a willingness to listen to, and communicate humanely with, patients. The complex skills required for this can be developed through what have become known as the `medical humanities', or the application of philosophy and other humanities to medical education.

This argument was first explored and tested in the UK by researchers at the University of Glasgow (UoG), where the key actors in the UK medical humanities movement worked together to articulate and trial humanities content to students of medicine.

The impact this can have on medical practice has been recognised by the General Medical Council, funding streams in the Wellcome Trust and other major funding bodies, the Royal Colleges and NHS units. From the pioneering work at Glasgow, there are, as of 2013, five centres of medical humanities in the UK and 24 in total worldwide, and humanities content is delivered to medical students at module or degree level in 30 of the UK's 32 medical schools.

Underpinning research

The first experiments introducing philosophy and the arts to UK medical students took place at the UoG in the late 1980s. The first critical research into the value of the arts and humanities to the training, mindset and understanding of future doctors, and the most effective channels of delivery for these elements, was carried out at UoG through the 1990s-2000s. Among the originators of the medical humanities movement in the UK, each playing a unique role in its development and its widespread adoption, were:

— Robin Downie (UoG: Professor of Moral Philosophy, 1969-2002; and, Professorial Research Fellow 2002-);

— Sir Kenneth Calman (UoG: Professor of Oncology, 1974-84; and, Dean of Postgraduate Medicine 1984-89. Later Chief Medical Officer for Scotland; Chief Medical Officer UK; and, Vice-Chancellor of the University of Durham. UoG: Chancellor, 2006-present); and,

— Jane Macnaughton (UoG: Lecturer in the School of Medicine's Department of General Practice, 1995-2000. Later Director of UK's first Medical Humanities Centre at University of Durham, under Calman's vice-chancellorship).

The initial insights into the value of an arts education in the medical curriculum were gained 1987-1995, pre-dating but continuing into the REF Impact timeframe. After 1995 Downie and Calman built on successful extra-curricular student clubs they had established that offered discussions of literature, poems and the arts for students and staff in UoG's then Faculty of Medicine: this was an entirely new concept at the time. In 1991 Calman was appointed Chief Medical Officer for Her Majesty's Government and was in a position to use UoG research to influence thinking at the General Medical Council (GMC). Following his intervention, the GMC incorporated a humanities element into their suggested medical curriculum via Special Study Modules (SSMs) as they were called in the initial version of Tomorrow's Doctors (1993): since 2003 they have been called Student-Selected Components.

Between 1995 and 2000 Downie and Macnaughton focused their research on the development of initial findings regarding the value of, and most effective delivery channels for, humanities elements in medical education. Downie and Calman had argued that students should be trained to be interested in the patient as a whole — including being aware of his/her social context — rather than just disease symptoms. This training requires attention to values and to the language of communication, which are skills central to the humanities. In order to investigate this further, Downie and Macnaughton offered a Special Studies Module in Philosophy in which second-year medical students attended a course normally taken by philosophy students. The medical students spent five weeks studying Plato's `Republic' and attending lectures on political philosophy. These lectures were not tailored to medical students but instead were aimed at bringing them into a very different academic field and culture, training them to apply philosophical analysis in their approach to an argument. The researchers found that this approach was effective in enabling medical students to assess the strength of an argument and to question received wisdom. In their evaluations, the successive cohorts of medical students claimed that they had developed skills enabling them to assess claims — eg, made by pharmaceutical companies — and had also gained a greater understanding of the moral values underpinning the society in which they were to practise.

Macnaughton conducted further research at UoG, supervised by Downie, on the value of the humanities in informing and guiding clinical judgement. This led to her PhD in 1998, and subsequently to a book jointly written by Downie and Macnaughton entitled Clinical Judgement: Evidence in Practice (OUP, 2000). The researchers argued that `good clinical judgement requires both technical evidence and a humane attitude. [...] A humane attitude involves ethical sensitivity, but also a broad educated perspective which can be derived from the arts.' In other words, sound clinical judgment requires more than a technical component, and the `more' can be developed via the humanities.

During this period, through a combination of the ongoing research at UoG and the continued support for medical humanities from Calman, the UoG training model was gaining acceptance well beyond this HEI. In June 1996 a commentary written by Calman and Downie was published in The Lancet: `Why arts courses for medical curricula?' argued that the restructuring that was taking place in medical curricula following new GMC guidelines meant that there was a `modest slot [...] for the introduction of an "arts" component via special study modules.' In December 1996 Calman convened the first in a series of meetings, supported by the Nuffield Foundation, to explore the benefits and challenges of incorporating humanities into medical education.

In 1997 the Royal College of Physicians and Surgeons at Glasgow (RCPS) celebrated its 400^th anniversary by hosting a medical humanities conference, co-organised by Downie. This was the first conference in the UK on the topic held by a Royal College. As part of the RCPS celebrations the British Medical Journal, in conjunction with Downie, organised a short story competition for doctors. This provided an opportunity for doctors to articulate their experiences for a wider readership, and encouraged the development of creative writing in medical education.

By 2000 Calman had been appointed Vice-Chancellor of the University of Durham. Collaboration with Downie and Macnaughton had continued throughout, and at his instigation Macnaughton took on the inaugural directorship of the UK's first centre for medical humanities at Durham in 2000. This Centre became one of two to gain strategic awards in Medical Humanities from the Wellcome Trust in 2007.

Between 2000-07 Downie and Macnaughton continued to research the specific benefits to medical education offered by the humanities and, in particular, how ethics can be taught via the humanities. In parallel, Downie and Fiona Randall (part-time researcher at Glasgow, 1999-2006; and, NHS consultant in palliative medicine) also researched and developed a programme around the use of philosophy as a tool to offer both a critique and positive suggestions for the speciality of palliative medicine.

References to the research

The research findings were first published in the above top peer-reviewed journals, but much fuller and more easily accessible accounts of the research are contained in these books [AVAILABLE FROM HEI]:

— Robin Downie and Jane Macnaughton, Clinical Judgement: Evidence in Practice (Oxford: Oxford University Press, 2000). (Nominated as `Book of the Month' by the Royal Society of Medicine).

— Robin Downie and Jane Macnaughton, Bioethics and the Humanities: Attitudes and Perceptions. (London: Routledge-Cavendish 2007).

— Fiona Randall and Robin Downie, The Philosophy of Palliative Medicine (Oxford: Oxford University Press, 2007). (Awarded the Medical Journalists' Association of Great Britain Prize for the best book on a medical specialty for 2007.)

Details of the impact

Drug development, technological advancements and improved living conditions have had a huge influence on the field of medicine and healthcare practitioners. More than ever doctors need critical and independent thought, empathy and understanding, and the ability to communicate as they and their patients navigate the multitude of choices now available from before conception to post-mortem examination. Incorporating elements of the arts and humanities into the rigorous discipline that is the study of medicine allows future doctors to gain insight into the human conditions of illness and suffering, to sharpen their powers of perception — of their professionalism and that of others and of their responsibilities to self, colleagues and patients. Exposing them to the arts and literature has been shown to develop their observational skills, analytical reasoning, empathy and self-reflection.

Over 30 years of research initiated at UoG has led directly to:

— early recognition by the General Medical Council of the importance of humanities elements as part of the medical curriculum for `tomorrow's doctors';

— recognition by key agencies — including the Nuffield, Wellcome — of the importance of the field and support for its development — eg, the journal Medical Humanities was established with support from the British Medical Association and first edited by Macnaughton to 2010); and the Association of Medical Humanities was established with Nuffield support in 2002 `to promote the medical humanities in education, healthcare and research in the UK and Ireland';

— the establishment of the first Centre of Medical Humanities at Durham University, with a total of 24 such centres or units worldwide in 2013;

— thirty of the UK's 32 medical schools now offer medical humanities as undergraduate modules or as postgraduate degree programmes — in 2013 the majority of students in schools of medicine in the UK will have a humanities component in their curriculum.

All of the above are continuing impacts, which have been ongoing throughout the census period. The Special Study Modules first offered by UoG and advocated by the General Medical Council are now an integral curricular component, with the importance of medical humanities for doctors and patients widely recognised. By 2010 the majority of the medical schools in the UK had accepted this finding. Following on from the success of the pioneering work at UoG and the establishment of the centre at Durham, the Universities of Aberdeen, St Bartholomew's, Brighton and Sussex, Birmingham, Bristol, Cambridge, Cardiff, Edinburgh, Exeter, Hull-York Medical School, Keele, King's College London, Leeds, Leicester, Liverpool, Manchester, Nottingham, Oxford, Plymouth, Sheffield, Southampton, St Andrews, University College London and Warwick all subsequently opened Medical Humanities units offering a range of courses from modules to postgraduate study. Between them, these institutions represent about 80% of the undergraduate medical teaching offered in the UK, meaning that the vast majority now incorporate a medical humanities element to their teaching.

The NHS Greater Glasgow & Clyde operate the Glasgow Medical Humanities Unit in collaboration with the University of Glasgow — it was the first unit of its kind in Scotland. In addition to the dedicated centres, a number of institutions have gone beyond the offering of the Glasgow-model SSMs to provide intercalated and postgraduate masters' degrees.

In his capacity as former Chief Medical Officer for the UK and Scotland, Professor Sir Kenneth Calman writes:

It is relevant to reflect on the impact the studies in Glasgow had on the wider medical community. Medical education and practice has always been based on a broad range of values, and had a strong ethical component. The work in Glasgow on the medical humanities provided an important new focus and impetus for considering medicine from the point of the patient, and in ensuring that the ethical values were maintained. The initiative came at just the right time and [...] began to feature in educational programmes in ethics, palliative care, discussions on quality of life, care of the elderly and public health challenges. Each of these benefitted from viewing the subject from a different angle, and this had consequences in clinical practice and patient well-being. It provided a catalyst for new thinking and bringing together people from different backgrounds and interests all focussed on improving patient care.

UoG's Centre for Medical Humanities focuses on the healing environment and the role of visual arts in improving the experience of patients. In 2009 funding was obtained from the Scottish Arts Council (now Creative Scotland) to develop the centre's work with participation by visiting artists. The result was the establishment of an SSM entitled `Framework for healing: the arts, architecture and the doctor's working environment'. In 2011 Creative Scotland funded teaching in an SSM on `Medicine, the arts, and the doctor's way of seeing' and the `Creative Space' was opened in Glasgow Western Infirmary, a collaboration between the Medical Humanities Unit and NHS Greater Glasgow & Clyde. The Creative Space facilities an exhibition programme and arts events within a healthcare context, with the aim of bring arts and health practitioners together in an acute medical context.

As Brazil is seeking to incorporate a humanities strand into its provision of medical education, Downie was interviewed in late 2012 by a researcher from the Universidade Federal de Sao Paulo (Paulista School of Medicine) interested in learning about the development of the UoG model and the successful implementation of Special Study Modules. The prolonged consultation with Downie inspired the Brazilian university to develop their `Laboratory of Humanities': `...it made our prolonged dreams become solid research ideas become government sponsored grants. It also made us less wary about trying to find reverberating voices [in Brazil] and to rather develop our own way of configuring this as a new discipline within Medical Schools in Brazil today.' The now-established Centre for the History and Philosophy of the Health Sciences offers postgraduate degrees and special modules for undergraduates, and an average of 50 participants each week discussing literature and philosophy in their Laboratory of Humanities, in much the same way that the original extra-curricular clubs operated for medical students in Glasgow.

Sources to corroborate the impact

Evidencing the importance of the Glasgow research in the development of the medical humanities movement in the UK:

• Supporting statement: Professor Sir Kenneth Calman — available from HEI.
• Testimonial from Professor Jane Macnaughton, Centre for Medical Humanities, Durham University — [contact details available from HEI].
• NHS Greater Glasgow & Clyde web page for the Medical Humanities Unit, illustrating the embedding of the medical humanities approach in the healthcare system [link]
• Launch announcement for The Creative Space, a collaboration between UoG, NHS GG&C and Art in Hospital [link]

Evidencing the importance of the Glasgow model abroad:

• Statement from Universidade Federal de Sao Paulo (Paulista School of Medicine) — available from HEI.