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The Cultural Cauldron

Daniel Martini gives an insight into the undergraduate Medical Humanities program at UC Santa Barbara.

In 2019, a disaster emergency physician, Jason Prystowsky, who often spends time in the Navajo nation with past stints in Sudan, Uganda and the Democratic Republic of Congo, approached UC Santa Barbara with a proposal: a medical humanities program for undergraduates. Treating patients across different languages and belief systems had made it clear to Dr Prystowsky that in addition to poverty, war and ethnic inequities, the main barrier to healing was often cultural. If this seems like a stretch to any readers, suffice to consider the case of the toddler Lia Lee, made famous by Anne Fadiman in The Spirit Catches You and You Fall Down (1997). The Lee family were Hmong refugees living in California after the Vietnam War, but their interaction with the US healthcare system was by their own account even more disastrous. Their daughter Lia had 17 emergency admissions and 100 outpatient visits in 4 years followed by two decades in a vegetative state before her death in 2012. The family and the doctors simply did not understand each other. Why should Lia take pills and not rely on a shaman; what is a pulse and how do you measure a minute? Similarly, how could local doctors make sense of the family’s distrust of western medicine without knowing that Hmong believe anesthesia induces soul loss, or that their people were betrayed by the US government after the war?

In short, experience shows that it is too late, and potentially too dangerous, to start thinking about these issues once physicians find themselves in the cultural cauldron. Added to this is the frequent lack of translators or social workers on site. In many if not all cases, the treating physician will have to become the trust builder. So, the course at UC Santa Barbara developed around this question: how can future professionals develop an attentiveness towards cultural contingency, the lived experience of illness, and different modalities of healing?

Many of our peers teaching medical humanities in Europe and the US will stress the need for real-life experience or suggest that students will have forgotten their undergraduate classes by the time they are on the ward. These are of course valid concerns – but as many medical schools can also attest to, students who are forced to take mandatory survey courses slotted between pathology and pharmacology often become disengaged. Or, if voluntary, the enrollment numbers might dwindle once the real subjects become too demanding. Hence, we chose at UC Santa Barbara to start our classes at the earliest time possible – before medical school – to inculcate an appreciation for the modes of thinking usually associated with the humanities: critical, reflective and intentional.

But how do we make the course relevant when students at most have internships as ER scribes, volunteer at the student health center, or act as drug counseling peers?

One benefit of living in a beautiful coastal city is the influx of tenured professor emeriti with an eagerness to support the next generation. From UCLA to Columbia University, College of Physicians and Surgeons (UCSB does not have its own medical school), our adjuncts generously show up (or log on) to each class. They work with the instructors to help students understand why the topics from the humanities matter. For example, when studying Leo Tolstoy’s The Death of Ivan Ilyich (1886) and the suffering caused by ignoring someone’s death and illness, one pediatric surgeon shared how to talk to parents who have lost a child. The best thing is to validate their feelings: your child mattered, your child fought so hard, your child taught us all something. This is, of course, precisely what happens to Ivan Ilyich when the butler’s son Gerasim listens to his concerns. It’s an example of intentional and attentive communication.

Something similar happens when the local hospital chaplain, ethics committee chair or palliative neurologist enters the room. How do you check your reaction when a next of kin derides your appearance or sexuality? How does the Jewish doctor feel when their patient sports a swastika tattoo across the chest? How do you justify the allocation of ventilators during COVID? These are all real-life conversations that we have had with our students. Their appetite for learning is huge once they hear why developing a reflective practice matters, or why learning to be vulnerable with your professional peers is crucial to a better working life.

As much as society talks about how busy and distracted young minds are, let’s not forget that they are also incredibly impressionable. The input from our group of fifty students is always stimulating and even personal across the 10-week quarter favored by the University of California. Each week, they submit a reflective piece of writing that narrates in a story-like format what they have learnt plus extract one or two concrete principles or practices that they will use in their future, or very nascent, careers. This format culminates in a final paper, like an op-ed (some students have already published on the social media site KevinMD), a case study or letter to one’s future self, or dean. It may well be the only class in their long venture into health care not focused on right answers.

Despite the use of senior clinical adjuncts, we never expect our students to be repositories of knowledge, blindly accepting whatever they are told – a very one directional process that the educator Paulo Freire (1968) called banking. Rather, our aspiration is to make students conscious of what they are studying precisely by framing our discussions of health, illness and care around so-called cognizable objects, that is, a shared, shifting reality. In our case, this is the challenge of delivering medicine in the multicultural and, frankly, unjust US healthcare system.

Crucially, a commitment to this fluid pedagogical space also involves a constant (and honestly frightening) necessity, in the words of bell hooks, to not “fear losing control in a classroom where there is no one way to approach a subject.” (hooks 2003: 35). As a scholar of literature, philosophy and cognitive science, I have to accept my limitations in a room full of clinicians with decades underneath their belt (and the grey hairs to match). But this commitment to advancing together is also a refreshing chance to learn from my students, and I know my clinical colleagues feel the same kind of hope. We strive to accompany each other, to use a term from Barbara Tomlinson and George Lipsitz, on the quest to develop “a disposition, a sensibility, and a pattern of behavior” with the power to address even the most stubborn institutions, be it within the doors of the academy or the entire healthcare system (Tomlinson and Lipsitz 2013: 9).

Obviously, we are not immune. Our certificate program is only one year young and will undoubtedly – hopefully – undergo iterations and tweaks as we work towards a more refined experience. For one, we may have to make the two 10-week classes (Introduction to Medical Humanities and Medical Humanities in the World) less nuanced. A lot of ground is covered (history, ethics, narrative, culture, trauma, spirituality, mindfulness) and the pace may be too fast, for even the keenest of students. In addition, we continue to strive for more funds so that the certificate, which comes at a minor but nonetheless additional cost, might be fully subsidized to minimize barriers of entry. Talks are also underway about offering a version of the class to local healthcare professionals.

In whatever format, our confidence in the urgency of medical humanities for undergraduates guides all that we do. If one thing has become clear from these last twelve months, where we have collectively witnessed the result of a deeply fractured American society and battled a pandemic, it is that we need to talk about what scares us. By having the most complicated conversations early, with honesty and humility, clinician to teen, teacher to student, we are actively shaping a better and healthier future for us all. In that we are unapologetic optimists.

Further information
The Medical Humanities Initiative at UC Santa Barbara

References
Freire, Paulo.  Pedagogy of the Oppressed. Translated by Myra Bergman Ramos. New York: Continuum, 2005.
hooks, bell. Teaching Community. New York: Routledge, 2003.
Fadiman, Anne. The Spirit Catches You And You Fall Down: A Hmong Child, Her American Doctors, And The Collision Of Two Cultures. New York: Farrar, Straus and Giroux, 2012
Tolstoy, Leo. The Death of Ivan Ilyich. Translated by Richard Pevear and Larissa Volokhonsky. New York: Vintage Classic, 2012.
Tomlinson, Barbara and George Lipsitz. “American Studies as Accompaniment.” American Quarterly. Vol 65, No. 1, 2013.

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Daniel Martini is a PhD Candidate in Comparative Literature with an emphasis in Cognitive Science and a core instructor in Medical Humanities at UC Santa Barbara. A fellow of the Unconscious Memory project, Daniel is always happy to collaborate on interdisciplinary research and teaching, via danielmartini.com and @dannimartini