MEDICAL HUMANITIES AND ITS ROLE IN SHAPING ETHICS IN MEDICAL GRADUATES

Medicine as a field is unique in the sense that the skill to relate to people weighs heavier on the doctor than the skill required to practise it. Medical humanities is an interdisciplinary field that considers issues of health in the context of history, philosophy, social studies, and anthropology among others, enabling students to change their practice from “looking” to “seeing” the patient as a whole. Unfortunately, current medical training is focused on academics with students left on their own to acquire communication and ancillary skills. In the core medical curriculum, a structured training in medical humanities remains lacking. Herein, we discuss the need, student’s perspectives, and the approach going forward in the inculcation of medical humanities in the medical training with a particular focus on medical ethics.

INTRODUCTION "To her fair works did Nature link The human soul that through me ran; And much it grieved my heart to think What man has made of man." -William Wordsworth, Lines Written in Early Spring Education refers to the acquisition of knowledge and training of one's mind and character. It is about inculcating compassion as much as knowledge, about wisdom rather than only information. In medical education, man is at the centre of the stage. Rote learning of the various aspects of the anatomy of Homo sapiens needs to be complemented by knowledge about the behaviour of man. The humanities provide a unique perspective on the ways of man.
Humanities refer to academic disciplines that study human society and culture. Humanities include religion, philosophy, and literature. As opposed to the sciences that focus on natural processes, humanities study human constructs and concerns. As an academic discipline, medical humanities may appear to be at odds with the medical curriculum as traditionally training in basic sciences and clinical medicine is considered as the backbone of undergraduate training. The current focus of medical education is more on the science than the art of medicine, wherein medical students spend most of their time learning theoretical knowledge and skills. Will

MEDICAL ETHICS EXPERT OPINION
the medical graduate who is seeking lines of evidence as bases for making decision reconcile with abstract thinking? Evidence-based medicine is indispensable in modern medical practice. But are the humanities dispensable then?
Unlike other professions, where skill is the most important factor for becoming an expert par excellence in their field, the medical profession is hugely different. For doctors, treatment of the patient as a whole is more valuable than treatment of the disease. Therefore, humanities need to be an integral part of the medical training wherein shifting of the focus from the disease to the patient is important. Designing the approach and management strategy based on the socio-culturaleconomic background is of utmost importance in the holistic care of the patient.
Medical humanities is an interdisciplinary field that considers issues of health in the context of history, philosophy, social studies, and anthropology among others (Table 1), enabling students to change their practice from "looking" to "seeing" the patient as a whole [1]. It teaches students the skills required as a doctor which are beyond the boundaries of clinical skills, competency and reasoning [2].
Literature is the source of understanding human emotions, behaviour and empathy, as well as improving performance in the narrative aspects of medicine. Art enables sharpening of observational skills which are extremely important for doctors. Philosophy aids in developing rational thinking and reasoning. Social sciences help study the socio-cultural background of patients. History of medicine allows the study of the past, enabling better preparedness for the future [3,4].
Thus, the art of medicine is closely interwoven with the discipline of humanities, which help train medical students to become more insightful and compassionate doctors. Taken together, we hypothesize that the inclusion of medical humanities in the medical curriculum can help develop better ethics in medical graduates.

MEDICAL HUMANITIES IN THE MEDICAL CURRICULUM
Presently, many medical schools have incorporated medical humanities as part of their medical curriculum [5,6]. However, its inclusion is predominantly in the form of additional courses. It still lacks a proper framework for teaching and assessment. As there is no objective evaluation of the learning outcomes, what the courses delivered was questionable for most programmes.
The subspecialty of medical ethics has received the maximum attention among all the subspecialties of medical humanities over the last four decades. Despite this attention, the teaching format is usually a theoretical course or a case-based discussion. Working closely with students and discussing ethical dilemmas while working in the clinics and wards are approaches more valuable than talking about being virtuous [7].
To date, the institution of medical humanities has still been considered as an 'add-on' to the conventional medical teaching rather than an integral part of it. Voluntary enrolment of a majority of students into a humanities-based study module was observed in a study from India, and more than 80% of the students found the module to be effective and they suggested its incorporation into the medical curriculum [8]. Another study from London showed that these subspecialities should not be assessed, and no consensus has been reached on whether these subspecialities should be voluntarily taken. The incorporation of these subspecialities into conventional medical teaching has been aimed for, specifically in the first three years [9].
Another study from Germany assessed the view of students on medical ethics and history, and found an overall positive view towards these subspecialities with greater importance rendered to the former [10]. More global, multicentric studies are required to gauge the perspectives of students on specific subjects, types of teaching, and evaluation.

MEDICAL ETHICS
Ethics is defined in the NCBI medical search headings (MeSH) as the philosophy or code of what is ideal in the human character and conduct, as well as the field of study involving the principles of morality [11].
Louis Pasteur could not have proven the effectiveness of his vaccine if he were bound by current rules of ethics. All graduates need to know about the Nuremberg Trials and the Tuskegee Syphilis Study to understand the need for ethics [12,13]. Thus, medical humanities reveal both sides of an argument to the student.
Current medical ethics focuses primarily on biomedical ethics. This includes consent taking and the ethical use of patient-derived information and clinical material (e.g., blood, urine, stool or tissue samples) for research purposes to safeguard the interests of the patient more so from a legal perspective than ethical. However, medical ethics includes both biomedical ethics and clinical ethics. Clinical ethics addresses the delicate patient-physician relationship. As an example, patients may freely interact with a physician on social media. This will come under the purview of clinical ethics. Are these issues regarding clinical ethics discussed with medical graduates?

SCIENCE VERSUS ART
Medicine is supposed to be a "scientific study and its practice an art" [14]. Notably, the science of medicine has been rapidly evolving and ever-changing, whereas the art of medicine has remained stale and inactive. There is undue dwelling upon the race of catching up to the latest scientific advances by both teachers and students alike, and unfortunately, the art of medicine has been left up to the students to develop by their own means through a trial-and-error method rather than a structured teaching approach. The art of medicine is dying and needs to be revived. One strategy is to introduce the formal teaching of medical humanities as a discipline.

BALANCING VASTNESS OF COURSES VERSUS PRACTICAL TEACHINGS
Courses on these subspecialties in addition to the vast courses in the medical curriculum as a separate discipline are likely to add unnecessary burden to students and build resentment. The option of being offered as an elective course reaches out to only a minority of students and defeats the purpose.
First, these subspecialities should be incorporated and evaluated in the day-to-day teaching of the core medical curriculum. Some unique approaches may be teaching anatomy with paintings and diagrams which incorporates valuable skills of art; presenting a brief history about a particular topic before discussing the main topic; doing reflective writing on a particularly difficult clinical scenario in the ward; and discussing socio-cultural practices relevant to medicine in the clinic [15,16]. Second, the above concept is a long-term process. Until then, these subspeciality courses can be made available at regular intervals and taken by a group of students based on their feasibility and convenience as an elective. But these well-planned courses should be made compulsory to be taken once at least during the medical school program.

BENEFITS OF MEDICAL HUMANITIES BEYOND DEVELOPING ETHICS
Good clinical practice and abiding by the principles of medical ethics have direct medico-legal implications and determine the reputation of a physician among colleagues and patients. However, a thorough knowledge of other aspects of medical humanities helps the physician to readily attain the primary goal of patient welfare. It is only after ensuring patient well-being that the science of diagnosis and treatment holds importance. Medical textbooks and guidelines hardly ever adapt to a patient, and every patient needs to be treated individually based on numerous factors.
Without considering the social, cultural, and economic background factors; without practising the art of listening and observing; and without empathizing compassionately with the patient, one remains a medical practitioner but not necessarily evolve into a fully-trained medical doctor.
Additionally, the involvement of medical graduates with medical humanities may serve as a welcome distraction to refresh the mind. Medical humanities may pave the way for them to pursue new hobbies. The use of history and anecdotes may make a dry pedantic lecture into a joy ride of discovery. Such learning may be better appreciated and better remembered. Also, engaging with humanities can help develop better medical teachers [17].
Reading great works can enhance language skills and make the physician a better communicator. Researchers and physicians alike are presently turning to social media for the ethical promotion of their work [18]. Exposure to medical humanities will likely enable physicians to design more engaging contents. Exposure to the English literature can help non-Anglophone authors to develop their writing skills and thus avoid falling prey to unethical practices such as plagiarism [19].

CURRENT MEDICAL EDUCATION: IS IT MOVING AWAY FROM MEDICAL HUMANITIES?
There are some barriers that may preclude medical humanities from being incorporated in the current medical curriculum. Firstly, the huge curriculum of medical graduates induces a paucity of time. Second, the graduates themselves may not see the benefits of such subspeciality courses. Third, there is a gradual shift of medical education to online modules [20], which may further limit the inclusion of medical humanities.
There may be a vicious cycle wherein a graduate who was relatively unexposed to medical humanities becomes a new faculty. As there was limited prior exposure to medical humanities, the newly appointed faculty may not realise its importance and further reduce any exposure to medical humanities. Thus, with every passing generation of medical graduates, there can be a gradual exodus of medical humanities from the medical curriculum.

IMPLICATIONS FOR CENTRAL ASIA
We have described the potential of upcoming researchers and academicians from Central Asia [21,22]. Incorporating medical humanities can help them further develop another unique dimension that can help them in both their academic and patient-centric activities. Central Asia has rich and diverse roots in various humanities from their relationship with Europe and the Mediterranean region.
The Sustainable Development Goals have set forth novel, elaborate health goals for evolving health care systems with greater social impact [23]. Understanding societal needs is pertinent for achieving such goals. These are particularly relevant to low-and middleincome countries that need to ration their health resources.

CONCLUSION
The art and science of medicine are like two sides of a coin, and neither sides can be sufficient to produce a competent doctor. As a traditional convention, the focus has been more on the science of medicine as it can be easily taught and assessed. Incorporating medical humanities may become an extra burden for medical students. The cream must be fully decanted to achieve the maximum benefits for medical students.

CONFLICTS OF INTEREST
The authors have no potential conflicts of interest to disclose.

DISCLAIMER
No part of this article has been submitted simultaneously or published elsewhere. All views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any institution or association.