Exploring the intersection between medicine and the humanities

By Emily Margosian, Assistant Editor, October 1, 2022

“Physicians have become small cogs in a humongous machine, and they resent it. That’s not what most of us imagined when we got into medical school,” said Salvatore Mangione, MD, associate professor of medicine at Thomas Jefferson University. “The causes of burnout are loss of autonomy, loss of control — we become ‘providers.’ When I came to this country from Italy as a medical student in the 1970s, the term provider did not exist. Now, physicians have become ‘providers‘ and patients, unfortunately, have become customers. It’s a disparity that takes away what makes medicine a multifaceted profession.”

While many physicians reported feelings of burnout prior to COVID, the pandemic has exacerbated the problem across nearly all specialties. In a recent 2022 Medscape poll, two-thirds of physicians reported that burnout had begun negatively impacting their personal lives.

Recently, some physician advocates have proposed a multifaceted approach to what they see as a multifaceted problem. “There are a lot of opportunities where engagement in the arts can really have an impact, especially around the mental health aspects of burnout,” said Alan Siegel, MD, a family physician at Contra Costa Health Services, and board member of the National Organization for Arts in Health (NOAH). “It particularly has value when people have the opportunity to use different parts of their brain and let off steam. I think we’re on the edge of starting to research and show outcomes, but it certainly should be part of the toolbox for burnout.”

This month, DermWorld speaks with physician proponents of the arts about why they think reintegrating the humanities into medicine may help address the burnout problem.

Early career involvement

As medical training continues to evolve, some experts say a widening divide between science and the humanities is doing new trainees a disservice. A 2018 study found that medical students involved in the arts tended to have higher levels of empathy, tolerance of ambiguity, and other traits considered positive in a doctor, in addition to reduced levels of burnout. Dr. Mangione, one of the study’s authors, has been a long-time proponent that engagement in the arts may enhance the ability of a student to excel in medical school and become a physician in practice. “Medical school attracts those who are left-brain dominant and proceeds to atrophy what remains of the right brain. Creativity is lacking in medicine. We’re very good at memorizing and regurgitating facts that may not even be correct after time passes, but creativity is not something we foster.”

Beyond creative capabilities, Dr. Mangione also believes that physicians with some background in the humanities are better prepared to handle the more human aspects of medicine. “Since changes to the medical curriculum dating back to the 1910s, the way that we recruit medical students is really focused on the sciences. That raises the issue of what ingredients go into the unique cocktail of what we consider an effective physician. The sciences are, of course, important, but we’re not taking care of carburetors; we’re taking care of human beings,” he said. “My wife, unfortunately, was diagnosed with ovarian cancer a couple of months ago, so we are going through what it means to be a patient in the United States. It’s not a lot of fun. We can immediately tell which physicians have certain interpersonal skills that are independent of their medical competence.”

“The sciences are, of course, important, but we’re not taking care of carburetors; we’re taking care of human beings.”

Some universities have begun to incorporate courses in the performing and visual arts in their medical school curriculum to address this gap. In the 1990s, dermatology professor Irwin Braverman, MD, FAAD, pioneered courses of this type at Yale alongside curator Linda Friedlaender, which continue to be taught to students today. The idea to have dermatology students hone their observational skills by looking at art came to Braverman during a 1998 grand rounds session when he noticed dermatology residents weren’t describing what they saw on patients as thoroughly as he thought they should.

This power of perception, shared by artists and physicians alike, is a critical skill to foster among trainees, according to Dr. Mangione. “The humanities can make more effective physicians, not only because of the interpersonal aspects, but also because they make you a better observer. I think we really need to revisit not only the curriculum, but the way we recruit and train medical students. You have to bring them in as humanists, and then turn them into scientists.”

Physician burnout in a COVID world

“Historically, it’s been hard to get attention for staff, and COVID finally brought attention to medical staff in a way that hadn’t existed for a long time,” said Dr. Siegel. “Much of burnout is related to the fact that we’re practicing in a system in which we’re almost set up to fail. Twice I’ve been through depression, and certainly one of those times was probably a combination of depression and burnout with work. This issue is very real, and we clearly need to do something about it.”

For a better part of the last decade, Dr. Siegel, who is also a musician, has helped run an arts in health program for his health system. “Every year, we hold a staff event at the hospital where people perform either music, dance, poetry, or show visual art that they create. We had to take a break for a couple of years because of COVID, but were able to get permission to hold it again a few weeks ago,” he said. “I think it’s a powerful experience for people to be able to see the creative and artistic sides of their colleagues, as opposed to just the normal working day stuff we do in hospitals and clinics. It can be challenging to get permission from the C-suite to do this work, but I think it’s critical and really needs to come from the top. Certainly, the arts aren’t a magic bullet, but they’re certainly a tool that’s being underutilized.”

There is some evidence to support this theory. A 2019 report by the World Health Organization found the arts to be an effective way to support health care workers, enhancing mental health, lowering stress, improving resilience, and helping with secondary post-traumatic stress.

“Obviously, system change is a big part of the answer to burnout, but I think the arts are also part of that answer,” said Dr. Siegel. “The NOAH website offers some examples of best practices being used around the country and offers some ideas for people to take back to their own programs or practices. I think we can expect that burnout is going to get worse as COVID continues. People can fight a war for a while, but when the war is over, that’s when the real casualties are going to emerge among health care workers.”

Dermatologists put the humanities into practice

Among dermatologists, some have found that maintaining a creative outlet has helped them manage professional burnout and foster a healthy mental balance independent from work.

Aisha Sethi, MD, FAAD, associate professor of dermatology at Yale School of Medicine, has had a lifelong interest in poetry, which was reignited after a 2015 medical mission to Jordan. Since then, she has found catharsis in the writing process. “In the past three years since COVID, I’ve written so much. Every two weeks or so, I write something and it’s helped me so much to cope with the pandemic and a recent move to Chicago, among many other things,” she said. “It’s definitely helped me make sense of what the world has been going through recently.”

As opposed to a formal practice with a set schedule, Dr. Sethi says she writes when the inspiration strikes her. “I don’t necessarily set time aside for it; I’ll just start writing in the ‘notes’ app on my phone. It’s a therapeutic way of getting my feelings out. I’ve written a lot about COVID, Afghanistan, and Ukraine. A lot of my poetry is inspired or triggered by recent events or feelings. Sometimes I’ll also write about things I’ve seen in my practice, or patient stories.”

“I think it’s really good to challenge yourself to learn new skills over time that are outside of our profession. It’s healthy for your brain to have an outside focus that can take you completely away from your day job.”

Alison Ehrlich, MD, FAAD, former founding chair of dermatology and director of clinical research at George Washington University, also has a long-standing relationship with art. “I’m mostly focused on water-soluble oil painting right now, but my history with art endeavors goes back very far. I had a darkroom when I was a teenager, and somewhere in my mid-forties I started taking classes in different types of art,” she said. “I think it’s really good to challenge yourself to learn new skills over time that are outside of our profession. It’s healthy for your brain to have an outside focus that can take you completely away from your day job.”

According to Dr. Ehrlich, observational skills honed from art are of particular value in dermatology. “There’s a quote I like from Marcel Proust that says, ‘The real voyage of discovery consists in not seeking new landscapes, but in having new eyes.’ I think painting allows you to look at things differently, which is really helpful in dermatology. It trains your brain to see color and skin lesions better.”

While attempting a new artistic endeavor may be intimidating, there are lots of options available to choose from, said Dr. Ehrlich. “I have a colleague who does woodworking, which is its own art form. Some people may be hesitant to pursue painting, but there are so many different things to try. I think it’s important to have hobbies outside of your career because very few physicians are still working at 80, so you need to have other things you enjoy doing. I enjoy the time I spend painting because I’m so focused on what I’m doing that it doesn’t allow me to think about other things. It’s refreshing for your brain to have that outlet, and it’s worthwhile to broaden your horizons a bit and challenge yourself in ways other than just professionally.”

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