Promoting and teaching the history of medicine in a medical school curriculum

Since 2004, the Galter Health Sciences Library staff has participated in years I and II of the Northwestern University Feinberg School of Medicine's medical doctor (MD) curriculum by offering a history of medicine seminar as part of the “Patient, Physician and Society” (PPS) course. The seminar's goals are to introduce students to the library's rare books and its special collections; to learn the social, cultural, and ethical aspects of medicine; and to improve communication skills. Because the MD curriculum is based on lifelong learning principles, students are encouraged to explore their interests in history by selecting a disease, health condition, or medical specialty and tracing it back in time; presenting their observations of what they learned to the seminar; and engaging in discussion about rare books and their content as a means of learning about the history of their profession.


INTRODUCTION
Since 2004, the Galter Health Sciences Library staff has participated in years I and II of the Northwestern University Feinberg School of Medicine's medical doctor (MD) curriculum by offering a history of medicine seminar as part of the ''Patient, Physician and Society'' (PPS) course. The seminar's goals are to introduce students to the library's rare books and its special collections; to learn the social, cultural, and ethical aspects of medicine; and to improve communication skills. Because the MD curriculum is based on lifelong learning principles, students are encouraged to explore their interests in history by selecting a disease, health condition, or medical specialty and tracing it back in time; presenting their observations of what they learned to the seminar; and engaging in discussion about rare books and their content as a means of learning about the history of their profession.

Literature review
A review of the literature offers many articles promoting the value of teaching the history of medicine and the other health sciences in a school's curricula. Howell's course at the University of Michigan offers a useful example of incorporating the history of medicine into an MD curriculum [1]. Howell describes a fourth-year medical school elective course for students interested in a more in-depth study of historical topics. The course is limited to six students per month, is offered from one to three months during the year, meets twice weekly for three hours, and is highly participatory, not lecture driven. The student's course goal is to produce a research paper, an annotated bibliography, or a detailed research proposal. After the introductory week, the instructor and students discuss the students' proposals so that students learn from each other.
A somewhat different model is offered by Casey and Flannery [2]. At the University of Alabama, first-year students taking medical gross anatomy are required to visit the library's special collections to examine historical anatomy texts, specifically, Vesalius's De humani corporis fabrica, and ''write an essay about what they learned'' [2].
Burns suggests that it is in the context of medical humanities that ''the history of medicine may yet find its more useful and congenial place in the medical curriculum'' [3]. The model presented here is an example of this ''useful and congenial place.'' The Northwestern seminar differs from Howell's model in several ways. A major difference is the course instructor: Howell holds both MD and doctor of philosophy (PhD) degrees and appointments in the departments of internal medicine and history, while the authors of this brief communication are health sciences librarians. Howell's course emphasizes investigation and research on student topics using multiple sources and methods, which would lead to a publication or a plan for further research. The Northwestern seminar approaches the history of medicine from the weekly examination and use of rare books, covering several historical time periods. The use of rare books is similar to what Casey and Flannery report, though at Northwestern, the emphasis is on discussing the students' own observations about what they learn from history, using multiple titles rather than one or two anatomy texts.

Seminars in medical humanities
The Galter Library's history of medicine seminar is one selection out of several that year I and year II students choose to fulfill the requirements of the PPS course. The seminars are managed and coordinated by the school's Medical Bioethics and Humanities Program. Other seminar choices include art and anatomy, physicians in films, human rights, the Black Death, and many more. The seminars in medical humanities are presented each winter quarter, with students attending one afternoon session per week for five weeks [4]. The seminar's educational goals are aimed at strengthening students' abilities [5]-including discussion of the social, cultural, and ethical aspects of medicine-and strengthening the students' communication skills.
For several years after the current MD curriculum was in place, librarians discussed ways to incorporate a library-based component into the humanities' portion of the curriculum, especially one that would promote use of the library's rare books and special collections. The school's humanities faculty stressed that a lecture series would not meet the curriculum goals. Faculty challenged the authors to design a seminar that would engage students, allow for personal exploration of a historical topic but within the context of a group activity, and promote lifelong learning habits. Besides exploring history through rare books, other major themes underlying the seminar's purpose are: what do we learn about medicine from history and how does learning from the past inform today's understanding of medicine?

METHOD
The five-week history seminar meets weekly for two hours for the year I and year II courses. Seminar sessions are held in the library's special collections reading room.
As there is limited seating, a maximum of six students are admitted to the seminar. When students sign up for the seminar, they are asked to pick a disease (e.g., cancer, leprosy), health issue (e.g., sanitation), medical specialty (e.g., surgery), or other topic that they want to research back through time. The first session introduces students to the collections and how to find and select titles for their topic, and each student reports (ten to fifteen minutes each) why they selected their topic and what they know of it based on the current literature (twentieth and twenty-first centuries). At subsequent sessions, the students report on the literature from the nineteenth century, eighteenth century, and so on.
When using the rare books, students are instructed in handling guidelines, such as the use of gloves to protect printed pages from oils and residue; restrictions on writing instruments for note taking (pencil or use of a laptop computer only); and restrictions on photocopying (use of phone cameras as an alternative). These conditions stress the importance and value of special collections for current research, an aspect of the course that students appreciate.
In a five-week seminar, it is impossible to read several books in their entirety. Students are instructed to use a review method of reading that stresses examining the book as a whole by studying its structure and organization and reading select chapters to get the essence of the book's content. By reading the introductory pages, the first chapter, a sampling of several key chapters or portions of a chapter, and the conclusion, students can examine several books to cover a range of years. See the onlineonly appendix for guidelines.
Topics chosen by the students over the last few years vary, but some remain constant (e.g., cancer). Students' reasons for selecting topics also vary, but students most often choose topics in which they hope to specialize after graduation, so they use the history seminar to learn more about their future specialty practice. Students also choose topics to learn more about the history of a disease or chronic condition that they or a member of their families currently have or has addressed in the past.
To add some variety to the weekly sessions, the special collections librarian also presents a ''show and tell.'' These demonstrations include the history of printing and bookbinding and the early development of scientific journals; highlights from the library's instrument collection (stethoscopes, microscopes, etc.); a history of the medical school's founders and noted figures, buildings, and locations in Chicago; and ''treasures'' of the library's rare books (incunabula, nonmedical rare books, and other artifacts). These special topics are also coordinated to match some of the rare books mentioned in the students' discussion and to reflect on the highlights for the century under discussion for a given week.

EVALUATION
The history of medicine seminar uses the school's standard evaluation forms for the humanities seminars. Students are evaluated on attendance (mandatory), participation, knowledge, attitude, and completion of assignments. A pass/fail grade is given. Students also evaluate the seminar. A total of 74 students participated in the seminar from 2004 to 2010 and provided a total of 61 evaluations and 100 comments. Students' evaluation criteria include: good things about the seminar, usefulness or relevance to medical education and future life as a physician, and things that could be changed. The format for the students' course evaluations is open comments.
Evidence of the students' achieving the seminar's learning goals-namely, understanding the history of medicine through examining rare books and learning the social, cultural, and ethical aspects of medicine-is found in their responses to identifying the ''good things about the seminar.'' The major themes in the students' responses include the intellectual challenge of learning about the history of medicine, the experiential aspect of using historical texts and rare books, appreciation of the perspective the past teaches about the present and future, pursuit of their own interests in the history of medicine, and the helpfulness of the instructors. Use of rare books accounts for 35% (35) of the comments for this question from 2004 to 2010, followed by 29% (29) for the challenge of learning about the history of medicine for the same time period, 14% (14) for the opportunity to pursue their personal interests in history, 14% (14) for the helpfulness of the instructors, and 8% (8) for the perspective that history teaches about the present and future.
In terms of the seminar's ''usefulness or relevance to the rest of your medical education…[or] to your life as a physician,'' the themes from the students' comments include: understanding the context of medicine's development as a profession, learning the perspective that history teaches, learning about the development of human health, learning more about what the library collections offer to students, and other. For all years, the dominant theme was learning a perspective from history (50.0%, 35 comments), followed by 28.5% for comments about learning the context of the medical profession's development (20 comments), 8.5% (6) for comments about realizing the library's value as a resource because of its rare book and special collections, 4.2% (3) for comments about valuing how human health has advanced over time, and 4.2% (3) for other comments, which included an appreciation for technology's impact on medicine and the instructor's weekly presentations. From 2004 to 2008, usefulness was measured only by the students' open comments. Beginning in 2009, student responses to the usefulness question were tabulated separately from the open comments. The counts reflect a more objective view of student opinion about the seminar's literal usefulness to their lives as students or their future role as physicians. Based on the counts for 2009 and 2010, most students did not find the history of medicine seminar useful in a practical way. Student comments indicated that learning the history of medicine is important for what it teaches them about the medical profession and how it has developed over time via the science and art of medicine. As with other humanities seminars, this seminar is not designed to be practical for learning or practicing current medicine, but to help students understand the ethical, cultural, and social context of medicine.
The students' evaluation comments provided many suggestions for improvements to the seminar. For all years, a dominant theme was the desire to lessen the seminar's workload. This theme generated 28.0% (16) of the comments from students. These comments also reflected a need to improve communication on the part of the course instructors because students did not fully understand the expected workload; in other words, they liked examining the content of the rare books but objected to creating a presentation each week. Students also provided friendly suggestions on improving the seminar's format; this theme generated 40.0% (23) of the comments for all years. Suggestions included reversing the direction of study from the present to the past; concentrating on examination of different diseases during different historic periods, thereby covering more material and more rare books; offering a review of general history or a syllabus in the first session so students could better pick a topic of interest for the remaining 4 sessions; or concentrating on selected historical figures, their discoveries, and their writings for a more in-depth approach to the history of medicine. Other ideas for changing the seminar represented another 31.5% (18) of the total comments. These ideas included: rescheduling the seminar series so as not to conflict with exam schedules, adding examination of ancient medicine, and expanding coverage to include the social context of medicine for the time periods covered. All the suggestions were helpful to the instructors by challenging their assumptions on how best to organize the seminar. Many gratifying comments discussed the instructors' enthusiasm for the seminar and for the special presentations by the special collections librarian. One student commented that these presentations were like a private tour of a medical museum.

DISCUSSION
Several lessons have been learned from facilitating the seminars. History is a popular topic when chosen freely by students. Each year, the limit of six students has been reached. Students want to learn about history of their new profession and use rare books. Some seminar topics become very personal, while other topics tend to repeat. The key is to make the seminar interesting for students by suggesting different subtopics that would engage their interests as well as provide opportunities for new insights into old topics.
Participating in the seminar is a learning experience for the librarians. In particular, the special collections librarian learns more about the collection while preparing for each seminar. Over the years, the librarian reviews different periods of medical history and examines relevant titles from the collection to see how they would contribute content and perspective to the students' research. This review allows the librarian to understand where there are gaps in the collection, examine alternative online selections that could fill those gaps, and complete any missing data in the cataloging records.
An issue that has surfaced over time is the increasing availability of rare books in digital format. Originally, the proposal to teach the seminar was designed to promote the ''use'' of the Galter Library's rare book collection. With open access to digital copies of rare books, the question has surfaced whether student research should be restricted to what is available locally in print versus what is easily accessible online. Because students have busy schedules, varied interests, and limited time, the instructors recommend that students either schedule an appointment to see and use the library's rare books or use resources they find online. When asked if there is a difference, students frequently comment that handling an actual rare book is a special feature of the class that cannot be gained from using an online text. To students, handling and reading a ''real'' rare book impart the lesson of history: that the book is verification of a historical event, activity, or a medical observation and is testimony to a fact of history, whereas an online text serves to relay information or content. Touch, then, is valuable for forming perspective and observation and is very similar to the difference between student participation in a gross anatomy lesson versus using an online simulation.
The availability of this seminar also points out how librarians contribute to other parts of the curriculum besides informatics. Librarians are capable of aiding student research efforts in the humanities and can guide students' interests toward fulfilling their personal and educational goals. The seminar also gives Galter librarians additional curricular contact with students, even though it is on a limited scale.

CONCLUSION
This model is another example of how librarians provide a teaching a role in a medical school curriculum. While teaching in the informatics component of the curriculum is a valuable and natural contribution by librarians, participating in the humanities component can be another entry point into the curriculum. Librarians want to see the collections used, especially, the rare books and other special resources, and so promoting their use via the humanities component of the curriculum accomplishes the library's promotional goal and contributes to the students' educational goals. For the handful of students who enjoy history, access to the library's rare books satisfies their personal and professional interests, while also satisfying their educational requirements.