A call for increased librarian support for the medical humanities

Sir William Osler revolutionized medical education with his focus on training physicians at the bedside, but there was another bedside recommendation that he made that gets a little less attention. Osler advocated for a “Bedside Library for Medical Students,” consisting of just a few nonmedical books on one's nightstand to be read for thirty minutes before retiring each night [1]. Osler believed the physician should be a well-rounded individual, in the tradition of the scientists and practitioners of previous generations. As Osler said, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head” [2]. In the past few decades, increasingly vociferous advocates for the medical humanities have sought to apply the Oslerian ideal to the hustle and bustle of managed care. A number of medical schools have taken up the charge in varied and creative ways, but on the whole, librarians have not been as involved in these efforts as they are in other curricular arenas such as evidence-based medicine. Even with the wonderful programs already thriving in medical schools, the medical humanities enterprise could greatly benefit from a librarian's touch.

Sir William Osler revolutionized medical education with his focus on training physicians at the bedside, but there was another bedside recommendation that he made that gets a little less attention. Osler advocated for a ''Bedside Library for Medical Students,'' consisting of just a few nonmedical books on one's nightstand to be read for thirty minutes before retiring each night [1]. Osler believed the physician should be a well-rounded individual, in the tradition of the scientists and practitioners of previous generations. As Osler said, ''The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head'' [2]. In the past few decades, increasingly vociferous advocates for the medical humanities have sought to apply the Oslerian ideal to the hustle and bustle of managed care. A number of medical schools have taken up the charge in varied and creative ways, but on the whole, librarians have not been as involved in these efforts as they are in other curricular arenas such as evidencebased medicine. Even with the wonderful programs already thriving in medical schools, the medical humanities enterprise could greatly benefit from a librarian's touch.
To understand how librarians can involve themselves in the medical humanities, we must first reach a working definition of the term. For New York University, the medical humanities encompass ''an interdisciplinary field of humanities (literature, philosophy, ethics, history and religion), social science (anthropology, cultural studies, psychology, sociology), and the arts (literature, theater, film, and visual arts) and their application to medical education and practice'' [3]. While many medical librarians have undergraduate degrees in science, almost all have advanced degrees in library science-itself an interdisciplinary field that includes elements of information technology, education, communications, and social science research [4]. Who better to assist medical faculty in building a well-rounded student body than their librarian colleagues, who are themselves so versatile?
How academic medical librarians can be involved in the medical humanities The ways that librarians can assist in this endeavor are manifold. Libraries can provide simple supports such as making meeting rooms available for student book clubs, hosting events with guest speakers on medical humanities topics, and offering wall space for student and faculty art. Librarians can support the medical humanities through developing collections in areas like history of medicine and leisure reading and promoting existing collections to medical humanities' faculty and students. If narrative medicine is a focus of the curriculum, the library could offer writing workshops or essay contests. The only true limit to what librarians can do is their own time.
Many librarians already undertake these roles without framing them in the guise of medical humanities, but viewing them through this lens can aid in forging new relationships with the medical faculty and with students. Often librarians and medical faculty each toil separately to offer great opportunities for students to foster and exhibit creativity without realizing their colleagues are making similar efforts. In these days of evidencebased medicine, when librarians are increasingly embedded into medical curricula, librarians should attempt to forge relationships with faculty on the medical humanities plane as well.

Why the medical humanities matter
The dearth of humanities education for medical students begins before they even enter medical school. Admission policies that focus solely on high school science grades and Medical College Admission Test (MCAT) scores are part of the problem. When Abraham Flexner reformed requirements for medical education with a focus on science, he did not mean that focus should negate a liberal arts education; in fact, he felt that a liberal education was such a given that it did not need to be stressed in his reports, something he later regretted [5]. Somehow this intention has been lost over the years, to the point that some undergraduate premedical programs include very little humanities education, and students tend to take only the courses that will help their chances of getting admitted to medical school. As a reaction against this trend, Mount Sinai School of Medicine has enacted a program that admits students with liberal arts degrees who have not taken the MCATs. The students take summer courses to get up to speed on some basic science before beginning their formal medical education. Mount Sinai has found that, although those students tend to struggle at first, they graduate with the same objective level of knowledge and success in the field as their peers with undergraduate degrees in science [6].
Medical students will likely prioritize the subjects, and therefore values, that their schools require of them. Medical schools, and the greater medical community, are now increasingly stressing humanistic values. The civil rights era and notorious Tuskegee experiments brought attention to the need for more empathetic and socially aware physicians, and that realization was codified in the recommendations and requirements of bodies like the Accreditation Council for Graduate Medical Education (ACGME) and Liaison Committee on Medical Education (LCME) [5]. In 1993, Arnold Gold began holding white coat ceremonies at Columbia to welcome students into the profession while imparting an air of gravity about their responsibilities as future physicians. In 2010, approximately 94% of schools of medicine and osteopathy held white coat ceremonies [7]. For some, the ritual has become a symbol of medical humanities at work.
Once medical students pass this rite, they cannot simply be left to rote scientific memorization and lengthy hours of study without any regard for their emotional well-being. Findings from a longitudinal study using the Jefferson Scale of Physician Empathy, Medical Student Version (JSPE-MS), raised alarm bells when statistically significant decreases in levels of empathy emerged between medical students' first-year and third-year scores. The study's authors warned, ''The downward trends suggest that empathy may indeed decrease during this critical period in a physician's development, raising the question of which aspects of medical training contribute to this decline and, in turn, which interventions could be effective in minimizing or even reversing this trend'' [8]. It is disheartening to think that students drawn to medicine because of a desire to help people can have the humanity beaten out of them through the course of their education. Like soldiers at war, budding doctors face situations that can propel otherwise empathetic people toward a cold, purely clinical manner in order to survive with their fragile human hearts intact. It may be that very fragility that makes for good doctors, an understanding of the patients as people like themselves, prone to the same weaknesses that make up our collective human condition. Faculty and librarians must work together to fight the characterization of medical care as a ''dehumanizing experience'' for students and patients alike [9].
Proponents of the medical humanities point to its methods as a way to help students process and reflect on the experiences they endure in medical school, hopefully resulting in more empathetic doctors. Though educators do hope that increased empathy is achieved, demonstrating that trend scientifically has proved difficult. Very little research about the effect of the medical humanities exists at all, and those studies that do are plagued with uncertainties. Andrea Wershof Schwartz acknowledges that studies that do show improvements in humanities students' empathy test scores can be skewed, because when the medical humanities are incorporated primarily as electives, already communicative, empathetic students tend to populate those classes, so real improvement is hard to measure: ''This lack of research is partially due to the diverse reasons why medical educators turn to the study of the humanities. Humanities courses are used in a variety of settings at the premedical and medical school levels, with no consensus in the medical community about the desired outcomes or benefits from participation in these courses, which are often more qualitative than quantitative'' [8]. Medical librarians can help close gaps in the research by using their social science research skills to craft strong studies to show the relationships among medical humanities education, medical student empathy, and general well-being.
A focus on the medical humanities need not be limited to bolstering student art shows and poetry. It can foster an environment of palpable scientific discovery. Young students initially enamored with the wonders of science can be turned off by abstractions as the subject matter becomes more technical. Increasingly, researchers are taking a broader view of science and looking for interplay among disciplines via translational medicine, and medical humanities can put students in the correct mindset for interdisciplinary work. Librarians can aid researchers in discovering the information from other fields that they need to make these innovations and teach them the best methods for processing complex interdisciplinary data. With teams of scientists from different fields aided by librarians, more holistic and interdisciplinary approaches to old medical problems could eventually result in groundbreaking solutions.
The growing influence of the medical humanities on medical education affords many rewarding opportunities for academic medical librarians. By combining traditional librarian support roles, collaboration with medical faculty, and librarianled research efforts, the medical humanities are much more than a nice thing to have. The medical humanities present great possibilities for librarians to find even more ways to make themselves indispensable to their users. Claire Hooker describes the balance that the inclusion of the medical humanities attempts to strike: ''From time to time, both doctors and patients complain when medicine feels like it is only a set of tools used to affect specific body parts-and not like an interaction between fallible, complicated and, in the end, deliciously irreducible human beings'' [10]. Perhaps the assistance of some deliciously irreducible librarians is just what the doctors ordered.