Our Experiences With ‘Sparshanam’, A Medical Humanities Module For Medical Students At KIST Medical College, Nepal

*Dept. of Medical Education,**Dept. of Medicine,***(Principal) Dept. of Medical Education,****Deputy Director Academics,Dept.of Microbiology,KIST Medical College, Imadol,Lalitpur.(Nepal)

Abstract

Medical Humanities (MH) uses subjects which are traditionally known as humanities in the pursuit of medical educational goals. MH programs are not common in South Asia. A voluntary module for medical students and interested faculty was previously conducted at Pokhara, Nepal.
KIST Medical College is a new medical school in Lalitpur district of Kathmandu valley. A MH module for faculty members was conducted. The first year medical students joined the MBBS course in mid-November 2008. An MH module using small group and activity-based learning was conducted for all students. Case scenarios, brainstorming sessions, role plays and paintings were used to explore various aspects of MH. In this article, the authors share their experiences of conducting the module.

Medical Humanities (MH) has been defined as ‘an interdisciplinary and increasingly international endeavour that draws on the creative and intellectual strengths of diverse disciplines including literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology and history in pursuit of medical educational goals’ (1). MH programs are common in developed nations but are not common in South Asia. Nepal is a small developing country in South Asia and many medical schools have opened in the country in the last fifteen years.
The first author conducted a voluntary MH module for interested students and faculty members at Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal (2).Twenty-six students from the third, fifth and sixth semesters and interested faculty members participated. The participants enjoyed being a part of the module. They had problems with certain literature excerpts and wanted more literature and art from a South Asian context. The author’s experiences while conducting the module have been mentioned in a recent article (3). Making the module interesting and informative was the main challenge faced. Keeping an open mind and employing a flexible approach were also important.

KIST Medical College
KIST Medical College (KISTMC) is a new medical school in the Lalitpur district of the Kathmandu valley which is committed to

excellence in holistic healthcare, education and research. A module was previously conducted for faculty members and medical/dental officers at KISTMC. The participant feedback on the module was positive (4). The group dynamics during the sessions were satisfactory, but certain literature excerpts were felt to be complicated. Certain respondents were uncomfortable with role plays dealing with sexual and reproductive issues.

The 75 first year medical students joined the undergraduate medical (MBBS) course in mid-November 2008. There was a week long orientation program for students where they learnt about, ‘what it means to be a doctor’ and ‘medical ethics’ and were introduced to the faculty members and different departments. There was also a session on the ‘Art of medicine’.

Can We Have An MH Module For All First Year Students?
The curriculum of Tribhuvan University (TU) to which the college is affiliated, emphasizes early clinical contact and learning of communication skills by students (5).Students attend the clinical teaching sessions every Wednesday morning from 8 am to 12.30 pm in the teaching hospital.

We wanted to introduce the students to Medical Humanities. The first task was to prepare a module outline. The module concentrated on empathy, the doctor, the patient, the doctor-patient relationship, dealing with HIV-positive patients, the family, the healthcare team, the medical student and ‘what it means to be sick in Nepal’, among other topics. There were a total of 11 topics and each topic was to be completed in two sessions. The MH sessions were held from 8 am to 9.30 am every Wednesday. We were apprehensive about involving all students in the module. Engaging the large student number (75) and creating, maintaining and sustaining their interest in MH were the major challenges faced by the organizers.


What Was Covered?
The topics selected for the module were based on those covered in other MH modules worldwide, discussions with other MH educators, our experiences with various topics during previous MH sessions and feedback obtained from participants of previous modules. Topics like empathy, the doctor-patient relationship, the family, the doctor and ‘breaking bad news’ were covered in previous sessions. The new topics introduced during the present module were the healthcare team, the medical student, individuals who are victims of deprivation and ‘what it means to be sick in Nepal’. We felt these were topics of particular interest to medical students in the context of Nepal. The two home assignments were ‘Death of the family doctor’ and ‘Your friendly neighborhood medical representative’. There is a trend towards increasing specialization and super specialization in Nepal, especially in urban areas and the trend towards being ‘the general practitioner or family doctor who could treat most conditions and was a friend and counselor to the family’ is becoming increasingly uncommon. Aggressive pharmaceutical promotion is common in urban Nepal and has a major impact on the prescribing behaviour. We wanted the students to reflect on these two phenomena.

Name Of The Module
The next major challenge was naming the module. We wanted a name which reflected the module contents and objectives and that which was rooted in Nepalese culture. We ultimately settled on ‘Sparshanam’, which means ‘touch’ in Sanskrit. Many languages of South Asia including ‘Nepali’, the national language of Nepal, are derived from Sanskrit. Touch is a powerful gesture and can always comfort the patient. In many instances, touch can be therapeutic also. We wanted to emphasize the importance of touch in the doctor-patient relationship, in relationships between the patient and other health professionals and in the care and support given by the family and other care givers.

Teaching-Learning Methodologies And Activities Used
Like in previous modules, we used small-group and activity-based learning strategies. The challenge which we faced, was to adapt these methodologies for a large number of students. Case scenarios, role-plays, paintings and literature excerpts were used previously and participants had problems with certain literature excerpts. We decided not to use literature in the present module.

We started each session with a brief introduction by the facilitators and then had a brainstorming session, followed by two activities. Towards the end of the session, there was a ‘Khula Manch’ (open forum) where participants could talk about various aspects of the module or interpret MH through songs and music, followed by a ‘Take home’ message by a student and conclusion by a facilitator. Power Point slides were used to link together various activities and to keep the session on track. Students identified major issues in each case scenario and interpreted it using role-plays. The activities with regard to paintings were, ‘What do you see’ and ‘What do you feel’, to create a story or around 100 words about the scene depicted in the painting, to create and sing a song or poem about the scene depicted and to interpret the issues covered in the painting using role-plays (6).

Cofacilitators
We decided to have cofacilitators for the module, considering the large student body. The first two authors of the article acted as facilitators, while six other faculty members acted as cofacilitators. The cofacilitators were from the departments of Medicine, Surgery, OB-GYN, Paediatrics, Pathology and Family Medicine. The 75 students were divided into six groups of 12 or 13 students each and each small group was under a particular cofacilitator. The aims of having cofacilitators were, to involve more faculty members in the module, to facilitate small group dynamics and to train cofacilitators to act as facilitators in future sessions.

The first author had met Dr. Huw Morgan at Patan Hospital where he had delivered a talk on MH. Dr. Morgan is a family physician and medical educator from the United Kingdom, with a keen interest in MH. Dr. Morgan was interested in the KISTMC MH module and promised to help and facilitate sessions whenever he was able to manage time from his responsibilities at Patan Hospital. Dr. Morgan attended four sessions at KISTMC, acted as a facilitator, shared his experience with the students and brought an international perspective to the sessions.

Where To Hold The Sessions And Forming Student Groups
The next challenge was to find a suitable location to conduct the sessions. The place had to be large to accommodate 75 students comfortably, suitable for conducting activity-based sessions and with facilities for LCD projection. The college auditorium on the top floor of the hospital fulfilled these criteria and it was used. We arranged the seating of the auditorium before each session to suit our requirements. Students were seated on chairs around a worktable. Group presentations were conducted using flip charts and white boards. A microphone system was available. Arranging the groups so that the participants could see the white boards, flip charts and the projection area and in such a way that they could work together comfortably in small groups, was a challenge.

Each group was named after a famous worker in the field of MH. One of the first assignments given to each group, was to submit a short write up about the person after whom their group was named. Each group had to select a group leader, a time keeper, a recorder and a presenter. These roles were rotated during each session. Our aim was to develop qualities of leadership and problem solving among students.

Creating And Maintaining Interest
At the beginning of the module, each participant was given a curriculum outline mentioning the topics to be covered and a topic description giving a brief outline of each topic. Lesson plans were prepared for all sessions and were discussed with the cofacilitators. We relied on activities to create and maintain interest. The case scenarios covered issues of importance to medical practice in Nepal.

The participants explored issues using role-plays. The facilitators gave frequent constructive feedback to the students. ‘Khula Manch’ was especially popular. The participants used it to explore various issues through songs and music. Initially, the emphasis was on romantic film music, but under our guidance, songs exploring other issues were also performed. Some participants composed their own songs or recited their own poems. Formative assessment of small groups was carried out frequently and participant feedback was taken at the end of each session. The facilitators concentrated on creating a safe and non-threatening environment for the participants.

Student Facilitators
To develop leadership and facilitation skills among students, we decided to have student facilitators for certain sessions. There was a certain amount of apprehension among the facilitators about the idea. Some felt that students would not be able to facilitate the session satisfactorily and that it may affect their learning. We decided to give it a trial.

The feedback from the student facilitators was positive. The students discussed and worked with the facilitators to develop the lesson plan for the session. Then they conducted the sessions, invited help and contributions from faculty facilitators where required and facilitated group dynamics. We felt that the student facilitators did a good job and were energetic and committed. The students facilitated five sessions. Most of the student participants felt that the ‘student facilitators’ had done a good job. Somehowever, felt that the student facilitators were a bad idea and that the concept should be reexamined for future sessions.

Problems Of Attendance
Student attendance was an occasional problem, especially if there were assessments of ‘Basic Science’ subjects. We were flexible regarding the attendance and usually anywhere between 55 to 70 students attended each session. We aimed to make the sessions interesting and informative. We also made the attendance of group members a criterion during the formative assessment of groups. The students were given two multiple choice examinations during the module, to gauge their understanding of topics discussed.

Paintings
The paintings used in the module were works by western artists. These were obtained from the literature, art and medicine database maintained by New York University. The database gives detailed annotations and interpretations of the paintings. The students had no problem relating to the scenes depicted in the paintings. Among the artists whose paintings were used in the module were Vincent van Gogh, Pablo Picasso, Alice Neel and Frieda Kahlo among others (6). The paintings were projected using the LCD projector so that students could appreciate them in colour. We had tried photocopies of paintings during the module at Pokhara, but colour photocopies were not available and black and white reproductions led to the loss of a large amount of information. Colour plays an important role in paintings. The groups carried out their activities and presented their findings, which were followed by discussion and comments by other groups. The facilitators then presented the annotations. Interpreting the scene depicted in the paintings using role-plays was extremely popular.

Lessons For Educators In Developing Countries Which Are Starting With MH Modules
Careful planning and preparation are necessary before starting an MH module. MH modules are not common in developing countries. Feedback and support can be obtained from educators in developed nations, but the responsibility of adapting and modifying topics to suit local requirements is that of the faculty member/s. Maintaining participant interest was a challenge. We would recommend around 8 or 9 topics for a new module. We had difficulty in sustaining the interest of the students for all the 11 topics. As we explored each topic in two sessions, we had a total of 22 sessions. We used small group and activity-based learning strategies. We obtained regular participant feedback and feedback from other facilitators to ensure that we were on the right track.

Future Sessions
We plan to continue with MH sessions for students in future. We are considering using paintings by Nepalese artists if possible, for certain topics. We plan to use literature excerpts from South Asia if we can get easily understandable excerpts which are relevant to our topics.

Royal free and University College Medical School, London, England. Acad Med 2003; 78:1048-53.