Do the medical humanities enrich learning during an undergraduate anaesthetic placement?

The value of humanities may not be immediately apparent to those focused on the medical sciences. Medical humanities offer a range of learning opportunities, complementing the sciences to enhance medical education (Lake, Jackson and Hardman, 2015). This study examines whether the humanities enrich learning during an undergraduate anaesthetic placement. Method 26 third-year medical students completed a questionnaire following a two-week placement in anesthetics. Students had previously completed a compulsory humanities project. Inductive thematic analysis was carried-out on qualitative data by two independent assessors, before combining results to find common themes. Summary of Results 69% reported no previous experience of studying the humanities. 80% considered studying humanities beneficial. 34% responded that humanities were significant to anaesthesia. 85% used the humanities project to further explore and reflect on previous anaesthetic learning. Conclusions Despite minimal exposure, students agree with medical educationalists that the humanities can complement the sciences to create and change in ideas and behaviours, and therefore improve patient care (Oyebode, 2010). The majority of students regarded the medical humanities project a useful learning exercise; students valued the opportunity to choose a personally pertinent topic before using creative techniques to explore and reflect on it further. Students’ responses frequently demonstrated a deepening of knowledge leading to a favourable change in their attitudes and behaviour across topics difficult to explore using solely the sciences. Not all students responded enthusiastically to this style of learning with some preferring a more traditional approach.


Introduction
The value of the medical humanities may not be immediately apparent to those focused solely on the sciences. Indeed, the formal learning objectives for our third-year undergraduate anaesthetic placement are confined to the clinical application of physics, pharmacology and physiology. The basic and applied sciences are clearly important in anaesthesia, but it is the medical humanities that provide a different cognitive and affective experience (Spicer, Harrison and Winning, 2013). Learning through the medical humanities develops and enhances critical thinking and enables students to holistically challenge and analyse evidence (Naughton, 2000); skills essential to personal development and life-long learning.
Arguably, the medical humanities can elevate a competent doctor to an excellent one through complementing biomedical models of illness with deeper sensitivity and insight into the complex and varied human experience of health and disease (Gordon and Evans, 2007). Our project seeks to establish whether the introduction of a humanities project would serve to enrich the learning of third-year medical students during a two-week anaesthetic attachment.
Methods 26 third-year medical students were asked to complete a reflective assignment at the end of a two-week placement in anaesthesia. The assignment could be applied to any aspect of the placement and students were encouraged to choose an area which had the most personal impact; it did not have to align with the formal learning objectives of the placement. The project could be presented in any format, including, but not limited to, video, prose, picture or song. After submitting the assignment, students were invited to complete an anonymous questionnaire consisting of nine questions and free-text responses. Free text answers were chosen to not bias or limit the student response.
Inductive thematic analysis was carried out on the qualitative data by two independent assessors, before results were combined and common themes established to determine the outcome for each question.

Results/Analysis
The student responses to each question will be reported in the order that it appears within the questionnaire.
Firstly, students were asked "Do you have previous experience of the medical humanities". 14 students reported 'no', 4 were doubtful, 6 said 'yes', and 2 students gave no response. Of the students that answered 'yes', 5 had past experience in an applied format, while 1 student had past experience of pure medical humanities. Answers are summarised in table one.  Next, students were asked "do you consider any specific humanity disciplines significant to anaesthesia?". 12 students gave no response, 1 said 'no', 4 were uncertain and 9 students reported 'yes'. Included within the positive responses, 5 students considered philosophy, 3 considered spirituality and 2 history. Answers are summarised in table three. focused on the role of the anaesthetist, with 9 highlighting non-technical skills and 3 elaborating on anaesthetic technical skills. 8 students looked at sub-specialities relevant to anaesthesia, 3 focused on the patient's perspective, 2 students documented a personal experience during the placement and 1 student did not answer the question. The responses from students are summarised in table four. Question five asked students "why did you choose this aspect of anaesthesia?". 11 students felt their project was representative of their anaesthetic placement, 3 students exploited an area of clinical interest, 4 students did not answer the question and a further 11 students based their project on a new area of thinking or ideas. Included within the theme of 'new thinking', 6 students focused on human factors, 2 looked at an emotional impact and 3 students explored the patient's perspective. The results are summarised in table 5. Students were next asked "what was the format of your project?". 16 students chose a text format, 9 projects were art based and 1 was presented via data. Of the text-based projects, 7 were poems, 3 were blogs and 6 were prose. The results are summarised in table 6. Question seven asked students "why did you choose this format?". 15 students chose a format to allow freedom of expression, 7 students considered their format to facilitate further reflection, 2 wanted to use a new medium, 3 chose an enjoyable style, 2 students chose a format which they considered to be easy and 2 students did not answer the question. Next, students were asked "did the humanities project enhance your learning?". 17 students gave a positive response, of which 14 said a definite 'yes' and 3 were fairly sure. 9 students gave a negative response, of which 4 were a definite 'no' and 5 were doubtful of any learning benefits.
The final question asked students: "how did the humanities project enhance your learning?" 12 students gave no response, 3 stated that the project had not been helpful and 11 students reported benefit though personal reflection. The results are summarised in table eight.

Discussion
Only 6 students (23%) felt they had previous experience of the medical humanities, while a further 4 (15%) were not certain that they definitely had not encountered it. Medical ethics, writing diary entries and reflective tasks were common areas that students felt they had engaged with the humanities.
Despite minimal exposure, students were readily able to describe potential benefits of learning through the medical humanities; only 4 students (15%) provided no response and 1 student (4%) was uncertain. The remaining students grouped their responses into three main areas: 'personal', 'educational' and 'care and compassion'. Typical responses included: "Provides an opportunity to step away from the technicalities and intricacies of science for a moment and think about our roles as future doctors in a more rounded way! Science isn't always the answer." "Develop other skills including writing for a non-medical audience, opportunity to reflect" "It makes you remember the personal side to medicine as well as the science" "Especially with anaesthetics-you are balancing an art and medicine. Familiarising ourselves with the humanities would benefit the patient." Students seem to agree with medical educationalists that the humanities can complement the sciences to create and change in ideas and behaviours, and therefore improve patient care (Oyebode, 2010).
When asked which disciplines of the medical humanities are relevant to anaesthesia, 12 students (46%) gave no response, 1 (4%) felt there were no relevant disciplines and 4 (15%) were unsure. Only 9 students (35%) were able to engage with the question and considered philosophy, spirituality and history to be relevant. "Potentially in a theoretical sense but less so in terms of day-to-day work" Lack of engagement in the question could be secondary to reduced understanding of the subspecialties which contribute to the medical humanities or represent a limited understanding of anaesthetic practice. Responsive students frequently made two or three different suggestions demonstrating a significant disparity of awareness within the cohort of students.
The student projects covered a wide range of subjects. Most (46%) focused on the role of the anaesthetist, with three-quarters of these interested in human factors or non-technical skills. 31% of projects were related to an anaesthetic subspecialty, e.g. obstetrics or paediatrics. Student comments included: "The responsibility an anaesthetist has on patients" "Emotional aspects of anaesthetics" "The patient experience of anaesthesia" "Putting in cannula" Reasons influencing student topic choice were similarly varied. 38% of students felt their topic was representative of the placement, while a further 38% chose something which represented a new idea, knowledge area or novel way of thinking. Only 3 students (10%) completed a project closely related to the basic sciences, and 4 (14%) did not answer the question. Student rationale included: It is encouraging that 22 students (85%) utilised the project to reflect on ideas and experiences gained from the twoweek placement anaesthetic placement. The rationale for topic choice was similarly interesting as it often represented very personal responses across themes that are frequently difficult to access using solely the sciences.
The rationale for choosing the format was similarly varied with many students having multiple reasons for their choice in presentation style. Most students, 15, chose their medium to engender freedom of expression while 7 students chose a style to facilitate further reflection. 3 students chose a medium which they found enjoyable while 2 wanted to try something new. 2 students chose a presentation style for its ease of production and 2 students did not provide a response.
"I have never written a poem before, so why not?" "I imagined it as a river with many tributaries and, whilst definitely not an artist (sorry!), it was easiest to try and depict this via a drawing. The patient just thinks they are going off to sleep, but there is so much going on, risks being avoided, the anaesthetist is literally keeping them alive whilst putting the patient under as little stress as possible." "It helped me express my thoughts about the experience" "Quick and easy" While it is encouraging that the majority of students chose a medium to assist their learning, the choice of an 'easy' presentation style may reflect reduced student value of the project. Perceived lower value may be attributed to a lack of respect for the medical humanities, or external time pressures.
The majority of students (65%) found the project to be a useful learning experience while 35% did not find the task valuable. Comments included: Despite the positivity associated with the task, students demonstrated difficulty in explaining how the project was helpful. 12 students (46%) did not answer the question and 3 students (12%) reiterated that they did not find educational value in the task. 11 students (42%) considered personal reflection the most instrumental part of the learning process, by allowing organisation of thought processes and ideas relating to behaviour change.
"I had to think about why it made such an impact on me" "It made me think about how I would cope if things went wrong"

"It got me to think about the experience and how it could make me a better doctor" "Was already reflecting throughout, not really a very creative person and would have preferred to instead have a group reflective session where we discussed a topic each or something….would be interesting to see if others felt the same way and had similar experiences"
A high level of insight is required into a student's own learning techniques in order to accurately describe 'how' they learned. This may be particularly difficult for students dealing with a new learning strategy and limited expertise in analysis, evaluation and personal reflection. Perhaps there is a role for enhanced reflection through facilitation from seniors to maximise student benefit from the process (Henderson et al, 2002). Indeed, students may become better equipped with analytical and reflective skills following increased exposure to the medical humanities.

Conclusion
Students reported limited exposure to the medical humanities prior to undertaking this project. However, they attributed an holistic approach to medicine and a greater understanding of the patients' perspective to the study of the medical humanities. Students reported that spirituality and philosophy were relevant to anaesthesia, in particular the unconscious mind. This is a complex topic that is difficult to explore using solely the sciences.
The majority of third-year medical students regarded the medical humanities project as a useful learning exercise; students valued the opportunity to choose a personally pertinent topic before using creative techniques to explore and reflect on it further. A wide range of themes was evident and students' responses frequently demonstrated a deepening of knowledge leading to a favourable change in their attitudes and behaviour. Not all students responded enthusiastically to this style of learning; some prefer a more traditional approach to teaching or learning that focuses on the medical sciences. A greater understanding and respect of the medical humanities throughout the undergraduate curriculum may help to improve students' engagement with similar projects in the future.

Take Home Messages
Despite minimal exposure, students agree with medical educationalists that the humanities can complement the sciences to create and change in ideas and behaviours, and therefore improve patient care (Oyebode, 2010). The medical humanities have much to offer undergraduates in anaesthesia, though not all students respond enthusiastically to this style of learning. The humanities project offered students a structure with which to further explore, analyse and reflect on a topic of personal interest within anaesthesia creating a deeper, holistic learning experience. The medical humanities may be particularly beneficial in developing non-technical skills in medical students with learning extending beyond the anaesthetics placement.

Notes On Contributors
Dr Helen Westall is a ST7 anaesthetic trainee within the Imperial School of anaesthesia, London. Educational interests include the medical humanities, assessment and the clinical application of simulation training; a deeper understanding of which has been gained through completion of a teaching fellowship and postgraduate certificate in medical education.
Dr Amardeep Riyat is an anaesthetic consultant and college tutor at London North West University Healthcare NHS Trust, London. A keen educationalist, he oversees a local teaching fellowship, regularly supervising and facilitating local research and quality improvement projects. Educational interests include simulation training, the medical humanities and professionalism in undergraduates.

Acknowledgements
Thank you to the 26 third-year Imperial College medical students who engaged with the humanities project and completed the additional questionnaire.

Appendices
Below is the raw data collected from the student questionnaires. Each student has been assigned a number between 1 and 26 . Provides an opportunity to step away from the technicalities and intricacies of science for a moment and think about our roles as future doctors in a more rounded way! Science isn't always the answer. 3 Especially with anaesthetics-you are balancing an art and medicine. Familiarising ourselves with the humanities would benefit the patient 4 5 Puts everything into context 6 It makes you remember the personal side to medicine as well as the science 7 Integrating their clinical skills and practical knowledge into the wider context of the human experience 8 A chance to unleash their creative minds 9 Nice change to the normal very scientific nature of the course. Could be much more extensive 12 An opportunity to perceive medicine from a non-scientific standpoint; helping to put into perspective how medicine fits into the greater picture 13 Give a worldly view of medicine in society 14 The chance to give the holistic view of the patient 15 Other, more useful ways of learning 16 Develop other skills including writing for a non-medical audience; opportunity to reflect 17 18 approaches to thinking 19 More rounded education. Better development of writing style. 20 understanding ethical issues, helps in writing essays, more rounded education 21 well, it could make you a more rounded person 22 a more rounded education 23 a better understanding of human behaviour and interactions 24 good for reflection and be able to evaluate what we have done in our practice 25 26 The opportunity to consider looking at different things from different perspectives. This is useful when considering layman's options and perspectives Table 3. Question 3 raw data: do you consider any specific humanity disciplines significant to anaesthesia? Question 3: Do you consider any specific humanity disciplines significant to anaesthesia? 1 Definitely philosophy as it goes hand in hand with themes such as unconsciousness 2 Not really 3 4 Spirituality 5 Spirituality and philosophy the unconscious state. History: when GA came around etc. 6 7 8 Philosophy; anaesthetists may have philosophical and legal views to weigh up. 9 History would have a large impact, as anaesthesia has developed so much over time.  Table 4. Question 4 raw data: which aspect of anaesthesia did you choose to do your project on? Question 4: Which aspect of anaesthesia did you choose to do your project on? 1 The responsibility an anaesthetist has on patients 2 The patients perspective of anaesthesia is a mysterious thing 3 The patient experience of anaesthesia 4 Pharmacology 5 Labour ward 6 Paediatric anaesthesia 7 Ventilation with reference to a specific case I had observed 8 Teamwork and the humour I saw 9 Pharmacology 10 The art of anaesthesia 11 Emotional aspects of anaesthetics, importance of people in medicine and anaesthetics, responsibilities of anaesthetics. 12 Panic i.e. when things go wrong 13 Intra-operative care 14 experience in the labour ward 15 Complications of anaesthesia and incidence 16 The role of anaesthetists in surgery and asking if their role is subordinate to that of the surgeon 17 Theatres 18 the experience as a whole 19 All -general overview of each subspeciality 20 Overall aspect 21 an overview of my two weeks of anaesthesia 22 Putting in cannula 23 experience of patient 24 team work and anaesthesia 25 26 Role of anaesthetist Table 5. Question 5 raw data: Why did you choose this aspect of anaesthesia? Question 5: Why did you choose this aspect of anaesthesia? 1 Because that was the quality I saw all doctors in this specialty had and took very seriously. On a personal level I think I learnt what it truly meant during this placement 2 -going to 'sleep' compared to the medical reality of actually GA meaning putting patients into an induced coma-actually really technical and quite scary for people which is perhaps why we don't really tell them! 3 In theatre on placement we see a lot from the medical perspective so I thought it would be interesting to think from the other side 4 I have a degree in pharmacology 5 It was great to see a baby being born and the fact that the mother was awake for the procedure 6 Because it made me think 7 I found this to be very interesting 8 The anaesthetists were really welcoming and that really improved my time in theatre 9 Because it is a major part of the process of anaesthetics and I found the details of each drug interesting. My experiences during 2 weeks here showed me, above all else, those aspects of anaesthetics. 12 It's an inevitability of practicing medicine 13 It's interesting/daunting to see how carefully a patient has to be monitored during an operation, how many factors come into play. 14 It was an experience that really stuck with me. It was a very emotional experience seeing a baby being born, then seeing the anaesthetist respond in an emergency. 15 Watched numerous inductions of children and parents were often nervous about the complications of anaesthesia 16 a consultant anaesthetist said to me that they are often thought of as 'handmaids to the surgeon' 17 this is where I spent most of my time observing anaesthetics 18 to reflect on what I've learned over the past two weeks 19 Because I wanted to reflect on my entire experience 20 21 22 Because it was something I hadn't done before and something I really enjoyed 23 24 I was really struck by how supportive the teams were of each other and how able they felt able to ask others for help 25 26 It's not always appreciated as being 'vital' I have never written a poem before, so why not? 5 Enjoyable to write and more creative/less scientific than we are usually asked to do 6 As I was watching the procedure I had many thoughts, I wanted to piece to show my trail of thoughts 7 I felt this was the best way to effect what I had seen/observed 8 They aptly gave me an opportunity to write in a format usually reserved for humour about anaesthetics 9 I've always enjoyed art and it was a lovely having a chance to reflect in a creative way 10 I imagined it as a river with many tributaries and, whilst definitely not an artist, (sorry!), it was easiest to try and depict this via a drawing. The patient just thinks they are going off to sleep, but there is so much going on, risks being avoided, the anaesthetist is literally keeping them alive whilst putting the patient under as little stress as possible.