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The Arts and Medicine
August 27, 2019

How to Fix the Premedical Curriculum—Another Try

Author Affiliations
  • 1Hartford Hospital, Hartford, Connecticut
JAMA. 2019;322(8):710-711. doi:10.1001/jama.2019.11480

Forty-one years ago, physician-essayist Lewis Thomas proposed that applicants to medical school who were traditional premed science majors be considered last, if at all, for admission.1 Instead, he wrote, preference should be given to students who concentrated on “some central, core discipline, universal within the curricula of all the colleges, which could be used for evaluating the free range of a student’s mind, his [sic] tenacity and resolve, his innate capacity for the understanding of human beings and his affection for the human condition. For this purpose,” he concluded, “I propose that classical Greek be restored as the centerpiece of undergraduate education.”

In other words, future physicians should be able to read, in their original language, the great works of the tragedians (Aeschylus, Euripides, Sophocles) and of Homer, including and perhaps especially the dramatic scene at the end of The Iliad in which Priam, king of Troy, visits the Greek warrior Achilles and begs him to return his son Hector’s body for a proper funeral. Achilles had killed Hector in a fury at having lost his best friend Patroclus to Hector's sword and, in violation of the mores of men and gods, dragged Hector’s corpse around the walls of Troy for 11 days in grief and vengeance. In his appeal to Achilles, Priam invokes his grief for his son and his old age and that of Achilles' own father, causing the 2 men to weep together—Priam over Hector; Achilles over his father Peleus and his friend Patroclus (Supplement).

The Brygos Painter, Hector’s Ransom Skyphos, circa 490 bce, clay pottery (h, 250 cm), Kunsthistorisches Museum, Vienna, Austria (for complete details see ja.ma/PriamAchilles). Priam, king of Troy (left) approaches a reclining Achilles (right) to solicit the body of his son Hector (beneath the couch).

Reprinted with permission of the Kunsthistorisches Museum, Vienna, Austria.

This passage is justly deemed one of the gems of Western literature and is paradigmatic of the many contingencies of human life—honor, compassion, grief, loss at the hands of apparently meaningless forces beyond our control, tragedy, and our human capacity and willingness to share all of these even with those who have hurt us. These are scenes, themes, and experiences known by Thomas to reside in the Greek and other classics, and he anticipated that students literate in the canon could access them in their clinical relationships with patients.

If students can read The Iliad and other classics in highly regarded translations,2,3 why bother with Greek? Thomas’ take was that “The capacity to read Homer’s language closely enough to sense the terrifying poetry in some of the lines could serve as a shrewd test for the qualities of mind and character needed in a physician.” He may have known that the original Homeric Greek conveys meaningful lessons to students training in the caring professions such as medicine. For example, when Priam reaches his hand to Achilles’ lips in line 506 (Supplement), the text uses the verb form ὀρέγεσθαι (oregesthai) in the Greek middle voice, which gives it a reflexive meaning that has 2 equally valid interpretations: Achilles touching Priam's mouth in respect and pity, or Priam touching Achilles’ in ritual supplication.4 Either is possible, and both are correct, signaling mutuality and a moment of connection and compassion.

Similarly, the Greek word for remembering in line 509 (μνησαμένω [mnēsamenō]; Supplement) is a participle in the dual number modifying 2 people.5 Although not a verb form we can appreciate in English, it succinctly signals to the reader that the 2 subjects it describes, Priam and Achilles, are not only 2 in number—2 men already in a relationship of physical exchange thanks to that middle voice verb of reaching/touching 3 lines previous—but also intimately related. It thus sets up the climactic dual weeping, in concert, 2 persons affected by the war as a duet, crying as one, a linguistic reminder that in their grief and compassion, these 2 war-torn men, caught up in a conflict not of their making, are doppelgängers, indistinguishably unified in suffering. Try translating that in a single verse. English poet William Cowper came close more than 200 years ago with the translation “Remembrance melted both.”6

Padovanino (Varotari Alessandro Leone), Priam and Achilles, 16th century, oil on canvas, 35.9 × 28.1 cm, Far Eastern Art Museum, Khabarovsk, Russia.

Reprinted with permission of the Bridgeman Art Library, London, United Kingdom.

In both examples, the verb form captures the essence of empathy (from the Greek language for in and feeling). The mutuality of the patient-physician relationship is inherent to the grammar and is surely a component of what Thomas had in mind when he voted for Greek as the basis of a physician’s education. In medicine, the English verb form to care easily takes on a similar dual meaning in the middle voice, as any physician who has cared for patients realizes, one caring for the other and thereby caring for himself or herself as well.

By all appearances Thomas’ proposal did not go far, though the humanities have advanced undeniably in some curricula and campuses of undergraduate medical education.

Consider a more modest proposal: that all students applying for admission to medical school major in the humanities with an optional minor in biology and science topics. No premed majors need apply; the science training will come after acceptance. Any grounding in the humanities would suffice. As Thomas hinted, patients could look forward to being cared for by physicians “who have learned as much as anyone can learn, in our colleges and universities, about how human beings have always lived out their lives.”

Whether they are art history majors who have learned a visual language of compassion from Michelangelo's Pietà; French majors learning the secret passages of the heart from Marguerite Duras or Marcel Proust; African Studies majors reading Mazisi Kunene’s magisterial Zulu myth-epic Anthem of the Decades; philosophy majors reading about alterity in Gabriel Marcel, Emmanuel Levinas, or Martin Buber (who reflected on the philosophical middle voice in his sentiment that the “purpose of relation is the relation itself—touching the You. For as soon as we touch a You, we are touched by a breath of eternal life”7); or English majors reading Shakespeare—any Shakespeare; or Ralph Ellison’s Invisible Man—any firm basis in the humanities will, as other advocates of Thomas’ proposal have affirmed,8 prove efficacious for “evaluating the free range of a student’s mind, his tenacity and resolve, his innate capacity for the understanding of human beings, and his affection for the human condition.”

Compassion expressed in any genre or format is moving, edifying, and life-changing. Journeying into and through the humanities, studying them, discussing them—these are the fruits of the education Thomas so desperately wanted physicians to enjoy for themselves and to reach forth to the lips of their patients.

On behalf of our patients, our profession should require it as a condition of medical school acceptance. Forty-one years later, are any medical school admissions committee chairpersons up to the challenge?

Submissions: The Arts and Medicine editors welcome proposals for features in the section. Submit yours at artsandmedicine@jamanetwork.com.
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Article Information

Corresponding Author: Richard M. Ratzan, MD, Hartford Hospital, PO Box 270026, Hartford, CT 06127 (rmratzan@gmail.com).

Additional Contributions: I would like to thank David J. Elpern, MD, for prompting me to write this essay and Sally Kennedy for useful comments during its adolescence. Neither was compensated in association with their contribution to this article.

References
1.
Thomas  L.  Notes of a biology-watcher: how to fix the premedical curriculum.  N Engl J Med. 1978;298:1180-1181. doi:10.1056/NEJM197805252982106PubMedGoogle ScholarCrossref
2.
Homer, Bryant  WC.  The Iliad of Homer Translated Into English Blank Verse. Boston, MA: Houghton Mifflin; 1916.
3.
Homer, Nagy  G.  The Iliad. Fitzgerald  R, trans. London, England: David Campbell; 2000.
4.
Homer.  The Iliad: book 24:468-506.https://tinyurl.com/y6soqy5n. Accessed May 8, 2019.
5.
Homer.  The Iliad: book 24:507-551. https://tinyurl.com/y3wzg99q. Accessed May 8, 2019.
6.
Cowper  WS, Southey  R.  The Works of William Cowper, Esq., Comprising His Poems, Correspondence, and Translations. Vol. XII; The Iliad of Homer. Vol. II. Southey  R, ed. London, England: Baldwin and Cradock; 1870:336.
7.
Buber  M.  I and Thou. Kaufmann  W, trans. New York, NY: Charles Scribner's Sons; 1970:112-113.
8.
Gunderman  RB, Kanter  SL.  Perspective: “how to fix the premedical curriculum” revisited.  Acad Med. 2008;83:1158-1161. doi:10.1097/ACM.0b013e31818c6515PubMedGoogle ScholarCrossref
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    3 Comments for this article
    EXPAND ALL
    Humanities Exposure is Important But No Guarantee of Empathy and Compassion
    Edward Volpintesta, MD | Bethel Medical Group
    I agree that any grounding in the humanities in the pre-med years before going on to the sciences is a good way for physicians to learn how to deal with the emotional and social difficulties that afflict many of their patients.

    Applying empathy and compassion at times are more difficult for physicians than applying medicine or performing a surgical procedure.

    But merely being exposed to the humanities is not enough. Students must have a certain innate capacity and desire to understand the human condition.

    In addition to exposure to the humanities, admission committees would do well
    to consider the importance of this personal quality to the personal interview.

    Much can be learned from the way an applicant engages in conversation, their tone of voice and sense of humor, their range of interests, the books they may have read, their hobbies and even their responses to questions like “what do you think is right wrong with medicine today?”

    After 44 years in practice as a general practitioner I have known physicians who have a great capacity for empathy and compassion and some physicians who don’t.

    And I don’t think that being exposed to the humanities before immersion in the sciences would have made much difference for any of them.
    CONFLICT OF INTEREST: None Reported
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    Fixing the Premedical Curriculum
    Joel Brown, MD | University of Hawaii John A Burns School of Medicine
    Dr Ratzan refers to Lewis Thomas’ proposal to teach premedical students compassion by majoring in the humanities, especially classical Greek language and literature (1,2). Dr Ratzan refers to the Trojan War scene in Homer’s Iliad where Achilles shows compassion by acceding to King Priam’s pleas to return the body of his slain son, Hector. He dwells on the value of reading Greek classics in Greek to learn compassion and empathy.
    We need not learn compassion from ancient literature; just turn a few pages in the same issue of the journal and read Dr WIce’s narrative about confronting his
    wife’s devastating illness (3). We need not read Homer’s story of Telemachus searching for his father, Odysseus, who had not returned from the Trojan War. We can reflect on our own Trojan War--the Vietnam War--and our continuing search for the fathers and sons who have not returned. Thousands of Americans have shed tears of compassion when visiting the Vietnam Veterans Memorial in Washington D.C. Few shed tears when reading ancient Greek literature.

    The Merriam-Webster dictionary defines compassion as “sympathetic consciousness of others' distress together with a desire to alleviate it.” Compassion is an emotion, and humans have variable amounts of this quality. It is unclear if compassion can be taught. Most medical students and young physicians have an innate quality of compassion, a quality enhanced by early exposure to real life experiences, patients, and compassionate faculty role models. Unfortunately, a physician’s sense of compassion can be diminished by the increasing demands of our current medical practice environment, which contributes to the growing problem of physician well-being and burnout.

    The Mount Sinai School of Medicine Humanities and Medicine Program demonstrated that students with humanities majors who omitted organic chemistry, physics, and calculus and did not take the MCAT performed well in medical school and residency (4). Most undergraduate schools require students to select a major after the first two years, which is appropriate for students truly interested in a subject or who intend to enter related specific careers. However, after graduation, many students enter careers unrelated to their major, and many employers favor a broad education. The University of Illinois Chicago’s Bachelor of Arts in Liberal Studies does not require a major field of study, which allows more flexibility in course selection, and could be a model for premedical education (5).

    References

    1. Ratzan RM. How to Fix the Premedical Curriculum—Another Try. JAMA. 2019;322(8):710–711. doi:10.1001/jama.2019.11480.
    2. Thomas L.. Notes of a biology-watcher: how to fix the premedical curriculum. N Engl J Med. 1978;298:1180-1181. doi:10.1056/NEJM197805252982106.
    3. Wice MB. A Difficult Conversation. JAMA. 2019;322(8):727–728. doi:10.1001/jama.2019.11757.
    4. Muller D, Kase N. Challenging traditional premedical requirements as predictors of success in medical school: The Mount Sinai School of Medicine Humanities and Medicine Program. Academic Medicine. 2010;85.
    5. University of Illinois at Chicago. BA with a Major in Liberal Studies. Available at https://catalog.uic.edu/search/?search=liberal+studies&fscaturl=%2Fucat&gscaturl=%2Fucat. Accessed August 30 2019
    CONFLICT OF INTEREST: None Reported
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    Premedical Education:
    Robert Dyson, MD | Retired
    Empathy has nothing to do with whether one has trained in the arts or the sciences. It is built in and we do not have a good way to measure it. Having great empathy for the patient who is dying because you did not have the knowledge and skill to get the diagnosis right the first time you saw them is not an improvement. It really does matter how much a doctor knows. Ability and training is how you get there. The more facts to which you are exposed, the more will be retained and available in recall. Reading Homer is not going to help.
    CONFLICT OF INTEREST: None Reported
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