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Illness Performed and Imagined: An elective course using Humanities to teach student pharmacists about illness
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Currents in Pharmacy Teaching and Learning 5 (2013) 120–128
Research
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Illness Performed and Imagined: An elective course using Humanities to teach student pharmacists about illness J. Russell Teagarden, BSPharm, MA, DMHa,*, Michelle Assa-Eley, BSPharm, PhDb, Ruth E. Nemire, BSPharm, PharmD, EdDb a
Advanced Clinical Science & Research, Medco Health Solutions Inc., Franklin Lakes, NJ b Touro College of Pharmacy, New York, NY
Abstract Objective: To describe an elective course featuring the use of the Humanities to provide students with an understanding of the illness experiences people face from their health problems and as they are distinct from disease processes. Methods: The course was delivered mostly through online media and online class chat sessions as well as asynchronous discussions. In between these sessions, students studied assigned Humanities works in literature, film, drama, and television. Students were evaluated and assessed through class discussion, written papers, discussion board contributions, and final projects. Student surveys were administered to assess specific aspects of the course. Results: The course was well received and considered highly valuable by both students and college faculty as discerned from student and faculty surveys as well as other mechanisms available for input from students. Discussion: Pharmacy education puts an understandable emphasis on the pathophysiological basis of disease and on the pharmacological basis of treatment. As a result, students focus most of their attention on biomedical elements of health problems while giving little attention to the illness experiences people face. Our course aims to give students a way to give more attention to the illness experience, and the course draws from the Humanities for this content. The positive response from students and faculty suggest that providing more education about the illness experience through the use of Humanities could be effective in producing more empathetic and caring pharmacists. r 2013 Elsevier Inc. All rights reserved. Keywords: Humanities; Pharmacy education; Instructional design
Introduction Illness can be understood as the subjective elements of health problems, while disease can be understood as the pathophysiological basis of health problems.1–3 Both illness and disease have always been part of the human condition, but only during the last 200 years following the advent of pathological anatomy, have illness and disease been distinguished to an extent that one can be addressed and not The institutions for all authors were accurate at the time of submission. * Corresponding author: J. Russell Teagarden, BSPharm, MA, DMH, Advanced Clinical Science & Research, Medco Health Solutions Inc, 100 Parsons Pond Drive, Franklin Lakes, NJ 07417. E-mail: [email protected]
the other.4 Since that time, medical scientists, clinicians, educators, and their institutions and traditions—collectively, Biomedicine—have created a culture that places increased focus on the pathophysiological basis of disease. This focus is further fueled by the inexorable advancement and allure of health care technology. Attention has consequently shifted away from the illness experience in practice and education. Yet, the illness experience still requires attention and should be accommodated in health professions education. As an academy of educators we should be cautious not to let what pharmacists can do to help people with their illness experiences fall from view. With that caution in mind, we developed a course, Illness Performed and Imagined, to provide students at the Touro College of Pharmacy in New York City with an
1877-1297/13/$ – see front matter r 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cptl.2012.09.017
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appreciation for the illness experience, and to help them see the connection between the arts and sciences in order to make them more effective health care professionals. Competencies driven by pharmaceutical care doctrine and the Center for Advancement of Pharmaceutical Education (CAPE) outcomes related to patient-centered care recognize patient needs stemming from their illness experiences beyond those that can be addressed by treatments directed at pathophysiological derangements.5,6 We chose to draw insights on illness experiences from the Humanities because the human condition has been the concern of the Humanities across the millennia, and because writers, artists, filmmakers, poets, and performers can best help us imagine and comprehend our plights, including those involving illness.
Rationale and objectives Pharmacy educators have not featured the Humanities in their curricula as a means to teach students about the challenges their patients face. Isolated use of the Humanities in a curriculum has been directed at providing portrayals of pharmacists and at modeling professional behaviors that take human suffering into account and that generate empathy for their patients.7,8 The Humanities requirements and electives in pharmacy schools are more commonly aimed at broadening the educational experience in a general sense. In contrast, the Illness Performed and Imagined course drew from the Humanities for the explicit purpose of providing students with insights on illness experiences as they can be conveyed by different genres. This approach gave students the most vivid accounts of what patients face during their lives as a result of health problems. The location of the Touro College of Pharmacy in New York City gave additional poignancy and urgency to the course. The school is located in Harlem so that students can appreciate the challenges people face in crowded, urban environments inhabited by under-represented minorities. The range and intensity of the human condition in this environment are often the focus of the Humanities. The insights on illness experiences offered our students in this class were thus further supported and validated by the environment in which the school is situated. For example, one of the paintings featured in the course depicted a person with tuberculosis living in Harlem during the 1930s, and a play selected for the class featured the HIV experience of two black women in urban environments in two different parts of the world, but neither character so different than the people of Harlem. We report here the details of the course, including specific objectives and requirements. We also describe the content chosen and content delivery methods. We report on our assessment of the outcomes and give some examples of student responses and work. Lastly, we propose some changes we would make prior to offering the course again. The course design provided students with insights on illness experiences as they are available through the
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Humanities. As such, the content was purposefully chosen to create an appreciation among the students for the value the Humanities offer about the human condition more broadly and the health system and individual patient situations more specifically. The course objectives addressed at the highest level show students how illness figures into the human condition, and at the most detailed level how pharmacists can affect a patient’s illness experience based on knowledge drawn from the Humanities (Table 1).9 Objectives also addressed other aspects such as: identifying particular elements of the illness experience covered in any particular work; discerning possible meanings a particular work may have for patients, populations, and health care systems; and determining the relevance of genre to a particular work. We mapped the general purpose of the course and the specific course objectives to expected overall outcomes of the Touro College of Pharmacy program. The expected outcomes mapped were those pertaining to advocacy for patients, good communication across diverse populations, ethical practices, and awareness of the special health challenges faced by underserved populations (Table 1). We also mapped the course to the two following CAPE outcomes.10 1. Maintain professional competence by identifying and analyzing emerging issues, products, and services that may impact population-based, therapeutic outcomes. (From: Pharmaceutical care: Provide populationbased care.) 2. Maintain professional competence by identifying and analyzing emerging issues, products, and services that may affect the efficacy or quality of disease prevention services to amend existing or develop additional services. (From: Public Health: assure the availability of effective, quality health and disease prevention services).
Materials and methods The course was delivered mostly through internet-based media. The online course method was employed so that adequate time was available for students to study the assigned works. Considerable time can be necessary to fully contemplate certain works, and the amount needed can differ among students and across the assignments. We believed standard, frequent lectures would be less effective than less frequent, online-class chat sessions. Therefore, we assembled the class for a two-hour online chat session every three weeks. On one occasion an in-class session was held for a dramatic reading of a play featuring the HIV experience. We engaged professional actors, a producer, and a director to participate with the students in a live environment. In between the online sessions, students were assigned literature, art, film, or television shows to study, papers to write, and online discussion to stimulate their learning and reflect on topics. Students were also assigned final individual and group projects.
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Table 1 Course objectives and related expected outcomes Course objectives
Expected outcomes
Upon completion of the course, the student should be able to:
Upon completion of the course, the student will partially or completely meet the full expectation of the Touro College of Pharmacy outcomes: Serving as advocates for patients and the profession.
Examine the genre in which an illness is presented, and what meanings, and actions that expression of illness is likely to have on the individual, population, or health professional. Identify and characterize the elements of illness portrayed by an artist Aware of cultural diversity and ethical practices in a painting. Argue why and how illness can be considered part of the human Accomplished in clear and effective communication condition. Recognize and describe how a pharmacist ought to affect change in the Recognizing barriers to health care access in underserved populations illness experience. Drawing from various depictions from the arts, describe and illustrate how the illness experience impacts the health care system.
A two-hour online chat session marked the start of the course and served as an introduction to the topics and method for learning and work. Student project presentations at the end of the course were also counted towards the total number of chat sessions. Topics covered during the live chat sessions included: how illness is distinguished from healthy states in the Humanities; how illness is presented in the Humanities; how the Humanities characterize illness experiences and how illness can be seen as integral to the human condition; and how the Humanities informs pharmacist roles in helping people with their illness experiences. The internet-based technology we used for the online chat sessions was Cisco WebEx, which permitted students and instructors to see one another and contributed to lively, interactive sessions. We assigned five, three-page reflection papers during the course. The students were asked to respond to a prompt we provided. The papers were assigned to engage and focus the students on particular elements of assigned works and for them to argue a point of view. For example, the reflection paper assigned for the film As Good As It Gets required a response to the following prompt11: In the film, As Good As It Gets, many of the characters could be said to be boxed in or trapped in certain ways. Describe how the characters Melvin, Carol, and Simon are each boxed in or trapped, that is, what is it that boxes each of them in. Also, describe how the director uses the film medium to reinforce the idea that these characters are boxed in or trapped in certain ways, for example, how does the director frame shots to convey this idea? Students also participated in three online asynchronous discussions, during which they were expected to respond directly to the prompt and to provide thoughtful replies to the input of two other students. While we did not expect the input from students in these online discussions to be as well formed as the reflection papers, we still required that students provide thoughtful perspectives in response to the
prompt. As an example, one of the prompts concerned an assigned graphic novel12: Harvey Pekar and Joyce Brabner, in their book, ‘‘Our Cancer Year’’ (illustrated by Frank Stuck), use the comic book or graphic novel genre to tell the story of Pekar’s cancer experience. This genre has its fans and its critics, especially when used for serious subjects or longer stories. Did the comic book genre help or hinder you in gaining insights on what Pekar experience during his cancer year? Cite some examples that support your position. The semester was divided into three week units. Each of these units began with a chat session, and utilized a mix of Humanities genres (Table 2). The second unit, for example, focused on how the illness experience has been presented in the Humanities. We used Wit, because of its vivid rendering of what people with terminal diseases experience as subjects Table 2 Assigned works Genre
Title
Literature
On Being Ill18 Brave New World19 The Death of Ivan Ilych14 Intoxicated by My Illness20 My Cancer Year12
Film
Garden State21 Wit13 As Good As It Gets11 Aurora Borealis22
Art
The Sick Child15 T.B. Harlem16
Drama
In the Continuum23
Television
Monk17
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in clinical research, as well as how the illness experience can lead to redemption.13 For similar purposes we used Tolstoy’s novella The Death of Ivan Ilych.14 This work gives students an idea of what can go through the mind of someone nearing death and who experiences both physical pain from disease and emotional pain from the behavior of people nearby. Two paintings we chose to use for this unit were Edvard Munch’s The Sick Child,15 and Alice Neel’s T.B. Harlem.16 In both paintings there is nothing to obscure plain illness and suffering, that is, none of the signs and artifacts of Biomedicine avert the viewer’s gaze from the utter misery illness can cause people. Neel’s painting goes further to indict the socioeconomic conditions of Harlem and the medical treatments used at the time as causes for this suffering. Lastly, we included episodes from the television series Monk, that showed students how illness experiences can affect everyday life and how they can be effectively accommodated.17 Monk also prompted students to consider that one man’s illness may be another man’s quirkiness. The innovation of this course involves drawing insights from the Humanities to give students an appreciation for illness experiences their patients will endure. Nothing about the content or the delivery methods were experimental, and so we did not seek Institutional Review Board approval. The course proposal was circulated among Touro College of Pharmacy faculty, adopted by the curriculum committee, and enthusiastically supported for inclusion as an elective in the curriculum (vide infra).
Results The course was designed to encourage creativity and to develop an individualized approach to study the Humanities among the students. No formal exams were given. Rather, we relied on class discussion (online chats), written papers, discussion board contributions, and final projects to measure student learning.
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The final course evaluation completed by the students offers a glimpse of student reactions to the course. Only seven of the 22, or 32% of the students completed the online-course evaluation form, but they had many positive comments and suggestions for improvement. Table 3 itemizes many of the key questions from the student course evaluation form with the mean and standard deviation for the students’ responses. For all questions, students were asked to indicate their agreement with the statement on a scale from 1 (strongly disagree) to 5 (strongly agree). In addition to the Likert-type questions, students rated the value of the various modalities used in the course, and were given an opportunity to provide open-ended comments on the evaluation form. The student response to the overall course was overwhelmingly positive, as can be seen by the high means on the items in the course evaluation. According to the students, the course was successful in meeting its goals and objectives, was well organized and helped students learn the material with the readings, exercises, and online activities. Of particular interest was the finding that students valued both the group projects, and online discussions and chats. When asked to rate these parts of the class in terms of their value, students who rated them gave them a ‘‘valuable’’ or ‘‘extremely valuable’’ rating. In written comments, many students indicated that the course helped them gain a new appreciation for the experience of illness apart from biomedical interventions and that this new appreciation for the illness experience will help them provide better patient care. One student said, ‘‘It’s one thing to be TOLD to be empathetic, but to view and read about a patient’s experience is a whole different concept.’’ Another said the class ‘‘may in fact be the most beneficial to my career as a pharmacist!,’’ and still another said, ‘‘I’m a changed person because of this class.’’ Many students remarked that they intend to share the works they studied with patients who they think could benefit from them. Student papers provided the instructors with other insights towards the value of the course in the curriculum.
Table 3 Student responses to course evaluation items (mean/standard deviation) Item
Mean/std. dev
The required texts and reading materials were useful resources for the course The graded exercises (e.g., assignments, performance assessments, exams) helped me learn what is important in this area of study The course content was organized in a manner that helped me learn Course objectives were presented clearly in the syllabus The course content was directly related to the goals and objectives of the course Exercises and activities helped me achieve the course objectives I understand how the content in this course is applicable to my future professional practice This course has fostered my development as a life-long learner As a result of this course, I am better prepared to function as a public health advocate who promotes health, wellness, and disease prevention
4.83/0.41 4.83/0.41 4.83/0.41 4.83/0.41 4.83/0.41 4.83/0.41 4.67/0.52 4.50/0.84 4.67/0.52
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We’ve explored the world of illness Over the past couple of weeks, Examining movies, literature and pictures, And the thousand of words they speak.
My interpretation of illness Has taken a whole new perspective. Empathizing and recognizing patient needs Has become my chief objective.
To describe the illness experience, Our group chose to use imagery and art. We depicted how science and patient care Should not be worlds apart.
Illness is an unfortunate experience Causing those affected to recollect On their life and their accomplishments, All their memories and regrets.
Drawing from various depictions And analyzing what we were taught, We discussed our many ideas And created pictures from our thoughts.
Perhaps illness in the media Can play a major part In offering a feeling of comfort In matters of the heart.
It was fulfilling to interpret All the insights we had gained And to recognize how pharmacists can affect A patient’s illness, grief and pain.
To be sick is not just to have poor health, But also a test of one’s faith. It’s how one chooses to deal with it That determines the path that it creates.
“The working together of two things To produce an even greater effect”b; Our project focused on synergy, Finding ways for illness and the arts to connect. There exist many emotions That may influence a patient’s care; Sadness, misery, confusion, Loss of hope and feelings of despair.
In the battle between illness and the soul, Only one can win, And only when a patient looks beyond their sickness Can the healing process truly begin. As future pharmacists, There are many voids we can fill In our ultimate goal and future mission To provide true care and healing to the ill.
As a student pharmacist I will start to assume the role, Not only as a health professional, But as a listener and caregiver of the soul. a b
Written by Charlene Dwarika and reproduced with her permission. www.wordernetweb.princeton.edu/perl/webwn Fig. 1. Student poem used for final projecta.
A recurring theme in student papers was that they felt better able to help patients in treating their disease states now that they have a better understanding of what that truly means to patients themselves and their lives. Ideas from other courses relating to pharmacology and therapeutics took on a new meaning for students when they considered the effect that disease and medications can have on a patient’s life. That deeper understanding of the illness experience can ultimately produce more dedicated, patient-centered caregivers. The final projects also gave us an indication of student engagement in the course. Students used a full range of genres including art, film, short stories, photography, and poetry to convey their understanding of how the Humanities can contribute to the perception of the illness experience.
All of the team and individual projects were excellent but do not fit within the media for this paper. Two projects shared here show a particularly sophisticated appreciation for the illness experience (Figs. 1 and 2). In lieu of a formal peer review for a course, which had not yet been instituted at the college when this class was taught, we asked faculty members in the Department of Pharmacy and Health Outcomes to review the syllabus and offer their opinions of the course at a department meeting in the fall of 2009. After listening to a brief presentation about the course and reviewing the syllabus, faculty were asked to answer the following questions: (1) Do you think that this course is innovative in a College of Pharmacy?
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Fig. 2. Student group painting.
(2) Was there a course like this available when you were in pharmacy school? If so, did you take it? If not, would you have taken it if it had been available? (3) Does this course help the student meet the Touro educational outcomes? (4) Do you think students who completed this course would be more likely to see patients as human beings rather than as their disease states? (5) Does this course meet the educational needs for a pharmacist practicing in 2025?
Their responses suggested overwhelming support for the inclusion of this type of course in a pharmacy curriculum. Sixteen faculty members submitted written responses to the questions. Fifteen of the 16 respondents indicated they believed this course to be innovative and one wrote, ‘‘This is a great opportunity to better understand illness from a patient’s point of view.’’ Such a course was not available to any of the respondents in pharmacy school but most (15) of them would have been interested in taking it if they were given the opportunity. One respondent commented they would have been very interested to take it, not just because it’s different and unique, but because it uses examples from the real world, examples that are relevant and thought provoking. Ten of the respondents agreed that the course meets the Touro Educational Outcomes and cited ethics and communications outcomes as examples. Discussion People with serious health problems can face daunting challenges that include managing the quotidian and burdensome requirements the health care system imposes on them, altering their life plans as necessary, and reconfiguring their situations so they can live a meaningful life. While working through these challenges, people with serious health problems worry about how their position among family, friends, and colleagues may change, how they can maintain their dignity,
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and how they can come to an understanding—often a new understanding—of their place in the world. All these elements encompass the illness experience, and are generally the elements of health problems that must be addressed outside the biomedical sphere. Pharmacy education, for obvious and understandable reasons, puts an emphasis on the biomedical dimensions of health problems. Biomedical dimensions of pharmacy education constitute the pathophysiological basis of health problems, therapeutic principles involved in treating health problems, and medication therapy management implications that entail health problems. While the biomedical emphasis on disease can be patient centered, this emphasis does not easily accommodate the illness dimension of health problems. Understanding the illness dimension of health problems is nonetheless extremely important to health care professionals if they are to be effective in any of the roles they perform. What we set out to do with this course, and what makes this course innovative, was to draw insights from different Humanities genres that bear witness on the illness experience in ways that give pharmacy students a better appreciation for what people encounter from health problems than they can attain otherwise through the biomedical prism. Suffering often attends the illness experience. As suffering is at the heart of the Humanities, we believe the Humanities offer pharmacy students ways to see illness that Biomedicine cannot show. Marcel Proust, a novelist who knew something about the illness experience said the arts make it possible ‘‘to see the universe through the eyes of another, of a hundred others, to see the universes that each of them can see or can be.’’24, p. 237 Our course aims to give pharmacy students the eyes of a hundred others so they can see what illness is and can be across its full spectrum. A secondary aim and another element of innovation of our course is to help students see the connection between the arts and sciences. The dominance of scientific and biomedical content in pharmacy school curricula can exacerbate student views that the arts and sciences are of opposite worlds and are irreconcilable. These views threaten student openness to the benefits the Humanities offer to their understanding of the illness experience. We included content that addressed the arts and sciences chasm, and thread this issue through the course. This course serves as a bridge over the chasm between Biomedicine and Humanities in the curriculum and takes advantage of what each discipline offers students towards the understanding the predicaments people face resulting from their health problems. The Touro College of Pharmacy mission and location also motivated us to implement this course. Conveying the whole spectrum of illness to students of the college is profoundly important for a school located in the heart of Harlem and dedicated to preparing graduates to work in dense urban environments and serve under-represented minorities. We believe emphatically, that the Humanities can be used effectively to show students what people in
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these environments experience as a result of health problems. In addition to providing students with a broader view of the illness experience this course gives opportunity for student pharmacists to be well-rounded and compassionate health care professionals. Our experience and assessment of outcomes indicate that students can respond to insights on the illness experience when drawn entirely from the Humanities. Because our course was an elective, our assessment could be affected by a selection bias towards students already open to the benefits of the Humanities. Nevertheless, most students expressed a new or incremental appreciation for the illness experience to an extent they believe will affect their practices and their lives, which was the primary objective of our endeavor. Several individual elements of the course contributed to the overall success. In particular, organizing the course into four sections gave us the ability to focus the students on how the Humanities can be helpful in understanding the illness experience. The first section, ‘‘Orientation, Expression of Illness in the Humanities,’’ concentrated on how we can think of health and illness generally and how the Humanities contribute to an understanding of both of those concepts. We encouraged students to begin considering how the arts and the sciences work in complimentary ways. With the next section, ‘‘Role in Society, Presentation of Illness in the Humanities,’’ the students focused on works that show how illness has been presented in the Humanities, and then progressed to the third section, ‘‘Patient Experience, Illness as a Human Condition.’’ During the third section students went further into how the Humanities can show ways illness figures into the lives of people who are affected. The fourth and last section introducing particular content, ‘‘Pharmacists Role in Affecting the Illness Experience,’’ is where we connected what can be discerned about the illness from the Humanities with the role of the pharmacist in patient care. With this sequencing, the students were encouraged to explore the connections between arts and sciences through the relationship of the Humanities and illness and the application of what can be learned from the Humanities to pharmacy practice. Contributing to the strengths of the course was the wide spectrum of genres within the Humanities we drew from. These included literature, film, art, drama, and television. We purposely involved these different genres so that the students could consider what the particular genres offered them towards understanding the illness experience in addition to the content presented. We also assigned a mix of classic and contemporary works. We included older works, such as Edvard Munch’s 19th century painting, The Sick Child to show that illness has been present in the Humanities for a long time,15 and we included newer works such as the recent film Garden State to show that illness is a current focus of Humanities as well and can be found in works that the students are likely to be familiar with.21 We included classic works, such as Tolstoy’s The Death of Ivan
Ilych, which is not only part of the Medical Humanities canon, but it also shows how the illness and near-death experiences can be illustrated in a highly literary manner.13 The more contemporary works and genres were also included to make the content relevant to the age of the students. For example, we included the graphic novel, Our Cancer Year by Harvey Pekar, which was the story of the author’s year of treatment for cancer.12 The New York City location of the school made available more than just an environment manifesting many of the conditions and predicaments covered in the Humanities. It also provided access to museums and performance venues where students could see original productions of the works they studied. The location also made it possible to arrange a dramatic reading of In the Continuum, which is a play about the separate but simultaneous stories of two young women, one in South Central Los Angeles and the other in Harare, Zimbabwe, who both learn they are pregnant and infected with HIV.23 The play shows how HIV infection upends the high aspirations of these two women in similar ways though they are of are of different cultures and face different circumstances. In addition to the two professional actors who performed the reading in class, both the producer and director of the play were in attendance and participated in discussions about the content of the play and various aspects of its production. The students were highly engaged in the play, and many of them said they had been profoundly affected by it. The cast and production staff also indicated that they had a new appreciation for how the arts could affect the student pharmacist and subsequent practice. Delivering the course through internet media was advantageous in some respects and not in others. Student understanding of particular Humanities works is aided by discussion. Through the internet instructional technology we used, robust discussions took place and involved every student whereas in classroom situations student involvement can be hampered by other dominant personalities, by social inhibitions, or by time constraints. The internet delivery method also facilitated discussions on an ongoing basis rather than intermittently based on class meetings. However, the online chat sessions every third week enabled us to cover subjects and issues best heard by all students at the same time, for example, introductory material on coming units. But, not all Humanities content is best suited for independent study, especially for students not extensively schooled in the Humanities. Thus, some material can be precluded when delivering a course like this through Internet media. For example, we thought students would not be able to fully appreciate what the play In the Continuum could offer because of complicated stage directions, which is the reason we arranged for a class meeting to watch a dramatic reading by professional actors accompanied by the play producer and director. Without the ability to stage an in-person reading, this play would probably have been dropped from the course. But, by and large, internet media aided delivery of this course.
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While we consider the course a great success based on student work and feedback, the course is isolated from other parts of the curriculum, which furthers the current cultural divide between the arts and sciences.25 We intend to offer the course again, but we also hope to incorporate specific works into appropriate places in the syllabi of other courses throughout the curriculum. For example, we would draw from Paul Harding’s novel Tinkers to augment therapeutic lessons involving epilepsy. Harding’s description of the seizure experience of his character Howard goes far beyond what any therapeutics text can provide: The aura, the sparkle and tingle of an oncoming fit, was not the lightning—it was the cooked air that the lightning pushed in front of itself. The actual seizure was when the bolt touched flesh, and in an instant so atomic, so nearly immaterial, nearly incorporeal, that there was almost no before and after, no cause A that led to effect B, but instead simply A, simply B, with no then in between, and Howard became pure, unconscious energy. It was like the opposite of death, or a bit of the same thing death was, but from a different direction: instead of being emptied or extinguished to the point of unselfness, Howard was over-filled, overwhelmed to the same state. If death was to fall below some human boundary, so his seizures were to be rocketed beyond it.26, pp. 47–48 Incorporating content from the Humanities that elaborate on the illness experience associated with particular diseases will bring more immediacy and a better appreciation to students about what patients face. Our intention is to link Humanities content to corresponding coursework in therapeutics and medication therapy management so that exposure to applicable Humanities content is not confined to and concentrated in an elective course. Although Virginia Woolf’s famous lamentation in 1930 about the lack of attention writers and artists give to illness,18 there is now no shortage of material that can be used for a course on illness in the Humanities, and more is created all the time. With the increasing attention paid to illness in the Humanities, any course relying upon them to any degree will be continually changing, and this elective course will be no different. For example, the Illness Performed and Imagined course will be modified to accommodate the novels So Much For That and Still Alice.27,28 These novels cover important elements of the illness experience that are not otherwise available because they are either not within the disease treatment context or they are precluded from public debate by statutory or political exigencies: the subject of depleting family finances for last-ditch, experimental treatments is covered in So Much For That, and debates within a family about when personal opportunities can be pursued at the possible expense of a family member with dementia. To make room for these novels, the film Aurora Borealis and the novel Brave New World will be dropped.19,22 The television show Big C will replace Monk because it offers an opportunity to
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consider the place of humor in understanding the illness experience.29 Big C was previewed during the Illness Performed and Imagined course at the suggestion of one of the students. As course instructors, we perceived this suggestion as validating that students understood the value and relevance to their future practices. In offering this course to pharmacy students, we are hoping to respond adequately to Agazzi’s eloquent challenge to consider patient needs in addition to those related to the pathophysiology of their health problems: In addition to medicine, other views must help the patient in challenging this existential impasse, helping him, first of all, overcome that kind of separation of himself from his own body that illness normally produces; helping him in seeing illness as a manifestation of his finitude, without transforming it into an anguish, even when a total recovering of health is out of sight; helping him especially in giving some kind of positive sense to illness itself, bringing him to feel that illness does not strike the deepest levels of his personality, does not diminish his dignity.30, p. 14 From where can we best draw to help pharmacy students understand illness experiences as they exist separately from the pathophysiological processes of their health problems? The Humanities can serve as a primary source of instruction for student pharmacists (and practicing pharmacists) towards affecting their practices so that they extend to the illness experiences their patients face. We found that a course involving Humanities content from different genres addressing illness experiences produced an important impact on the students. The students were able to perceive and comprehend insights from the Humanities, and they were able to represent their own perceptions of the illness experience through various art forms. To fully realize the benefit of Humanities on student learning however, we believe Humanities content will need to be integrated throughout the curriculum in addition to isolated courses, and that is how this course will evolve. Acknowledgments We thank Charlene Dwarika, Sarah Awad, Niveditha Kadiyala, and Victoria Yagadaev for permitting us to include their class work in this paper. We also thank all the students in the class for their enthusiastic participation and valuable insights. References 1. Hofmann B. On the triad of disease, illness and sickness. J Med Philos. 2002;27:651–673. 2. Cassell E.J. The Healer’s Art. Cambridge, MA: MIT Press; 1976. 3. Brody H. Stories of Sickness. 2nd ed. Oxford, UK: Oxford University Press; 2003.
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4. Foucault M. The Birth of the Clinic. New York, NY: Vintage; 1994 [Sheridan-Smith AM, Trans.]. 5. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533–543. 6. Pharmacy Practice Supplemental Educational Outcomes Based on CAPE 2004. American Association of Colleges of Pharmacy. /http://www.aacp.org/resources/education/Documents/ PharmacyPracticeDEC006.pdfS. Accessed January 31, 2013. 7. Poirier S, Mrtek RG. Images of pharmacy in the arts: the humanities in pharmacy education. Am J Pharm Educ. 1985;49:10–16. 8. Bumgarner GW, Spies AR, Asbill CS, Prince VT. Using the humanities to strengthen the concept of professionalism among first-professional year pharmacy students. Am J Pharm Educ. 2007;71(2) Article 28. 9. Fink LD. Creating Significant Learning Experiences. An Integrated Approach to Designing College Courses. San Francisco, CA: Jossey-Bass; 2003. 10. Educational Outcomes 2004. American Association of Colleges of Pharmacy. /http://www.aacp.org/resources/education/ Documents/CAPE2004.pdfS. Accessed January 31, 2013. 11. Brooks JL. As Good As It Gets (DVD). USA: Tri Star; 1997. 12. Pekar H, Brabner J. Our Cancer Year. [Stack F, Illust]. Philadelphia, PA: Running Press; 1994. 13. Nichols M. Wit (DVD). USA: HBO Home Video; 2001. 14. Tolstoy L. The death of Ivan Ilych. The Riddle of Life and Death. New York, NY: The Feminist Press; 2007. 15. Munch E. The Sick Child (Painting). London: Tate Modern; 1907.
16. Neel A. T.B. Harlem (Painting). USA: National Museum of Women in the Arts; 1940. 17. Breckman A, Hoberman D, Shalhoub T, et al. Monk (Television). USA: Universal Cable Productions; 2002-2009. 18. Woolf V. On Being Ill. Ashfield, MA: Paris Press; 2002 4 [Original work published in 1930]. 19. Huxley A. Brave New World. New York, NY: Harper Perennial; 2004 [Original work published in 1932]. 20. Broyard A. In: Broyard A, ed. Intoxicated by My Illness: And Other Writings on Life and Death. New York, NY: Fawcett Columbine; 1992. 21. Braf Z. Garden State (DVD). USA: Fox Searchlight; 2004. 22. Burke J. Aurora Borealis (DVD). USA: Regent; 2006. 23. Gurira D, Salter N. In the Continuum. New York, NY: Samuel French; 2005. 24. Proust M. The Prisoner [Collier P, Trans.]. London: Penguin Books; 2003 [Original work published in 1923]. 25. Snow CP. The Two Cultures. Cambridge, UK: Cambridge University Press; 1998. 26. Harding P.Tinkers. New York, NY: Bellevue Literary Press; 2009. 27. Shriver L. So Much For That. New York, NY: Harper; 2010. 28. Genova L. Still Alice. New York, NY: Pocket Books; 2009. 29. Bicks J. The Big C (Television). USA: Show Time; 2010. 30. Agazzi E. Illness as Lived Experience and as the Object of Medicine. In: Tymieniecka A-T, Agazzi E, eds. Life— Interpretation and the Sense of Illness within the Human Condition: Medicine and Philosophy in a Dialogue. Milan, Italy: Kluwer Academic; 1998.
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Research
http://www.pharmacyteaching.com
Illness Performed and Imagined: An elective course using Humanities to teach student pharmacists about illness J. Russell Teagarden, BSPharm, MA, DMHa,*, Michelle Assa-Eley, BSPharm, PhDb, Ruth E. Nemire, BSPharm, PharmD, EdDb a
Advanced Clinical Science & Research, Medco Health Solutions Inc., Franklin Lakes, NJ b Touro College of Pharmacy, New York, NY
Abstract Objective: To describe an elective course featuring the use of the Humanities to provide students with an understanding of the illness experiences people face from their health problems and as they are distinct from disease processes. Methods: The course was delivered mostly through online media and online class chat sessions as well as asynchronous discussions. In between these sessions, students studied assigned Humanities works in literature, film, drama, and television. Students were evaluated and assessed through class discussion, written papers, discussion board contributions, and final projects. Student surveys were administered to assess specific aspects of the course. Results: The course was well received and considered highly valuable by both students and college faculty as discerned from student and faculty surveys as well as other mechanisms available for input from students. Discussion: Pharmacy education puts an understandable emphasis on the pathophysiological basis of disease and on the pharmacological basis of treatment. As a result, students focus most of their attention on biomedical elements of health problems while giving little attention to the illness experiences people face. Our course aims to give students a way to give more attention to the illness experience, and the course draws from the Humanities for this content. The positive response from students and faculty suggest that providing more education about the illness experience through the use of Humanities could be effective in producing more empathetic and caring pharmacists. r 2013 Elsevier Inc. All rights reserved. Keywords: Humanities; Pharmacy education; Instructional design
Introduction Illness can be understood as the subjective elements of health problems, while disease can be understood as the pathophysiological basis of health problems.1–3 Both illness and disease have always been part of the human condition, but only during the last 200 years following the advent of pathological anatomy, have illness and disease been distinguished to an extent that one can be addressed and not The institutions for all authors were accurate at the time of submission. * Corresponding author: J. Russell Teagarden, BSPharm, MA, DMH, Advanced Clinical Science & Research, Medco Health Solutions Inc, 100 Parsons Pond Drive, Franklin Lakes, NJ 07417. E-mail: [email protected]
the other.4 Since that time, medical scientists, clinicians, educators, and their institutions and traditions—collectively, Biomedicine—have created a culture that places increased focus on the pathophysiological basis of disease. This focus is further fueled by the inexorable advancement and allure of health care technology. Attention has consequently shifted away from the illness experience in practice and education. Yet, the illness experience still requires attention and should be accommodated in health professions education. As an academy of educators we should be cautious not to let what pharmacists can do to help people with their illness experiences fall from view. With that caution in mind, we developed a course, Illness Performed and Imagined, to provide students at the Touro College of Pharmacy in New York City with an
1877-1297/13/$ – see front matter r 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cptl.2012.09.017
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appreciation for the illness experience, and to help them see the connection between the arts and sciences in order to make them more effective health care professionals. Competencies driven by pharmaceutical care doctrine and the Center for Advancement of Pharmaceutical Education (CAPE) outcomes related to patient-centered care recognize patient needs stemming from their illness experiences beyond those that can be addressed by treatments directed at pathophysiological derangements.5,6 We chose to draw insights on illness experiences from the Humanities because the human condition has been the concern of the Humanities across the millennia, and because writers, artists, filmmakers, poets, and performers can best help us imagine and comprehend our plights, including those involving illness.
Rationale and objectives Pharmacy educators have not featured the Humanities in their curricula as a means to teach students about the challenges their patients face. Isolated use of the Humanities in a curriculum has been directed at providing portrayals of pharmacists and at modeling professional behaviors that take human suffering into account and that generate empathy for their patients.7,8 The Humanities requirements and electives in pharmacy schools are more commonly aimed at broadening the educational experience in a general sense. In contrast, the Illness Performed and Imagined course drew from the Humanities for the explicit purpose of providing students with insights on illness experiences as they can be conveyed by different genres. This approach gave students the most vivid accounts of what patients face during their lives as a result of health problems. The location of the Touro College of Pharmacy in New York City gave additional poignancy and urgency to the course. The school is located in Harlem so that students can appreciate the challenges people face in crowded, urban environments inhabited by under-represented minorities. The range and intensity of the human condition in this environment are often the focus of the Humanities. The insights on illness experiences offered our students in this class were thus further supported and validated by the environment in which the school is situated. For example, one of the paintings featured in the course depicted a person with tuberculosis living in Harlem during the 1930s, and a play selected for the class featured the HIV experience of two black women in urban environments in two different parts of the world, but neither character so different than the people of Harlem. We report here the details of the course, including specific objectives and requirements. We also describe the content chosen and content delivery methods. We report on our assessment of the outcomes and give some examples of student responses and work. Lastly, we propose some changes we would make prior to offering the course again. The course design provided students with insights on illness experiences as they are available through the
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Humanities. As such, the content was purposefully chosen to create an appreciation among the students for the value the Humanities offer about the human condition more broadly and the health system and individual patient situations more specifically. The course objectives addressed at the highest level show students how illness figures into the human condition, and at the most detailed level how pharmacists can affect a patient’s illness experience based on knowledge drawn from the Humanities (Table 1).9 Objectives also addressed other aspects such as: identifying particular elements of the illness experience covered in any particular work; discerning possible meanings a particular work may have for patients, populations, and health care systems; and determining the relevance of genre to a particular work. We mapped the general purpose of the course and the specific course objectives to expected overall outcomes of the Touro College of Pharmacy program. The expected outcomes mapped were those pertaining to advocacy for patients, good communication across diverse populations, ethical practices, and awareness of the special health challenges faced by underserved populations (Table 1). We also mapped the course to the two following CAPE outcomes.10 1. Maintain professional competence by identifying and analyzing emerging issues, products, and services that may impact population-based, therapeutic outcomes. (From: Pharmaceutical care: Provide populationbased care.) 2. Maintain professional competence by identifying and analyzing emerging issues, products, and services that may affect the efficacy or quality of disease prevention services to amend existing or develop additional services. (From: Public Health: assure the availability of effective, quality health and disease prevention services).
Materials and methods The course was delivered mostly through internet-based media. The online course method was employed so that adequate time was available for students to study the assigned works. Considerable time can be necessary to fully contemplate certain works, and the amount needed can differ among students and across the assignments. We believed standard, frequent lectures would be less effective than less frequent, online-class chat sessions. Therefore, we assembled the class for a two-hour online chat session every three weeks. On one occasion an in-class session was held for a dramatic reading of a play featuring the HIV experience. We engaged professional actors, a producer, and a director to participate with the students in a live environment. In between the online sessions, students were assigned literature, art, film, or television shows to study, papers to write, and online discussion to stimulate their learning and reflect on topics. Students were also assigned final individual and group projects.
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Table 1 Course objectives and related expected outcomes Course objectives
Expected outcomes
Upon completion of the course, the student should be able to:
Upon completion of the course, the student will partially or completely meet the full expectation of the Touro College of Pharmacy outcomes: Serving as advocates for patients and the profession.
Examine the genre in which an illness is presented, and what meanings, and actions that expression of illness is likely to have on the individual, population, or health professional. Identify and characterize the elements of illness portrayed by an artist Aware of cultural diversity and ethical practices in a painting. Argue why and how illness can be considered part of the human Accomplished in clear and effective communication condition. Recognize and describe how a pharmacist ought to affect change in the Recognizing barriers to health care access in underserved populations illness experience. Drawing from various depictions from the arts, describe and illustrate how the illness experience impacts the health care system.
A two-hour online chat session marked the start of the course and served as an introduction to the topics and method for learning and work. Student project presentations at the end of the course were also counted towards the total number of chat sessions. Topics covered during the live chat sessions included: how illness is distinguished from healthy states in the Humanities; how illness is presented in the Humanities; how the Humanities characterize illness experiences and how illness can be seen as integral to the human condition; and how the Humanities informs pharmacist roles in helping people with their illness experiences. The internet-based technology we used for the online chat sessions was Cisco WebEx, which permitted students and instructors to see one another and contributed to lively, interactive sessions. We assigned five, three-page reflection papers during the course. The students were asked to respond to a prompt we provided. The papers were assigned to engage and focus the students on particular elements of assigned works and for them to argue a point of view. For example, the reflection paper assigned for the film As Good As It Gets required a response to the following prompt11: In the film, As Good As It Gets, many of the characters could be said to be boxed in or trapped in certain ways. Describe how the characters Melvin, Carol, and Simon are each boxed in or trapped, that is, what is it that boxes each of them in. Also, describe how the director uses the film medium to reinforce the idea that these characters are boxed in or trapped in certain ways, for example, how does the director frame shots to convey this idea? Students also participated in three online asynchronous discussions, during which they were expected to respond directly to the prompt and to provide thoughtful replies to the input of two other students. While we did not expect the input from students in these online discussions to be as well formed as the reflection papers, we still required that students provide thoughtful perspectives in response to the
prompt. As an example, one of the prompts concerned an assigned graphic novel12: Harvey Pekar and Joyce Brabner, in their book, ‘‘Our Cancer Year’’ (illustrated by Frank Stuck), use the comic book or graphic novel genre to tell the story of Pekar’s cancer experience. This genre has its fans and its critics, especially when used for serious subjects or longer stories. Did the comic book genre help or hinder you in gaining insights on what Pekar experience during his cancer year? Cite some examples that support your position. The semester was divided into three week units. Each of these units began with a chat session, and utilized a mix of Humanities genres (Table 2). The second unit, for example, focused on how the illness experience has been presented in the Humanities. We used Wit, because of its vivid rendering of what people with terminal diseases experience as subjects Table 2 Assigned works Genre
Title
Literature
On Being Ill18 Brave New World19 The Death of Ivan Ilych14 Intoxicated by My Illness20 My Cancer Year12
Film
Garden State21 Wit13 As Good As It Gets11 Aurora Borealis22
Art
The Sick Child15 T.B. Harlem16
Drama
In the Continuum23
Television
Monk17
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in clinical research, as well as how the illness experience can lead to redemption.13 For similar purposes we used Tolstoy’s novella The Death of Ivan Ilych.14 This work gives students an idea of what can go through the mind of someone nearing death and who experiences both physical pain from disease and emotional pain from the behavior of people nearby. Two paintings we chose to use for this unit were Edvard Munch’s The Sick Child,15 and Alice Neel’s T.B. Harlem.16 In both paintings there is nothing to obscure plain illness and suffering, that is, none of the signs and artifacts of Biomedicine avert the viewer’s gaze from the utter misery illness can cause people. Neel’s painting goes further to indict the socioeconomic conditions of Harlem and the medical treatments used at the time as causes for this suffering. Lastly, we included episodes from the television series Monk, that showed students how illness experiences can affect everyday life and how they can be effectively accommodated.17 Monk also prompted students to consider that one man’s illness may be another man’s quirkiness. The innovation of this course involves drawing insights from the Humanities to give students an appreciation for illness experiences their patients will endure. Nothing about the content or the delivery methods were experimental, and so we did not seek Institutional Review Board approval. The course proposal was circulated among Touro College of Pharmacy faculty, adopted by the curriculum committee, and enthusiastically supported for inclusion as an elective in the curriculum (vide infra).
Results The course was designed to encourage creativity and to develop an individualized approach to study the Humanities among the students. No formal exams were given. Rather, we relied on class discussion (online chats), written papers, discussion board contributions, and final projects to measure student learning.
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The final course evaluation completed by the students offers a glimpse of student reactions to the course. Only seven of the 22, or 32% of the students completed the online-course evaluation form, but they had many positive comments and suggestions for improvement. Table 3 itemizes many of the key questions from the student course evaluation form with the mean and standard deviation for the students’ responses. For all questions, students were asked to indicate their agreement with the statement on a scale from 1 (strongly disagree) to 5 (strongly agree). In addition to the Likert-type questions, students rated the value of the various modalities used in the course, and were given an opportunity to provide open-ended comments on the evaluation form. The student response to the overall course was overwhelmingly positive, as can be seen by the high means on the items in the course evaluation. According to the students, the course was successful in meeting its goals and objectives, was well organized and helped students learn the material with the readings, exercises, and online activities. Of particular interest was the finding that students valued both the group projects, and online discussions and chats. When asked to rate these parts of the class in terms of their value, students who rated them gave them a ‘‘valuable’’ or ‘‘extremely valuable’’ rating. In written comments, many students indicated that the course helped them gain a new appreciation for the experience of illness apart from biomedical interventions and that this new appreciation for the illness experience will help them provide better patient care. One student said, ‘‘It’s one thing to be TOLD to be empathetic, but to view and read about a patient’s experience is a whole different concept.’’ Another said the class ‘‘may in fact be the most beneficial to my career as a pharmacist!,’’ and still another said, ‘‘I’m a changed person because of this class.’’ Many students remarked that they intend to share the works they studied with patients who they think could benefit from them. Student papers provided the instructors with other insights towards the value of the course in the curriculum.
Table 3 Student responses to course evaluation items (mean/standard deviation) Item
Mean/std. dev
The required texts and reading materials were useful resources for the course The graded exercises (e.g., assignments, performance assessments, exams) helped me learn what is important in this area of study The course content was organized in a manner that helped me learn Course objectives were presented clearly in the syllabus The course content was directly related to the goals and objectives of the course Exercises and activities helped me achieve the course objectives I understand how the content in this course is applicable to my future professional practice This course has fostered my development as a life-long learner As a result of this course, I am better prepared to function as a public health advocate who promotes health, wellness, and disease prevention
4.83/0.41 4.83/0.41 4.83/0.41 4.83/0.41 4.83/0.41 4.83/0.41 4.67/0.52 4.50/0.84 4.67/0.52
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We’ve explored the world of illness Over the past couple of weeks, Examining movies, literature and pictures, And the thousand of words they speak.
My interpretation of illness Has taken a whole new perspective. Empathizing and recognizing patient needs Has become my chief objective.
To describe the illness experience, Our group chose to use imagery and art. We depicted how science and patient care Should not be worlds apart.
Illness is an unfortunate experience Causing those affected to recollect On their life and their accomplishments, All their memories and regrets.
Drawing from various depictions And analyzing what we were taught, We discussed our many ideas And created pictures from our thoughts.
Perhaps illness in the media Can play a major part In offering a feeling of comfort In matters of the heart.
It was fulfilling to interpret All the insights we had gained And to recognize how pharmacists can affect A patient’s illness, grief and pain.
To be sick is not just to have poor health, But also a test of one’s faith. It’s how one chooses to deal with it That determines the path that it creates.
“The working together of two things To produce an even greater effect”b; Our project focused on synergy, Finding ways for illness and the arts to connect. There exist many emotions That may influence a patient’s care; Sadness, misery, confusion, Loss of hope and feelings of despair.
In the battle between illness and the soul, Only one can win, And only when a patient looks beyond their sickness Can the healing process truly begin. As future pharmacists, There are many voids we can fill In our ultimate goal and future mission To provide true care and healing to the ill.
As a student pharmacist I will start to assume the role, Not only as a health professional, But as a listener and caregiver of the soul. a b
Written by Charlene Dwarika and reproduced with her permission. www.wordernetweb.princeton.edu/perl/webwn Fig. 1. Student poem used for final projecta.
A recurring theme in student papers was that they felt better able to help patients in treating their disease states now that they have a better understanding of what that truly means to patients themselves and their lives. Ideas from other courses relating to pharmacology and therapeutics took on a new meaning for students when they considered the effect that disease and medications can have on a patient’s life. That deeper understanding of the illness experience can ultimately produce more dedicated, patient-centered caregivers. The final projects also gave us an indication of student engagement in the course. Students used a full range of genres including art, film, short stories, photography, and poetry to convey their understanding of how the Humanities can contribute to the perception of the illness experience.
All of the team and individual projects were excellent but do not fit within the media for this paper. Two projects shared here show a particularly sophisticated appreciation for the illness experience (Figs. 1 and 2). In lieu of a formal peer review for a course, which had not yet been instituted at the college when this class was taught, we asked faculty members in the Department of Pharmacy and Health Outcomes to review the syllabus and offer their opinions of the course at a department meeting in the fall of 2009. After listening to a brief presentation about the course and reviewing the syllabus, faculty were asked to answer the following questions: (1) Do you think that this course is innovative in a College of Pharmacy?
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Fig. 2. Student group painting.
(2) Was there a course like this available when you were in pharmacy school? If so, did you take it? If not, would you have taken it if it had been available? (3) Does this course help the student meet the Touro educational outcomes? (4) Do you think students who completed this course would be more likely to see patients as human beings rather than as their disease states? (5) Does this course meet the educational needs for a pharmacist practicing in 2025?
Their responses suggested overwhelming support for the inclusion of this type of course in a pharmacy curriculum. Sixteen faculty members submitted written responses to the questions. Fifteen of the 16 respondents indicated they believed this course to be innovative and one wrote, ‘‘This is a great opportunity to better understand illness from a patient’s point of view.’’ Such a course was not available to any of the respondents in pharmacy school but most (15) of them would have been interested in taking it if they were given the opportunity. One respondent commented they would have been very interested to take it, not just because it’s different and unique, but because it uses examples from the real world, examples that are relevant and thought provoking. Ten of the respondents agreed that the course meets the Touro Educational Outcomes and cited ethics and communications outcomes as examples. Discussion People with serious health problems can face daunting challenges that include managing the quotidian and burdensome requirements the health care system imposes on them, altering their life plans as necessary, and reconfiguring their situations so they can live a meaningful life. While working through these challenges, people with serious health problems worry about how their position among family, friends, and colleagues may change, how they can maintain their dignity,
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and how they can come to an understanding—often a new understanding—of their place in the world. All these elements encompass the illness experience, and are generally the elements of health problems that must be addressed outside the biomedical sphere. Pharmacy education, for obvious and understandable reasons, puts an emphasis on the biomedical dimensions of health problems. Biomedical dimensions of pharmacy education constitute the pathophysiological basis of health problems, therapeutic principles involved in treating health problems, and medication therapy management implications that entail health problems. While the biomedical emphasis on disease can be patient centered, this emphasis does not easily accommodate the illness dimension of health problems. Understanding the illness dimension of health problems is nonetheless extremely important to health care professionals if they are to be effective in any of the roles they perform. What we set out to do with this course, and what makes this course innovative, was to draw insights from different Humanities genres that bear witness on the illness experience in ways that give pharmacy students a better appreciation for what people encounter from health problems than they can attain otherwise through the biomedical prism. Suffering often attends the illness experience. As suffering is at the heart of the Humanities, we believe the Humanities offer pharmacy students ways to see illness that Biomedicine cannot show. Marcel Proust, a novelist who knew something about the illness experience said the arts make it possible ‘‘to see the universe through the eyes of another, of a hundred others, to see the universes that each of them can see or can be.’’24, p. 237 Our course aims to give pharmacy students the eyes of a hundred others so they can see what illness is and can be across its full spectrum. A secondary aim and another element of innovation of our course is to help students see the connection between the arts and sciences. The dominance of scientific and biomedical content in pharmacy school curricula can exacerbate student views that the arts and sciences are of opposite worlds and are irreconcilable. These views threaten student openness to the benefits the Humanities offer to their understanding of the illness experience. We included content that addressed the arts and sciences chasm, and thread this issue through the course. This course serves as a bridge over the chasm between Biomedicine and Humanities in the curriculum and takes advantage of what each discipline offers students towards the understanding the predicaments people face resulting from their health problems. The Touro College of Pharmacy mission and location also motivated us to implement this course. Conveying the whole spectrum of illness to students of the college is profoundly important for a school located in the heart of Harlem and dedicated to preparing graduates to work in dense urban environments and serve under-represented minorities. We believe emphatically, that the Humanities can be used effectively to show students what people in
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these environments experience as a result of health problems. In addition to providing students with a broader view of the illness experience this course gives opportunity for student pharmacists to be well-rounded and compassionate health care professionals. Our experience and assessment of outcomes indicate that students can respond to insights on the illness experience when drawn entirely from the Humanities. Because our course was an elective, our assessment could be affected by a selection bias towards students already open to the benefits of the Humanities. Nevertheless, most students expressed a new or incremental appreciation for the illness experience to an extent they believe will affect their practices and their lives, which was the primary objective of our endeavor. Several individual elements of the course contributed to the overall success. In particular, organizing the course into four sections gave us the ability to focus the students on how the Humanities can be helpful in understanding the illness experience. The first section, ‘‘Orientation, Expression of Illness in the Humanities,’’ concentrated on how we can think of health and illness generally and how the Humanities contribute to an understanding of both of those concepts. We encouraged students to begin considering how the arts and the sciences work in complimentary ways. With the next section, ‘‘Role in Society, Presentation of Illness in the Humanities,’’ the students focused on works that show how illness has been presented in the Humanities, and then progressed to the third section, ‘‘Patient Experience, Illness as a Human Condition.’’ During the third section students went further into how the Humanities can show ways illness figures into the lives of people who are affected. The fourth and last section introducing particular content, ‘‘Pharmacists Role in Affecting the Illness Experience,’’ is where we connected what can be discerned about the illness from the Humanities with the role of the pharmacist in patient care. With this sequencing, the students were encouraged to explore the connections between arts and sciences through the relationship of the Humanities and illness and the application of what can be learned from the Humanities to pharmacy practice. Contributing to the strengths of the course was the wide spectrum of genres within the Humanities we drew from. These included literature, film, art, drama, and television. We purposely involved these different genres so that the students could consider what the particular genres offered them towards understanding the illness experience in addition to the content presented. We also assigned a mix of classic and contemporary works. We included older works, such as Edvard Munch’s 19th century painting, The Sick Child to show that illness has been present in the Humanities for a long time,15 and we included newer works such as the recent film Garden State to show that illness is a current focus of Humanities as well and can be found in works that the students are likely to be familiar with.21 We included classic works, such as Tolstoy’s The Death of Ivan
Ilych, which is not only part of the Medical Humanities canon, but it also shows how the illness and near-death experiences can be illustrated in a highly literary manner.13 The more contemporary works and genres were also included to make the content relevant to the age of the students. For example, we included the graphic novel, Our Cancer Year by Harvey Pekar, which was the story of the author’s year of treatment for cancer.12 The New York City location of the school made available more than just an environment manifesting many of the conditions and predicaments covered in the Humanities. It also provided access to museums and performance venues where students could see original productions of the works they studied. The location also made it possible to arrange a dramatic reading of In the Continuum, which is a play about the separate but simultaneous stories of two young women, one in South Central Los Angeles and the other in Harare, Zimbabwe, who both learn they are pregnant and infected with HIV.23 The play shows how HIV infection upends the high aspirations of these two women in similar ways though they are of are of different cultures and face different circumstances. In addition to the two professional actors who performed the reading in class, both the producer and director of the play were in attendance and participated in discussions about the content of the play and various aspects of its production. The students were highly engaged in the play, and many of them said they had been profoundly affected by it. The cast and production staff also indicated that they had a new appreciation for how the arts could affect the student pharmacist and subsequent practice. Delivering the course through internet media was advantageous in some respects and not in others. Student understanding of particular Humanities works is aided by discussion. Through the internet instructional technology we used, robust discussions took place and involved every student whereas in classroom situations student involvement can be hampered by other dominant personalities, by social inhibitions, or by time constraints. The internet delivery method also facilitated discussions on an ongoing basis rather than intermittently based on class meetings. However, the online chat sessions every third week enabled us to cover subjects and issues best heard by all students at the same time, for example, introductory material on coming units. But, not all Humanities content is best suited for independent study, especially for students not extensively schooled in the Humanities. Thus, some material can be precluded when delivering a course like this through Internet media. For example, we thought students would not be able to fully appreciate what the play In the Continuum could offer because of complicated stage directions, which is the reason we arranged for a class meeting to watch a dramatic reading by professional actors accompanied by the play producer and director. Without the ability to stage an in-person reading, this play would probably have been dropped from the course. But, by and large, internet media aided delivery of this course.
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While we consider the course a great success based on student work and feedback, the course is isolated from other parts of the curriculum, which furthers the current cultural divide between the arts and sciences.25 We intend to offer the course again, but we also hope to incorporate specific works into appropriate places in the syllabi of other courses throughout the curriculum. For example, we would draw from Paul Harding’s novel Tinkers to augment therapeutic lessons involving epilepsy. Harding’s description of the seizure experience of his character Howard goes far beyond what any therapeutics text can provide: The aura, the sparkle and tingle of an oncoming fit, was not the lightning—it was the cooked air that the lightning pushed in front of itself. The actual seizure was when the bolt touched flesh, and in an instant so atomic, so nearly immaterial, nearly incorporeal, that there was almost no before and after, no cause A that led to effect B, but instead simply A, simply B, with no then in between, and Howard became pure, unconscious energy. It was like the opposite of death, or a bit of the same thing death was, but from a different direction: instead of being emptied or extinguished to the point of unselfness, Howard was over-filled, overwhelmed to the same state. If death was to fall below some human boundary, so his seizures were to be rocketed beyond it.26, pp. 47–48 Incorporating content from the Humanities that elaborate on the illness experience associated with particular diseases will bring more immediacy and a better appreciation to students about what patients face. Our intention is to link Humanities content to corresponding coursework in therapeutics and medication therapy management so that exposure to applicable Humanities content is not confined to and concentrated in an elective course. Although Virginia Woolf’s famous lamentation in 1930 about the lack of attention writers and artists give to illness,18 there is now no shortage of material that can be used for a course on illness in the Humanities, and more is created all the time. With the increasing attention paid to illness in the Humanities, any course relying upon them to any degree will be continually changing, and this elective course will be no different. For example, the Illness Performed and Imagined course will be modified to accommodate the novels So Much For That and Still Alice.27,28 These novels cover important elements of the illness experience that are not otherwise available because they are either not within the disease treatment context or they are precluded from public debate by statutory or political exigencies: the subject of depleting family finances for last-ditch, experimental treatments is covered in So Much For That, and debates within a family about when personal opportunities can be pursued at the possible expense of a family member with dementia. To make room for these novels, the film Aurora Borealis and the novel Brave New World will be dropped.19,22 The television show Big C will replace Monk because it offers an opportunity to
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consider the place of humor in understanding the illness experience.29 Big C was previewed during the Illness Performed and Imagined course at the suggestion of one of the students. As course instructors, we perceived this suggestion as validating that students understood the value and relevance to their future practices. In offering this course to pharmacy students, we are hoping to respond adequately to Agazzi’s eloquent challenge to consider patient needs in addition to those related to the pathophysiology of their health problems: In addition to medicine, other views must help the patient in challenging this existential impasse, helping him, first of all, overcome that kind of separation of himself from his own body that illness normally produces; helping him in seeing illness as a manifestation of his finitude, without transforming it into an anguish, even when a total recovering of health is out of sight; helping him especially in giving some kind of positive sense to illness itself, bringing him to feel that illness does not strike the deepest levels of his personality, does not diminish his dignity.30, p. 14 From where can we best draw to help pharmacy students understand illness experiences as they exist separately from the pathophysiological processes of their health problems? The Humanities can serve as a primary source of instruction for student pharmacists (and practicing pharmacists) towards affecting their practices so that they extend to the illness experiences their patients face. We found that a course involving Humanities content from different genres addressing illness experiences produced an important impact on the students. The students were able to perceive and comprehend insights from the Humanities, and they were able to represent their own perceptions of the illness experience through various art forms. To fully realize the benefit of Humanities on student learning however, we believe Humanities content will need to be integrated throughout the curriculum in addition to isolated courses, and that is how this course will evolve. Acknowledgments We thank Charlene Dwarika, Sarah Awad, Niveditha Kadiyala, and Victoria Yagadaev for permitting us to include their class work in this paper. We also thank all the students in the class for their enthusiastic participation and valuable insights. References 1. Hofmann B. On the triad of disease, illness and sickness. J Med Philos. 2002;27:651–673. 2. Cassell E.J. The Healer’s Art. Cambridge, MA: MIT Press; 1976. 3. Brody H. Stories of Sickness. 2nd ed. Oxford, UK: Oxford University Press; 2003.
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4. Foucault M. The Birth of the Clinic. New York, NY: Vintage; 1994 [Sheridan-Smith AM, Trans.]. 5. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533–543. 6. Pharmacy Practice Supplemental Educational Outcomes Based on CAPE 2004. American Association of Colleges of Pharmacy. /http://www.aacp.org/resources/education/Documents/ PharmacyPracticeDEC006.pdfS. Accessed January 31, 2013. 7. Poirier S, Mrtek RG. Images of pharmacy in the arts: the humanities in pharmacy education. Am J Pharm Educ. 1985;49:10–16. 8. Bumgarner GW, Spies AR, Asbill CS, Prince VT. Using the humanities to strengthen the concept of professionalism among first-professional year pharmacy students. Am J Pharm Educ. 2007;71(2) Article 28. 9. Fink LD. Creating Significant Learning Experiences. An Integrated Approach to Designing College Courses. San Francisco, CA: Jossey-Bass; 2003. 10. Educational Outcomes 2004. American Association of Colleges of Pharmacy. /http://www.aacp.org/resources/education/ Documents/CAPE2004.pdfS. Accessed January 31, 2013. 11. Brooks JL. As Good As It Gets (DVD). USA: Tri Star; 1997. 12. Pekar H, Brabner J. Our Cancer Year. [Stack F, Illust]. Philadelphia, PA: Running Press; 1994. 13. Nichols M. Wit (DVD). USA: HBO Home Video; 2001. 14. Tolstoy L. The death of Ivan Ilych. The Riddle of Life and Death. New York, NY: The Feminist Press; 2007. 15. Munch E. The Sick Child (Painting). London: Tate Modern; 1907.
16. Neel A. T.B. Harlem (Painting). USA: National Museum of Women in the Arts; 1940. 17. Breckman A, Hoberman D, Shalhoub T, et al. Monk (Television). USA: Universal Cable Productions; 2002-2009. 18. Woolf V. On Being Ill. Ashfield, MA: Paris Press; 2002 4 [Original work published in 1930]. 19. Huxley A. Brave New World. New York, NY: Harper Perennial; 2004 [Original work published in 1932]. 20. Broyard A. In: Broyard A, ed. Intoxicated by My Illness: And Other Writings on Life and Death. New York, NY: Fawcett Columbine; 1992. 21. Braf Z. Garden State (DVD). USA: Fox Searchlight; 2004. 22. Burke J. Aurora Borealis (DVD). USA: Regent; 2006. 23. Gurira D, Salter N. In the Continuum. New York, NY: Samuel French; 2005. 24. Proust M. The Prisoner [Collier P, Trans.]. London: Penguin Books; 2003 [Original work published in 1923]. 25. Snow CP. The Two Cultures. Cambridge, UK: Cambridge University Press; 1998. 26. Harding P.Tinkers. New York, NY: Bellevue Literary Press; 2009. 27. Shriver L. So Much For That. New York, NY: Harper; 2010. 28. Genova L. Still Alice. New York, NY: Pocket Books; 2009. 29. Bicks J. The Big C (Television). USA: Show Time; 2010. 30. Agazzi E. Illness as Lived Experience and as the Object of Medicine. In: Tymieniecka A-T, Agazzi E, eds. Life— Interpretation and the Sense of Illness within the Human Condition: Medicine and Philosophy in a Dialogue. Milan, Italy: Kluwer Academic; 1998.