Most clinical training bodies have recognised that there are dimensions of clinical competence which are distinct from factual knowledge and strictly technical skills and that these tend to be rooted in personal characteristics and ‘habits of mind’. Many of these qualities have been associated with humanities learning. The classic paper on the non-technical aspects of clinical competence, ‘Defining and Assessing Professional Competence’ by Epstein and Hundert, (Journal of the American Medical Association, 287, 2002), highlights tolerance of ambiguity, the ability to observe one’s own thought processes, wide social awareness, critical curiosity, and the capacity to recognise and respond to cognitive and emotional biases. Until 2013, the role of the humanities in developing these qualities was championed by the British General Medical Council (GMC). But the last two editions of Tomorrow’s Doctors, the document setting out the GMC’s standards for teaching, learning and assessment in medicine, have ceased to mention the humanities at all in connection with clinical training. All of the previous editions gave them a central place. Indeed, the establishment of Special Subject Modules in humanities disciplines in UK medical schools might not have happened without the GMC’s original endorsement. The GMC’s guidelines on Good Medical Practice (2013) – which have a direct impact on postgraduate training – have also become more muted about the value of the humanities in clinical practice. Instead the emphasis has been on the acquisition of ‘skills’ in communication, empathy, etc., via training days, or self-administered computerised training programmes.
This superb book, by Robert Marshall and Alan Bleakley, is, among other things, a jeremiad against the turning-away from the humanities. Robert Marshall has been a consultant pathologist for thirty years at the Royal Cornwall Hospitals, where he was Director of Postgraduate Medical Education at the University of Exeter Medical School, UK. He trained as a classicist before becoming a doctor. Alan Bleakley was until recently a professor of Medical Education, also at Exeter, and is one of the most important advocates of the humanities in medical training anywhere in the world. He trained as a post-Jungian psychotherapist and wrote a doctorate in that field. The two authors have been discussing Homer together on and off for several years and this book describes their attempts to use Homer’s two great epics, the Iliad and the Odyssey, to illuminate some of the difficulties of day-to-day clinical work. Marshall and Bleakley are not so naïve as to suggest that Homer’s epics contain ‘solutions’ to any of these difficulties. Rather, the Iliad and the Odyssey are useful because they help the neophyte to recognise, and work with, complexity, instead of wanting to eliminate it. Each of this book’s thirteen chapters is devoted to a single theme: compassion, anger, breaking bad news, making mistakes, whistleblowing, abuse and resilience all feature.
One of the best chapters, called ‘Putting It Bluntly’, uses the episode in Book 9 of the Iliad in which Odysseus, Phoenix and Ajax try to persuade Achilles to return to fight with the Greeks who stand on the brink of disaster in their war with the Trojans. Achilles is consumed with hatred of Agamemnon, the Greek commander who deprived him of the mythical queen, Briseis, originally seized by Achilles as a war prize, but who regarded him as her husband nonetheless. Achilles, in Marshall’s and Bleakley’s account, resembles a patient or a relative who has been stunned by a diagnosis. He does not wish to be cajoled, or coaxed. The three persuaders, Odysseus, Ajax and Phoenix, fail to bring Achilles around, according to Marshall and Bleakley, because they are too goal-directed. They listen to Achilles skilfully enough but they don’t really hear what he is telling them. The whole episode furnishes an object lesson in the failure of rhetoric. There are no formulae by which Achilles will return to fight for Agamemnon and sometimes the most important thing that can be communicated to someone in Achilles’ position is acceptance of their point of view. Marshall and Bleakley throw some well-aimed barbs at the idea, so prevalent in medical education today, that successful communication involves avoiding difficult emotions.
Another winning chapter entitled ‘Sing, Muse!’ addresses the ways in which doctors are taught to talk to one another about patients, whether it’s by giving a case summary on a grand round, or completing hospital case notes, and describes the ways in which learning to communicate professionally shapes one’s identity. The best professional is aware of the genres and styles he is inducted into and can move between genres as the case demands. It takes time and practice. The chapter on ‘Compassion’ is a tour de force. Marshall and Bleakley suggest replacing the terms ‘compassion’ and ‘empathy’ – which are increasingly taught as ‘instrumental skills’ with the older term ‘pity’, understood as a verb rather than a personality trait. The trouble with compassion and empathy, as they are commonly construed, is that they load all virtue onto the holder of these qualities. The person who feels pity bears witness to the virtue in someone else.
We need more books like this one: books that revel in the moral complexity of clinical work and that initiate fruitful dialogues across disciplines to explore it. Marshall and Bleakley see medicine as an art as well as a science and use Homer as a model of what style, presence and refinement might mean in a clinical context. Their book is a salutary intervention at a time when medical education is increasingly laying on algorithmic habits of mind. They evoke the human dimension of medical practice as skilfully as the best physician writers: Rita Charon, say, or Jerome Groopman. At a time when the humanities are in retreat in medical schools, this book offers much-needed food for thought to anyone wanting a detailed account of how the humanities might contribute to clinical training.
