William Osler, in his inaugural address at the British Classical Association in Oxford on May 1919, told his audience “The men of your guild secrete materials which do for society at large what the thyroid gland does for the individual. The Humanities are the hormones” [1]. This is one of the many ways used by the author to convey the need to foster humanistic education within medical training so that it may become a real “school of life” instead of a mere occasion for theoretical and technical learning. On the path of this tradition the present work deals with a realistic integration of Humanities from within medicine. Literature and the arts more generally do not have a value in their own right, but, when they are authentic, with the words of Shakespeare, they are “the mirror of the life”.

Specifically, over the last years the modern medical culture has replaced the critical and reflexive skill with an ignava ratio [2] inscribed within a materialistic perspective and merely declined in terms of usefulness. This condition is not absolutely surprising since it is mainly a consequence of the functionalist view of science and man within the university. Accordingly, the hard sciences’ methodology has become the only valid method for any activity that wants to qualify itself as scientific.

For this reason, we have to deal with a gap between knowledge and practice in modern medicine: on one hand we are faced with remarkable advances in the biomedical sciences and in the technology derived from them, in medical therapy as well as in development of diagnostic devices, so that people still have confidence in the power of medicine [3]. This trustful view, on other hand, coexists with the perception of some degree of dehumanization in treating the patients and within medical school itself [4].

Specifically, the call for humanizing the knowledge and practice of modern medicine does not amount to a need for moral training for each physician; it also concerns the retrieval of what Bernard Lown called “the lost art of healing” focused on a direct and human relation with patient as well as on a teaching style that goes beyond a mere reductionist medical model [5].

In this regard, Spiro points out that “college students start out with much empathy and genuine love - a real desire to help others people. But we teach them to see themselves as experts, to fix what is damaged, and to ‘rule out’ disease in their field” [6].

Thus, medicine is gradually turned away from the clinic since it becomes more and more governed by physicians and scholars who are enticed by quantitative models derived from non-clinical domains and focused on ‘hard data’, together with the apparent advantage to escape the challenges concerning serious clinical and human issues [7]. However, as Israel suggests, this transformation of medicine “into a science like the others” determines an approach to the patient in purely objective terms, “with the accompanying underestimation of the subjective and interpersonal components” [8]. Therefore, the tendency to set aside the human dimension from the science leads to a reduction of its object to its merely quantitative aspects and to overlook that these last represent a partial description of the human condition. There is a deep difference between a patient in tears for a diagnosis of advanced cancer and one who is crying because a foreign object struck his eyes. The reductionist approach of science, if exclusive, is thus dangerous in medicine because it loses sight that the clinical practice has specific features which are not present in the field of science itself.

The scientific training is not enough to understand the whole man since human sufferance and our ways to cope with it cannot be reduced to the model and a style of teaching merely based on the empirical sciences. Physicians and medical students have to seek elsewhere, in humanistic education, the tools to help themselves to manage and articulate in the proper way the problems of the daily clinical practice which are first and foremost a human problems. Thus, a more humanistic medicine implies to deal with a critical and conscious approach to healthcare which is sensitive to the entirety of the patient’s needs. This implies, in turn, a different way to conceptualize the insertion of Humanities in medicine: namely it is neither sufficient to teach some literature, history of medicine, and art to doctors, nor to promote the humanist domain exclusively in terms of human sciences, that is as activities aimed to the scientific study human phenomena. Such a use of Humanities is certainly effective in medicine but it does not exhaust the reality in this domain. Humanities have to become an essential tool that works from within clinical practice in order to develop and foster procedures and behaviors that conform to the humanistic attitude itself.

The word humanism generally refers to each doctrine which strives to understand the human experience as such [9]. Since this definition is too broad, a further clarification is required. Specifically, we use the word humanism in reference to the cultural dimension of the human being, that is to say, to denote all those experiences, from painting to architecture, from music to literature, by which a human being intentionally modifies the space in order to reach a certain end, such as trying to live more comfortably, through his own technical ability and specific methodology. This view of humanism clearly requires a due consideration of the role of one’s own will [10] and the recovery of the final cause that was programmatically rejected by modern science [2]. In other words, the main feature of man is the ability to wish and thus to plan according to a truth that is firstly linked not so much to a scientific and technical knowledge of the single act performed but to the awareness of its own final end.

Therefore Humanities cannot be reduced to the status of efficient causes of an effect that is, in our case, the moralization and humanization of the clinical practice, according to the optimistic view typical of positivism. Both the subjects who realize an humanistic experience and those who use it would be deprived of responsibility.

In this light, the true and brave realism of George Steiner well highlights an essential step for humanistic education, that is, the responsibility to orient Humanities toward the human truth and to its service. In this regard he claims that “If we do not make our humanistic studies responsible, that is if we do not discriminate in our allocation of time and interest between that which is primarily of historical or local significance and that which has in it the pressure of sustained life, then the sciences will indeed enforce their claim. Science cannot begin to tell us what brought on the barbarism of the modern condition. It cannot tell us how to savage our affairs. A great discovery in physics or biochemistry can be neutral. A neutral humanism is either a pedantic artifice or a prologue to the inhuman” [11].

In this perspective Humanities can be proposed to physicians not only as useful tools for the scientific and technical acting but also as occasions of reflection and search for meaning of clinical practice and of what revolves around it. This is a way to help in developing the awareness of the specific aims of medicine so that these may be effective to promote a new and genuine motivation to work. At the crossroad between the Humanities and the promotion of an authentic professional motivation we can see that the artistic experiences have a pedagogical role that “touches student more deeply at a personal level than does the training process. Education is not just concerned with what someone can do, but about what kind of people they became as a result of their education” [12]. The task of making the Humanities more responsible is a necessary and important one, since medicine is ultimately a science and art made by men and men are confronted with their own and others’ sufferance and whatever this implies.

In this perspective, although for a long time science and Humanities have been thought as distinct and incommunicable culture [13], the integration of Humanities in medical training goes beyond that polarization. Indeed, it can meet the new needs of medicine as well as of Humanities itself if these are understood correctly.

As Gadamer notes, “applying science in fields where the understanding of humans have of themselves is called into question causes not only conflicts but also comes into play extra-scientific factors that claim their legitimacy” [14].

Accordingly, Humanities should not move away from the lived experience or abstractly replace it [11]: this would mean to turn useful humanistic experiences into something dangerous. Moreover, losing the link with their humanizing aims arts would restrain those faculties that instead should take force and impetus from them.

Thus Humanities can acquire the possibility to limit the dehumanizing trends present in them by a good supplement rather than supplant of the living experience [15] so that they may foster the achievement of authentic meaning. John Gardner well epitomizes the right integration between Humanities and medicine by stating that “True art is moral: it seeks to improve life and not debase it. It seeks to hold off, at least for a while, the twilight of the gods and us” [16].

In regard to that specific finality, it is important to distinguish two different constitutive dimensions within humanism: passive humanism and active humanism. Reading a novel is quite different from writing it, as well as studying clinical methodology is not caring for a patient. Those two dimensions are mutually different without disregarding their ties. For instance, a humanistic experience is both to listen to a concert and play it; these acts do not overlap and at the same time are linked as absolutely constitutive of a unique experience, that is the experience of that concert. Furthermore, the active humanistic experience to write a book makes the passive experience of reading it possible, although the latter is always a free and intentional act. This involves that experiences such as reading a novel or observing famous paintings have also a dimension of passivity which is due to the emergence of effects that you can only partially restrain. For this reason books or concerts are not all the same (this consideration applies for each kinds of art), so that a choice among them involve responsibility. In other words, reading a novel or watching a movie are always free and intentional act and however we must be aware that every time we perform those actions you chose a specific end through those means. Understanding how these experiences are not neutral will help us to overcome a positivistic and uncritical view of humanities as activities involving almost necessarily a moral force. In spite of this, our intention is not a diatribe against arts in their own right but toward a reductionism that appears much more inefficient if it occurs in the Humanities.

To clarify this idea, let us consider the following example. Sherlock Holmes’ novels are often used as example of rigorous approach to reality focused on apology of rationalism as the only scientific method in all cases of life. In turn, the current methodological approach of the Evidence Based Medicine (EBM) has provided a new epistemological rigor to clinical practice with its emphasis on evidence as essential tools to investigate the truth.

However, it is properly lived experience that challenges these methodological reductionisms by showing us its qualitative dimension made up of fear, suffering, love, rage and so on. Denying these facts means to reduce reality, which is multidimensional, to just one of its dimensions – the quantitative and measurable one - while everything else simply does not exist. In this sense, the famous novel Flatland by Abbott [17] is useful to understand that reality is not a flat–land because it presents more interconnected dimensions which can be grasped with an adequate effort of sensitivity, developed for instance through an integrated and finalized medical education.

Multidimensionality and the qualitative dimension are expressed at every level of medical practice, including clinical reasoning. How doctors think by Gerome Groopman [18] duly portrayed the cognitive experience of the physician as an existential act conducted in the first person, by initiating a reflection on the way doctors think as integrated into the whole of their agency. In other words, the act of thinking is a unitary act springing out of the person in her entirety.

In turn, Sir Luke Fildes in his painting The Doctor well exemplifies that medicine is not exhausted in care and technology because it comprises also the compassionate “art” of doctoring [19]. Therefore, that humanistic tool can contribute to medical education by showing the need to strengthen the initial humanity of the students.

Although this multidimensional view of medicine can seem very disconnected from reality, it is not foreign to professional clinics. A significant example is the one of the already mentioned Bernard Lown, Nobel Prize winner and developer of the current defibrillator. Based on his fifty year long experience devoted to the practice of medicine, he wrote that “healing is best accomplished when art and science are conjoined, when body and spirit are probed together. Only when doctors can broad for the fate of a fellow human afflicted with fear and pain do they engage the unique individuality of a particular human being. A sick patient become more than his or her illness” [5].

Also the experiences of active humanism are fundamental as they involve the subjects in a way that these activities are real part of their lives and selves. Experiences including work camps, theatre, team games, clubs can be important to encourage specific attitudes such as fairness, openness, humility, attention to the small staff, reflection, selfconfidence, which are precious experiences for learning to take care of patients.

Those universities which talk about medical humanities and at the same time forget the formative contribution of active humanism experiences, renounce not only to an important amount of humanistic education, but also hinder the effectiveness of passive humanism.

It must be stressed, however, that medical students and doctors have the freedom to intentionally choose to take up the opportunity of enriching, improving, or developing their personal baggage by drawing from these diversified humanistic experiences, and to work with a conscious impetus that comes from these roots [12].

In short a good doctor is not exclusively the product of an appropriate scientific and technical training, but also requires both personal determination and a wealth of personal skills that may be learnt through the exercise of reflection, and the study and practice of the good humanistic practices.

Given that people differ in attitude and motivations, we suggest also to integrate the humanistic education and the medical training with Counseling and Tutoring services in order to personalize what otherwise would remain standardized and hence not entirely effective. The personalization of medical training and education is set up as a quiet and continuous work of personal relations with the students and has turned out to be the first and more effective among Humanities.

A realistic program of integrated humanistic education

The humanistic experiences mentioned above are just some examples about how the good Humanities may be valuable for medical training. Broadly speaking, arts as well as human sciences can be a useful supplement:

• to create a bridge between health problems and social responsibility [20];

• to enhance the performance of thought (intellect, intuition, imagination);

• to develop awareness of the human factor for a good clinical practice (link between personal skills and medical skills);

• to favor the attention to details (all that exist makes sense and can help to describe the real);

• to promote a baggage of personal skills (good communication, listening, empathy, self-confidence);

• to remember that chemistry does not exhaust the human;

• to integrate the functionalistic approach with a more cognitive and essential attitude (the question of truth and its recognizability, the dimensions of suffering, the relation between body and spirit);

• to nourish a deep and personal interest for people (patients, nurses, family, colleagues) toward a good compliance;

• to assist in the inner journey of self-awareness and critical assessment of one’s own conceptual frameworks [20];

• to make the passion for one’s work and expertise flourish;

• to deepen a reflexive and critical attitude, even toward oneself, by gaining the dictum of Socrates “the unreflective life is not worth living”.

• to understand that the real is multidimensional, and that this fact asks for an integrated clinical approach;

These humanistic contributions can be considered as general aims for which it is necessary to identify suitable procedural strategies. Otherwise, they can be viewed as aims of the subject in the first person which require also a wider cognition and awareness in the fields of anthropology, logic, ethics, psychology, law, history of medicine, metaphysic and bioethics in general.

In other words, it is a matter of an authentic program of integration of humanistic education and scientific and technical knowledge as needed components of a clinical practice which is intrinsically complex.

In the intentions of its founders, the EBM was born as a multidimensional approach. Indeed, Sackett explicitly states that “it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice” [21].

The critical debate has mostly produced a misinterpretation of EBM by reducing it to a mere evidence. However, it is useful to promote the teaching of this methodology by considering its effort to integrate different aspects of the clinical practice; at the same time we need to point out the important preservation of the qualitative dimension at all levels of clinical practice, such as research, care, reasoning, medical training, medical education, as well as within the Humanities themselves.

For instance, in medicine it is essential both to know guidelines and best evidences about a specific treatment and to be able to inspire confidence and to feel joy in saving a life. All these basic instances may be dealt through a set of concrete humanistic tools including:

• A theory of clinical thinking mainly concerned with the logical and a-logical dimension of thought. For instance, an humanistic approach to clinical observation will educate to consider the unavoidable role of the subject in observation [8].

• An education to the self-personal domain and to virtues as professional attitudes [22]. Let us consider, for example, how important is the virtue of prudence during anamnesis: it allows the patient to talk without being interrupted.

• An education to attention to details (complete physical examination, accurate anamnesis). As Southgate states, “If we are attentive in looking and in listening and in waiting, then sooner or later something in the depths of us will respond” [23].

• A training of personal skills, such as humility, acceptance of one’s limitations, loyalty, sincerity, open-mindedness, responsibility toward others and themselves;

• A philosophy of medicine which allows for the definition of its specific goals so that each physician can be responsibly aware in pursuing a genuine happiness as well as his /her personal aims.

• A personalistic theory of the human being, with particular regard to his relational, spiritual and historical dimensions [24]. For example, if we embrace exclusively a materialistic approach to the man and suffering the activity of care will become not only dehumanizing but unreal. Human suffering has an extra-physical dimension which implies fear, anger, anxiety, view of life in its horizontal and vertical relationships. All these aspect need to be taken into account toward an accurate and acceptable approach to medical care [25].

These humanistic efforts should accompany the whole path of medical training, and become more focused in specialties in order to better address clinical practice. For example, it can be useful in Oncology to study the philosophy of cancer aimed to provide an essential definition of this disease [26].

In this way, the Humanities become subjects and tools which integrate from within the clinical practice into a broader framework of knowledge and skills. It follows that the greater the expansion of one’s own personal baggage and opportunities of reflection is, the deeper one’s own understanding and acting in clinical practice can be [20].

In this essay we have offered a deeper way to conceptualize the approach of Humanities in medicine. Considering the distinction between the terms “additive” and “integrated” suggested by Greaves and Evans we believe that the best way to approach this problem is talking about an integration of Humanities from within medicine. The scope of the Humanities is not to mitigate or support the sciences and technology through different perspectives; these are aimed “to refocus the whole of medicine in relation to an understanding of what it is to be fully human” [27].

In other words, an effective and good medicine requires openness toward a multidimensional understanding of reality, especially when the latter deals with a human being. Indeed if physicians are narrowly focused on the world of science and technology their clinical practice will be necessarily reductive. It means setting aside the qualitative dimension of lived experience although it is a unavoidable component of man. As observed by Silverman, doctors face today a paradox “revered when they were relatively ineffectual, they now find themselves increasingly reduced when they are able, for the first time ever, to change the expected course of so many disabling and fatal disorder” [19]. Perhaps this occurs because doctors allured by the growing intimacy between medicine and science have neglected the importance of bedside manner and the personal investment in human relationships with patients [5].

In this perspective, Humanities can be a valuable and diversified tool for medicine in order to promote processes of self-learning and self-awareness and develop a deeper sensibilities, above all the one well epitomized by Terence’s dictum: homo sum: humani nihil a me alienum puto.

Summarizing, we could say that, first Humanities can be viewed as sources non-strictly medical knowledge (phycology, ethics, anthropology, philosophy of clinical reasoning, philosophy of cancer) which is essential to guarantee a good clinical practice on different levels. Second, Humanities can offer precious space for reflection, searching for meaning, stimulation or suggestion, mainly with regard to specific instances that otherwise could be learnt only partially or not learnt at all. Finally, they can contribute to develop a baggage of personal skills which jointly with the medical skill stand for what Jaspers calls the preservation of the idea of doctor and in turn of clinical practice as exercise of concrete philosophy [28].

In short, it is fundamental to educate medical students and doctors to understand the unitary structure of medical knowledge which involves a real responsibility of thinking and acting. For these reasons, we do not devaluate Humanities by asserting that they should be seen in medical education merely as means to an end [12] since, paraphrasing Osler, there must be a very different humanization or there will be no humanization at all.

We hope to have given some suggestion about the main conditions underlying a realistic integration of Humanities for medicine, that are given below:

• A responsible integration which goes beyond a linear view of Humanities as instances of moralization;

• A personalized integration as a further occasion to promote virtuous habits which take into account both individual differences and the possibility that not all medical students exhibit an enthusiastic response to humanistic education [12].

• An integration that does not fail to grasp the need of a multidimensional approach to clinical practice;

• An integration capable to lead doctors to a new and constant process of reflection through which they could become more and more aware of the ends of their medical activity and ultimately of the human condition;

• An integration that enhances the humanitarian side of the interaction between the doctor and the patient by connecting the arts and science.

We would like to conclude by referring again to the Osler tradition and in particular to one of his admonition about what medicine and art should never lose sight of being their common goal. He claims:

“The Practice of Medicine is an art, based on science. Working with science, in science, for science, it has not reached, perhaps never will, the dignity of a complete science, with exact laws, like astronomy and engineering. Is there no science of medicine? Yes but in part only, such as anatomy and physiology, and the extraordinary development of these branches during the present century has been due to the cultivation of method, by which we have reached some degree of exactness, some certainty of truth. But in the practice of medicine our study is man” [29].