Learning the Past To Make Better Healthcare Providers

On this episode of Health Science Radio, Daniel Goldberg, associate professor and director of education in the Center for Bioethics and Humanities,  breaks down the importance of history and its place in a modern health sciences curriculum by examining the practical uses of thinking like a historian to better serve patients, inform research and build stronger bonds with the communities future health science leaders will serve.

Transcript

Thomas Fuller, a 17th century English historian, once described the benefits of learning history as allowing someone to achieve: “the experiences of age, without either the infirmities or inconveniences thereof.”

History is threaded throughout the evolution of the health sciences. From Hippocrates being the originator of the term ‘cancer,’ to the individual social, political and economic contexts that are behind each discovery – the fields of history and health science are closely linked. So what can modern health science students learn from studying the past? 

In this episode of Health Science Radio, we discuss the complexities of teaching history in the health sciences with Daniel Goldberg Goldberg, associate professor and director of education in the Center for Bioethics and Humanities. 

Matt Hastings

All right, Daniel. So I think we'll just start at the top then with a pretty straightforward, basic question. Should providers learn the historical context of their field?

Daniel Goldberg 

Yeah, I think that they should, and I think the key point here is really thinking for two different possible reasons why providers should learn the historical context of their field. One possibility is because it's interesting and of intrinsic value, we might say. Like it's worth knowing things about the past just for its own sake. I think that's actually true, by the way, okay?

But I think what I'm really interested in now is a second possible answer to that question, which is maybe healthcare providers and healthcare professionals should know the historical context of their field because doing so will actually be useful to their practice. It will actually help themselves and it will help others as well. It will help patients, populations, and communities who are served. I think that's a really sort of interesting and second possible answer to the question, and it's one in which I'm sort of particularly invested.

Matt Hastings

Do you think that there's room in the modern curriculum for history, and what does that look like with a field that is so focused around skill and competency as a profession?

Daniel Goldberg 

Yeah, I think there is room. I mean, that's always the tricky part, is something I've sometimes called the ‘no villains problem.’ And what that means is there's no one who's really standing up and saying, "No, I hate this stuff, and it should ..." Well, not no one, but not a lot of people are really standing up and saying, "No, it would be terrible for public health professionals, and medical students, and nursing students to learn about the history of these fields," and as a way of informing present and future practice, most people think that there's some value to that.

But the problem is that the curricula are just packed so tight. The question is really, "Well, what are we not going to include something else?" Right? And so that's partly why I've been interested in this idea of, "How can we fit historical training of any kind?," we're not trying to make historians in health professional schools, but, "How can we fit historical training of any kind into a skill and competency-based profession?" And that's why I sort of focused on that second question that I mentioned earlier, which is not just teaching people about history.

That's fine, and I think it's worth doing and important, but actually giving them some skills and competencies in historical reasoning and historical understanding that really enable them to apply those skills to unanticipated new problems they may experience in the health professions. I think that's what's really sort of interesting, and I think if we do that, then there's really no reason that we can't nest history into these health professional curricula, right? It just looks like anything else we might do, right? We are teaching people some skills and some competencies that we think will improve their practice and be better for the people with whom they're working and the communities they serve. And in that light, history really doesn't look that different from a lot of other things that are in these curricula.

We still have some challenges in finding space for these worthy products, but it really sort of helps us understand that history can be thought of as something that really looks like any of the other kinds of skills and competencies they might be learning in their curriculum.

Matt Hastings

A lot of popular conceptions of history are still focused on: it’s rote memorization, it’s learning dates, it’s remembering places, and often battles, and very boring stuffy generals, and those sorts of things. It's more, it seems like, what you're saying, a listing of skills and analytical devices to be able to interact with those portions of history and sort of take that and run with that going forward.

Daniel Goldberg 

Just to give a couple examples, sometimes when I talk about this with colleagues, they're like, "Okay. Well, what are some examples of the skills and competencies?" I think that many of us who teach history or who are trained in history, we are creating these problems because we are teaching people to think about history as the stuff itself, the dates, the facts.

And as you get further into it, you understand that actually, history is much more than that, and it does have methods, it has skills. There are things we can teach others about how to, not to do history per se, because again, we're not trying to create professional historians here, but the key for me is how to think like a historian, right?

That's what I'm really interested in. That's the overarching skill. What would it mean for health professionals to be able to do a little bit of thinking like historians? What skills and competencies would be included there? 

So just a couple of examples, the first one, and probably the major one is history and historians who are good at this are really all about contextualization, right? It's really about understanding the problems, the events, the ideas, the conditions, the motivations that people have, all of these things in a broader context that helps us really understand, "What's happening?," "Why is it happening?," "Why did things happen this way, instead of another way?" 

And you can't answer that question unless you sort of enlarge to understand the context, right? So the better we are at contextualization, I think generally, it's probably a good rule of thumb, the better the work, the understanding of histories that we are going to have. And I think that kind of contextualization is really, really important. 

So I work in public health, for example, and in public health, if you're thinking about when we were rolling out COVID vaccines, and we were thinking about a vaccine that was created amazingly at a very high rate of speed, actually, there were communities who have documented, for very good reasons, they do not find public health officials trustworthy in general, and there are good reasons why these communities don't find public health officials trustworthy. And so understanding the broader context, as well as situations in which vaccinations have been introduced into communities that don't find public health officials trustworthy, can really help inform on a very practical level, what we do, what we don't do, who we talk to, how we collaborate and partner and work with communities, the kinds of background understanding that can shape the interactions and the intervention that we're trying to introduce in some really productive ways.

So contextualization is one example. The other sort of obvious example is professional historians and people who are trained in history, they spend a lot of time really interpreting texts, right?

Now, not only texts. Of course, historians work a lot with visual imagery and iconography and stuff like that, but a lot of historians spend a lot of time synthesizing and understanding texts, including texts that are written in different languages, in different times, in different places, in different contexts. And I can think of a number of ways in which the ability to really synthesize and understand texts that are coming from people who have wildly different experiences and wildly different sort of cultural and social understandings and approaches. I can think of a lot of different ways that might actually be very practically useful when we're thinking about how to work with and partner with communities and the health professions.

Matt Hastings

Totally. Yeah, and I think you, in article back in May, when you were ... I think you wrote a paper that was about the need for historical fluency, specifically related to pandemics, and I think right at the top, you really clearly outlined this is for probably those who are really deeply involved both in history and education and teaching and learning in general of Bloom's Taxonomy and sort of how that is organized traditionally as a pyramid, where you have, I think what people generally associate with history, that's just knowledg e, which is sort of the bottom rung of that pyramid, whereas you have near the top, you have synthesis and evaluation, so you have to move through that process when it comes to a historical event and what do we know about it? What was written about it? Who was involved with it?

"What was their background with it?" All of that informs how you would implement something like a pandemic response.

Daniel Goldberg (08:51):

We teach people stuff. That's what we do in the health professions. We give them a lot of knowledge, right? But that's not enough, of course, to actually be skilled and competent. We know that, right?

You have to be able to do more. The next level up on that pyramid usually is application, and that's really where that idea, the skill of historical fluency that I was talking about, at least my vision for it, is that's where I really tried to situate it. It's not sufficient just to know stuff.  It is good to know stuff about the past. I think that's true, but I don't think that's going to fit as well in a skill or a competency-based approach, right? 

I think what we really want to be able to do is to be able to apply that knowledge, especially to new, novel and maybe unanticipated problems or scenarios. If you are able to apply historical understanding, if you're able to apply contextualization the way we've discussed new and novel problems, to take the historical understandings you have, and apply them to a current situation that will change our understanding. That will change the conversations we have. That may change who we decide to partner with. That may change how we decide to implement the intervention, or even potentially which intervention we decide to implement in partnership with communities. I think that that's really where the skill and the competency comes into play, right? That's where it can really be practically useful. That's the concept that I was going for, is this idea of historical fluency as an applied skill is really the most important part. You do have to know stuff, but then, you have to be able to apply it as well.

Matt Hastings

Yeah. I think the other part of  this conversation that seems to fluctuate in and out of vogue, and probably goes back a lot longer than a lot of people realize of how long this conversation's been going on, is the value and the importance of teaching history in the health sciences. It's really oscillated a lot over the centuries. You have really wild examples, the Rene Laennec, for example, who was the early pioneer of the stethoscope, for example. His medical school dissertation in 1804, he spent his thesis defending the continuing relevance of Hippocrates to medical practices.

That's an old example. That's a Dusty Tomes example, but that is part of this conversation. So you see a lot of news articles over the last 10 years or so, that this sort of oscillates back and forth on its importance. So all of that to say is What is the current state of teaching health science history within the United States? 

Daniel Goldberg 

I think it has a small footprint largely because of the ‘No Villains’ problem that I discussed earlier, right?

I think that, although it actually, as you point out, Matt, correctly, right, there is actually a pretty extensive, no pun intended, history of teaching history in the health professions primarily within medical schools and nursing schools, in particular. It often struggles to find a place in a heavily sort of skill and competency-based curriculum. And again, not because anyone is really opposed to it, I think, but more because there's so much that's packed into health professional curricula. It becomes a problem to figure out what will move out in order to accommodate that kind of thing. So partly I think that's what's happening.

It does have a place. It usually has a relatively small footprint. Oftentimes it is not part of what we would call the core curricula. It's not something that everybody who's in this particular curriculum has to learn, for example, in order to be able to matriculate through the program. There might be electives, there might be opportunities for people who are involved or who are interested to self-select into that kind of education, and actually people do that.

They pursue training, they pursue courses. Sometimes people pursue degrees, right? It's not unusual. There's a long history of having clinician historians that's actually quite old, but as everybody knows, it is difficult to put anything into the core curricula in health sciences education.

Daniel Goldberg 

And actually, there's nothing really that unusual about history in that way. It's difficult to get anything in there, right?

Matt Hastings

Is it possible to balance what students need to know, but also why they need to know it?

Daniel Goldberg 

Yeah, I think so. Do we want to think of the study of history as something very different from what learners are doing in health professionals, or do we want to think about it as just another example of the kinds of things they're already doing? And there are advantages and disadvantages to both of those, and you probably get six historians here – you might get four or five different responses to that.

Matt Hastings

That sounds about right. 

Daniel Goldberg 

You know? But for better or worse, I've thrown in my hat to at least the part of the answer which says, "There are some important similarities, at least that we can harness." Right? And the way is that, in a skills and competency-based curriculum, we are always thinking, "Why is it important for students to know this?" Right?

If a particular piece of knowledge in anything, biochemistry, immunology, microbiology, pathology, it doesn't matter what it is, if a particular piece of knowledge, we think, has absolutely no connection whatsoever to any kind of skill that a health professional might actually want to use once they're actually in full practice, then we start to ask some questions about, "Why is this still in the curriculum?" Right? And there might be answers to that actually, but it's at least a good sort of benchmark for us to stop and say, "If this isn't directly connected to the skills that a professional will have to use to take care of people in any kind of health professional context, then why are we asking them to know about it?" Right?

Daniel Goldberg 

And I really don't think history is different in that way, right? I think the question is, we might give some students some historical knowledge, and then we also need to help them help ourselves and understand, "Why are we asking them to learn this?" Right? "Is this going to help them forge any skills or competencies that they can use in their practice?" And I think the answer to that question, as I've been sort of arguing, is yes.

Daniel Goldberg 

If the answer to the question is no, like I said, it doesn't necessarily mean we can't have it in there, but then, we do have to ask some further questions. I think about, "Okay, if it's not helping to generate a skill or competency, why is it here?" And there are answers to that question. I mean, everybody who teaches and works in a skill and competency-based curriculum understands perfectly well that there are important things to learn and important parts of education that are not reducible to skills and competency.

So no one really thinks that skill and competency-based learning is everything, right? It's just the model that we use. So sometimes, for example, a colleague and I have developed for a particular educational experience, we co-direct for medical students, we've developed a model that we call Competency Plus, because for exactly that reason, we are really focused on skills and competencies, but we also understand that there are some things that we think that would be useful for learners to think about and to reflect on, that really aren't reducible to skills and competencies.

Matt Hastings

So let's dive into that a little bit. How does CU Anschutz teach and incorporate history into our health programs? What does that Competency Plus sort of look like in practice, and what are some examples of it?

Daniel Goldberg 

I can only speak to the experience of which I'm aware, right?

Matt Hastings

Sure, yeah.

Daniel Goldberg 

And so there are certainly, there may well be courses and people doing other things all over this campus that I'm not fully aware of. I would love to be aware of them, by the way. If anyone's listening, please contact me, okay? So, for example, we can start with that Competency Plus model, which is what Dr. Brian Jackson and I have used to design an educational experience known as the Trail. And the Trail is a late-stage experience for medical students.

It's composed of two two-week immersions, which are synchronous, and they're separated in the middle with a distributed learning phase when a lot of the medical students are doing clinical work, and so they're pursuing some of their own, almost individualized kinds of learning experiences in the middle. And so, for example, next week, in fact, the timing is really good. We will have a history day in the second immersion, which begins next Monday, and this history day will involve us actually going to the Strauss Health Sciences Library and looking at some of the rare artifacts.

Daniel Goldberg 

Particularly in the history of anatomy and anatomical practice, and then asking ourselves some questions, a couple of different questions, both what we can learn from thinking about anatomical artifacts, anatomical books, what that means for histories of medical education, histories of anatomy, in particular, and medical education and health professional education, the role that they've played in what has been referred to memorably as A Traffic of Dead Bodies, which is the title of a book, a famous book on the history of anatomy.

And then, we will also, as part of that program, be engaging in some of the current controversies that medical museums are actually thinking deeply about in terms of the provenance, for example, of human remains, right? So there's a lot of, I think, very good and important conversations that are going on with museums, particularly medical museums that have historically displayed human remains, and there are questions about if we don't know, sometimes we do know, and then there is a whole different set of questions where we know where this came from. There are some problematic histories in this Traffic of Dead Bodies, and so what does that mean for the display of these parts? Right?

What does that mean for us? Is this really appropriate and ethical? Do we have obligations to restore human remains to the communities from which they were taken? And that's happening, that conversation is an international conversation that's going on right now.

Daniel Goldberg

And we have tried to incorporate on a micro level, a learner's ability to engage and think through some of those issues through this kind of history today. So that's one example. We are also going to History Colorado, and we have a whole different set of experiences that we are planning as part of the Trail. And then, in other curricula, for example, in the Colorado School of Public Health, where I also teach and which I'm also appointed, we actually have several classes actually, where we cover the history of public health, one that is open both to any learner in the school of Public Health, and then one that is specifically targeted for DrPH students, in particular. They actually engage a history of public health as a way of thinking through histories of inequality, histories of marginalization, and histories of oppression in the name of public health, and thinking about, again, "What would being able to think like a historian do for the kind of work that doctoral level public health learners want to be able to do with and for the communities they serve?"

Matt Hastings

Do you find it to be of use when setting up a curriculum or teaching students about history in the health sciences – do you find it helpful to have those efforts, really student-driven and student-directed so that they can engage with something that is intrinsically interesting to them to be able to have that initial hook where they feel like they are really engaging with the content and engaging with the material to be able to really understand and drive home the lessons of contextualization that we were talking about earlier?

Daniel Goldberg 

Yeah, absolutely. This has to be learner-driven, this has to meet learners where they are. And there's no question that that involves some compromises, right? So for example, Matt, you said you studied history. You spent years. You probably read thousands and thousands of pages, because there's a lot of reading when you're studying history, as you know, right?

Matt Hastings

Sure did, yeah.

Daniel Goldberg 

You know, for health professionals, we can't fairly ask them to do that, I think, right?

That would be great. The people who really want to do that, well, those are the people who self-select into additional training, as we discussed. They pursue certificates, they take full courses. They sometimes pursue additional degrees, for example, right? But it's not really fair.

If we think that history is relevant for the curriculum as a whole, that means everybody in the curriculum is going to move through that. It's not really fair, I think, to ask learners to really do the work you would have to do to really become trained in any kind of way in academic history. It might be fun. I'm not so sure that it's useful, number one.

Matt Hastings

Yeah. Asking too much.

Daniel Goldberg 

And I think we're asking too much, right? So partly, this interest that I have, in this idea of historical fluency that we were talking about earlier, it's partly born from that exact point that you were raising, right? It's learner-centered. Where are our health professional learners? What are their educational lives like?

What do they need? What can we fairly ask of them if we think this is important? I'm sure the biochemistry teachers would love to have a lot more time to teach their learners biochemistry, right?

And I'm sure that the microbio teachers would love to have the same, but there are good reasons why we cannot give that same level of training. The PhD anatomist is going to be doing different things with their master's level anatomy students than they can do with health professional learners. We all, as health educators, health professional educators, sometimes have to make some compromises for what we would really ideally love everybody to know and to be able to do with what the learners actually need and what they can benefit from to be able to practice the way that they want to practice.

Matt Hastings

I have two final questions sort of on the personal side of things. What drove your interest in teaching history to health science students initially?

Daniel Goldberg 

That's a really good question, Matt. First and foremost, I think of myself. I mean, I've heard of myself as a scholar teacher, so I do quite a lot of research and scholarship, but scholarship informs my teaching. The research I do informs my teaching, and teaching informs my research and my scholarship, right? If the research and scholarship that I'm doing has absolutely no bearing or relevance with the kind of educational work that I'm often asked with doing, then personally, that's not enough for me. It might be enough for others, so I'm not judging, right?

That's okay. Sometimes people just want to do research and scholarship, and they're not particularly invested or interested in education, and that's okay. There's room for people who want to do that, but that's not me, right? I think sometimes, of the model of the early humanists, for example, we think of history as one of the, the sort of the liberal arts, the studia humanitatis. Most people don't know that the history of the humanists – the humanists were actually very practical, right? They valued learning as a tool to help cultivate virtue in the world, right?

Matt Hastings

Civic virtue.

Daniel Goldberg 

Yeah, civic virtue.

Many humanists actually were served their patrons, who were often aristocrats and politicians, diplomats as it turns out, and what they wanted to be able to do was to use their learning to help the people whom they were serving and with whom they were working to help them do and be better in the world basically, and to create a more virtuous world. I'm not saying they always succeeded in that, or succeeded in that as often as we might like, but I like the idea, right? And so for me, the idea of being able to think about the things I was learning about history and the ways I was thinking about history, not just the stuff that I was learning, as we described, but the skills of being able to think like a historian, if there was no way that that would be relevant and useful for the learners with whom I would be working, then frankly, I probably would not give myself the luxury of pursuing it as much, if that makes sense, right? I think that this idea of being able to really translate research and scholarship is one we talk about a lot in the health professions, and actually, this is probably a surprise for a lot of people, but the humanities is a model for that, actually. We don't often do a good job of that in the humanities.

So if you're sitting there thinking, "That does not sound like any humanities class I've ever taken," I actually am quite sympathetic to you, right? We have not always honored the traditions well from where we sprung in the humanities, I think, but those are our traditions. I think there are good reasons for us to sort of hew to those traditions and to do that. So that's probably where it started, was an effort to really think about, "This stuff feels so important to me." Being able to think like a historian for me, I know, has been very practically useful. I am the person in the room who raises their hand and says, "Well, what if we broaden the context a little bit and start to think about one, two, and three?"

And I have seen how my colleagues seem to respond to that, in some ways. They seem to think it's useful, right? Let them be the judge. I'm biased, right?

Daniel Goldberg

But they seem to think that there is some use and utility to this kind of approach, and then I started to think, "Geez, we really need to find some way to help our learners, at least imagine what it might be like to be able to do this as a goal to move towards."

Matt Hastings

That's great. I'll let you out of here on this last one. I just would be curious.

Daniel Goldberg 

Yeah, yeah. Of course.

Matt Hastings

What's your favorite anecdote from the history of the health sciences? 

Daniel Goldberg 

I don't know if it's a favorite. Favorite is-

Matt Hastings

I think it would probably depend on the subject matter – most interesting, maybe? 

Daniel Goldberg 

Yeah. You know, you mentioned Laennec. So I tell this one about Laennec all the time. I think this one is fascinating, right? I have an unpublished manuscript, which needs a lot of work, by the way, okay?

But it is actually complete. It's complete, but it needs a ton of work, unfortunately, right?

Daniel Goldberg 

And actually, it's an intellectual history of the X-ray. So I'm really interested in the history of medical and scientific imaging, in particular. And what's really interesting when you go back, the opening chapter in this unpublished draft is the stethoscope. Now, most people do not think of the stethoscope as a seeing device. Most people think of it as a listening device, but Laennec is very clear on this.

It is a seeing device. The auditory sense is the means that we use to be able to create an image in our mind of the inside of the thorax, of the cardio-thorax, basically. So Laennec is very clear that this is an imaging device. You would use our ears to hear, but that's not the end, that's the means. The end is actually being able to visualize.

So the anecdote is, "Why did Laennec create this?" As far as we know, the stethoscope was basically a rolled-up cardboard tube, okay?

So what prompted Laennec to create this? And there's a number of different answers. One of them is that idea of being able to visualize and form a picture in your mind of the inside of the cardio-thorax. That's definitely part of his motivation. 

But the reason that I've come back to this one a lot is there's very good evidence that the other reason, and probably the more important reason why: Laennec was doing rounds in the charity hospital, in Paris, and that was where all indigent people, people who could not afford to go elsewhere to seek medical and therapeutic care, they went to this charity hospital, so there were a lot of people from different classes, let's just say, in the charity hospital in Paris at this time, in the early 19th century, and Laennec found that disgusting, to be honest with you.

So he created the stethoscope in part so that he would not have to put his ear directly on the chest of the unwashed masses. And we know that Laennec, that's part of the reason he did it because Laennec said that basically in his work. So that should prompt for us some interesting, I think, and important conversations about class and, no doubt, gender and race as well when we think about some of the most important origins and symbols of what it means to be in the health professions, that stethoscope, which is often not used anymore, remains a very powerful and important icon of the field, in general, and so to the extent that it stands as an icon, we probably want to think a little bit critically about the extent to which medical technology separates health professionals from their patients and the communities that they serve.

Matt Hastings

That's great. That's a perfect example. That's history in action right there and contextualization in action right there.

Daniel Goldberg

Yeah, yeah.

Matt Hastings

Thank you so much, Daniel.

Matt Hastings

I really appreciate it.

Daniel Goldberg

Yeah. Thanks, Matt.