Taking Medical Education to the Source

Earlier this year, the Bulletin of the History of Medicine introduced a new section on Pedagogy designed to share approaches to and experiences of teaching the history of medicine in diverse classrooms. The section will appear twice a year and is complemented by Recommended Dosage: A Blog About Teaching the History of Medicine. The initial Pedagogy section was curated by Dominique Tobbell and Lois Hendrickson from the University of Minnesota. They discussed their collaborative approach to using primary sources in the undergraduate classroom. Tobbell and Hendrickson joined us for a Q&A about the section and their research.

How did the courses you teach using primary resources develop? And what led to the partnership that the two of you use in your teaching?

DT: We teach two courses using primary sources: Technology and Medicine in Modern America and Women, Health, and History. I developed the first course, Technology and Medicine in Modern America when I was a graduate student at the University of Pennsylvania. At Penn, I didn’t have the opportunity to work with curator or archivist of history of medicine rare books, manuscripts, and artifacts and so the course was based only on secondary sources.

When I joined the faculty in the Program in the History of Medicine at the University of Minnesota, my office was just a couple of doors down from the Wangensteen Historical Library of Biology of Medicine. I learned that Lois, assistant curator of the library at that time, was already working with some of my colleagues in their courses and so I asked Lois if she’d be interested in working with me on Technology and Medicine in Modern America. We talked about the curriculum and what artifacts, manuscripts, and other primary sources the Wangensteen Library had in its collection that we could incorporate into the curriculum and our teaching.

When I arrived at the University of Minnesota, Women, Health, and History had previously been taught by one of my colleagues. I decided to revise the course and, after the success of teaching Technology and Medicine in Modern America with primary sources, I again worked with Lois to incorporate primary sources from the Wangensteen Library into the curriculum. At the time, I was also oral historian for the University of Minnesota Academic Health Center Oral History Project and had collected several oral history interviews with retired and still-active nurses and nursing faculty who had practiced and worked from the 1940s onwards. I also knew of an edited volume of oral histories with female physicians who had trained in the United States during different periods in the twentieth century, and a collection of published oral history interviews with African American nurses who had worked in Detroit during the Civil Rights era. With these resources at hand, I decided to also incorporate the use of oral histories into the curriculum and teaching.

LH: Prior to Dominique’s arrival, I’d been using primary resources in course-integrated instruction for quite some time. I had developed several exercises and active learning activities as models. Although I was fairly new to the Wangensteen Historical Library at the time, I had already begun to explore our under-used artifact collections, experimenting with uses in several venues.  Dominique’s classes provided a chance to incorporate my interests in teaching with primary resources and to expand it to include artifacts to support key concepts in the course.

What do you recommend to faculty members who may not have access to an extensive collection of primary sources?

DT: Even if you don’t have access to an extensive collection of unpublished primary sources including artifacts on your own campus, you can still make use of published primary sources that are either available online or in hardcopy in your campus libraries. The National Library of Medicine Digital Collections (https://collections.nlm.nih.gov) and the Wellcome Library’s Wellcome Images (http://wellcomeimages.org) are free online resources of still and moving images, including images of artifacts from their respective collections.

Several oral history projects have transcripts and/or audio excerpts posted online or available on request such as the University of Minnesota Academic Health Center Oral History Project (http://editions.lib.umn.edu/ahc-ohp/), the National Library of Medicine Oral History Collections (https://www.nlm.nih.gov/hmd/manuscripts/orallist.html), and the Regional Oral History Office at the University of California-Berkeley (http://bancroft.berkeley.edu/ROHO/collections/subjectarea/), which has several collections related to the biomedical sciences and health care.

Old clinical journals, which can still be found in most campus biomedical libraries, are increasingly available online, and historical newspapers are available online through the Proquest Historical Newspaper database.  Having students read and analyze articles from medical journals in the late 19^th century, nursing articles from the early-20^th century, or old newspaper articles in the context of class readings and lectures can be a very productive exercise. In the Women, Health, and History class, for example, my students read a series of articles published in the New York Times between August 30, 1871 and October 4, 1871 that reported on the death of a young woman from an apparent abortion and the subsequent arrest and trial of the two accused abortionists. From these articles, my students learned how abortion was investigated and what the consequences were—medically, legally, and socially—for those implicated in the abortion.

LH: I believe that the basic principles and practices of working with primary resources can be achieved with a small subset of resources in a variety of formats (primary printed, unpublished archives and manuscripts, audio and visual artifacts and material objects).  Students are still developing historical thinking skills, so the primary resources that an advanced scholar might quickly parse, are more challenging for students who need a guided inquiry path.  This works takes time, often more than we anticipate, which can obviate the need for a large number of items.  Students learning objectives, including many critical thinking skills, can be met with such a set of curated items.

As Dominique points out, these could be digital resources from freely available resources such as the Digital Public Library of America or The Library of Congress, among many others.  There are also rich troves of primary resources in local historical institutions, college and university archives, and primary printed resources in general library collections.  In a unit in Women, Health, and History we used items from several collections to trace change over time. The Wangensteen Historical Library had five 19^th c. pamphlets from early nursing schools that were used alongside documents held in the Health Sciences Library from the 1930s-1980s. Students used these resources to compare and contrast expectations, curricula and educational standards and trends in nursing education. We supplemented this with historical hospital nursing photographs from the University of Minnesota online media site (freely available at http://umedia.lib.umn.edu).  These provided context for students who later used oral history nursing interviews.

In Technology and Medicine in Modern America, initially a seminar, I brought two or three artifacts and two or three primary printed resources to contextualize them. As a group, we examined and discussed these resources.  Later, we scaled this exercise to accommodate a larger enrollment, using artifacts and texts in think|pair|share exercises, including a large group sharing period.  The Wangensteen Historical Library has a generous amount of teaching artifacts and primary printed resources, and so we were able to use variations of this model for other units in the curricula. However, a smaller number of learning experiences with primary resources could still provide students with memorable, transformative experiences that provide them with a window into direct evidence of human activity, and allow them to widen their perspectives and gain insights into historical problems or situations.

How important is it to reach students with a variety of post-graduation plans so they understand the importance of primary sources in any discipline?

LH: Practical, analytical, ethical and theoretical concepts guidelines for primary source literacy translate into post-graduation plans in a variety of ways. Many students who take these two classes are pre-health care majors, and teamwork and collaboration are programmatic outcomes in health care education.  Practically, classroom exercises require peer interactions and learning, just as in a professional setting.  Students also learn to take careful notes from the evidence and data in primary resources, practice critical thinking skills (develop and refine arguments), and start to understand that questions inevitability change over time.

Health care disciplines ask students to take factual, objective learning (anatomy, microbiology) and transfer that knowledge into unique situations – e.g. finding out what works for a patients, what doesn’t, and why.  In evidence based medicine students are asked to determine what the root of the problem is, and what the treatment options are – much as they need to refine a historical research questions and use evidence to support their thesis. As students decide what resources and information are crucial, they practice informatics type skills used in electronic medical records – what to discern from the information in the record and what to add to a patient’s record.

Ideally students learn basic strategies and processes of finding and using information, which they can build on in future classes and later, on the job. Students may need to continue to build their own body of knowledge and research to present compelling arguments to peers, clients, and patients, or to teach others.  And, as students enter the workplace or post-graduate study, the ability to have a voice at the table, to teach patients, to work alongside other health care professionals in an inter-professional arena becomes critical.

Students also become more comfortable grappling with information and with the uncertainty they feel when faced with an unknown artifact, manuscript or ephemera. They begin to learn to parse ambiguity and certitude. Self-disclosure is important in medicine, you have to be willing to admit you don’t know and be teachable.  When you assume you know, you could endanger the patient. Finally, students develop visual observation and assessment skills (critical to health professionals) and communication skills – how to have a conversation that is not on a device.

Integrating the theory of primary source literacy with hands on practice helps students recall and transfer learning from one context to another, and helps them develop a nimble intellect.

As technology makes it easier to share documents, how will this kind of teaching continue to develop?

LH: Digital pedagogy theory and the practice of teaching using digital objects and in a digital environment continues to evolve and change swiftly. We briefly touched on the wide availability of digitized print, manuscript and audio surrogates. One area of interest to me is collaborative annotation tools. Students could develop close reading skills using multitude audio, text analysis and social reading tools to collaboratively annotate primary resources with text, images, comments, or hyperlinks. They could work together to unpack the context of particular passages, entities, or do more sophisticated work such as visualization, network diagrams or sentiment analysis. 

For example, in one of our exercises in the Women, Health, and History class, students all review various copies and editions of Florence Nightingale’s Notes on Nursing.  Currently they examine, compare and contrast them using a guided worksheet, reporting their findings orally to the class.  Collaborative annotation techniques would allow students to see others’ digital surrogates, mark-up changes, and to comment on differences. I’m also interested in how the increasingly widespread practice of creating digital 3D representations of artifacts, and their use in a virtual reality environment, will change both access and our interactive experience with these collections