The meaning of humanization for first-year medical students - The use of narratives in medical school


 Purpose To analyze the meaning of humanization by first-year medical students as well as to find out about their role models and what were their personal experiences of humanization and dehumanization before entering medical school. Methods The authors performed a qualitative study using narratives of first-year medical students. The data were analyzed through content analysis. The narratives were used as a strategy to stimulate students' reflection and to understand their perspectives and values at the beginning of the medical program. Results The study included 167 participants: 67 females (40.1%) and 100 males (59.9%). The participants' ages ranged from 16 to 38 years. The analysis of the narratives showed three main themes: socio-political and economic aspects of medicine, humanization of healthcare, and dimensions of humanization and dehumanization. In their narratives, the students expressed the desire to become doctors, to help and improve people's lives, and the intention to emulate good role models. Another desire was to contribute to the development of the Brazilian healthcare system. The students considered the humanization of healthcare as an integral vision of the human being that includes perceiving the context and personal history, as well as the complexity, of the human being. The students emphasized the importance of "going beyond the technical dimension" in the relationship between physician and his/her patient. Some students recognized the transdisciplinary aspect of medicine. Conclusions The students in the first-year of the medical program have a clear understanding of the meaning of humanization in medical practice, regardless of their social and economic conditions, age, sex, and religion. The students' narratives expressed their expectations for a more humane society with respect, solidarity, and compassion. The use of narrative is a strategy to develop critical thinking and to better get to know our students: who they are, what they think, and how they feel.


Background
The debate about humanization in healthcare remains alive and necessary because medicine is not just the application of biomedical sciences, but it is also the recognition of human values and needs.
Thus, there is a need to place medicine in a social, cultural, and historical context to lead medical students to recognize patient's social problems and to be able to think about appropriate solutions regarding their medical practice. And since training, physicians are aware that understanding the personal and sociocultural contexts in which their patients are involved will significantly transform their clinical practice and develop their relationships with their patients so that care reaches the quality levels expected by both In this way, humanization in medicine depends on the recognition of the physician and medical student, that his professionalism is related to a deep and permanent personal commitment to medicine as a social and moral activity [1,2].
Humanism as a philosophical perspective stresses the intrinsic value, dignity and rationality of human beings, placing focus on total human experience and the human at the center [3]. Humanization in this study refers to actions that seek to value human interactions, especially in the context of health services, respecting the subjectivity, history and need of each one. Humanization in healthcare can be defined as the culture of no violence; quality of service, associating technical excellence with the capacity of reception and response; to offer good working conditions, take care of the health professionals; increase the capacity of communication between users and services [4]. It can be considered as the democratization of relationships involving care, leading to greater dialogue and improvement of the communication between health professional and patient, as people acting in the therapeutic process [5].
Therefore, teaching humanization is part of responsibility of medical program, and it involves more than cognitive contents; it includes reflection about students' experiences and good role models. The development of ethical behavior and humanization practices can result from observing teachers that demonstrated higher professionalism [6,7].
The use of narratives is an innovative strategy in medical training to teaching and learning humanization in health care, using student reflection. Narratives permit the development of communication skills, the capacity for reflection, empathy, and to take patients' perspective [8][9][10][11][12][13]. It can also be used to develop professionalism [14][15][16].
In this study, we proposed to use students' narratives as a strategy to stimulate their reflection and to understand the meaning that they attribute to "humanization" in the beginning of the medical program. We also analyzed their role models and their personal experiences of humanization and dehumanization before entering medical school.

Study design
This qualitative study was conducted in 2016 using narratives of first-year medical students from the School of Medicine of the University of São Paulo. Participation was voluntary, and anonymity was guaranteed, as the participants did not give any personal information, such as names or other identification information. Access to the results was also guaranteed. There was no monetary compensation or any advantage in participating, and the refusal to participate did not result in loss or damage of any nature.

Participants
All first-year medical students from the School of Medicine of the University of São Paulo were invited by the researchers of this study to participate at the end of a lecture in the first week of the medical program to fill out a sociodemographic questionnaire and to write their narratives. The researchers were not teachers of these students.

Instruments
The sociodemographic questionnaire contained questions about sex, age, profession of parents, religion, family income, and type of high school attended (public or private). Two statements were presented to inspire the students in their narratives: 1) "Humanizing is..." and 2) "Relate an instance of humanization or dehumanization experienced by you." Narratives are linguistic registers of stories and experiences that, inserted in a historical, social and cultural context provide a panorama of the reality of people and their social roles. Experiences, values, ways of inhabiting, seeing and thinking the world compose and fill narratives, whose function is to reshape, represent, and structure human action in language and text [8,9].

Data analysis
For the analysis, the theoretical reference of Narrative Medicine [17,18] and Content Analysis were used. It consists of a set of systematic and objective techniques and procedures for describing the contents, in a way that allows the categorization, elaboration of inferences, and interpretation of the data [19,20]. The qualitative analysis of the narratives by two researchers of the study, followed traditional content analysis methods, that is preparation of the material (typing of the answers of the open questions and organization of the data), free reading, highlighting subjects by relevance and/or repetition, categorization of the emerging categories and derived issues, discussion with all members of the research group, and a descriptive presentation of the results using quotes from the participants answers

Results
The initial sample of this study had 180 students enrolled in the first year of Medical school. At data collection, 13 students were absent. The study included data from 167 participants: 67 females (40.1%) and 100 males (59.9%). The participants' ages ranged from 16 to 38 years, with an average age of 20 years. We collected 4 pages per participant, with a dataset size of 668 pages.
Regarding the religion of the respondents, 40% declared themselves Christian, 31% were not affiliated with any religion, and 29% belonged to other religions. We observed that 64% of respondents studied in private high schools, 35% in public high schools, and 1% studied in both.
Regarding the parents' professions, 15% of the fathers and 8% of mothers were physicians, 2% of the fathers and 12% of the mothers had other healthcare professions.
The analysis of the narratives showed three central themes: socio-political and economic aspects of medicine, humanization of healthcare, and dimensions of humanization and dehumanization.
In their narratives, the students expressed the desire to become doctors, to help and improve people's lives, and the intention to emulate good role models. Another desire expressed was to Another important aspect highlighted by the students was the fact that being a doctor gives them the possibility to transform their realities, especially for the students with financial vulnerability.
"I am proud to be the first in my family to graduate." Male student, 17 years The students considered humanization of healthcare as an integral vision of the human being, which includes perceiving the context and personal history as well as the complexity of the human being.
The students emphasized the importance of "going beyond the technical dimension" in the relationship between physician and his/her patient. Some students recognized the transdisciplinary aspect of medicine.
"I have decided to pursue a medical career to be able to provide those who need care with attention that goes beyond technique, embracing more humanistic aspects such as the psychological imbalance in such a delicate situation." Male student, 20 years "To humanize is to see beyond the technical dimension, noting that behind a disease or diagnosis there is also a human being immersed in its ethnic, socioeconomic and cultural issues." Female student, 18 years Empathy was considered an essential aspect of the humanization of healthcare by the majority of the students.
"To humanize is to understand the patient as a complex human being with pain, desires, and values and to treat him or her with compassion." Female student, 18 years With regard to the dimensions of humanization and dehumanization, they mentioned situations lived in the social context of inequality and in disease situations where they or their relatives were themselves involved. They referred to the lack of attention in medical practice as dehumanization and considered the ability to be integrally present with the patient (mindfulness) as humanization.
Several students mentioned the humanization experiences that they had in their first week at the university when they had the opportunity to tell stories to hospitalized children. The students recognized as their role models their own physicians and pediatricians, their parents who worked in healthcare professions, and humanitarian aid institutions as "Medecins Sans Frontiers" and "International Committee of the Red Cross." Frequently, students wrote that their choice of career was made in their early years as we can observe in the following segments of narratives: "The recent experience of humanization, which I had the privilege of living, was during the first week at the university. We were required to ask the patients "What would you consider a good doctor?" Almost all answers reinforced the importance of listening, paying attention, and looking in the eyes of patients." Female student, 19 years "To be in a public hospital as a patient gave me positive and negative experiences about the healthcare system. It encouraged me to choose a profession to improve the system." Female student, 22 years Table 1 Categories and issues from analysis of student's narratives.

Category
Issues

Discussion
The narrative has the function of reshaping, representing, and structuring the human language in a text. It is composed and filled with experiences, values, ways of inhabiting, seeing and thinking the world. Once the human experiences and actions are in the narrative, its reading and interpretation can explore the social, economic and cultural conditions [8,21]. In this study, narratives were used to stimulate students' reflection, to access their perception of humanization, and to allow them to recognize their values and expectations, as well as relevant experiences lived by the students before entering the medical graduation.
The interpretation of the text also allows researchers to evaluate students' ability to organize their actions and experiences in the narrative, expressing the signs, rules, and norms that give direction to their lives [8,21]. Thus, the fragments of lived stories constructed the narratives of the students, the interaction with other people in circumstances of illness or good health, and the consequent happy or unhappy feelings which facilitated their reflection about humanization and the construction of their narratives.
The use of narratives in medical training was described as a strategy to develop critical thinking and to discuss several aspects of practice lived or observed by the students [10,11,14,17,22]. It is a stimulus to reflection about the practice in medical training, and an opportunity to apply the reflection pedagogy of Paulo Freire, a constructivist method based on a sequence of action-reflection-action. It means that after the learner has experiences the teacher gives him or her the opportunity to think about those experiences and to resignify. The next step is for the student to return to the practice and try to find a way to do better [23] .
Other learning objectives related to the use of narratives were to develop communication skills, empathy, and professionalism, and to access the student's feelings in case the patient died [15,24].
The student's narratives were also used to evaluate the program and the hidden curriculum, and for the teacher to better get to know the students [22]. Authors affirmed that the use of narratives in medical training helps students to consider the humanistic dimension of their patients and access their own emotions [10,25,26].
Many aspects of the contemporary world were present in the student's narratives, with the sense of humanization based on the idea of transforming the environment and the society in which they live as observed in their answers to some of the contemporary ills, such as crises involving the healthcare field and extreme social inequalities. The latter is of particular importance especially for developing countries such as Brazil. For these students, the possibility of transforming their lives and society was one of the reasons to choose a medical career as their colleagues said in the previous study [27].
The narratives of this study demonstrated that students establish relationships between humanization and sensitivity toward the cultural aspects of each patient. The students said it is necessary to listen to patients, to know about their history, culture, habits, and to be willing to help them not only in a clinical setting but with hospitalization and when treating them with prescriptions. They also showed humanistic values when they attributed importance in healthcare to human relationships and commitment to human happiness.
The effects of technical-scientific advances can be clearly seen in modern medicine when, at times, it separates physical, psychological, social and cultural aspects. Some authors affirm that physicians and medical students give more importance to scientific rationality than to the social, cultural, and psychological dimensions to understanding the patient and his or her disease [28]. Kumagai (2014) emphasizes the humanist aspect of the medical profession. The construction of a humanized relationship between healthcare professionals and patients requires ethical behavior, dialogue, and feedback. In this context, it is possible to fuse their horizons as each human being involved is considered, valued, and potentiated.
This group of students demonstrated an understanding of the social and cultural constructs present in the personal life of each human being, in this case, doctors and patients, and how they interfere with the relationship between them. Curiously, the respondents of this study were young people in the first week of medical school. Accordingly, we can affirm that they entered school with values inherent in their future profession, but the medical program will add complexity and sometimes cause these values to change [29][30][31][32].
The meaning of humanization for these students is related to the "doing" and the "how to do" in medical practice, including the ethical, cultural and professional dimensions. They also recognize that the technical and scientific knowledge is linked to the ethical behavior aimed at human development and commitment to the life and happiness of others.
The strengths of this study lie in the use of narratives with undergraduates to promote student reflection, to create a baseline about their concepts and values, to get to know the freshmen better, all the while helping us in the educational planning. Another strength is to bring about new perspectives of humanization to the medical education. Its weakness is the fact that the vision presented by the students is a snapshot of the moment and the social context at the time of data collection. The analysis and conclusions are valid for this universe of medical students, and generalization is not possible.

Conclusion
The students in the first-year of the medical program have a clear understanding of the meaning of humanization in medical practice, regardless of their social and economic conditions, age, sex, and religion. The students' narratives expressed their expectations for a more humane society with respect, solidarity, and compassion for the ethical, cultural, and professional aspects of humanization are interconnected. The use of narrative is a strategy to develop critical thinking and to better get to know our students: who they are, what they think, and how they feel.

Declarations
Ethics approval and consent to participate This study, with qualitative approach, was approved by The Human Research Ethics Committee of the University of São Paulo. The participants were all volunteers and did not receive any remuneration or advantage. They also signed a written informed consent before data collection.

Consent for publication
Not applicable Availability of data and material The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors report no conflict of interests concerning the study.

Funding
Funding/Support: This study was supported by CAPES (Brazilian Federal Agency for the Support and Evaluation of Graduate Education) and CNPq (National Council for Scientific Development), Brazil