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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Suggested Citation:"7 Integration in Graduate and Medical Education." National Academies of Sciences, Engineering, and Medicine. 2018. The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree. Washington, DC: The National Academies Press. doi: 10.17226/24988.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

7 Integration in Graduate and Medical Education1 Preparing the next generation of graduate students to tackle the com- plex problems facing the twenty-first century may necessitate a shift in thinking about graduate training (Begg et al., 2015; Begg and Vaughan, 2011; Borrego and Newswander, 2010; Bullough, 2006; Graybill et al., 2006). The argument is that a traditional, disciplinary approach to gradu- ate education may not equip students with the awareness, knowledge, and skills needed to approach, frame, and solve contemporary and increasingly complicated problems, “which tend to defy traditional, disciplinary, and institutional boundaries” (Meyer et al., 2016, p. 1). Practicing scientists, as well as policy makers, have recognized the need for this shift toward inter- disciplinarity in graduate research and education since the mid-1990s. For example, the National Academies of Sciences, Engineering, and Medicine (Institute of Medicine, National Academy of Sciences, and National Acad- emy of Engineering, 1995) published the report Reshaping the Graduate Education of Scientists and Engineers, in which it recommends the develop- ment of a modified model for Ph.D. training that prepares graduate students for “an increasingly interdisciplinary, collaborative, and global job market” (Martin and Umberger, 2003, p. 87). There have been similar calls for greater integration in medical train- ing. In its 2017 Standards for Accreditation for medical schools, the Liaison 1  The Committee wants to acknowledge and thank the research consultant, Dr. Matthew Mayhew, for his significant contributions to this chapter. A commissioned literature review written by Dr. Mayhew on behalf of the committee contributed directly to the writing of this chapter. 141 PREPUBLICATION COPY—Uncorrected Proofs

142 BRANCHES FROM THE SAME TREE Committee on Medical Education, which is the accrediting body recognized by the Department of Education for all M.D.-granting programs, stated that medical schools should integrate social and behavioral sciences, societal problems, medical ethics, cultural competency and health disparities, com- munication, and interprofessionalism.2 Many medical schools now offer required and elective courses that integrate the humanities and arts with medicine. The goals of such programs are varied but include the following: (1) ingrain aspects of professionalism, empathy, and altruism; (2) enhance clinical communication and observation skills; (3) increase interprofessional- ism and collaboration; and (4) decrease burnout and compassion fatigue. In this chapter, the committee reviews the literature on integrative and interdisciplinary graduate education and considers established fields of graduate study that are interdisciplinary. We also review the research on the positive learning outcomes associated with integration of the arts and humanities with medical training—a practice that has become widespread in medical education. FEDERAL AGENCIES AND FOUNDATIONS HAVE SUPPORTED INTEGRATIVE GRADUATE EDUCATION In response to the national call for graduate interdisciplinary educa- tion, the National Science Foundation (NSF) implemented the Integrative Graduate Education Research and Training (IGERT) initiative in 1998. This program challenged university faculty and administrators to develop interdisciplinary education programs to “meet the challenges of educating U.S. Ph.D. scientists and engineers who will pursue careers in research and education, with the interdisciplinary backgrounds, deep knowledge in cho- sen disciplines, and technical, professional and personal skills to become, in their own careers, leaders and creative agents for change” (Brown and Giordan, 2008, p. 2). In the first 10 years of this program, 4,232 doc- toral students were exposed to interdisciplinary education and research through one of 195 grants at one of 96 American universities (Brown and G ­ iordan, 2008). NSF has also supported interdisciplinary research through its CreativeIT program.3 This program supported research in four main ­ areas: (1) new theoretical models for understanding creative cognition and computation; (2) integrating creativity-based methods, practices, and theo- ries to stimulate breakthroughs in science and engineering; (3) innovative educational approaches that encourage creativity; and (4) computational 2  See https://www.aamc.org/members/osr/committees/48814/reports_lcme.html. (Accessed October 1, 2017). 3  See https://www.nsf.gov/cise/funding/creativeit.jsp. (Accessed October 1, 2017). PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 143 tools and creative methods that support solution finding and problem solv- ing (see Chapter 6 for additional information on this program). Although the IGERT initiative, in particular, is one of the most well- known interdisciplinary training programs, other federal organizations have also designed similar strategies to foster interdisciplinarity among graduate students. The National Institutes of Health (NIH) started sup- porting the Clinical and Translational Science Awards (CTSA) program in 2006 to “advance integrated and interdisciplinary approaches to education and career development in clinical and translational science” (Begg et al., 2014, p. 2). This program emphasizes the role of interdisciplinary courses in promoting innovation when combined with discipline-specific education (Meyers et al., 2012). In a survey of CTSA education leaders, 86 percent felt that interdisciplinary team science training was important for graduate stu- dents, and 62 percent of those institutions offering interdisciplinary training did so in collaboration with another unit—such as a school of business, education, or law—within the university (Begg et al., 2014). The National Endowment for the Humanities has also supported interdisciplinary gradu- ate work through a new program called the Next Generation Humanities PhD Planning Grants, which strives to prepare doctoral students more multidimensionally for the challenges facing academic institutions and the wider world.4 In addition to the federal organizations, The Andrew W. Mellon Foundation has also supported integrative efforts through their Higher Education and Scholarship in the Humanities program. This pro- gram supports efforts at the graduate level that broaden the intellectual and professional preparation of students and “aspire to be transformative and integrative, rather than merely additive.”5 These initiatives have increased the number of graduate students with interdisciplinary training, and evaluation of these programs has also con- tributed to a proliferation of literature on interdisciplinary and integrated learning within graduate education. Papers describing the results from the summative and formative assessments required by NSF and NIH, as well as the common elements of successful proposals, have added greatly to the scholarship on interdisciplinary training as both a process and an outcome. However, because most of these programs tend to focus on providing opportunities to integrate among similar disciplines, less is known about interdisciplinary education across fields, especially those initiatives looking to integrate aspects of the arts and humanities with science, technology, engineering, mathematics, and medicine (STEMM) graduate education, 4  Personal communications with the National Endowment for the Humanities (Accessed October 1, 2017). 5  See https://mellon.org/resources/shared-experiences-blog/revitalizing-graduate-education/) (Accessed October 1, 2017). PREPUBLICATION COPY—Uncorrected Proofs

144 BRANCHES FROM THE SAME TREE or vice versa. This type of integrated learning has gained more attention in recent years as a preferred practice in undergraduate education, as advocates champion its possibilities to enhance college student learning and development (Borrego and Newswander, 2010; Catterall, 2012; Dail, 2013; Ge et al., 2015; Grant and Patterson, 2016; Maeda, 2013; Sousa and Pilecki, 2013). MOST OF THE RESEARCH HAS FOCUSED ON INTEGRATION IN GRADUATE EDUCATION BETWEEN SIMILAR DISCIPLINES Despite the call for more integrated graduate practices that promote interdisciplinary work, and despite the existence of long-standing integra- tive graduate programs in established interdisciplinary fields (e.g., Science, Technology, and Society; Bioethics; Human–Computer Interaction; Gender and Ethnic Studies, etc.), such approaches to graduate education are repre- sented in the literature, for the most part, across and between similar disci- plines. The research literature suggests that scholars and researchers within the STEM fields, even those engaging in interdisciplinary work tend to work with other scholars in these fields. A similar within-disciplinary pattern is observed for educators in the humanities and the humanistic social sciences because these scholars tend to collaborate with peers in other humanities and social science fields, respectively (Bullough, 2006). Of course, this begs the questions: Are the interdisciplinary efforts in graduate education exam- ined in the research literature effectively interdisciplinary? Are they effective at helping students integrate ideas across disciplines? Several reasons have been offered to explain the challenges of interdis- ciplinary graduate practice. First, traditional and often static organizational structures within the academy, especially as they relate to graduate educa- tion, render interdisciplinary efforts (i.e., reconciling faculty loads between disciplines, credit-bearing differences between disciplines) logistically dif- ficult to manage (Borrego and Newswander, 2010). Second, faculty often use their disciplinary frameworks for ascribing value to the interdisciplinary effort, with faculty in the humanities often framing successful integra- tion as any student’s progress toward achieving critical awareness (i.e., the critical, by definition, is the integrated) and those in the STEM fields viewing successful integration as collaborative work in teams (Borrego and Newswander, 2010; Engerman, 2015). These competing approaches to interdisciplinarity sometimes lead to conceptual confusions in course design, enacted practice, and, ultimately, student experiences. Finally, fac- ulty within a discipline may not know how to approach problem solving from a discipline other than their own (Borrego and Newswander, 2010). Integrative graduate work at the interface of the arts, humanities, and STEM subjects may face challenges similar to those faced by within-STEM PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 145 interdisciplinary efforts. In 2010, the NSF CreativeIT program—a project from the Computer, Information Science, and Engineering directorate—and the National Endowment for the Arts sponsored a series of workshops to explore the challenges and opportunities of interdisciplinary research and education at the interface of science, art, and technology. Many of the challenges noted above were captured in workshop proceedings for the event: Strategies for Arts + Science + Technology Research: A Joint Meet- ing of the National Science Foundation and the National Endowment for the Arts, held at the NSF Headquarters in Arlington, Virginia. The goal of the workshop was to bring together a community-of-interest with unique interdisciplinary methods, requirements, and concerns. As captured in the StoryMap that resulted from this workshop, participants identified several challenges (see Box 7-1). The challenges noted by the participants included the following: • “There are real and perceived differences in how we (artists, scien- tists, technologists) validate what we value.” • “Silos and unleveled playing fields create disparities in resources, infrastructure, and teaching-to-research ratios between disciplines.” • “Demonstrating impact of Art + Science + Technology (AST) research is difficult as research archives are not linked.” • “AST networks in the US tend to be part of academic clusters. They are vibrant yet closed to those outside of the system.” Our review of the published literature also revealed that a dispropor- tionate number of articles on integrative graduate study framed interdis- ciplinary graduate work as a proxy for participation in interdisciplinary courses (Meyer et al., 2016; Newswander and Borrego, 2009; Posselt et al., 2017) or on interdisciplinary research teams (Borrego and Cutler, 2010; Borrego and Newswander, 2010; Hackett and Rhoten, 2009; Newswander ­ and Borrego, 2009; Rhoten et al., 2009). As a result, and due to the lack of rigorous research designs, many of the lessons extracted from the empiri- cal articles on interdisciplinary work reflect an emphasis on working on interdisciplinary teams, rather than on exposure to and participation in interdisciplinary graduate experiences. Criticisms of this approach have questioned the use of work on inter- disciplinary teams as the primary means for enacting interdisciplinary grad- uate practice: specifically, authors have cautioned that this emphasis may reinforce the mindset that “more (disciplines) is better” (Strengers, 2014, p. 550), overemphasize problem-based learning in interdisciplinary work (Stentoft, 2017), and neglect the nuances associated with how individuals solve interdisciplinary problems within interdisciplinary teams (Zhang and Shen, 2015). We caution readers in this regard: By centering interdisciplin- PREPUBLICATION COPY—Uncorrected Proofs

146 BRANCHES FROM THE SAME TREE BOX 7-1 StoryMap and Gap Analysis from Strategies for Arts + Science + Technology Research: A Joint Meeting of the National Science Foundation and the National Endowment for the Arts The current state landscape depicts the silos that often occur between disciplines clumped together in categories of Arts and Humanities and Sciences and Technology. There are a few emerging disciplines, institutions, and individu- als that gravitate toward the ramp that connects the current and future state. The ramp represents the gap analysis topic areas. Above the ramp float drivers and trends that align the workshop topic with broader national and global opportunities in innovation, education, and economic development. Each gap analysis topic is represented by a ramp slab. Culled from a large quantity of workshop notes, each topic is divided into a “word-byte” for the “challenge” and the “opportunity.” The Future State world is perhaps better named “the future/now” as many of the goals, visions, missions, and activities are promoted in most progressive education, corporate, and nonprofit institutions. Champions and supporters of the goals of this gap analysis build the ramp pillars and assure its structural integrity to connect the “current” and “future” states. The “future state” is a land of trans- formative breakthroughs flanked by banners of the National Science Foundation and National Endowment for the Arts review criteria – Intellectual Merit; Broader Impact; and Artistic Excellence. The global city silhouettes emphasize that integra- tive research, practice and education strengthens the ties between our national and global communities. Jennings, P. & Shigekawa, J., Grove Consultants Inter- national (2010). Strategies for Arts + Science + Technology RE/search StoryMap, http://www.grove.com/cs_NationalScienceFoundation.php. PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 147 ary research teams as the hallmark of graduate interdisciplinarity, there may be an increased likelihood of assuming that working on these research teams will naturally produce the integration-based skills and competencies necessary for future work. GRADUATE EDUCATION IN ESTABLISHED INTERDISCIPLINARY FIELDS The foregoing discussion focuses on efforts to bring an integrative dimension to doctoral-level graduate training in traditional disciplines, but another important form of integration in graduate education is estab- lished programs in “interdisciplines,” that is, in fields that have grown up at the intersection of established disciplines but have developed different approaches and areas of study than the disciplines that they grew out of. Such fields often focus on areas of intellectual and social importance that are neglected within the traditional disciplines. In this regard they are fun- damentally different from the interdisciplinary initiatives discussed in the previous section. Examples of fields that include integrative approaches include Bioethics; Arts, Design, Media and Technology programs; Sci- ence and Technology Studies (including history of science, technology, and medicine); Sustainability; Cognitive Science; Gender Studies; Ethnic Studies; Geography; Environmental Humanities; Digital Humanities; and Medical Humanities. While some of these fields are young and in the process of tak- ing shape, others are more well established and have their own scholarly approaches, professional societies, academic journals, and graduate training programs that are distinct from the disciplines they originally grew out of. Yet all of these fields, in one way or another, integrate knowledge from STEMM, the arts, and the humanities. Although some are more science focused and some more humanities or arts focused, and although they may focus on very different points of intersection between the arts, humanities, and STEMM fields, they all draw upon and synthesize knowledge from various disciplinary domains to frame and address important questions in their fields, and in society more generally. Because they are sustained fields of inquiry, as opposed to relatively small-scale, one-off efforts at integra- tion such as the IGERT programs discussed earlier, they offer importantly different opportunities and insights. The graduate training programs that exist in these fields include impor- tant examples of programmatic approaches to integration at the graduate level. While there do not appear to be studies in the educational literature that systematically evaluate learning outcomes associated with these types of graduate programs, the growth of fields such as Sustainability; Science, Technology, and Society Studies; and Women’s and Gender Studies reflect both the interest of prospective graduate students in training in integra- PREPUBLICATION COPY—Uncorrected Proofs

148 BRANCHES FROM THE SAME TREE tive fields and a recognition by certain institutions of the importance of such programs within the portfolio of graduate education. Thus graduate training programs of integrative interdisciplines warrant attention, both as well-established spaces for doing programmatic integrative education and as sites for further attention and study. Some of these fields also exemplify integrative approaches to socially important issues and the sorts of grand challenges that are not adequately addressed within siloed disciplines (see introduction). For instance, the field of STS grew in part out of the recognition that the ever-increasing importance of science and technology in social life demanded sustained scholarly attention to their social, cultural, political, and ethical dimen- sions (Jasanoff, 2010). Women’s Studies developed as a critical response to systemic power asymmetries between the sexes (Ginsberg, 2008). Sustain- ability, a younger but rapidly growing field, reflects a recognition that the environmental challenges of our day are multidimensional and require an integrated response that attends to social, cultural, economic, and politi- cal dimensions alongside scientific and technological ones (Miller et al., 2014b). Such fields have been important domains of innovation in integra- tive approaches in both scholarship and in graduate training. In addition, these fields are important reservoirs of expertise about how to do robust, integrative interdisciplinary scholarship and teaching. Students trained in these fields learn how to move between disciplinary approaches, recognize their critical limitations, and integrate them—skills that are invaluable for future teachers who will provide integrative learning opportunities at the undergraduate level. Indeed, these fields can (and in some cases already do) play an impor- tant role in integrative, undergraduate education. Graduate programs that train faculty in integrative scholarly approaches also produce future teach- ers. While there are certainly examples of innovative integrative teaching by faculty trained in traditional disciplines, the committee heard from experts who noted that high-quality integrative education benefits from well-qual- ified teachers whose own training bridges between disciplinary domains in an integrative way. Indeed, an increasing number of faculty trained in integrative graduate degrees such as Arts, Design, Media and Technology, Medical Humanities, Bioethics, and STS are providing integrative under- graduate education, including in some of the undergraduate courses and programs discussed in earlier chapters (see “Compendium of Programs and Courses That Integrate the Humanities, Arts, and STEMM”).6 Therefore, one important outcome of integrative graduate education can be to increase institutional capacity for providing integrative undergraduate education. 6  Available at https://www.nap.edu/catalog/24988 under the Resources tab. PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 149 While undergraduate opportunities for integrative learning can be enhanced by integrative graduate programs, both depend on the presence of qualified faculty. This, in turn, requires institutional support for integrative scholarly fields and faculty, for instance, in faculty hiring and in support for research. Training future faculty will be an effective means to contribute to integrative learning primarily if there are faculty positions for graduates of interdisciplinary degree programs to occupy, and only if the promotion and tenure requirements associated with those positions recognize and reward integrative teaching and research. Traditional disciplinary control of faculty positions and of promotion and tenure requirements can be a significant barrier (see “The Disciplinary Segregation of Higher Education” in Chap- ter 2); however, because criteria of faculty evaluation are entirely within institutional control, criteria can be adjusted to encourage development of faculty whose research and teaching contribute to integration. In short, integrative education at both the undergraduate and graduate levels is not independent of broader support for both research and training in integrative, interdisciplinary fields. Providing such support requires rec- ognizing the value of investing in such programs, including by recognizing the contributions of established, integrative interdisciplinary fields where institutional infrastructure for supporting integrative education already exists and does not need to be built up from scratch, but simply supported, valued, and capitalized upon. If integrative education has a central role to play in 21st-century higher education, then interdisciplinary fields that provide graduate training that integrates across arts and humanities and STEMM fields are likewise central to this mission. As such, they represent an important resource for future efforts to integrate STEMM, the arts, and humanities, both as fields capable of directly contributing to integrative education and as reservoirs of experience and expertise about interdisci- plinary innovation. THE IMPACT OF GRADUATE PROGRAMS THAT INTEGRATE THE HUMANITIES, ARTS, AND STEMM Unfortunately, little has been published about the impact of graduate programs that integrate disciplines from the STEMM fields with those in the arts and humanities. This is surprising, given the number of gradu- ate programs that integrate the humanities, arts, and STEM subjects (see “Compendium of Programs and Courses That Integrate the Humanities, Arts, and STEMM”). The committee faced two main challenges when reviewing the research on graduate education. First, there are few publications that describe gradu- ate programs designed to integrate STEMM fields with those in the arts and humanities, and second, most of the programs described in the published PREPUBLICATION COPY—Uncorrected Proofs

150 BRANCHES FROM THE SAME TREE literature did not provide ample information regarding the programs’ effi- cacy in helping students achieve the desired learning outcomes. Neverthe- less, the programs the committee considered describe positive outcomes and provide a sense for the motivations of such programs. For example, at the University of Oklahoma, faculty developed the Designing for Open Innovation course as an interdisciplinary, flexible, learner-centric environment for engineering graduate students (Ifenthaler et al., 2015). This course, which is organized around addressing economi- cal, sociological, and environmental dilemmas arising from energy policy, uses content-based lectures along with student teams to support learning. Researchers used measures of engineering attitudes, engineering self-con- cept, and team-related knowledge as well as written mental models to assess student learning. By comparing posttest to pretest scores, they found that students who participated in this course made gains in positive attitudes toward engineering, confidence in their ability to perform engineering tasks, and higher team-related knowledge. Rider University created an integrative graduate program that com- bined global studies, environmental literacy, and corporate social respon- sibility into a set of interdisciplinary, study abroad “Business-Science” courses (Denbo, 2008, p. 215). These courses were designed to achieve the “dual goals of fostering integrated learning and global studies” (p. 215) and provided undergraduate science and liberal arts students, undergraduate business students, and graduate business students an opportunity to “not only study, but also experience, the complex interaction of legal, economic, social, and environmental factors in an international setting” (p. 216). Fac- ulty specializing in marketing and legal studies worked with their colleagues in geological and marine sciences and biology to plan the course, which included both international science- and business-related site visits. Students participated in three courses (each lasting 4 hours) prior to the study abroad component. They learned about the legal, economic, and political structure of the country as well as sustainable business practices, environmentally sustainable marketing issues, corporate social responsibility, environmental law, and ecotourism related to their trip, as well as geological features and biodiversity of the destination country. Upon arriving at the international sites, students met with local business representatives and toured their facilities (Denbo, 2008). They also engaged in scientifically focused excursions, visited a local university, and partici- pated in cultural events. While abroad, students wrote daily in journals as a way to reflect on their experiences, and they completed a research paper or science project upon their return. Denbo (2008) provides some descrip- tion of how faculty evaluated student learning through the assignments and indicated that students perceived the experience positively (Denbo, 2008). PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 151 Presenting quotes from MBA students as evidence for her claims of program interdisciplinary efficacy, she noted the following: Significantly, many of the students indicated that the trip was personally enriching and that they now feel more confident about their ability to travel or work abroad on their own. All students responded that the course broadened their understanding of the interaction of business and science, as well as the importance of being able to conduct business in different parts of the world. (pp. 236-237) The nanomedicine program at Northeastern University, which pro- vides a unique interdisciplinary opportunity for graduate students to apply nanoscale and nanotechnology to medical problems (van de Ven et al., 2014), offers an additional example. Though primarily focused within STEM, students in this program also learn how to “translate basic research to the development of marketable products, negotiate ethical and social issues related to nanomedicine, and develop a strong sense of community involvement within a global perspective” (p. 23) through programmatic elements, such as “experiential research, didactic learning, networking, and outreach” (p. 24). Program leaders developed four interdisciplinary special- ized courses, a weekly seminar series, and outreach activities in K–12 public schools to complement the formalized dual mentoring that students receive from program faculty and placement in a required nonacademic internship. Students provide yearly progress reports to a faculty committee that evalu- ates their progress and ensures compliance with the program. From 2006 to 2014, the Northeastern University nanomedicine pro- gram recruited 50 doctoral students in 10 different departments (e.g., bioengineering, biology, chemistry, electrical and computer engineering, mechanical and industrial engineering, materials science and engineer- ing, and physics), 54 percent and 22 percent of whom identify as women and underrepresented racial minorities, respectively (van de Ven et al., 2014). These enrollment numbers exceed the national standards for IGERT programs (Carney et al., 2011, as cited in van de Ven et al., 2014), as does the nanomedicine program’s retention rate of 94 percent. Van de Ven et al. also note that the program’s trainees “have published 117 peer-reviewed manuscripts and presented at 189 conferences” (p. 26) as of 2014, with program Ph.D. graduates producing “an average of 3.9 manuscripts and 4.1 conference presentations directly related to their Nanomedicine ­ roject” p (p. 26). These graduates have also pursued careers in the health care sector and academia or have started their own companies. Other programs, such as the Research-oriented Social Environment (RoSE) project at the University of California (Chuk et al., 2012), have focused on the integration of the humanities and engineering. This socially PREPUBLICATION COPY—Uncorrected Proofs

152 BRANCHES FROM THE SAME TREE networked system was designed to “represent knowledge in the form of relationships between people, documents, and groups” (p. 93) and was designed by a team of scholars in the humanities, software engineering, and information studies. This type of collaboration represented a central component of the emerging field of the digital humanities. One of the challenges for the digital humanities noted by Chuk et al., (2012) was developing “collaborations that bring together the expertise of the various disciplines invested in it” (p. 94). For example, the scholars from the humanities, software engineering, and information studies were all essential to the development of the RoSE project. More specifically, humanities scholars brought critical inquiry to the discussion, suggesting improvements to RoSE and general reflections on the purpose and goals of the project. The information scientists introduced an organizational approach to metadata that mediated the distinction between real entities (persons) and their digital representations. The software engineers trans- lated abstract ideas into formal models that resulted in the material form of the RoSE project as a system (p. 96). However, these collaborations were not always easy and simple. Chuk and colleagues (2012) noted that the aims and epistemologies of the dis- parate disciplines often conflicted during work on the RoSE project. As a result, the authors recommend scholars on similar teams be aware of their disciplinary assumptions and be willing to vet unfamiliar new ideas with others. As graduate students working on this project, Chuk et al. (2012) concluded that the RoSE project provided an opportunity for syn- thesis of differing disciplinary perspectives and interrogation of disciplinary assumptions. The University of Michigan has one of the only interdisciplinary gradu- ate residency programs, the Munger Graduate Residencies.7 They actively recruit students from all 19 academic units on campus and place them in living suites based on interests, not disciplines. Their website states, “Expe- rience true multi-disciplinary collaboration. The world increasingly presents challenges that cut across multiple disciplines and skillsets. At the Munger Graduate Residences, a diverse mix of graduate and professional students from various fields live, study and interact together, building a culture of collaboration.” Among the many existing graduate programs that did not appear in the published literature are many that integrate art and technology. For example, graduate programs and degrees such as the New York University Integrated Technology program; the Carnegie Mellon University master of entertainment technology degree; the Stanford master of arts in music, science, and technology; the University of California Santa Barbara Media 7  See http://mungerresidences.org/. (Accessed September 21, 2017.) PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 153 Arts and Technology program; the Dartmouth master in digital musics degree; the University of Miami master of science in music engineering technology degree; and the Georgia Tech M.S. and Ph.D. programs in music technology are only a few of the existing graduate programs that integrate music and STEM. It is unfortunate that more is not known about the impact of these programs on students. WHAT CAN WE LEARN ABOUT PROMISING PRACTICES FOR INTEGRATION BETWEEN SIMILAR DISCIPLINES THAT COULD APPLY TO THE INTEGRATION OF THE HUMANITIES, ARTS, AND STEMM Though the existing research literature cannot tell us much about the impact on students of graduate programs that integrate the humanities, arts, and STEMM, and the research on within-STEMM integration is also sparse, when taken together, some broad lessons can be extrapolated. Some empirical efforts use innovative research questions to argue for the importance of interdisciplinarity in the graduate context. Also, some argue that interdisciplinarity may help graduate students from groups underrepresented in STEMM to thrive and negotiate the challenges of the graduate experience. Results also suggest that graduate interdisciplin- ary work should be supported at each stage of the graduate journey. As students, many interdisciplinarians struggle with finding their intellectual home, navigating priorities, and presenting scholarship (Calatrava Moreno and Danowitz, 2016; Graybill et al., 2006). As graduates, they must com- bat common notions within the academy that conducting interdisciplinary research hinders individuals’ career advancement (Millar, 2013). In either case, educators who design interdisciplinary contexts for graduate students may need to adopt a developmental approach to supporting them—what may be perceived of and experienced as supportive by new graduate stu- dents may not be thus perceived and experienced by matriculating graduate students. Other studies concluded that discipline-specific content mastery should never be compromised for interdisciplinarity. Mastery of discipline- specific material was critical for effective engagement in graduate interdis- ciplinary practice. Finally, the mechanisms for meaning making across disciplinary bound- aries seemed to vary based on the task at hand. The idea that interdisci- plinary thinking or ways of constructing information and solving problems is not naturally occurring appeared in several studies. This serves as an important reminder to educators that effective interdisciplinary practice needs intention and structure: Placing graduate students on interdisciplinary teams with the expectation that integration or interdisciplinarity will just occur is a fundamentally flawed practice. PREPUBLICATION COPY—Uncorrected Proofs

154 BRANCHES FROM THE SAME TREE SUMMARY OF EVIDENCE ON INTEGRATION IN GRADUATE EDUCATION For the past 15 years, interdisciplinary training programs have emerged as a common practice for graduate education in the STEM fields, in par- ticular. These initiatives combine cross-disciplinary curricula and courses, co-curricular seminars and workshops, and multidisciplinary research teams to prepare graduate students for the twenty-first­ century workforce. – Although collaboration among scholars in the social sciences, humanities and arts, natural sciences, and engineering exists in academia, the prepon- derance of interdisciplinary graduate programs described in the research literature occurs among those specializing in scientific fields, and to a lesser extent within the humanities or humanistic social sciences. These programs emphasize skill building as the primary focus of interdisciplinary work, and often use academic productivity metrics (e.g., counting interdisciplinary publications) and postgraduate career placements as indicators of success. Seemingly impressive, the lack of rigorous evaluation of these program- matic efforts (e.g., comparing program participants to nonparticipants) cannot conclusively indicate that program graduates achieve these interdis- ciplinary goals to any measured degree of difference than nonparticipants. We know even less about interdisciplinary programs that combine the arts and humanities with the natural sciences and engineering. How are these programs developed? Which programmatic components do educators use and how are they different from “intra-STEMM” initiatives? And, most importantly, what learning outcomes do students achieve due to their expo- sure to and participation in these initiatives? Given what we know about integration in undergraduate education, it seems as though these types of interdisciplinary training programs have the potential to influence graduate interdisciplinary learning, yet the efforts described in the research literature do not currently provide us with enough information to support this claim. Despite the limits of the existing research base on integrative graduate programs, there is much to learn from established integrative, graduate- level fields, such as STS, Gender Studies, Sustainability, and Bioethics, among others. These “interdisciplines” are an important resource for future efforts to integrate STEMM, the arts, and humanities, both as fields capable of directly contributing to integrative education at the graduate and under- graduate levels and as reservoirs of experience and expertise about inter- disciplinary innovation. PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 155 INTEGRATION IN MEDICAL EDUCATION Integrating the Arts and Humanities into Medicine The integration of the arts and humanities into medical training is a widespread practice. Since the 1960s, the field of medical humanities has provided a framework and pedagogy for including the humanities in medicine. The goals of a medical humanities curriculum are to (1) ingrain aspects of professionalism, empathy, and altruism; (2) enhance clinical communication and observation skills; (3) increase interprofessionalism and collaboration; and (4) decrease burnout and compassion fatigue. The curriculum, which can include literature, poetry, narrative, theater, or visual arts as part of a medical education (Naghshineh et al., 2008), can be used as a way to help medical students develop their diagnostic skills or as a way to create more humanistic physicians (Wachtler et al., 2006). One result of this initiative has been the establishment of health humanities programs, which more than quadrupled from 2000 to 2016, going from 14 to 57 (Berry et al., 2016). For the 2015–2016 academic year, 94 percent of medical schools surveyed had required and/or elective courses in medical humanities (see Figure 7-1). FIGURE 7-1 Data from the American Association of Medical Colleges showing the number of medical schools that include either required or elective courses in the medical humanities. SOURCE: https://www.aamc.org/initiatives/cir/406462/06a. html. PREPUBLICATION COPY—Uncorrected Proofs

156 BRANCHES FROM THE SAME TREE A common method in the medical humanities is narrative medicine, which has been defined as “clinical practice fortified with a narrative com- petence to recognize, absorb, interpret, and honor the stories of self and others” (Miller et al., 2014). Narrative medicine creates a platform where the voices of patients and health care providers can be heard and valued in a way that produces a more humane way to practice medicine. Narrative medicine views patient histories as stories and analyzes them as one might unpack a novel’s themes and plot strands. Using the intellectual tools and heuristics of close reading may enable students in a course in medicine, as Fraser (1987) observes, to liberate their thinking. Medical students who are given opportunities to perform artistically in groups or write poetry may learn to approach team learning more creatively. Studies of narrative medicine have demonstrated efficacy in increasing empathy, resilience, and teamwork (Sands et al., 2008). The medical humanities and other examples of integrating the humanities and art into medicine do not apply just to medical students and residents. Though much of the literature has focused on physicians-in-training, the entire health care team can be engaged in more humanistic medicine. While medical humanities programs are widespread, curricula are not standardized across medical schools. Also, medical humanities programs typically require an interdisciplinary team of clinicians and instructors with backgrounds in the arts and humanities, creating a need for profes- sional development and collaboration between multiple departments and institutions. Further, perceptions of rigor are important for lending legitimacy to medical humanities programs. In a study of narrative medicine for medical students, when asked about the reputation of the program, students used negative stereotypes, such as “fluffy,” “unnecessary,” and “touchy-feely” (Arntfield et al., 2013). At the University of Irvine, California, where the application of medical humanities to clinical care is a major tenet of medi- cal education, residents expressed incredulity that the humanities and arts could teach them anything useful for their daily management of patients (Shapiro and Rucker, 2003). In contrast, in an evaluation of the medical humanities and ethics scholarly concentration at the Stanford University School of Medicine, interviewees cited an enhanced sense of community, positive self-care and reflective practices, and rich and rigorous interactions with peers and faculty (Stanford Medicine, n.d.).8 Many believed these skills to be necessary safeguards against physician burnout and moral erosion. Despite skepticism among some students about the value of integrat- ing the arts and humanities with medical education, accrediting bodies are 8  More on the program is available at http://med.stanford.edu/bemh.html. (Accessed Oc- tober 2, 2017). PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 157 now pushing for greater integration of medical education with a variety of other disciplines. In a 2008 report titled “Recommendations for Clinical Skills Curricula for Undergraduate Medical Education,” the Association of American Medical Colleges included professionalism and communica- tion skills in a list of competencies that all medical students and residents should acquire (AAMC, 2008). In its 2017 Standards for Accreditation for medical schools, the Liaison Committee on Medical Education (LCME, 2016), which is the accrediting body recognized by the Department of Education for all M.D.-granting programs, stated that medical schools should integrate social and behavioral sciences, societal problems, medical ethics, cultural competency and health disparities, communication, and interprofessionalism. Some efforts to adopt social medicine in medical school curricula have emphasized the interplay between biology and the social determinants of health (Westerhaus et al., 2015) or the integration of health systems science, which is an interdisciplinary field that draws from a variety of disciplines to improve health care delivery for both individuals and populations (Gonzalo et al., 2016). Eleven medical schools formed a consortium to implement a health systems sciences curriculum by identify- ing cross-cutting domains and curricular content (Gonzalo et al., 2017). The integration of the arts in medical education is also a common practice that is often pursued with the goals of improving visual diag- nostic skills, communication skills, and critical thinking among medical trainees. For instance, an elective course at Harvard Medical School for first-year medical students seeks to improve physical examination skills through a combination of observation exercises at the Boston Museum of Fine Arts paired with lectures on physical diagnosis (Naghshineh et al., 2008) (see Box 7-2). The observation exercises use a methodology called Visual Thinking Strategies to develop critical thinking, communication, and visual literacy. After taking the course, students were able to make more observations than a peer control group—for example, in describing patient dermatology photographs—and also used more fine arts terminology in their observations. Art Rounds is another example of an innovative interdisciplinary pro- gram aimed at determining whether the use of fine arts instructional strate- gies benefits health professional education and is an elective course open to both nursing students and medical students at all levels. In their evaluation of the program, Klugman and Beckmann-Mendez note that “students were exposed to fine arts and taught to use Visual Thinking Strategies. The initial evaluation of the pilot program revealed improved physical observation skills, increased tolerance for ambiguity, and increased interest in commu- nication skills” (Klugman and Beckmann-Mendez, 2015, p. 220). The outcomes associated with the two preceding examples are consis- tent with those of several well-controlled studies that have demonstrated PREPUBLICATION COPY—Uncorrected Proofs

158 BRANCHES FROM THE SAME TREE BOX 7-2 Improving Physical Diagnosis Through Art Interactions Training the Eye OB/GYN residents from Brigham & Women’s Hospital discuss a Kathe Kollwitz sculpture at the Museum of Fine Arts, Boston, using the Visual Thinking Strate- gies framework to make connections to their clinical practice.over 30 medical schools and museums across the country that collaborate in art and medicine learning activities. that medical students, physicians, and nurses all benefit in a statistically significant manner from courses designed to educate visual observation skills through the examination and analysis of paintings and drawings (­ raverman, 2011; Dolev et al., 2001; Grossman et al., 2014; Kirklin et al., B 2007; Klugman et al., 2011; Naghshineh et al., 2008; Perry et al., 2011; Shapiro et al., 2006). Shapiro et al., (2006) found that medical students provided with 90-minute visual art and dance interventions weekly for 6 months had significantly improved pattern recognition skills compared with those viewing clinical photographs. PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 159 There are now many medical school–museum partnerships across the nation. The University of Texas at Dallas’s Edith O’Donnell Institute for the Humanities hosted an Art Museum and Medical School Partnership symposium at the Museum of Modern Art in June 2016. The published report documented the attendance of 130 medical and museum partners in attendance. See Box 7-3 for an example from Virginia Commonwealth University. Musical training also helps to develop pattern recognition and aural memory (i.e., aural imaging) alongside aural observation skills (Pellico et al., 2012; Sanderson et al., 2006; Wee and Sanderson, 2008). Mangione and Nieman (1997, 1999) tested 868 medical students and interns for their ability to learn how to distinguish between and correctly identify stethoscope recordings of 12 different typical heart diseases. Those who could play a musical instrument were statistically significantly more likely to get the diagnoses correct. Physicians and nurses also use aural obser- vational skills when dealing with surgical and critical care equipment uti- lizing melodic alarm functions. Studies demonstrate that physicians and nurses who had previously played musical instruments were significantly better at discriminating between, correctly identifying, and responding to melodic medical equipment alarms used in surgery and critical care settings (Sanderson et al., 2006; Wee and Sanderson 2008). This correlation is not limited to aural training among medical gradu- ate students. Boyd et al. (2008) introduced a group of 30 medical students without previous training to laparoscopic surgical procedures and found that those with no music training learned the techniques slowest; those who had played an instrument at some time in the past but were not currently practicing learned the techniques faster; and those that currently played an instrument learned the techniques most quickly and efficiently. Harper et al. (2007) reached the same conclusion in their study of 242 medical students learning robotic suturing and knot-tying techniques. Students who had been athletes or musicians were very significantly (p < 0.01) able to learn robotic surgical techniques much more quickly, and to make fewer errors while doing so, than those without such training. Another technique used to integrate the arts and humanities into medi- cine is anatomic bodypainting (Bennett, 2014). Anatomic bodypainting aims to teach by having students paint the underlying anatomy on a living and mobile subject. A student is able to gain an appreciation of perform- ing a clinical examination by visualizing the manipulation of the painted structures, which cannot be achieved in the same manner by dissection. One way in which medical schools have sought to further the inte- gration of the arts and humanities into medical education is by actively recruiting humanities majors. For example, the HuMed program at the Icahn School of Medicine at Mt. Sinai, which began in 1987 and is now PREPUBLICATION COPY—Uncorrected Proofs

160 BRANCHES FROM THE SAME TREE BOX 7-3 Integration of Art Making to Improve Clinical Observations Plastic surgery residents participate in a figure sculpting workshop taught by 2011 Virginia Commonwealth University (VCU) sculpture alumna, Morgan Yacoe, in a partnership with the Center for Craniofacial Care at the Children’s Hospital of Richmond at VCU directed by plastic surgeon Jennifer Rhodes. “­ lastic surgery P and sculpture have a great deal of crossover,” says Rhodes, “Having Morgan willing to provide our division with a class here in Richmond is a fantastic oppor­ tunity for us to enrich our resident experience by encouraging them to think creatively, fostering an appreciation of subtle anatomic details and applying their anatomy knowledge in a different way.” SOURCE: https://www.news.vcu.edu/ health/The_surgeon_as_sculptor. PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 161 known as the FlexMed program, offers early acceptance to sophomores with any undergraduate major and exempts them from taking the Medical College Admission Test. Students accepted through this alternative admis- sions process have not differed significantly from their traditional peers in academic achievement, such as clerkship honors, scholarly research, or first-author publications during medical school (Muller, 2014). Students from the HuMed program did have significantly lower Step 1 scores in the U.S. Medical Licensing Examination compared to their peers. Currently, the Icahn School of Medicine accepts about half of its medical school class through the FlexMed program. One study of the Harvard “New Pathways” program, which began in the 1980s and incorporated psychosocial and humanistic concepts into the curriculum through problem-based learning, followed up with graduates 12 to 13 years after they matriculated at Harvard Medical School. Those who participated in the New Pathways program were more likely to be in primary care compared with a control group who did not partake in this curriculum, and they also rated themselves higher on a scale rating their preparation to practice humanistic medicine and ability to manage patients with psychosocial problems (Ousager and Johannessen, 2010). A 2010 literature review of 245 articles about the medical humanities found that 224 of the articles praised the interventions or described and evaluated coursework (Ousager and Johannessen, 2010). While the 224 articles advocated for the inclusion of humanities coursework in medical education, only 9 of the articles sought to study the long-term impacts of medical humanities coursework. These articles examined the outcomes of integrating humanities in undergraduate medical education. One of the 9 papers referenced in the Ousager and Johannessen paper studied two groups of Harvard graduates, one from a traditional medical curriculum and one from a curriculum that was humanities oriented. Peters et al. found that students who came from the humanities-oriented curriculum were more prepared and inclined to pursue careers in humanistic medicine (such as primary care or psychiatry) compared to their peers who came from a more traditional medical curriculum. The students from the humanities- oriented curriculum were also more confident in managing patients’ psy- chosocial issues (Peters et al., 2000). Another study by DiLalla et al. used a survey to assess medical students and practitioners and found that exposure to educational activities that involve empathy, spirituality, wellness, and tolerance correlates to an increase in empathy and wellness in medical practice (DiLalla et al., 2004). The literature review conducted by Ousager and Johannessen reveals that, while there is a wealth of course descriptions and advocacy of the medical humanities, there continues to be a shortage of studies reporting evidence. PREPUBLICATION COPY—Uncorrected Proofs

162 BRANCHES FROM THE SAME TREE INTEGRATING MEDICINE INTO THE ARTS AND HUMANITIES Much of the literature on integration in medical education has focused on integrating the humanities and arts into medicine, but a few examples exist of medicine being integrated into the arts and humanities. Relatedly, arts therapy, which could be considered akin to arts as medicine, is being embraced by many who seek to use the restorative power of the arts to promote health and wellness. In this way, medicine acts as the inspiration for new applications of the arts. One example of the integration of medicine and the arts is medical illustration (see Box 7-4). Medical illustration is a relatively small field, with only three accredited programs in the United States at Johns Hopkins Uni- versity School of Medicine, University of Illinois at Chicago, and Augusta BOX 7-4 Medical Illustration SOURCE: https://www.ami.org/medical-illustration/enter-the-profession/education/graduate- programs. PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 163 University. Medical illustrators use visual media to represent biological or medical information with an emphasis on communication. Medical illustration requires individuals to possess fine arts ability as well as strong biological and medical backgrounds (Bucher, 2016). Though there are few programs, it is worth noting the incredible impact of medical illustration on how emerging doctors come to understand and visualize the physiology of the human body and medical phenomena. Many medical phenomena are invisible to the human eye, but medical illustrators bring biological processes to life in striking definition (see Box 7-4). Further, health, sickness, and death are themes that appear frequently in many media, such as visual art, literature, and theater. For example, graphic medicine is an area that depicts medicine using comics for both medical students and patients (Green and Myers, 2010). Deborah Aschheim, who has been an artist-in-residence at medical centers such as the University of California, San Francisco, is a visual artist who creates art installations using plastic, light, and electronics that reflect themes of memory and neural networks. In her artwork she tries to reconcile “the idea of the body as a kind of complex machine, with a more complex humanity” (UCSF Memory and Aging Center, 2011) (Box 7-5). Creative arts therapy is used in the context of integrative medicine to address the physical, emotional, social, and spiritual dimensions of a patient in a holistic manner. There are well-established programs across the nation offering fully accredited therapeutic training in art, dance, music, and theater therapy. There are also numerous arts in medicine enrichment programs where artists-in-residence bring their craft to bear in a medical or therapeutic environment with patients. Some of the flagship programs that have distinguished themselves are the University of Florida’s Center for Arts in Medicine, the University of Michigan’s long-standing Gifts of Arts program, and the robust Performing Arts Medicine program at Houston Methodist Hospital. For example, one of the programs under the UCLArts and Healing Program, which promotes mental health through integration of the arts, is a group drumming intervention that has been shown to improve the social-emotional behavior of low-income children (Ho et al., 2011). Arts therapy is now being used to help veterans and military patients who have been diagnosed with traumatic brain injury and psychological health conditions (Lobban, 2014; Spiegel et al., 2006). Through the Creative Forces: NEA Military Healing Arts Network, the National Endowment for the Arts, the Departments of Defense and Veterans Affairs, and state arts agencies have partnered to bring together creative arts therapists, musi- cians, painters, potters, writers, woodworkers, dancers, doctors, military service members, veterans, community leaders, and policy makers to work to harness the “transformative and restorative powers of art” to “help mili- tary personnel and veterans return to their homes, their missions and their PREPUBLICATION COPY—Uncorrected Proofs

164 BRANCHES FROM THE SAME TREE BOX 7-5 The Work of Artist-in-Residence, Deborah Aschheim “On Memory” is a work by Deborah Aschheim (installation at the Mattress Factory, Pittsburgh, PA, 2006–7, plastic, video, LEDs.) This piece is one of many that explores themes of memory. Aschheim uses her work to “contend with the uncomfortable knowledge that systems and organisms invisible to us and often too minuscule to control, determine the quality and length of our lives. The phenomenon of memory belongs to one such physically minute but function- ally far reaching realm” (Exhibition Review 2007). families whole, mentally fit, and emotionally ready for whatever comes next9 (Box 7-6). Organizations such as Athletes and the Arts view performing artists as athletes and integrate concepts of sports medicine into training to optimize 9  See https://www.arts.gov/partnerships/creative-forces. PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 165 BOX 7-6 Walter Reed Bethesda Art Therapy at the National Intrepid Center of Excellence Melissa Walker, a Creative Arts Therapist at the National Intrepid Center of Excellence, a directorate of Walter Reed National Military Medical Center, works with active duty service members suffering from traumatic brain injury and psycho- logical health conditions. Dedicated to helping recovering service members safely express their deep thoughts and emotions in a creative environment, Melissa designed the Healing Arts Program at the National Intrepid Center of Excellence in 2010 where she engages her patients in mask-making, a powerful mechanism for helping them express their invisible wounds. Melissa received her Master’s Degree in Art Therapy from New York University. SOURCE: https://www.ted.com/speakers/melissa_walke. PREPUBLICATION COPY—Uncorrected Proofs

166 BRANCHES FROM THE SAME TREE performance (Dick et al., 2013). This also creates recognition that perform- ing artists are a unique and potentially medically underserved population. An important and growing addition to this field in the past 15 years is arts and neuroscience, or neuroaesthetics. Johns Hopkins Medical Center opened a new International Arts + Mind Institute in January 2017 with the tag line “We’re the source for cross-disciplinary discussion in brain sci- ence, architecture, music and art.”10 The University of Houston’s School of Engineering was recently awarded a 5-year renewable National Science Foundation Ideas Lab grant for arts and neuroscience. The following are some of the subthemes and research foci: • Music/Arts cognition studies • Music/Arts and autism • Music/Arts and stroke recovery • Music/Arts cognition • Music/Arts and Parkinson’s • Music/Arts and Alzheimer’s • Music/Arts and epilepsy Other music and neuroscience programs and departments exist at universities throughout the country (see “Compendium of Programs and Courses That Integrate the Humanities, Arts, and STEMM” at https://nap. edu/catalog/24988 under the Resources tab). Such courses and programs combine music, psychology, acoustics, cognitive science, neuroscience, and evolutionary biology in varied and interesting ways (Society for Music Per- ception and Cognition, n.d.).  SUMMARY OF EVIDENCE ON INTEGRATION IN MEDICAL EDUCATION Studies on the integration of the arts and humanities with medicine show a positive impact on students. Studies of narrative medicine have demonstrated efficacy in increasing empathy, resilience, and teamwork (Sands et al., 2008), while the integration of arts observation into medical training has been shown to improve visual diagnostic skills (Naghshineh et al., 2008), increase tolerance for ambiguity, and increase interest in com- munications skills (Klugman and Beckmann-Mendez, 2015). Students who participated in a medical school curriculum at Harvard that incorporated psychosocial and humanistic concepts through problem-based learning were more likely to pursue primary care and rated themselves higher on a scale rating their preparation to practice humanistic medicine and ability 10  See https://www.artsandmindlab.org/. (Accessed October 2, 2017.) PREPUBLICATION COPY—Uncorrected Proofs

INTEGRATION IN GRADUATE AND MEDICAL EDUCATION 167 to manage patients with psychosocial problems (Ousager and Johannessen, 2010). Medicine has been integrated into the arts and humanities in various ways, including through medical illustration, arts therapy, and the field of neuroaesthetics, and as the subject of artistic scholarship and practice in a range of media. It is also worth noting that the committee observed that the great- est number of available research studies and evaluations on integration reviewed in Chapters 6 fell into two categories: the integration of the arts and humanities into medical training and the integration of the arts and humanities with engineering (see Chapter 6). The availability of these stud- ies may relate to the fact that both medicine and engineering are applied fields that have very direct impacts on people—in contrast, for example, to basic scientific research. Perhaps this direct connection to people and society places a greater demand on these fields to prepare students to understand the humanistic and artistic dimensions of medical and engineering practice. PREPUBLICATION COPY—Uncorrected Proofs

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In the United States, broad study in an array of different disciplines —arts, humanities, science, mathematics, engineering— as well as an in-depth study within a special area of interest, have been defining characteristics of a higher education. But over time, in-depth study in a major discipline has come to dominate the curricula at many institutions. This evolution of the curriculum has been driven, in part, by increasing specialization in the academic disciplines. There is little doubt that disciplinary specialization has helped produce many of the achievement of the past century. Researchers in all academic disciplines have been able to delve more deeply into their areas of expertise, grappling with ever more specialized and fundamental problems.

Yet today, many leaders, scholars, parents, and students are asking whether higher education has moved too far from its integrative tradition towards an approach heavily rooted in disciplinary “silos”. These “silos” represent what many see as an artificial separation of academic disciplines. This study reflects a growing concern that the approach to higher education that favors disciplinary specialization is poorly calibrated to the challenges and opportunities of our time.

The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education examines the evidence behind the assertion that educational programs that mutually integrate learning experiences in the humanities and arts with science, technology, engineering, mathematics, and medicine (STEMM) lead to improved educational and career outcomes for undergraduate and graduate students. It explores evidence regarding the value of integrating more STEMM curricula and labs into the academic programs of students majoring in the humanities and arts and evidence regarding the value of integrating curricula and experiences in the arts and humanities into college and university STEMM education programs.

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