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Empathy is extolled in Western healthcare and medical education as an exemplary quality to cultivate in trainees and providers. Yet it remains an elusive and inadequately understood attribute. It posits a "one size fits all" unidimensional attribute applicable across contexts with scant attention given to its multifaceted dimensions in intercultural contexts. In this article, we uncloak the shortcomings of this conventional empathy in intercultural settings, and instead propound an expanded "relational empathy".

We argue that biomedicine at root is not primarily instrumental, but shares aesthetic, ethical and political values with poetry. Yet an instrumentalist bias in medical pedagogy can lead to frustration of biomedicine's potential. Such unfulfilled potential is exposed when making a comparison with poetry, a knowledge system that expressly engages a range of value systems. How then to recover biomedical language's riches for medical education's gain?We combine scientific and artistic approaches by positing a common frame to which both medicine and poetry can aspire: the 'high-water mark' of language. Poetry's language is complex, intensive and connotative-concerned with mood, ambiguity, metaphor and embodiment. Biomedicine potentially engages with such linguistic complexities, particularly in metaphor production, yet persistently falls away from this high-water mark of language, reducing connotative language to denotation or literal meanings. We describe such instances of frustrated potential as 'trying to accelerate with the brake on'. This paradoxical state has become habitual in medical education. The resultant lack of productive metaphor insulates pedagogy from mood, separating it from the vernacular as a specialist tongue that ensures identification with the medical community of practice. Such language can alienate both patients and poets for the same reason: it is less human than technical.Using the example of clinical reasoning and attendant diagnostic work, we show that reductions from the connotative to the denotative not only mask but also contradict the complexity of implicit, embedded and distributed cognitive structures, creating a tension that medical education consistently fails to either resolve or draw upon as a resource. Further, poetry too has a complex set of implicit rules and formative structures that shape composition. These structures show symmetry, correspondence or even isomorphism with medical cognition, where both can aspire to activity that is aesthetically rich, intense and cognitively elegant.

Progress in teaching and learning clinical reasoning depends upon more sophisticated modelling of the reasoning process itself. Current accounts of clinical reasoning, grounded in experimental psychology, show a bias towards situating reasoning inside the skull, further reduced to neural processes signified by imaging. Such a model is necessary but not sufficient to explain the clinical reasoning process where it fails to embrace cognition extended to the environment and social contexts.Sufficiency for a model of clinical reasoning must include dialogues between doctor, patient, and colleagues, including the complex influences of history and culture, where artefacts and semiotics such as computers, testing, and narrative structures augment cognition. Here, 'extended' cognition is configured as an outside-in process of 'sensemaking' or 'adaptive expertise'.Current 'predictive processing' cognition models place emphasis on anticipatory cognition, where memory is reconfigured as active reconstruction rather than recall and recognition. Such an 'ecological perception' or 'externalistic' model provides a counter to the current dominant paradigm of 'ego-logical' cognitive reasoning - the latter, again, abstracted from context and located inside the skull. New models of clinical reasoning as an open, dynamic, nonlinear, complex system are called for.

A curriculum innovation for a new UK medical school - Peninsula, launched in 2002 - was grounded in a period of radical pedagogical innovation in medical education in the UK during the 1990s. Part of this thinking was to include the medical humanities as a medium for re-thinking medical practice, especially how medical students might better learn to communicate with patients and colleagues, and how they might become agents of change in progressing medicine through innovations. In designing the curriculum, Cultural-historical Activity Theory (CHAT) was used as a model to 'think', or reconceptualise, the purposes of a curriculum. The first question asked was: 'what do patients want?' Emphasis was placed on resisting a 'will-to-stability' in adopting safe curriculum process, in favour of adopting a 'possibility knowledge' framework that celebrated dialogue. This operated through three 'spearheads', or radical aims: democratic habits, towards the feminine, and tender-mindedness.

This is simply the best book that I have read on medical education, or, as Yrjo Engestrom prefers, gaining expertise in medical work. Engestrom’s account of more than 30 years’ worth of research in...

Learning through ritual humiliation used to be standard in work-based medical education as a rite of passage, a militaristic hardening. More enlightened pedagogies have emerged, but such abusive and shaming practices still linger, especially in surgery. Humiliation now includes harassment of women trainees through overt and covert sexism. We explore the resilience of such “compulsory mis-education” through “thinking with Homer.” Returning to Homer’s Iliad and Odyssey as Ur-texts for shaping the human imagination, we re-read shame and abuse in medical contexts, suggesting that these are products of historical shaping by metaphors of violence and conflict. It is only when such primary metaphors shift and more liberal metaphors emerge that a more collaborative and feminine medical culture will be shaped. We draw on distinctions between “honor–shame”/“tradition-directed” and “guilt”/“inner-directed” behaviors to explore medicine’s lingering authoritarianism. The former rely on gaining respect from pee...

'COLD' TECHNOLOGIES AND 'WARM' HANDS-ON MEDICINE NEED TO WALK HAND-IN-HAND: Technologies, such as deep learning artificial intelligence (AI), promise benign solutions to thorny, complex problems; but this view is misguided. Though AI has revolutionised aspects of technical medicine, it has brought in its wake practical, conceptual, pedagogical and ethical conundrums. For example, widespread adoption of technologies threatens to shift emphasis from 'hands-on' embodied clinical work to disembodied 'technology enhanced' fuzzy scenarios muddying ethical responsibilities. Where AI can offer a powerful sharpening of diagnostic accuracy and treatment options, 'cold' technologies and 'warm' hands-on medicine need to walk hand-in-hand. This presents a pedagogical challenge grounded in historical precedent: in the wake of Vesalian anatomy introducing the dominant metaphor of 'body as machine,' a medicine of qualities was devalued through the rise of instrumental scientific medicine. The AI age in medicine promises to redouble the machine metaphor, reducing complex patient experiences to linear problem-solving interventions promising 'solutionism.' As an instrumental intervention, AI can objectify patients, frustrating the benefits of dialogue, as patients' complex and often unpredictable fleshly experiences of illness are recalculated in solution-focused computational terms. SUSPICIONS ABOUT SOLUTIONS: The rate of change in numbers and sophistication of new technologies is daunting; they include surgical robotics, implants, computer programming and genetic interventions such as clustered regularly interspaced short palindromic repeats (CRISPR). Contributing to the focus of this issue on 'solutionism,' we explore how AI is often promoted as an all-encompassing answer to complex problems, including the pedagogical, where learning 'hands-on' bedside medicine has proven benefits beyond the technical. Where AI and embodied medicine have differing epistemological, ontological and axiological roots, we must not imagine that they will readily walk hand-in-hand down the aisle towards a happy marriage. Their union will be fractious, requiring lifelong guidance provided by a perceptive medical education suspicious of 'smart' solutions to complex problems.