|Year : 2019 | Volume
| Issue : 1 | Page : 96-103
Cinemeducation: Facilitating educational sessions for medical students using the power of movies
P Ravi Shankar
Department of Medical Education, Health City University, Gros Islet, Saint Lucia
|Date of Web Publication||12-Jun-2019|
Dr. P Ravi Shankar
Health City University, P. O. Box: Choc 8093, Castries
Source of Support: None, Conflict of Interest: None
Medical education focuses predominantly on the science of medicine neglecting the arts and human relationships. Medical humanities was developed to provide a “differing” perspective of the arts. Movies play an important role in the medical humanities and have been used to address various subjects such as medical ethics, doctor–patient relationship, clinical research, mental illness, and professionalism during medical school. Movies involve the affective domain, promote reflection, and link learning to experiences. Movies can teach empathetic behaviors, self-reflection, compassion, and other skills. Movies have been used in a variety of disciplines such as family medicine, psychiatry, internal medicine, and clinical pharmacology among others. Faculty should identify possible topics where movies can be used. Then, they have to create a shortlist of suitable movies and identify the movie to be screened. A list of suitable activities and exercises to promote critical analysis and reflection should be created. Before the screening, a brief introduction to the movie can be provided. The screening should be followed by group activities, presentations, and facilitator inputs. Movies have been used to address topics such as domestic violence, cultural medicine, and attitude toward chronic illness. Most published reports about the use of movies are from the USA. Reports from Canada, Europe, and Argentina are also common. Movies have been used in some Caribbean medical schools and are being increasingly used in South Asian medical schools. A variety of instruments can be used to obtain feedback. There are various databases and collections which will be helpful in choosing appropriate movies.
Keywords: Cinemeducation, films, medical education, medical humanities, movies
|How to cite this article:|
Shankar P R. Cinemeducation: Facilitating educational sessions for medical students using the power of movies. Arch Med Health Sci 2019;7:96-103
| Introduction|| |
Medical education has been criticized for not focusing enough on empathy and relational skills. Medical humanities was developed in the 1970s to address these lacunae and provide a “differing” perspective of the arts. Movies are increasingly being used to educate students about many of the essential values of the medical profession. Movies may address various consequences of disease such as suffering, emotions, social conflicts, and ethical dilemmas. Movies have been used as teaching–learning aids in diverse subjects/areas such as microbiology, pharmacology, medical ethics, doctor–patient relationship, clinical research, mental illness, and professionalism among others.
| Movies and the Affective Domain|| |
The first published report of the use of cinema in medical education was in 1979 when viewing of movies followed by thoughtful discussion was used in psychiatry residency education. Darbyshire and Baker argue that cinema utilizes sound and visuals, and the process of interacting with audiovisual media is comparable to the practice of medicine where doctors observe and listen to patients. Movies are a powerful means to involve the affective domain, link learning to experiences, and promote reflection. Movies bring dry content to life and help convey difficult topics and concepts and stimulate open discussion. The term “Cinemeducation” was coined by Alexander et al. to refer to the use of clips from movies and videos to educate medical students and residents about the psychosocial aspects of medicine.
| Movies and the Health Humanities|| |
Many authorities have suggested replacing the term “medical humanities” with “health humanities.” The humanities have expanded to curricula beyond medical schools and is an important part of many health professions curricula. The term also more accurately reflects the interdisciplinarity of the discipline and emphasizes health in distinction to medicine. Conventionally, the humanities have been used in the teaching–learning of medical ethics and in creating awareness about philosophical issues. Recently, the emphasis has broadened to include literature and the fine arts, expanding clinical empathy and dealing with the challenges of clinical medicine. The humanities can provide insights into commonly shared human experiences while also highlighting the uniqueness of each human being. Movies and other modalities such as plays, poems, and literature can demand an emotional response from the viewer/reader and could provide an understanding about individual biases and prejudices. Many of the benefits mentioned for literature, namely, exposing students to unfamiliar life situations, stimulating the imagination, and promoting reflection and moral values may also be true of movies.
Cinemeducation has been mentioned as an unique and enjoyable narrative medical approach to the teaching–learning of health humanities. Cinemeducation in group settings would be helpful in brainstorming, creating useful ideas, and sharing perspectives about the scenes and characters in the movie from different perspectives. The enormous emotional power of movies could be harnessed to teach empathetic behaviors, self-reflection, compassion, altruism, and professionalism which are usually ignored during medical school.
| Cinemeducation|| |
Movies have been used in general practitioner education to introduce students to mental illness and create a favorable attitude toward psychiatry; to provide opportunities to engage in difficult conversations regarding end-of-life issues, as part of a medical humanities module for 1st-year medical students; and to help students learn medical professionalism among others. Movies have been used by various specialties as part of education of both medical students and postgraduates.
| Use of Movies in Family and Internal Medicine|| |
Professor Blasco from the academic department of the Brazilian Society of Family Medicine has been using movies and literature to educate medical students in Sao Paulo state, Brazil, for many years. He mentions that exposure to literature and movies followed by an open discussion among students with the support of faculty members who highlight important issues and emerging themes is a useful and enjoyable way of teaching–learning which promotes reflection among students. Family medicine has used movies to address various issues. A recent study from Slovenia concluded that movies could be used to address all competencies listed in the educational agenda proposed by the European Academy of Teachers in General Practice/Family Medicine. The authors used 17 movies to address different competencies. The list of competencies addressed by different movies and of movies to address specific competencies will be helpful to educators. Television (TV) shows have been used to teach communication skills during internal medicine residency. Two excerpts from the TV show “The House” and one excerpt from “Grey's Anatomy” were used along with a brief presentation on doctor–patient communication.
| Use of Movies in Developing Countries|| |
The film “Wit” was used to educate 1st-year medical students at a Turkish medical school about the personal meaning of terminal illness. Over 80% of the students were of the opinion that the movie made them think about the emotional and spiritual suffering that dying patients go through and that this will have a positive impact on their future practice. Medical students from Thailand organized a cinemeducation project using five movies to address professionalism, doctor–patient relationship, informed consent and clinical trials, management of genetic disorders, patient management, and brain death and organ transplantation. One-month long workshop on medical humanities was held at Jorhat Medical College, Assam, India, during September 2015 involving both faculty members and students. Movies were used along with other modalities during the workshop. Movies were used to teach psychiatry residents about different issues in psychiatry, the doctor–patient relationship, and other issues at a medical college in Mumbai, India. At the Tehran University of Medical Sciences in Iran, an educational study regarding the use of movies in medical education was conducted from February 2013 to June 2015. Nine sessions were conducted to teach students' psychosocial aspects of medicine. The sessions were activity based, and the students observed and reflected on the movies. Most students enjoyed the use of movies to learn psychosocial topics; participating in movies was useful to them as a future physician and they would advise other students to attend similar sessions. Movies supported learning by observation, helped create tangible and supportive learning, and increased motivation for learning.
| Movie Screening and Activities|| |
Various authors have compiled lists of movies which could be used to address different topics.,,, A recently published book discusses cinemeducation and the use of movies to address various issues ranging from the individual and family cycle, adult diagnostic categories, doctor–patient relationship, and issues affecting specific populations. Most educational sessions utilize viewing of either excerpts or entire movies. Students should be introduced to the learning objectives of the sessions which utilize movies as a teaching–learning methodology as the use of this methodology is still not very common., Students usually watch the movie together as this is a powerful and enjoyable activity and can trigger emotions and influence the affective domain. This is usually followed by group activities and presentations by various groups and inputs from the facilitator. Students are provided with opportunities to reflect on the movie and the issues addressed. In a Caribbean medical school, the movie “My Left Foot” was used to introduce students to disability and its impact on the individual and the family. At a medical school in Aruba, the Dutch Caribbean, movie screening and activities were conducted during the afternoon for the entire cohort of basic science students. Interested basic science faculty members acted as facilitators. The students gathered in the school auditorium to watch the movie after inaugural comments by the facilitators. Students were divided into groups, with each group having members from different semesters. The groups worked on the activities with facilitator/s, providing help and support if needed. The group then reassembled at the auditorium for a plenary presentation and discussion. At the end of the session, the facilitators summed up the important learning objectives. Refreshments and snacks were provided.
| Use of Movies in Other Areas in Medical Education|| |
At the University of California, Irvine School of Medicine in the USA, a 2-h humanities-based session was added to the standard training about intimate partner violence for family medicine residents. Film clips, role plays, and poetry were among the modalities used to help residents recognize and resolve complex personal reactions.
At the University of Buenos Aires in Argentina, a monthly medicine and movies program was conducted for senior medical students and house officers. Feature films and movie vignettes were used to explore the clinical and epidemiological aspects of medicine and promote discussion of issues such as professionalism, compassion, medical ethics, and social injustice. At Stanford University in the USA, the movie “Hold Your breath” was used to teach cultural medicine to students. The film is about an Afghan refugee family who makes it to the USA, but the father is diagnosed with cancer and has to cope with language barriers and differing cultural and world views with his deep belief in Islam colliding with modern scientific medicine.
At the University of Barcelona in Spain, movies were used to teach certain topics in clinical pharmacology. The authors used the movies “Awakenings,” “Lorenzo's Oil,” and “Miss Evers Boys.” The general learning objectives that can be attained using these movies in the domain of clinical pharmacology and suggested strategies to be followed while using movies as a learning tool are also provided. The University of Salamanca in Spain publishes the Journal of Medicine and Movies on the use of movies in medical education. The journal can be accessed at http://revistamedicinacine.usal.es/en/ which provides a rich collection of articles about the use of movies in medical education, primarily from the Spanish-speaking world.
Among medical students in the United Kingdom and Australia, the effect of watching movies depicting electroconvulsive therapy (ECT) on attitudes toward ECT was studied. After viewing the scenes, one-third of the students decreased their support toward ECT and about 25% of the students would dissuade a family member from undergoing ECT. During the years from 2006 to 2008, a movie-making project during which students filmed patients with chronic illness was used to teach about the challenges of living with chronic illness. A mixed audience of students and faculty viewed the films resulting from the project during a 12-h video slam and the faculty also used the films in the formal curriculum. Encounters with clinical circumstances in movies evoke different responses from medical students in training compared to real-life situations. This has been termed the “ Don Quixote” effect. Possible reasons could be lack of direct responsibility for the patient, primacy of the emotional response, removal from reality, and provision of a zone of safety while watching a movie. In the novel “Don Quixote,” Sancho Panza is the practical servant of the knight who on occasions lives in and even loves the world of Don Quixote's chivalric imagination and becomes a more honorable and compassionate person.
| Guidelines for Conducting a Cinemeducation Session/module|| |
The first step is to identify the subject areas, competencies, or issues which could be addressed using movies. [Table 1],,,,,,,, shows a selection of movies to address different issues and competencies predominantly from Hollywood. The facilitator should read all the available information about the movie from reviews, interviews, and other sources and watch the movie critically a number of times. The best films are those focusing on a few critical and concrete issues and which will also address the social and humanistic aspects of diseases. The learning objectives for the session should be delineated, and points to spark debate and realistic assessments should be identified. Use of group work, group presentations, and a plenary session by the faculty and facilitators is also recommended. Participant feedback about the session can be obtained and depending on the competency, and issues addressed, other instruments can be used which will be discussed shortly. Movies provide a controlled learning environment where archetypal experiences and the collective unconscious support learning. Metacognitive strategies (thinking critically about thinking) could be employed on a variety of topics ranging from compassion, family dynamics, suffering, mental and physical illness, spirituality, grief, breaking bad news, and providing end-of-life and palliative care.
|Table 1: A selection of movies to address different issues and competencies in the medical curriculum|
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A recent article directs faculty to choose films with which young medical students are not familiar. While the choice need not be limited to local language and English movies, due to cultural and other differences between countries, movies should not be chosen based solely on the recommendations of other authors. Critically reading what other teachers have written about the use of movies may be useful. [Table 2] provides guidelines for conducting a cinemeducation session.
| Movies in Medical Schools in India and Nepal|| |
The description of modules or activities using movies in medical schools in India has been limited. Movies may have been used informally in institutions. During my undergraduate days, our medical college had a movie club which regularly screened movies. The screening was not, however, followed by either discussion or reflection. Movies could be an important means to address various issues in Indian medical schools. India has a rich movie-making tradition, with movies being made in a variety of languages. In addition, English-language movies are also popular. India is a key area of focus of the Foundation for Advancement of International Medical Education and Research (FAIMER) with many regional institutes. Fellows develop a curriculum innovation project with the help of FAIMER faculty and implement the same at their parent institutions. The FAIMER institutes have made a positive contribution to health professions education globally.
The search was mainly conducted using the databases PubMed and Google Scholar. Hence, some published articles may not have been included. However, the available published data seem to suggest that cinemeducation though becoming increasingly common may not yet have reached the mainstream of medical education. A survey among alumni of the PSG FAIMER Regional Institute in Coimbatore, India, revealed that movie screening and activities are used in medical schools in India. Many of these initiatives are yet to be published. At the Yenepoya University in Mangalore, movies are used to teach medical ethics. Among the movies used were “Wit,” “Miss Evers Boys,” “A Beautiful Mind,” and “Whose Life Is it Anyway.” At the PSG Institute of Medical Sciences and Research at Coimbatore, India, movies are used to educate community medicine postgraduates about the issues of public health importance. Movies such as “Padman” and “33” were used. At the Seth GS Medical College, Mumbai, India a movie club was started by faculty members with an interest in movies and is being supported by the Dr. Manu Kothari fund. The medical humanities committee can invite eminent film personalities and critics to the institution. In addition to English and Hindi movies, Marathi movies and plays are also staged. Movies have also been used to introduce students to ethical issues at a dental college in Bengaluru. At Karpaga Vinayaga Institute of Medical Sciences and Research in Tamil Nadu, movie clips have been used during the teaching of anatomy. The movie “Awakenings” is screened during the medical humanities module at Patan Academy of Health Sciences, Lalitpur, Nepal. The screening is followed by a group discussion and individual reflection. Hopefully, many of these initiatives will be published soon. At PSG Institute of Medical Sciences and Research, movies are being used during bioethics sessions for medical students and during the postgraduate diploma in bioethics. Among the movies used are My Sister's Keeper, Constant Gardener, Extraordinary Measures, Miss Evers Boys, Gattaca, Million Dollar Baby, Lorenzo's Oil, Philadelphia, The Boy in the Striped Pajamas, Thank you for Smoking, and Patch Adams. Both movie clips and full movies have been used at Mysore Medical College.
| Cinemeducation – a Global Perspective|| |
A systematic review and thematic analysis of movies used in medical education was published in 2012. The articles included originated from a number of countries, with the vast majority being from the USA. There were also studies from the United Kingdom, Canada, Brazil, Australia, Thailand, India, Israel, and Ireland among others. The majority of publications in the “Journal of Medicine and Movies” originated from Spain and Argentina. Mental health, human sexuality, clinical pharmacology, pediatrics, general medicine, social determinants of health, domestic violence, end-of-life care, empathy, and ethics were among the topics addressed. At the College of Applied Medical sciences, Jubail in Saudi Arabia, movies are used during the undergraduate medical curriculum. Munna Bhai M.B.B.S, Patch Adams, Wit, and 68 pages were among the movies screened.
| Measuring the Effectiveness|| |
Participant feedback about the session can be collected using a simple instrument. Evaluation by students and participants has been used by different authors. Tarsitani et al. used cinema clips to present psychiatric cases to residents, and the feedback from the students was good. Bhagar used movie clips to present psychiatric cases to 2nd-year medical students and again obtained a positive response. Improvement in a number of measures of knowledge and attitudes was noted among medical students in their pre- and post-seminar scores when movies were used to teach psychotherapeutic techniques. A simple feedback form was used to obtain student feedback during the movie screening sessions conducted at Aruba. A similar instrument was also used in a medical school in Saint Lucia to obtain participant feedback.
At a medical school in Italy, cinemeducation was used to strengthen helping behavior among medical students. Forty randomly selected participants were assessed using the Attitudes Toward Psychiatry scale (ATP-30), Social Distance Scale (SDS), Interpersonal Reactivity Index (IRI), and the Toronto Alexithymia Scale both at baseline and 6 months after the workshop concluded. A significant increase in the ATP-30 score and a reduction of the IRI and SDS scores were noted. Clinical vignettes from television programs such as “ER” were used to illustrate encounters with extremely emotional or personality-disordered patients to third year medical students. Students' knowledge and attitudes toward psychotherapeutic techniques significantly improved following the seminar. A segment of the movie “Wit” showing the communication of the diagnosis and the treatment proposed for a cancer was shown to university students, nurses, advanced medical students, and hospital physicians. The “Observing Patient Involvement in Decision Making” scale was used to assess the degree to which a doctor engages in shared decision-making with a patient. The instrument to be used depends on the competency or area being addressed by the movie. Based on this, validated scales to measure the same could be available from the scientific literature.
| Databases and Other Sources Providing Information About Movies|| |
The literature, art, and medicine database (http://medhum.med.nyu.edu/) maintained by the Faculty of Medicine of New York University provides annotations about different movies. These annotations provide a preliminary idea about the movie. The IMDb database (www.imdb.com) provides brief description of movies and TV shows and will also be useful to obtain a preliminary idea about movies. A Wikipedia article mentions a collection of online movie databases. Databases from many countries are mentioned, but films from South Asia are not included. FindAnyFilm (www.findanyfilm.com) is an online movie database created by the United Kingdom Film Council, and users can find English-language films and TV shows based on the search terms, including titles, actors, and genres among others. Another gateway mentioned is the Filmarchives online which provides online access to images from various European film archives. The TMDb movie database (www.themoviedb.org) is a community-built movie and TV database dating back to 2008. The database officially lists movies from 39 languages and has a description of South Asian movies also. Rotten Tomatoes (www.rottentomatoes.com) is an American website which aggregates film and TV reviews. I personally found the reviews by the community to be useful during the preliminary selection of possible movies to be screened. The New York University Library database of video collections provides a comprehensive list of video and film databases along with a brief description. The “Journal of Medicine and Movies” reviews and describes a variety of movies and their possible connections with health professions education and the human condition. The book on cinemeducation provides a comprehensive guide to using movies. Large parts of the book can be previewed using the Google Books website.
Issues of copyright are tricky. There are some guidelines regarding the screening of movies for educational purposes in the USA. Librarians are often asked for advice regarding this. An online guide provides some important guidelines to consider. A properly purchased or rented movie may be used for educational purposes in a classroom setting using face-to-face instruction. The screening must take place in a classroom or an instructional space in a nonprofit educational institution. Only teachers and students can be in attendance; the teaching activity must be face to face and the copy of the video must be legally acquired. While using videos from streaming services like Netflix, the licensing conditions of the site must be followed. The American Library Association has published detailed guidelines regarding the use of movies in the classroom. Some universities and educational institutions have created guidelines regarding the use of movies for cinemeducation.
Screening of movies in the public domain is to be recommended. Public domain is an intellectual property designation referring to the body of creative works and knowledge in which no person, government, or organization has any proprietary interest such as a copyright. These works may be used freely by all. There are hundreds of movies and TV shows which are in the public domain. However, there is no definitive or official list of public domain movies. Possible resources to identify public domain movies are Infodigi (http://www.infodigi.com/Public_Domain/films.html), OpenFlix (www.openflix.com), and Public Domain Movies (http://publicdomainmovies.net/). Public Domain Movies can be downloaded from the Internet Moving Image Archive (https://archive.org/details/feature_films) and Public Domain Torrents (http://www.publicdomaintorrents.info/).
| Neurocinema|| |
Cinema can affect neurophysiological processes in various ways. Watching a movie can affect different regions of the brain and is akin to consciousness structure. Cognitive Science Movie Index is a collection of movies showcasing various aspects of cognitive sciences. An Iranian movie, The Separation (2011) by Asghar Farhadi, examined the impact of Alzheimer's disease on people's lives. Dr. Wijdicks lists ten films about neurologic illness. Among these are “The Death of Mr. Lazarescu,” which portrays subdural hematoma; “Amour,” which shows the effect on an elderly couple of a diagnosis of stroke in the wife; “The Intouchables,” the story of a wealthy aristocrat who becomes a quadriplegic; “The Diving Bell and the Butterfly,” which delivers a glimpse of life from the perspective of a person with locked-in syndrome; “My Left Foot” dealing with cerebral palsy; “You Don't Know Jack,” based on the life of Dr. Jack Kevorkian; “Iris,” dealing with Alzheimer's disease, “Memento,” which depicts a person who cannot form new memories following an accident; “The Crash Reel,” dealing with recovery from a traumatic brain injury; and “Declaration of War,” depicting parents determined to fight back after their son is diagnosed with a malignant brain tumor.
At a university in Brazil, a project titled “Neurocine: from Art to Science” was developed. Each session used the screening of a movie dealing with a neurological condition or theme and was followed by a lecture delivered by a neurologist. The method was deemed as effective by the authors.
| Using the Humanities to Combat a Decline in Empathy|| |
Most students enter medical school as caring compassionate physicians wanting to contribute positively to patient care. However, studies have shown that there is a decline in empathy as students continue through medical school, and most of the decline occur during the 3rd year., The basic sciences offer a structured curriculum focusing on the medical students, whereas the clinical sciences offer a more challenging and chaotic learning environment, with the student no longer being at the center. Role-modeling by senior physicians also plays an important role. The humanities including movies have been shown to maintain empathy and compassion among medical students. At the Robert Wood Johnson Medical School in the USA, student clerkships included a mandatory humanism and professionalism component which included among other activities watching and discussing film. The authors concluded that providing a safe, protected area to 3rd-year students to discuss reactions to patient care situations encountered during clerkships may contribute to preserving empathy.
Mammals have developed mechanisms for care which are tapped into by films concerned with bonding. Humans are willing and able to resonate with sad situations depicted in films and be touched by sad music which contributes to our ability to feel with others. The experience of films consists of a double empathetic sharing: the first with the characters and the second with others present physically or in some cases virtually during the screening.
TV and movies have become an integral part of modern life. Drama, novels, and visual arts are important to provide insights into unfamiliar life situations and put oneself in the position of individuals going through those situations. Movies have a powerful emotional component and can influence brain activity in a variety of ways. Novels and written word require the reader to use their imagination to put themselves in the position of the characters and the situations they are experiencing, whereas movies directly transport the viewer to different situations and may require lesser use of the creative imagination. Movies deal with a variety of life situations, and a wide range of issues can be addressed.
| Conclusion|| |
Movies are used for a variety of purposes in medical schools. These range from medical ethics, clinical trials, empathy, professionalism, communication skills, and end-of-life issues among others. Majority of publications describing the use of movies are from developed nations. Movies are being increasingly used in developing countries also. Guidelines for conducting sessions are provided. Selection of suitable movie/s is important, and information sources to support the same are mentioned. Databases providing information about movies are described. Use of movies in the public domain is recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]