Med Student Mentor: Beyond the Diagnosis—Implementing Fine Arts in Medical EducationJul 23, 2015
Film presentations and art projects are usually not what you would expect to find at a medical school. But Dr. Gretchen Case from the University of Utah School of Medicine says this is a new and creative way of teaching the fundamentals of medicine that all medical students need to become a brilliant physician. Dr. Case talks about how she incorporates video and art in her class projects to better enhance her students’ medical education, and gives advice for other institutes that are looking to do the same.
Interviewer: An art show and video presentations as part of a class in med school? What's going on, what do the instructors hope to accomplish and what can med students learn from this type of project? We'll talk about that next on The Scope.
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Interviewer: So I saw this flyer for an event coming up called "Beyond the Diagnosis: Video Presentations and Final Artistic Presentations." Now, at a lot of other schools, that might not seem all that strange, but this was at a school of medicine, a medical school so I wanted to find out more about it. And the person to talk to, I was told, is Gretchen Case. She's the Assistant Professor in the division of Medical Ethics and Humanities. So what is "Beyond the Diagnosis: Video Presentations and Final Artistic Presentations?" What is this all about?
Gretchen: Well, it's a lot of things and it's evolved over the years. So what you saw was an invitation to our final presentations. This started out five years ago as a video project only and we called it "Beyond The Diagnosis," because what we wanted students thinking about was not just the diagnosis, not just the patient they see in the clinical setting, right, for 10 minutes or 15 minutes, the whole person, that everybody has a story beyond the diagnosis.
Interviewer: So is this part of a class, then?
Gretchen: It is now. Yes.
Interviewer: Oh, okay. But back then it wasn't.
Gretchen: Well, it was part of a different class.
Interviewer: Okay. Understood.
Gretchen: So it was part of Foundations of Medicine, which is a course that all the students take in their first year. And so what we did was I put the students into teams of three, four, sometimes five students, they take a video camera, really simple setup and a microphone and they go out and they interview someone about their healthcare experience. And that's all they know, that this person has had a healthcare experience. They don't know the diagnosis, they don't know how it turned out for them, they don't know if it was acute, chronic, anything. They just have a name and a way to contact them and that they're willing to talk. So these are all volunteers from the community who have a story to tell.
And the reason I did that is because the minute you say something like, "This person has diabetes," or, "This person is 85 years old," you start the story in your head, right? You already get a picture of who this is.
Interviewer: We all do that. Yeah.
Gretchen: Absolutely. So what we wanted was that the person gets to start the story. When the students call them or email them, they may decide to say, "I'm 85 and I have diabetes," or they may not. And there've been some really beautiful moments where students have showed up at someone's house and said, "That's not the person I expected to see," or, "This isn't what I expected to hear about."
And the students talk to them for about an hour, sometimes shorter, sometimes longer, but what was their healthcare experience. And that, as you can imagine, it was a million different directions. So we've had people who had something really acute, a really bad bike accident that had them in the hospital for a long time, but they've been healthy before and healthy after versus someone with diabetes that they've been managing for their whole life. They're going to have different experiences and that's great for the students to hear.
One of the questions that I always encourage the students to ask is, "So what makes a good doctor?" Because there's no answer for that that's true for everyone, but for each person, they can give some examples of, "This is when I felt really cared for. This is when I felt listened to. This is the reason I would go back to this doctor." They interview these people and really the experience is supposed to be about listening.
So the video camera is there to help them listen and record so they don't have to take notes or anything, but it serves a second purpose too, which is, the students come back and as a team, they watch all the video footage and they decide on about three to five minutes of a story that they want to tell from that. So it may be a theme that ran throughout their conversation, it may be one little section where the person really wanted to tell them one thing, they can do whatever they want.
And it's not a film class. I try to emphasize to them that it doesn't have to technically beautiful, although they always exceed my expectations and I try to give them a lot of support on that. We just use iMovie, something really simple. But a three to five-minute video that says something about that encounter.
And then this presentation, we show those videos and we invite all the first-year students as well as all the people who were interviewed and their family members often come, and then some of the faculty. This way, the students get to experience not only the interview they did but all the other interviews. And we have a chance to talk about it as a group. And the people who were there get a gift back, right, they get their story told back for them, and we get to discuss how that sounds. And sometimes people say, "Wow, I didn't know you would pick up on that," or, "You really crystallized what I was trying to say to you."
Gretchen: So that's the video portion of it. And like I said, that has been part of the first-year experience for the last few years.
Interviewer: So let me jump in quickly. What was the problem that you were trying to solve five years ago when you came up with this idea to do this learning exercise? Because I imagine it started out as a learning exercise.
Gretchen: Keeping in mind it's so easy, the minute you get into medical school, to start memorizing facts and figures and starting that, how do you do a differential diagnosis, how do you decide it's this not that, right? How do you keep sight of the person? And that intellectual exercise of editing, of deciding what am I going to tell, mirrors what they have to do as physicians, which is: what do I prioritize? Right?
So you talk to a patient for 10 minutes. If you're going to present that to your colleagues as they do on rounds or make a decision for yourself, you can't use all that information. You have to say, "This is important, this is important, I can do something about this, this is for later." That's what you do in editing too, right?
Interviewer: Yeah, sure.
Gretchen: So they're already starting that process and that's part of the intellectual exercise we were hoping for.
Interviewer: Gotcha. And you decided not to tell them, just send them in blind so they didn't go with all these . . . trying to figure out a problem or solve a problem.
Gretchen: Exactly. So this is actually based on something that others schools do, most notably, University of Michigan does a project like this that they do, actually over several years, and they stay with the same family. But I instituted this rule of "I tell you nothing" because I know that's what we all do as we start the process, we start the story and I really wanted the story to come from the other person. Because think about it, even when you got to the clinic as a patient, they walk in and already, they've got your chart.
Interviewer: Instead of even looking at you, sometimes the first thing the physician might look at is your chart.
Gretchen: Which makes sense.
Interviewer: They're walking in looking at your chart, they've already learned a little something about you and have made judgments that could be completely wrong.
Interviewer: Huh, okay, sure.
Gretchen: That makes sense because you have limited time in the clinic, so the reason the chart is there or the intake form is to save some time. And a good physician will still lock in and say, "Why are you here today? What did you come for?"
Interviewer: "Tell me your story."
Gretchen: "Tell me your story." But they've already got some ideas. So this is a chance to just tell me your story, I know nothing about you.
Interviewer: So it started out with videos and now this year you've added something else?
Gretchen: Well we've added a new course and we've added some different artistic projects. So this new course is called Layers of Medicine. We named it layers because at the base of medicine you absolutely have to have that scientific information. You absolutely have to have your clinical skills. So scientific information, clinical skills, but there's a lot of other stuff on top of that because we are not fixing machines. We are not robots fixing machines, there's delivery.
Interviewer: We're not mechanics fixing cars.
Gretchen: Exactly. That's the analogy that's often used. So what we cover in Layers of Medicine are a lot of the intangibles, like how do sex and gender issues relate to health care, talking about global health care, talking about ethics, talking about the ways that the arts and the humanities are part of the whole human experience, communication. All these things that are necessary to be a full person giving care to another full person and making that connection between two human beings. We cover a lot of stuff in Layers and we actually can't cover everything we need to.
One of the things that we have done is we've taken this video project into Layers so that it can be a part of what we do. We also ask the students to do an artistic project and it's just an artistic interpretation of any theme that comes up in class that they want to explore further. So if we talk about death, they can go any direction in thinking about death, with thinking about grief, with thinking about rituals around burial, any direction they want. We just ask them to interpret it artistically, which means they can't set up a lecture, they can't do PowerPoint slides, they can't write a paper.
Interviewer: All the things they've depended on to this point.
Gretchen: Exactly. And the intellectual exercise behind this is that you think differently when you're pulled out of that comfort zone of, "Here's how you do a lecture, here's how you do a poster." We've had students do sculpture, do glasswork, do poetry, do just about anything you can name of, sewing, fiber art, we've got some origami coming this semester. And this might sound a little "woo," but when you look at it, you think, "Wow, they really got to the heart of something there." And again, like the video project, it's not about, "Is this good art?" It's what did they do, what did they explore?
Interviewer: The process and also just examining issues in a way that a lot of us don't have time so we never do. You're forcing them to examine an issue like death in a very deep, meaningful way to understand it a little bit better.
Gretchen: Right and all of these students have come in with . . . medical students are exceptional in so many ways and a lot of them have artistic talents. And so some of them say, "Gosh, my guitar's been put away for most of this year, but now I had a chance to bring it out to use it again." Other students approach it as a way to try something new. So maybe they've done a lot of visual art but they've never done any performance and so they want to try that. And for some students, it still might be a mystery why they're doing this.
Interviewer: I was going to say, are there some students who are like, "I don't even get why I'm here."
Gretchen: Sure, there are always students where something just doesn't work for them and that's okay too because I take the long view and think, "Well, at least they had a new experience." And there may be a different point of their career where they want to explore this way of thinking a little bit more. And I certainly see that a lot with physicians mid-career, saying, "Wait a minute, there's something missing. I need to think a different way, work a different way, be in the world a different way. What's out there?" And they come back to literature or art or music or something. So at least now they know it's out there and that there are ways that it actually can really integrate nicely.
Interviewer: Into medicine.
Interviewer: Was this a hard sell to the people you had to sell this to get this class implemented?
Gretchen: No, not at all, in fact, this class is not in any way extra or on top of. It fulfills a lot of the requirements that the accrediting bodies for medical schools require. So things like understanding communication, understanding how sex and gender affect that world. So this is not different than anything any other medical schools do, what they teach and how they teach it. Certainly we have taken some different approaches, but it's absolutely part of most curricula in the United States.
Interviewer: So same material but you just chose to perhaps do some artwork instead of lecture.
Gretchen: Yeah, the class still meets every two weeks and we do lecture and small group discussion so that's there too.
Gretchen: And other schools do use art and the humanities in various ways too. So it's just a matter of layering it all together to make sense and that's an ongoing process.
Interviewer: Do you feel it's been successful?
Gretchen: Yeah. I can think of several projects that I've asked to keep to show to other people, where students have been surprised at what they've learned, where others in the class have watched or looked at the pieces and said, "Wow, I had no idea this person had this talent," or, "I never thought of it that way."
Interviewer: Which is one of the best things that could come out of this whole experience.
Gretchen: Exactly, exactly. And I know several of us were, by several projects, were moved to tears or moved to laughter or just astonished that someone was that creative, and going back to the video projects, that people were willing to share their stories so intimately with us.
Interviewer: If somebody else listening wanted to try this at their curriculum, what advice would you have for them?
Gretchen: Start out thinking simple and small because it can get complicated very quickly, so part of that is keeping your own expectations in check. But, even more, students can sometimes get really excited and then they can take on a lot in terms of a project. And just reminding them that they are not here to go to art school or film school, that this should be an extension of the other work they're doing so they don't have to build a Dale Chihuly glass sculpture. They can do something very small and simple and get their point across. Because again, medical students are generally people who've always done the best and the biggest and they're the brightest and keeping the scope small and remembering that small, simple things can be useful, too.
Interviewer: And just as impactful if not more impactful, a lot of times, right?
Gretchen: Exactly, exactly.
Interviewer: The simpler, the better. If there's a student at another institution that has a similar class that they're going to be going into, what mindset, and they're of the opinion of, "How's this going to make me a better doctor?" what would you say to them?
Gretchen: I would say, take the long view, that early on, it might not seem like it's going to help you, but thinking differently is important in lots of areas of medicine, like diagnosis, you have to be able to think creatively. Even test-taking, you need to think about what are all the options. So keep your mind open. Also, don't expect it to be everything and maybe it's not right for you right now, but take it in as more resources, more ways of thinking, more ways of learning and keep it for later if it's not something that appeals to you right now.
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