Cinemeducation: A pilot student project using movies to help students learn medical professionalism

Abstract

Background: Using movies has been accepted worldwide as a tool to help students learn medical professionalism. In the second year, a group of medical students conducted the “Cinemeducation” project to promote professionalism in the “Medical Ethics and Critical Thinking” course.

Method: Five movies with professionalism issues were screened with 20–30 students attending each session. After the show, participants then were asked to reflect on what they had learned in terms of professionalism. Two students led group discussion emphasizing questioning and argumentation for 60 min. Additional learning issues emerging from each session were also explored in more depth and arranged into a report.

Results: In the Cinemeducation Project, medical students have learned five main ethical issues in each film, which were the doctor–patient relationship, informed consent and clinical trials in patients, management of genetic disorders, patient management, and brain death and organ transplantation. In addition to issues of professionalism, they also developed critical thinking and moral reasoning skills.

Conclusion: Using a case-based scenario in movies has proven to be an effective and entertaining method of facilitating students with learning on professionalism.

Introduction

Professionalism has long been valued as one of the competencies every medical graduate student should develop throughout medical school (Wear & Castellani 2000; Leach 2004), yet training and evaluating professionalism has always been challenging. Learning through movies has proven to be another effective approach (Self et al. 1993; Ber & Alroy 2001; Ber & Alroy 2002; Rabinowitz et al. 2002). This article reports a student project, “Cinemeducation”, which aimed to utilize feature films as a tool to help promote the students’ professionalism.

There is no one way to define professionalism. According to the physicians’ charter on medical professionalism in the new millennium (2002), fundamental cores of professionalism are (1) prioritizing patients’ well-being above physicians’ self-interest, (2) respecting patients’ autonomy by helping them make informed decisions about their treatment, and (3) upholding social justice by distributing health care resources fairly. Similarly, the Royal College of Physicians of London (2005) signifies professionalism as “a set of values, behaviors, and relationships that underpins the trust the public has in doctors”.

Medical schools have assembled professionalism differently as a principle element into their curricula. Current methods include formal didactic teaching, faculty mentoring, workshops, modules, problem-based learning, role-play, and simulated patients. However, the mere curriculum does not guarantee students’ accomplishment unless patient-physician-friendly institutional culture is instilled at all levels (Ludmerer 1999).

Using movies as part of a case-based module has been shown as efficient and entertaining. Movies transform dry content into lives, thus making it easy to understand and remember. Therefore, using movies is a quick strategy to help convey concepts in numerous areas of academic fields such as history (Sprau 2001), philosophy (Asma 1999), political science (Lowery 2002), and religion (McCutcheon 1998). While emotionally captivating, they trigger the audience's opinions, and foster their critical thinking, as everyone can see one situation in the same way yet respond to it differently. When used to raise open discussion, participants feel free to share their points of view because movies are impersonal, so no one will be offended (Ber & Alroy 2002). Moreover, students at different ages learn to look at situations from various perspectives; from the angles of patients and relatives when in their preclinical years to the standpoint of physicians, as they experience bedside situations during their clinical years. Nonetheless, viewers need to keep in mind that not all doctors are portrayed correctly (Flores 2002), and they must not let their emotion overvalue the real message of the movies.

Regarding medical education, feature films have been utilized as a teaching tool in communication skills (Saab et al. 2005), psychiatry (Alexander et al. 1994; McNeilly & Wengel 2001; Garrison 2007), family medicine (Lenahan & Shapiro 2005; Weber & Silk 2007), and pharmacology (Farré et al. 2004). Upon reviewing the literature, we have found at least ten reports (Alroy & Ber 1982; Self et al. 1993; Blasco 2001; Ber & Alroy, 2001, 2002; Lepicard & Fridman 2003; Rabinowitz et al. 2002; Lee & Ahn 2004; Baños 2007) that support the use of whole-length films and movie clips, or trigger films to teach medical professionalism, medical ethics, and humanities. For example, Lee and Ahn (2004) introduced medically themed whole-length films in the “Medicine and Literature” Course with small-group discussions, reports, and group presentations followed by large-group discussions. Ber and Alroy (2002) implemented “trigger films”, which were short scripted situational videotaped encounters between patients and/or their families and medical staff, followed by small group facilitator-led discussions as an aid in teaching professionalism for more than 20 years. Likewise, Alexander et al. (1994) introduced the term “Cinemeducation” which means “the use of movies on video, particularly clips from such videos, to educate residents and medical students in the psychosocial aspects of medicine”.

We conducted the Cinemeducation Project with the aim of gathering more evidence to support the usefulness of this approach. However, we re-defined the term “Cinemeducation” as “cinema + medicine + education”, which meant using movies in medical education. The project originated in 2006 as a student assignment during the “Medical Ethics and Critical Thinking” course. Our goal was to help foster one another's critical thinking skills and professionalism through films, as well as learning to work cooperatively. We intended to focus on doctor–patient relationship, doctor–colleague relationship, and the doctors’ responsibility as a member of the society.

To our knowledge, this is the first project to be published that was entirely organized, facilitated, and attended by students. Moreover, it is the first project to focus on the whole aspect of professionalism, in addition to other projects that focus on some aspects regarding medical professionalism. Therefore, despite this concept being long talked about, we would like to report the experience from a fresh point of view.

Table

Practice points

Cinemeducation was primarily meant to use movie clips or videos to teach psychosocial medicine, but the authors generalized the term to “cinema + medicine + education” meaning the use of movies to help teach medicine. Movies brought dry content to life by helping to convey difficult concepts and stimulate open discussion, hence a useful case-based module was made for various academic areas, including medical professionalism, in which movies have excellent stimulating scenarios that help students prepare for real life situations. Different kinds of movies have proved effective whether trigger films, movie clips, or whole-length films are used, or when deciding between television series and motion pictures. Cinemeducation is an effective and entertaining method of helping medical students learn professionalism and also promote development in critical thinking and moral reasoning skills.

Work done

The working group consisted of 26 second-year medical students at Chulalongkorn Medical School. The project was carried out from August 2006 to February 2007. Participants, who were also second-year medical students, met every other week to view and discuss five selected movies.

The first and key step of the process was to choose movies that were time-efficient and suitable for introducing concepts of medical professionalism to preclinical students. We developed three criteria accordingly. Firstly, each movie had to involve doctors as main characters. Secondly, all of the movies had to contain different themes and depictions of conflicts about professionalism. Thirdly, each movie had to pertain to medical knowledge in accordance with the course being taken at that time. This could stimulate many ways of learning, in that students learnt to assimilate their classroom knowledge into context by watching the movie. At the same time, seeing the relevance to their future medical practice, students were encouraged to review and explore for more information.

After thorough discussions by the panel, the five movies chosen for the project were Patch Adams (USA), Awakenings (USA), Lorenzo's Oil (USA), The Death of Mr. Lazarescu (Romania), and two episodes of the television series, ER, which related to brain death and organ transplantation. The television program was picked out with the intention of diversity. Furthermore, we also anticipated that the fast pace and various subplots of the series could trigger the audience's attention and different responses.

Prior to showing the film, we screened for concepts that were needed to clarify and pinpoint main professionalism issues before discussion. We researched for more information and met to create a tailored questionnaire for each movie. Simultaneously, the trailers were previewed in front of the lecture room to promote the event 2–3 days beforehand.

The session started with projection of the feature film. Afterwards, two students led a discussion for approximately 1 hour. Their roles ensured that all participants were active in order to elucidate terms and concepts, and raise thought-provoking questions, which were previously prepared although, occasionally, new issues emerged during the session. In the same way, participants interactively exchanged their opinions regarding issues of professionalism in a fair and constructive way. Alternatively, they provided written opinions on an open-ended questionnaire. At the end of every session, students concluded their main messages from the movie and what ideas they had learned.

Later, we impartially arranged all points of view into an article as a summary. Scientific facts, ethical principles, and professional laws were rechecked by experts at the Faculty of Medicine.

At the end of the last session, the staff gathered to reflect on the overall project. Every group member took turns in speaking on what they liked or disliked about the project, what they had learned, and whether their attitudes had changed after completing this task.

Results

From the chosen films, five ethical issues were depicted as main themes for group discussion, which included the doctor–patient relationship, informed consent and clinical trials in patients, management of genetic disorders, patient management, and brain death and organ transplantation (further details in Table 1).

Table 1.  Professionalism issues and medical contents from each movie

Movies	Professionalism issues	Medical contents
Patch Adams	Doctor–patient relationship Doctor image
Awakenings	Therapeutic treatment and therapeutic research Clinical trials: laws and standards – Informed consent – Ethics committee	Encephalitis lethargica (Postencephalitic parkinsonism) and L-dopa
Lorenzo's Oil	Genetic counseling	Adrenoleukodystrophy
The Death of Mr. Lazarescu	Emergency patient management Holistic approach Communication skills Health care system Doctor's relationship with healthcare team
ER	Brain death and organ transplantation	Diagnostic criteria for brain death

Here are examples of the arguments raised during each session.

Patch Adams

After watching Patch Adams, we saw many characters developing different patterns of relationship with their patients, and how patients reacted to their doctors with different attitudes. We examined the problem of disconnection between doctors and patients and the heart-felt holistic approach that Patch Adams used to his patients. In group discussion, a question was raised as to whether it is appropriate for a doctor to dress like a clown and make friends with his or her patients, like Patch Adams did in the movie. Some students agreed that this strategy helps doctors develop a better relationship with their patients and makes it easier to deal with difficult patients such as dying patients and pediatric patients. However, others argued that there should be limitations in doctor–patient relationships and dressing like a clown seemed to disgrace the role of a doctor.

Awakenings

In Awakenings, Dr Malcolm Sayer prescribed L. Dopa, which is a medication for Parkinsonism, to treat Encephalitis lethargica patients without approval from the ethics committee. Some students agreed with Dr Sayer because a patient's family had already consented and was willing to take a chance, while others thought that any clinical trial should be approved by the ethics committee in order to assess the risks and benefits of the intervention before its application in human beings. After the session, we also researched the informed consent and clinical trial procedure in Thailand.

Lorenzo's Oil

Lorenzo's Oil was shown immediately after we had finished the Embryology and Genetics Course. This allowed us to understand how the knowledge we had learned in the preclinical period could be applied in clinical years. We learned how to deal with patients who have genetic disorders and how they provide genetic counseling to their families. We also realized how illness can affect both patients and their families. During the discussion, an interesting issue was raised by a medical student about Lorenzo being brought into the classroom to discuss his illness in front of 100 medical students. Most of the students in our group discussion suggested that discussing Lorenzo's illness should have waited until after he had left.

The Death of Mr. Lazarescu

We learned about patient management and failure of the public health system from the Romanian film “The Death of Mr. Lazarescu”, which is about a man who was rejected from four hospitals in one night and eventually died. The group discussed whom or what contributed most to his death. Some students stated that it was the patient himself, who drank excessive alcohol. Some blamed doctors at the third hospital who did not operate on the patient because he could not sign the informed consent. Others thought that the lack of an effective health care system was the most likely cause of his death. We discussed the limitations of patient management at each hospital in the movie and compared them to Thailand's. We also developed the concept of multidisciplinary teamwork, since being a good doctor requires cooperating with other people in the health care team including nurses, pharmacists, social workers, paramedics, therapists, and other doctors.

ER

From two episodes from the famous American television series “ER ”, we learned professionalism issues in terms of brain death and organ transplantation, which is one of the most controversial issues today. The plot is about a brain-dead patient who was resuscitated, despite his mother's intent not to resuscitate form, in order to save his organs and transplant them into another severely-ill patient. Some students considered the doctor's action as lacking respect for the patient's rights, since he resuscitated the patient against do not resuscitate (DNR) wish, whereas others understood the doctor's good intention to save another dying patient. After the discussion, we also studied legal issues of the brain death criteria, organ donation, and organ transplantation in Thailand.

Discussion

Using movies to teach medical students regarding issues of professionalism is well documented in many countries all over the world.

In the USA, video clips from “The Doctor” were used to teach residents in psychosocial aspects such as delivering bad news, the impact of terminal illness, and cross-cultural issues in medicine. Discussion questions and role plays were also used in the project after showing the movie clips (Alexander 2002).

In Brazil, the Academic Department of the Brazilian Society of Family Medicine did an educational project called “Literature and Movies for Medical Students”, in which students from various medical schools in Sao Paulo State participated in a group discussion after they had read books or watched selected films (Blasco 2001).

In Korea, the “Medicine and Literature” course was brought into the premedical curriculum in the Korean University College of Medicine to assist students in developing the expectations of their lives as doctors, and also understand the humanistic and social aspects of medicine. In this project, medical-themed movies and literature were used and at the end of each session was evaluated by students in a short essay, reflecting what they had learned in class and giving suggestions and comments (Lee & Ahn 2004).

In Israel, Bruce Rappaport Faculty of Medicine introduced the use of “trigger films” (Alroy & Ber 1982; Ber & Alroy 2001, 2002; Rabinowitz et al. 2002), defined as “short situational films, utilized as a medium for exposing medical students to a variety of aspects of the clinical experience that may be difficult to teach at the bedside”. Homemade video clips are highly recommended because they can present local problems, cultural issues, and the familiar clinical environment more clearly than foreign movies. A physician tutor facilitator started each session by explaining the main theme of each trigger film. While watching the film, the tutor occasionally paused after a specific important event and asked the participants to discuss alternatives to the physician-patient encounters they had viewed.

Some studies recommend watching the entire movie as part of the learning process (Lee & Ahn 2004; Masters 2005; Weber &Silk 2007), while others support using film clips to generate group discussion, points of view, and trigger emotions and thoughts from the viewers (Alexander 2002; Blasco et al. 2006). We found that although watching the entire movie was time-consuming, it helped to provide the background of each character and make we, the preclinical students, understand the many controversial issues in the movie more easily.

Blasco (2001) suggested that using the literature and films before an open discussion among students, and facilitating faculty educators to highlight emerging topics, has proven to be a useful and enjoyable way of teaching, which successfully reflects in the personal and professional attitudes and values of medical students. In our project, the group discussion was led by medical students, not educators, in order to stimulate one another to express views more openly. However, students must be careful not to be misled during the discussion by exaggerated content in the movie, the so- called “halo” or “Rashomon” effect (Ber and Alroy 2001).

The use of videos has been shown as an effective and innovative method of teaching, as reported in many recent articles in the medical literature (Alexander 2002). Movies have many advantages, in that students can engage in and gain acceptance from them. They can make abstract and dry content become alive and understandable and promote various kinds of learning methods (Masters 2005). Also, movies present a direct teaching scenario, in which particular scenes indicate important issues. Another benefit in using movies to teach professionalism is that emotions are depicted in accessible ways and they are easy to identify (Blasco et al. 2006).

In the “reflective discussion”, which was one of the evaluation processes conducted by the staff at the end of the project, students stated that this project had developed their critical thinking and moral reasoning skills, which correlated with the study conducted by Self et al. (1993). Our students also acknowledged that this project had helped them understand the impact of illness on patients and their families. In addition, it also prepared them to face inevitable situations, which they would have to encounter in clinical years, by watching scenarios from the movies and discussing how to deal with them, or whether they agreed with each character's decision. According to Chulalongkorn medical school's 2002 outcome-based medical curriculum, we would like to illustrate(as in figure 1) that the project had helped us achieve seven out of twelve outcomes, which are holistic approach, communication, medical knowledge, critical thinking, roles of doctor, personal and professional development, leadership and teamwork, and professionalism. We agreed to use a bicycle model as the metaphor for our project, as it gave us recreational value along with other six outcomes along our journey to reach our final destination, which is accomplishing a basic understanding of medical professionalism.

Figure 1. Cinemeducation compared to a bicycle to wheel our way to achieve “professionalism”.

A limitation is that four out of five films used in this project were Hollywood-based, which made generalization to our Asian culture more cautionary. Thus, we regard this project as a pilot study, which needs to be continuously perfected for fellow medical students in the long run.

An undeniably important question regarding the project is how to assess if the students actually learn and achieve professionalism by watching movies. The answer would lie in the Kirkpatrick's 4-level hierarchy of evaluation, consisting of reaction, learning, behavior, and results. To measure cognitive, attitude, and behavioral changes before and after watching movies, pre-test and post-test evaluation is suggested, as conducted by Self et al. (1993), using Rest's Defining Issues Test and compared with a control group. In addition, long-term follow-up is required to see how those students have applied what they learned during the project into their clinical clerkships and their future as doctors.

In conclusion, the “Cinemeducation Project” has proven to be another effective and entertaining method of facilitating learning on professionalism for students.

Note

The authors of this article were awarded Patil awards for a short communication that has made a novel contribution to the Conference in two categories: “teaching and learning” and “student issues” at the AMEE Conference 2007 in Trondheim, Norway.

Acknowledgments

The authors are grateful to all 26 members and other medical students who provided valuable contributions and helped in completing this project. We would also like to thank Professor Vorasak Shotelersak, Professor Anan Srikiatkhachorn, Doctor Puchong Laurujisawat, and Associate Professor Dr Annabel Bhamani Kajornboon, and Robert Kimmins for giving us invaluable advice during the project.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

Nuttha Lumlertgul

NUTTHA LUMLERTGUL and NARUCHORN KIJPAISALRATANA were both third-year medical students at Chulalongkorn Medical School at the time of writing this article. They are interested in medical education and stem cell research.

Naruchorn Kijpaisalratana

NUTTHA LUMLERTGUL and NARUCHORN KIJPAISALRATANA were both third-year medical students at Chulalongkorn Medical School at the time of writing this article. They are interested in medical education and stem cell research.

Nuttorn Pityaratstian

NUTTORN PITYARATSTIAN, MD, is a lecturer in child and adolescent psychiatry at the Faculty of Medicine, Chulalongkorn University. His clinical interests are cognitive behavioral therapy, ADHD, and disaster. Motivated by his fascination in movies, he runs a monthly session named “Psychi Film” with psychiatric residents and medical students.

Danai Wangsaturaka

DANAI WANGSATURAKA, MD, PhD, is a lecturer in medical education.