Prevalence of visual art education in medical school curricula: a national survey of US medical schools

ABSTRACT

Background: The Association of American Medical Colleges (AAMC) has recommended integrating medically-relevant arts and humanities curricula into medical student education in order promote physician skills development. An analysis of the state of existing visual arts-based medical school pedagogies was conducted to inform future implementation strategies.

Methodology: An electronic survey was distributed to representatives of US medical schools to describe the prevalence and characteristics of visual arts-based medical school curricula. Official courses, informal events, cross-registration opportunities, and established art museum partnerships were assessed.

Results: Survey response rates were 65% for US allopathic medical schools and 56% for osteopathic medical schools. A majority (79%) of responding institutions incorporate or support medical student art experiences in some format. Thirty-one percent (n = 36) of schools offer stand-alone humanities courses using visual arts. These were primarily allopathic programs (n = 35; 37% of allopathic programs) and only one responding osteopathic program (n = 1; 5% of osteopathic programs). Schools without dedicated courses are less likely to report other curricular and extracurricular visual arts engagement. Most visual art medical courses are offered at medical schools located in the Northeastern United States.

Conclusions: Many but not all medical schools are incorporating the visual arts into their medical education curriculum. Opportunities to promote increased uptake, more effective implementation, and collaboration strategies for the AAMC recommendations are proposed.

KEYWORDS:

• Art
• visual thinking strategies
• humanities
• medical education
• medical school

Introduction

In recent years, medical schools around the world have been integrating teaching methods that engage learners with the arts and humanities. A substantial body of literature demonstrates that incorporating activities pertaining to visual analysis and discussion of visual artwork can enhance physician communication, critical thinking skills, teamwork, empathy, tolerance for ambiguity, resilience, observation skills, and creativity – skills that are critical to the practice of medicine [1–11].

The Fundamental Role of Arts and Humanities in Medical Education (FRAHME), an initiative set forth by the Association of American Medical Colleges (AAMC), promotes integration of art into medical education through the following mechanisms: (1) stand-alone courses hosted by medical schools, (2) incorporation into existing courses, (3) short-term, singular sessions, and (4) long-term integration within existing programs [12,13]. In addition, the AAMC provides funding, didactic resources, and networking opportunities to support such efforts [13]. Heterogeneous opportunities exist as schools structure coursework according to resource availability and tailor courses to suit the needs of their particular institutions and student bodies. As a result of such variety across schools, there is a poor understanding of the current depth and breadth of visual arts-based offerings nation-wide. The objective of this report is to: 1) Describe the structure of visual arts-based course offerings at US medical schools. 2) Ascertain frequency of visual arts-based extracurricular medical school activities. 3) Assess likelihood of incorporating visual art into medical education based on school location and degree type (allopathic or osteopathic).

Methods

An educational survey aimed at identifying formal and informal coursework in the visual arts within the medical school setting across the United States was developed. The Harvard Medical School institutional review board reviewed the proposal and waived the need to obtain formal IRB approval. This report summarizes the findings of our survey of US medical schools to assess the prevalence of medical school engagement in visual arts-based teaching and extracurricular activities.

Participants

In 2020, there were a total of 185 U.S. medical schools, including the 148 LCME accredited allopathic and 37 COCA accredited osteopathic schools. All traditional four-year accredited programs were included, even if they had not yet graduated their first class. To identify knowledgeable representatives from each school, a search of each medical school’s website was conducted using the keywords ‘medical education’, ‘medical humanities’, ‘registrar’s office’, and ‘visual art(s)’. Deans, registrars, educational advisors, and faculty of arts and humanities programs were included. Additional contact information was obtained from the public directory of partnerships between U.S. medical schools and art museums maintained by the Edith O’Donnell Institute (EODI) of Art History at the University of Texas, Dallas [14].

Responses were collected from June 2020 to January 2021. Outreach was initially conducted by email. If multiple responses were obtained for an individual institution, they were reviewed in tandem for consistency. Follow up phone calls were made to increase survey response among non-respondents and to clarify course aims and structure if survey responses were unclear or inconsistent. However, this was only required for 9 allopathic schools. Calls to clarify ambiguities were made primarily due to inconsistent repeat responses, unclear course timing or depth of student engagement, or lack of clarity regarding involvement of the visual arts. No course classification changes were made based on the information obtained from these calls. Courses and activities offered to medical students of any level were catalogued and tallied. Courses or activities for other health care learners or providers were excluded. All activities utilized specifically visual art activities (i.e., creating or analyzing visual art); other arts-based humanities such as narrative fiction, poetry, or music were excluded. Thoroughly described medical school-art museum courses and medical student extracurricular collaborations that were listed in the EODI and which met the above criteria were also included, even if no representative from the school returned the survey.

Survey instrument

The survey instrument was an electronic questionnaire consisting of five questions developed by two course faculty and two pre-medical teaching assistants in the Harvard Medical School course ‘Training the Eye’ that utilizes visual artwork to improve communication, hone diagnostic and critical thinking skills. The survey was piloted by an associate and assistant professor of medicine prior to its release.

The questions included identifying information (school name), followed by five questions to assess (1) Stand-alone multi-session visual arts-based medical humanities courses; (2) Other core or elective courses that intermittently integrate visual arts-based pedagogies or content; (3) School-sponsored, non-curricular visual arts-based activities (i.e., orientation events, art shows or other activities organized and offered by school engagement offices); (4) Opportunity for cross-enrollment in visual art or design courses; and (5) Student-sponsored extracurricular visual art activities (Supplement A).

Data analysis

If multiple responses were received from an individual school, all visual arts-based activities were documented for that single school, with each school only represented once for purposes of statistical analyses. Free-text responses were analyzed by investigators [SN and IH] for data extraction to characterize visual art programming by latent analysis. It was determined if visual art courses were formal, stand-alone courses, activities within existing courses, or extracurricular experiences; if they were facilitated by medical school professors or entirely student driven; and if participation was mandatory or elective. In instances where responses were ambiguous, or if there was disagreement between reviewers, the respondent was contacted directly for clarification with success. Cross-enrollment opportunities were self-reported opportunities for medical students to enroll in other graduate or undergraduate programs in the visual arts, inclusive of auditing opportunities and for-credit electives.

Analysis of the distance between each medical school campus and the nearest art museum was conducted using Google Maps. Schools were categorized by Census Bureau-designated regions: Northeast, Midwest, South and West. If a school had multiple campuses, distances to the nearest art museum were averaged across campuses.

Statistical methods

The responses of allopathic and osteopathic schools were evaluated utilizing Fisher’s exact tests. Chi-squared analyses were performed to determine the differences in art utilization by schools based on geographic region. Tests of significance for geographic distances from medical schools to the nearest art museum were conducted using unpaired t-tests with Welch’s correction assuming unequal variances. P-values less than 0.05 were deemed statistically significant.

Results

Of 185 medical schools that met inclusion criteria, survey data and/or EODI course listings were available for 116 programs (62.7%), of which 95 were allopathic (65% of allopathic schools) and 21 were osteopathic (56% of osteopathic schools). Overall uptake of visual art activities built into the medical students’ curriculum was high, with 96 (83%) schools offering at least one of the categories of visual arts-based engagement. 31% of all schools offer a stand-alone visual arts-based medical humanities course (category 1), 50% cited examples of incorporating art into existing curricula (category 2), 38% sponsored non-curricular visual art school activities (category 3), 16% offered cross enrollment opportunities (category 4), and 38% reported existence of student-lead, extracurricular art-related endeavors (category 5).

Less than a quarter of medical schools require visual art activities

Mandatory visual-arts experiences included orientation exercises, visual arts activities within established foundational courses, and/or visual arts-based activities incorporated in core clinical rotations. Of the 116 responding schools, 26 (22%) required student participation in some form of visual arts-related session. Eleven (31%) of the 36 stand-alone visual-art medical humanities courses reported that these were mandatory classes that all students participated in.

Visual arts-based courses and activities are more often found in allopathic programs

There were statistically significantly more allopathic than osteopathic schools offering stand-alone visual arts courses as well as other exercises integrated into already existing curricula (categories 1 and 2). There were no significant differences in availability of school-sponsored non-curricular activities, opportunity for cross-enrollment, and student-led visual art extra-curricular activities at allopathic and osteopathic schools. And there were no significant differences in rates of compulsory involvement (25% of allopathic schools and 10% of osteopathic medical schools, p = 0.23). (Table 1)

Table 1. Allopathic vs. Osteopathic incorporation of visual art in medical education.

Category	Description	All Medical Schools (n = 116)	Allopathic (n = 95)	Osteopathic (n = 21)
1	Stand-Alone Course**	36 (31%)	35 (37%)	1 (5%)
2	Incorporated into existing Curricula**	58 (50%)	54 (57%)	4 (19%)
3	School-Sponsored, Non-Curricular Activities	44 (38%)	39 (41%)	5 (24%)
4	Cross-Enrollment	18 (16%)	17 (18%)	1 (5%)
5	Student-Led Extracurricular Activities	44 (38%)	39 (41%)	5 (24%)

Percentages are not summative as the categories are not mutually exclusive. Asterisks (**) indicate a statistically significant difference (p-value <0.01).

Schools with formal art courses are more likely to have other school-sponsored, extracurricular, and cross enrollment opportunities

Of the schools reporting having a stand-alone visual arts course, 91% reported having any other visual arts exposures, including within the curriculum and through extracurricular student activities: 55% also incorporated short-term art activities into medical curricula, 56% had student-led extracurricular activities, and 25% offered cross enrollment. Even in schools without a stand-alone visual arts course, the majority (70%) did offer other curricular or extra-curricular opportunities: 32.5% sponsored short-term art related activities, 33% had student-led extracurricular activities, and 12.5% offered cross enrollment. Specific examples of cross-enrollment opportunities included the ability to participate in undergraduate and/or other graduate program courses at the same institution or neighboring institutions as well as enrollment in local art college courses. Additional activities outside of structured stand-alone art courses included extracurricular literary and visual arts journals, student-run art shows, elective, evening museum visits, and opportunities to work on public murals.

Geographic factors may impact uptake of visual art humanities in medical education

36% of all survey responses were from the Southern United States, 31% were from the Northeast, 22% from the Midwest, and 10% from the West. Of the reported stand-alone visual arts medical courses in the US, 17 (47%) were located in the Northeast, 10 (28%) were in the South, 5 (14%) were in the Midwest, and 4 (11%) were on the West Coast; distribution was not statistically significant (p = 0.18). The percentage of schools offering a formal course within a geographic region was calculated to account for regional variation in school density and survey response rates (Figure 1), and although there was a trend toward higher rate of such courses being offered in the Northeast and West Coast regions, this did not reach statistical significance (p = .07). (Figure 1).

Figure 1. Percentage of schools per region that offer formal, stand-alone visual art courses.

Schools with formal art courses were located a median of 1.20 miles from the closest art museum compared to 1.55 miles for schools without a formal course (p = 0.17). Allopathic schools were 1.30 miles from the closest art museum compared to 6.30 miles for osteopathic schools (p = 0.17).

Discussion

Overall, a majority of responding schools offer some type of visual arts-based medical humanities activities which is consistent with current AAMC recommendations to utilize such methods to enhance the humanistic, well-rounded skill set of future physicians. Notably, this study found that the most common way in which schools reported doing so was through integration of visual arts-based methods into foundational courses or rotations and through community-building activities such as during orientation week. Such activities remain largely elective, with less than a quarter of schools reporting consistent use of visual arts-based pedagogies in the core required classes or rotations that all students take. Schools with such mandatory art engagement were 1.6 times more likely to also report elective participation through additional student-run extracurricular activities. It is possible that exposing all students to visual arts-based pedagogies or course activities signifies to students that artistic endeavors are valuable, purposeful, and feasible. Visual arts-based courses that establish connections with local art museums and introduce students to interested faculty mentors may prompt additional extracurricular opportunities and engagement.

Incorporating visual arts-based pedagogies into the medical student curriculum has been shown to improve observational skills, empathy, introspection and self-reflection and reducing burnout [15]. Furthermore, physician empathy is also a predictor of patient-perceived treatment outcomes [16]. Thus, the benefits of utilizing art in medical education is a two way street – benefiting both those delivering and receiving medical care.

Other studies have explored the use of visual art experiences within medical education [15,17–19]. Mukunda et al. highlighted 11 schools in the US (70 globally) that offer such courses and provided specific examples of visual arts-based curricula offered at different institutions. And initiatives such as FRAHME and EODI attempt to maintain current listings of programs engaging in visual arts-based medical humanities [13,14]. This review updates the penetrance of such programs and identifies opportunities in which such endeavors could be expanded, particularly in osteopathic programs and areas without proximity to art museums or without the presence of other undergraduate and graduate programs through which to cross-enroll or collaborate.

We note trends toward formal arts courses being more commonly offered in the Northeast and West and hosted by schools that are closer to art museums, although this was not statistically significant. It is possible that formal courses could be clustered coastally because of urban density as well as of the distribution of knowledgeable faculty willing to mentor and initiate new courses and programs. Virtual coursework in the arts and humanities can be a practical and valuable way to offer such exposure when local or in-person resources are otherwise limited [10]. However, viewing artwork virtually does also have limitations, namely from the two-dimensional rendering of three dimensional pieces and lack of environmental context within the museum. It is also subject to the potential challenges of participant engagement and distraction while on-line. Thus, such curricula could still be disadvantageous compared to those taking place in person. Additionally, the creation and publication of step-by-step syllabi, accessible, and adaptable course plans may make establishing new courses and short-term art activities more practical at schools with fewer local experts, art educators, or other resources. To this effect, the EODI has made several resources, including copies of established course curricula, freely available on-line [14], and a consortium of educators and physicians at University of Pennsylvania created a free year-long web curriculum, Rx/Museum [20]. Over time, such resources may further foster new course development at schools that do not currently have similar courses. However, schools must also be aware of the existence of such resources. There is an increasing body of literature emerging regarding the impact of incorporating visual arts education in healthcare settings. Understanding the impact of arts-based curricula is a critical first step toward a wider-spread uptake of novel teaching strategies. Presenting evidence supporting the integration of the visual arts at the medical student level at national academic meetings, cross-institutional collaboration, and gaining support by educational leadership may also increase dissemination, awareness, and uptake of new arts-based curricula. It will be essential for future studies to be conducted to elucidate the potential social, political, and economic barriers toward incorporating new visual arts-based teaching strategies.

Allopathic schools reported being more likely to host formal courses and to integrate art into the existing curricula compared to osteopathic schools. As the osteopathic curriculum includes additional components of osteopathic manipulation, and many osteopathic students elect to prepare not only for their required COMPLEX exams but also take the USMLE exams required by allopathic schools, it is possible there may be less attention and energy for visual arts-based humanities activities or any other courses considered to be non-essential. The current discrepancy in offerings may also reflect differences in location and geographic access, as well as in funding.

This study was limited by the typical challenges of surveys – incomplete response rate and potential bias by respondents with an interest in this topic. In addition, since this survey was distributed at the outset of the COVID-19 pandemic, it is unknown whether any of the courses or activities reported have been affected by the pandemic. Since the distribution of the survey, on-line courses and access to resources at geographic distance have expanded [10], and this survey did not specifically ask about on-line opportunities or courses. Lastly, the proximity of a medical school to a major art museum may not reflect other resources such as a university art museum or small independent galleries that could be available for collaboration.

Conclusions

This study is the first to quantify the prevalence of visual arts-based educational endeavors in the United States, and we found that most medical schools offer elective experiences incorporating visual arts-based experiences into medical education. Future studies are needed to evaluate the impact of the various visual arts-based pedagogies and exposures during medical school.

Statements and declarations

The authors have no financial or non-financial interests that are directly or indirectly related to the work submitted to publication.

The authors report no conflicts of interest.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

Raw survey responses as well as statistical analyses are available upon request in the format of an excel spreadsheet.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2023.2277500

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.