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Korean J Med Educ > Volume 33(4); 2021 > Article
Smith, Kemp, and Christie: Creating empathetic doctors through art: art-based teaching as a tool for understanding the patient experience, such as miscarriage
Society often struggles with conversations about difficult subjects, even those that are commonly experienced. There are sometimes unspoken rules that constrain and limit our ability to freely communicate difficult emotions, even amongst friends and family. These barriers can lead patients to feel unsupported and unrecognized during times of emotional hardship. The medical education system has a duty to train empathetic doctors who can acknowledge and overcome these barriers. It is now well understood that good medical practice addresses both the physical and the psychosocial elements of illness. With the best care given by clinicians who adopt a patient centered approach with insight into the embodied experience of illness. This raises the question of how is best to teach medical students to understand the patient experience of physical and mental illness.
The creativity of the arts has always encouraged a human-centered approach to education. Art is suggested to improve reflection, empathy, observation, and communication skills [1]. If this method of education were available to clinicians and medical students, it would encourage a more sensitized response to patients, validating and acknowledging their experience of illness. A report by the UK Culture and Wellbeing alliance stated that arts-based teaching has great potential for encouraging this approach [2]. Although there has been a recent uptake in art-based teaching in medical schools, there is still scope for medical teaching to be more aware of the benefits of art.
Art-based teaching encompasses the use of any artform including music, drama, literary, and visual art, all of which can be utilized in a variety of manners to facilitate learning [3]. Art-based interventions are often difficult to evaluate with quantitative outcomes; however, this does not suggest they are without value. Their potential is clearly evidenced by several studies, calling for further integration into medical education [1]. In response to a documented empathy decline in medical trainees, one study investigated the impact of art-based intervention on empathy in students [4]. Teaching techniques such as formal art analysis positively affected student’s cognitive aspects of empathy. In the recent review of “Art in medical education”, similar conclusions could be drawn, as well as the ability of art-based teaching to improve reflection and visual perception skills [5]. While further studies are needed with larger intervention groups, this provides promising support for the integration of art-based teaching into the medical curriculum. Reflection has been shown to be a process that needs active integration into our practice to enable us to learn from experience [6]. Art is a powerful form of reflection and a useful tool with which to equip students in preparation for their life as a doctor. Encouraging students to find ways to reflect on both the patient experience and their own.
White et al. [7] investigated the use of creative responses for reflective study, providing another example of the benefit of art-based teaching for student development. Students were paired with chronically ill volunteer patients, with whom they discussed the illness experience. At the end of the program, the students reflected on the patient experience by producing a creative response. The final products evidence the depth of thought and engagement the creative process stimulated. These created a forum and opportunity for appreciation of the illness experience in student’s formative years. In my first year of medical school, I took part in a similar program. When considering the teaching I have had through medical school, this experience is one that I have always considered to be valuable, as it enabled us to explore the social side of medicine in ways other teaching methods do not allow.
These teaching methods would be best utilized for common patient experiences that suffer from a lack of support. One such area where emotional support has been shown to be neglected both by society and by the medical profession is miscarriage. One in four pregnancies ends in miscarriage, yet many are unaware of how common the experience is unless they have had a miscarriage themselves [8]. Miscarriage is defined as the loss of pregnancy under 24 weeks gestation. Several studies have identified significant emotional consequences of miscarriage including depression and anxiety, just as with other forms of grief [9]. However, miscarriage is not validated by society in the same way other losses are. A study by Swanson et al. [10] identified that women with partners who were unwilling to talk about their loss are most at risk of prolonged depression. This failure by society and loved ones to validate the loss results in what Doka [11] terms “disenfranchised grief”, whereby an unacknowledged loss and isolated grief process complicate and prolong psychological recovery. While it may be difficult at first to create change at a societal level, it is crucial that doctors do not follow these same patterns of behavior. Wong et al. [9] investigated women’s experiences in the United Kingdom after miscarriage, identifying inconsistencies in the way “physical and emotional needs of these patients are addressed after discharge.” Many women felt alone and unsupported by their medical care, further contributing to their disenfranchised grief. There is a need for increased education for clinicians and medical students to ensure appropriate awareness of the emotional impact of miscarriage.
Art-based teaching offers avenues to explore these difficult subjects. There are several great artists who have created pieces on the woman’s experience of miscarriage. Frida Kahlo painted Henry Ford Hospital shortly after having a miscarriage in Detroit. Following which Judy Chicago explored a wide range of emotions and experiences during childbirth and pregnancy. In her book “The birth project”, she discusses how many women experience self-blame after pregnancy complications. More recently, art therapist Laura Seftel created an exhibition that focused on conveying the struggles of miscarriage. These artists offer opportunities for reflective activities and group discussion, which can be coupled with practical classes where students practice art themselves. The art process encourages extended reflection, enabling students to acknowledge the psychosocial aspects of miscarriage with future patients.
Clinicians do not intend to normalize miscarriage, just as they do not intend to upset their patients with their approach. By understanding the realities of the miscarriage experience through this method of art-based teaching, students would be better equipped to respond to their future patients in a caring and appropriate manner. By opening conversations in a clinical setting, we can begin to challenge the silence in society, and importantly, validate the loss women may be feeling after miscarriage.
Such emotional experiences can sometimes have a negative impact. It is important to be aware that these activities may be more difficult for some students than others. For those who have experienced miscarriage, the process is likely to give rise to difficult and unwanted memories. For this reason, arts-based teaching must come with content warnings prior to the session, to ensure no one takes part unwillingly. Students taking part should be made aware of support available within the university and encouraged to discuss any difficulties they have with the instructor either during or after the session. To facilitate private discussion during the session, it is advisable to have two members of staff present at any time. To learn from this method requires engagement with the process; however, the focus of the process is to empathize with the patient experience and not the final artistic product. Therefore, the educational potential of such a program is by no means limited to those who already practice art.
Visual art is just one of many art forms that can be used in medical education. In the White study, students engaged with the patient experience not only by producing visual artworks but also with spoken word and poetry. This illustrates how the same process of reflection and engagement can be achieved through a variety of artforms [7]. Different artforms are likely to benefit medical education in varying ways. For instance, visual art could be used for developing observational skills, whereas spoken word could help teach communication skills, attentive listening or provide a foundation for simulation scenarios or roleplay. The source material used in these educational sessions must also be relatable to students. Content should not be limited to classical examples of art, use of modern art and popular culture could increase engagement from students and should therefore be included where possible. The continuation of research in this area of education would provide us with a greater understanding of the benefit different artforms can have.
It is the duty of clinicians to care for both the body and mind of the patient. In recent years, many medical schools have become strong advocates for patient centered care and reflective practice. While it is important to lecture on these principles it is also vital that students have dedicated practical time to analyze and discuss the patient experience. Use of art-based teaching exercises offers a vital tool for this purpose. Emboldening a generation of future doctors to be both reactive and empathetic to patients embodied experience of illness. These skills are essential in areas such as miscarriage where the patient experience is complex.

Acknowledgments

None.

Notes

Funding
No funding was obtained for this study.
Conflicts of interest
No potential conflict of interest relevant to this article was reported.
Author contributions
Adina Smith: conception, design of the work, drafting the article, and final approval of the version to be published; Oliver Kemp: design of the work and drafting the article; and Sarah Christie: design of the work and critical revision of the article.

References

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