Learning through art
Art-mediated peer-topeer learning of empathy Jordan Potash, Centre on Behavioral Health, The University of Hong Kong Julie Chen, Family Medicine and Primary Care, The University of Hong Kong
SUMMARY Background: Making experiential art in a clinical clerkship offers opportunities for students to gain self-awareness and enhance their empathic understanding of patients. The student-created art can be further used as teaching material for other students. Context: The graduating class of 2012 from Ajou University School of Medicine in South Korea was interested in learning about medical humanities initiatives at the Li Ka Shing Faculty of
Medicine, University of Hong Kong (HKU), and made an educational visit in May 2012. Innovation: As part of the core family medicine curriculum, third-year HKU medical students created poetry and art based on their experiences witnessing patients in pain and suffering. Twenty of the artworks and accompanying reflective writing were chosen for an exhibition. The visiting students viewed the exhibit and created their own art based on their emotional
response to one piece selected from the exhibit. Implications: The combination of viewing art made by their peers and creating art in response resulted in empathic understanding of patient pain and suffering, and an appreciation of holistic care and the value of the doctor–patient relationship. Medical student-generated artwork has the potential to educate both students and professionals on humanistic aspects of medical care.
Students created poetry and art based on their experiences witnessing patients in pain and suffering
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 327–331 327
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Response art leads to a holistic awareness of situations and new perspectives on patient illness
INTRODUCTION
M
aking art is integrated in medical education for experiential learning to initiate transformational change that prompts self-awareness and empathy.1,2 Art created based on one’s emotions about a patient is referred to as response art by art therapists.3 Response art leads to a holistic awareness of situations and new perspectives on patient illness.4 Although useful in itself, medical studentgenerated response art can have uses beyond self-understanding or completion of an assignment. The art can gain new life as teaching material for other students, and as an aid to professional development for educators and practitioners.5 In this article we describe a medical student-generated poetry and art exhibition on the theme of patient pain and suffering that was exhibited, and combined with an art-making workshop, to enhance student empathy.
CONTEXT The graduating class of 2012 from Ajou University School of Medicine in South Korea participated in an educational visit to the Li Ka Shing Faculty of Medicine, University of Hong Kong (HKU), in May 2012 to learn about our medical humanities programme. In addition to formal presentations, students joined experiential workshops on either mindfulness or art.
INNOVATION As a unique approach to engaging medical students in the exploration and understanding of empathy, we initiated a peerto-peer model mediated through viewing and creating art. As the two groups of students came from different cultures, the exhibition additionally offered a cross-cultural learning experience.
Art of empathy: medical student exhibition As part of a 2011/12 medical humanities pilot project, half (n = 81) of the third-year cohort of medical students at HKU participated in an art and poetry workshop during the Family Medicine Clerkship rotation (Box 1). Workshop facilitators included a qualified art therapist and family doctor. We aimed to enhance empathy towards patient pain and suffering, assure relevance to medical practice,
and inspire interest and enjoyment. From the resulting creative work, two members of the project team independently selected and then reached consensus on 20 pieces to exhibit, based on expressing authentic emotions, creating evocative images and use of art materials.6 Students provided their consent to exhibit their poem, art and excerpt from their essay. Students also indicated whether they wanted their name displayed or wished to be anonymous.
Box 1. Art-making workshop for creating the exhibition (2.5 hours) Approximately 25 students per workshop Introduction (10 minutes): purpose and structure of the workshop, ground rules, based on art therapy principles (non-judgemental, based on personal experiences or emotions, confidentiality) Guided visualisation (10 minutes): breathing exercises, followed by memory of a time witnessing patient in pain or suffering Poetry (30 minutes): write words to describe sensory and emotional experiences to describe the memory, arrange as many or as few as the words needed to create a poem Drawing or painting (60 minutes): drawing or painting to depict the poem Display (15 minutes): review the creative work of others Discussion (30 minutes): independent small group and facilitated large group discussion pertaining to observations, themes, and discoveries Reflective essay (homework assignment): describe impact of the creative process and the resultant artwork on your understanding of patients
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Box 2. Response-art workshop (1.5 hours) Introduction (5 minutes): purpose and structure of the workshop, ground rules, based on art therapy principles (non-judgemental, based on personal experiences or emotions, confidentiality) Viewing the exhibition (15 minutes): self-guided tour of exhibition, select one piece that is ‘meaningful to you’, relational aesthetic questionnaire Response art (45 minutes): sit facing selected piece and create art based on emotional response Reflective writing (10 minutes): brief reflection on image created Discussion (15 minutes): independent small group and facilitated large group discussion pertaining to observations, themes and discoveries
Understanding pain and suffering: response-art workshop Following an introductory presentation on the HKU medical humanities programme, 14 students from Ajou University were welcomed to the art studio where the exhibition was installed. They participated in a workshop based on the principles of relational aesthetics,7 which prompts emotional engagement with art, and with procedures intended to induce empathy through viewing and creating art (Box 2).8
At the window, we both stare On the street, the sun is shining bright
the doctor holding the hand of the patient and looking eye-toeye, the student demonstrated how displays of empathy can positively affect patients. Holistic care Students also demonstrated their appreciation for holistic care by pairing responses for prescriptive conventional medical treatment with other non-medical approaches to management. An abstracted clock drawn with oil pastels was used to describe an ‘unpredictable, anxious, frightened, red, musky, future’ of a young patient living with HIV. A student who responded to this drawing copied the clock pattern and repeated it to form a flower (Figure 2). She wrote:
One of the goals was to foster student empathy through both viewing art and reflecting on it through response art
From the picture I’ve chosen, I felt strong anxiety and insecurity of the HIV patient. In my drawing, One of the students responded I tried to understand the to the piece by drawing the patient’s insecurity by the figures coming together in full colour, with the description, ‘Pain color red, and by gathering makes the world dark, but several more HIV patients, communication makes the world their anxiety could be IMPLICATIONS bright. If you share patient’s diminished and with close pain, you give a hope to the Students enjoyed the workshop and people around them, more patient and the world becomes described it as a meaningful way to bright’ (Figure 1). By depicting of their anxiety could be To the man, everything is just black and white
learn. Their art and reflective writing demonstrated core lessons of a medical humanities curriculum and family medicine values, including empathy, holistic care and doctor– patient relationships.
Empathy One of the goals was to foster student empathy through both viewing art and reflecting on it through response art. Several of the students focused on having empathy for the patient situation depicted, or for the medical student artist who created the art. An exhibit piece of two individuals in a hospital room, one in black and white and the other in colour, was accompanied by the following poem.
Thinking about the past, he murmurs in despair
Exhibited art
Response art
Figure 1. Empathy
Exhibited art
Response art
Figure 2. Holistic care
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 327–331 329
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Participation increased [students’] present state of empathy
diminished, making a bright glowing flower, which reflects our dream. Building on the artist’s focus on the emotions of the patient, the student responded with a suggestion for decreasing loneliness by extending the patient’s social network. The repetition and gathering together of similar forms reinforced the importance of attending to both biomedical and psychosocial needs. Doctor–patient relationships Acquiring empathy and recommending holistic care options relates to the importance of the doctor–patient relationship for comprehensive care. A chalk pastel drawing in the exhibit depicted a patient walking towards a yellow-lit doorway with her hand holding the hand of an unseen figure. The accompanying poem contained the line, ‘I can feel the pressure which is painful and makes me nervous’. In response to this drawing, a student depicted a doctor (Figure 3), and wrote:
Pain is still same. But if hope remains and there’s someone with me, I can overcome the pain. Doctors could be that someone… By identifying the supportive hand as that of a doctor, this response shows that a doctor can be more than the person who
Table 1. Mean scores for each item on the relational aesthetics questionnaire (ordered by ranking) Questionnaire item
Mean Score
The artist seems to be expressing important feelings
3.57
The art moves me
3.29
I was interested in the subject matter and content of the art
3.07
I was interested in the colours used in this art
2.93
I wanted to know more about this art
2.93
The artist seemed to be passionate about creating this art
2.79
I was interested in the style that the artist used to create the art
2.50
I wanted to know more about the artist
2.50
The art reminds me of an experience someone I know had
2.21
The art reminds me of an experience I had
1.50
Likert scale: 0, does not describe my reason for choosing…; 4, describes my reason for choosing…
accurately diagnoses and properly treats. Doctors can also be the one to accompany patients towards healing. Relational aesthetics questionnaire The relational aesthetics questionnaire was intended to prompt the students to focus their attention to their initial reasons for selecting one piece of art, and to help them relate to it emotionally.8 Our findings demonstrated that the art the students found meaningful were pieces that were emotionally expressive (‘seems to be expressing important feelings’) and evocative (‘art that moves me’) (Table 1).
Exhibited art Figure 3. Relationship between doctor and patient
Response art
State Empathy Scale We included an empathy scale to understand what effect the workshop may have on student empathy. Before and after the workshop, students completed the State Empathy Scale, which asks respondents to rate their present feelings on eight items.9 Five adjectives (softhearted, empathic, warm, concerned and compassionate) indicate empathic concern, whereas the remaining three adjectives (upset, alarmed and troubled) measure personal distress. Analysing the data with descriptive statistics, the results suggest that participation increased their present state of empathy (Figure 4). Limitations Although the workshop seemed to have the desired effect, there are limitations. The small and non-representative sample size impedes the generalisability of the findings. As the findings may be influenced by social desirability, it is unclear how empathy generated in the workshop may translate to actual patient encounters.
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3.00 2.50
REFERENCES PRE
1.
Law S. Using narratives to trigger reflection. Clin Teach 2011;8: 147–150.
2.
Frei J, Alvarez SE, Alexander MB. Ways of seeing: Using the visual arts in nursing education. J Nursing Ed 2010;49:672–676.
3.
Fish BJ. Response art: The art of the art therapist. Art Therapy: Journal of the American Art Therapy Association 2012;29:138–143.
4.
Moon BL. The role of metaphor in art therapy: Theory, method, and experience. Springfield, IL: Charles C. Thomas; 2007.
5.
Kelly M, Bennet D, O’Flynn S, Foley T. A picture tells 1000 words: learning teamwork in primary care. Clin Teach 2013;10:113–117.
6.
Kramer E. On quality in art and art therapy. American Journal of Art Therapy 2002;40:218–218.
7.
Moon CH. Studio art therapy: Cultivating the artist identity in the art therapist. Philadelphia, PA: Jessica Kingsley; 2002.
8.
Potash JS, Ho RTH. Drawing involves caring: Fostering relationship building through art therapy for social change. Art Therapy: Journal of the American Art Therapy Association 2011;28:74–81.
9.
Coke JS, Batson CD, McDavis K. Empathic mediation of helping: A two-stage model. Journal of Personality and Social Psychology 1978;36:752–766.
POST
2.00 1.50 1.00 0.50 0.00
Figure 4. Mean scores on state empathy scale by item, and by index, before and after workshop Likert scale: 0, not at all; 4, extremely
CONCLUSION Making art may offer medical students an opportunity not only for increased awareness regarding their own and their patients’ emotions, but also to educate each other on the important role that empathy plays in the medical profession. Through creating art, viewing art and creating additional art in response, the arts become a structure for continuous
dialogue. One student’s learning may become the impetus for another student, thereby forging a connection between peers. As an additional application, this process does not have to end in medical school. Such exhibitions and art-making workshops may be extended to practising doctors, nurses and other health care professionals for their own professional development, and to enhance patient empathy.
One student’s learning may become the impetus for another student, thereby forging a connection between peers
Corresponding author’s contact details: Dr Jordan Potash, Centre on Behavioral Health, The University of Hong Kong, 2/F Hong Kong Jockey Club for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong. E-mail: [email protected]
Funding: Development Fund for Medical Humanities, Li Ka Shing Faculty of Medicine, The University of Hong Kong. Conflict of interest: None. Ethical approval: The Human Research Ethics Committee for non-clinical faculties at The University of Hong Kong granted ethical approval (ref. no. EA150811). doi: 10.1111/tct.12157
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 327–331 331
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Art-mediated peer-topeer learning of empathy Jordan Potash, Centre on Behavioral Health, The University of Hong Kong Julie Chen, Family Medicine and Primary Care, The University of Hong Kong
SUMMARY Background: Making experiential art in a clinical clerkship offers opportunities for students to gain self-awareness and enhance their empathic understanding of patients. The student-created art can be further used as teaching material for other students. Context: The graduating class of 2012 from Ajou University School of Medicine in South Korea was interested in learning about medical humanities initiatives at the Li Ka Shing Faculty of
Medicine, University of Hong Kong (HKU), and made an educational visit in May 2012. Innovation: As part of the core family medicine curriculum, third-year HKU medical students created poetry and art based on their experiences witnessing patients in pain and suffering. Twenty of the artworks and accompanying reflective writing were chosen for an exhibition. The visiting students viewed the exhibit and created their own art based on their emotional
response to one piece selected from the exhibit. Implications: The combination of viewing art made by their peers and creating art in response resulted in empathic understanding of patient pain and suffering, and an appreciation of holistic care and the value of the doctor–patient relationship. Medical student-generated artwork has the potential to educate both students and professionals on humanistic aspects of medical care.
Students created poetry and art based on their experiences witnessing patients in pain and suffering
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 327–331 327
tct_12157.indd 327
7/7/2014 8:29:42 PM
Response art leads to a holistic awareness of situations and new perspectives on patient illness
INTRODUCTION
M
aking art is integrated in medical education for experiential learning to initiate transformational change that prompts self-awareness and empathy.1,2 Art created based on one’s emotions about a patient is referred to as response art by art therapists.3 Response art leads to a holistic awareness of situations and new perspectives on patient illness.4 Although useful in itself, medical studentgenerated response art can have uses beyond self-understanding or completion of an assignment. The art can gain new life as teaching material for other students, and as an aid to professional development for educators and practitioners.5 In this article we describe a medical student-generated poetry and art exhibition on the theme of patient pain and suffering that was exhibited, and combined with an art-making workshop, to enhance student empathy.
CONTEXT The graduating class of 2012 from Ajou University School of Medicine in South Korea participated in an educational visit to the Li Ka Shing Faculty of Medicine, University of Hong Kong (HKU), in May 2012 to learn about our medical humanities programme. In addition to formal presentations, students joined experiential workshops on either mindfulness or art.
INNOVATION As a unique approach to engaging medical students in the exploration and understanding of empathy, we initiated a peerto-peer model mediated through viewing and creating art. As the two groups of students came from different cultures, the exhibition additionally offered a cross-cultural learning experience.
Art of empathy: medical student exhibition As part of a 2011/12 medical humanities pilot project, half (n = 81) of the third-year cohort of medical students at HKU participated in an art and poetry workshop during the Family Medicine Clerkship rotation (Box 1). Workshop facilitators included a qualified art therapist and family doctor. We aimed to enhance empathy towards patient pain and suffering, assure relevance to medical practice,
and inspire interest and enjoyment. From the resulting creative work, two members of the project team independently selected and then reached consensus on 20 pieces to exhibit, based on expressing authentic emotions, creating evocative images and use of art materials.6 Students provided their consent to exhibit their poem, art and excerpt from their essay. Students also indicated whether they wanted their name displayed or wished to be anonymous.
Box 1. Art-making workshop for creating the exhibition (2.5 hours) Approximately 25 students per workshop Introduction (10 minutes): purpose and structure of the workshop, ground rules, based on art therapy principles (non-judgemental, based on personal experiences or emotions, confidentiality) Guided visualisation (10 minutes): breathing exercises, followed by memory of a time witnessing patient in pain or suffering Poetry (30 minutes): write words to describe sensory and emotional experiences to describe the memory, arrange as many or as few as the words needed to create a poem Drawing or painting (60 minutes): drawing or painting to depict the poem Display (15 minutes): review the creative work of others Discussion (30 minutes): independent small group and facilitated large group discussion pertaining to observations, themes, and discoveries Reflective essay (homework assignment): describe impact of the creative process and the resultant artwork on your understanding of patients
328 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 327–331
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Box 2. Response-art workshop (1.5 hours) Introduction (5 minutes): purpose and structure of the workshop, ground rules, based on art therapy principles (non-judgemental, based on personal experiences or emotions, confidentiality) Viewing the exhibition (15 minutes): self-guided tour of exhibition, select one piece that is ‘meaningful to you’, relational aesthetic questionnaire Response art (45 minutes): sit facing selected piece and create art based on emotional response Reflective writing (10 minutes): brief reflection on image created Discussion (15 minutes): independent small group and facilitated large group discussion pertaining to observations, themes and discoveries
Understanding pain and suffering: response-art workshop Following an introductory presentation on the HKU medical humanities programme, 14 students from Ajou University were welcomed to the art studio where the exhibition was installed. They participated in a workshop based on the principles of relational aesthetics,7 which prompts emotional engagement with art, and with procedures intended to induce empathy through viewing and creating art (Box 2).8
At the window, we both stare On the street, the sun is shining bright
the doctor holding the hand of the patient and looking eye-toeye, the student demonstrated how displays of empathy can positively affect patients. Holistic care Students also demonstrated their appreciation for holistic care by pairing responses for prescriptive conventional medical treatment with other non-medical approaches to management. An abstracted clock drawn with oil pastels was used to describe an ‘unpredictable, anxious, frightened, red, musky, future’ of a young patient living with HIV. A student who responded to this drawing copied the clock pattern and repeated it to form a flower (Figure 2). She wrote:
One of the goals was to foster student empathy through both viewing art and reflecting on it through response art
From the picture I’ve chosen, I felt strong anxiety and insecurity of the HIV patient. In my drawing, One of the students responded I tried to understand the to the piece by drawing the patient’s insecurity by the figures coming together in full colour, with the description, ‘Pain color red, and by gathering makes the world dark, but several more HIV patients, communication makes the world their anxiety could be IMPLICATIONS bright. If you share patient’s diminished and with close pain, you give a hope to the Students enjoyed the workshop and people around them, more patient and the world becomes described it as a meaningful way to bright’ (Figure 1). By depicting of their anxiety could be To the man, everything is just black and white
learn. Their art and reflective writing demonstrated core lessons of a medical humanities curriculum and family medicine values, including empathy, holistic care and doctor– patient relationships.
Empathy One of the goals was to foster student empathy through both viewing art and reflecting on it through response art. Several of the students focused on having empathy for the patient situation depicted, or for the medical student artist who created the art. An exhibit piece of two individuals in a hospital room, one in black and white and the other in colour, was accompanied by the following poem.
Thinking about the past, he murmurs in despair
Exhibited art
Response art
Figure 1. Empathy
Exhibited art
Response art
Figure 2. Holistic care
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 327–331 329
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7/7/2014 8:29:48 PM
Participation increased [students’] present state of empathy
diminished, making a bright glowing flower, which reflects our dream. Building on the artist’s focus on the emotions of the patient, the student responded with a suggestion for decreasing loneliness by extending the patient’s social network. The repetition and gathering together of similar forms reinforced the importance of attending to both biomedical and psychosocial needs. Doctor–patient relationships Acquiring empathy and recommending holistic care options relates to the importance of the doctor–patient relationship for comprehensive care. A chalk pastel drawing in the exhibit depicted a patient walking towards a yellow-lit doorway with her hand holding the hand of an unseen figure. The accompanying poem contained the line, ‘I can feel the pressure which is painful and makes me nervous’. In response to this drawing, a student depicted a doctor (Figure 3), and wrote:
Pain is still same. But if hope remains and there’s someone with me, I can overcome the pain. Doctors could be that someone… By identifying the supportive hand as that of a doctor, this response shows that a doctor can be more than the person who
Table 1. Mean scores for each item on the relational aesthetics questionnaire (ordered by ranking) Questionnaire item
Mean Score
The artist seems to be expressing important feelings
3.57
The art moves me
3.29
I was interested in the subject matter and content of the art
3.07
I was interested in the colours used in this art
2.93
I wanted to know more about this art
2.93
The artist seemed to be passionate about creating this art
2.79
I was interested in the style that the artist used to create the art
2.50
I wanted to know more about the artist
2.50
The art reminds me of an experience someone I know had
2.21
The art reminds me of an experience I had
1.50
Likert scale: 0, does not describe my reason for choosing…; 4, describes my reason for choosing…
accurately diagnoses and properly treats. Doctors can also be the one to accompany patients towards healing. Relational aesthetics questionnaire The relational aesthetics questionnaire was intended to prompt the students to focus their attention to their initial reasons for selecting one piece of art, and to help them relate to it emotionally.8 Our findings demonstrated that the art the students found meaningful were pieces that were emotionally expressive (‘seems to be expressing important feelings’) and evocative (‘art that moves me’) (Table 1).
Exhibited art Figure 3. Relationship between doctor and patient
Response art
State Empathy Scale We included an empathy scale to understand what effect the workshop may have on student empathy. Before and after the workshop, students completed the State Empathy Scale, which asks respondents to rate their present feelings on eight items.9 Five adjectives (softhearted, empathic, warm, concerned and compassionate) indicate empathic concern, whereas the remaining three adjectives (upset, alarmed and troubled) measure personal distress. Analysing the data with descriptive statistics, the results suggest that participation increased their present state of empathy (Figure 4). Limitations Although the workshop seemed to have the desired effect, there are limitations. The small and non-representative sample size impedes the generalisability of the findings. As the findings may be influenced by social desirability, it is unclear how empathy generated in the workshop may translate to actual patient encounters.
330 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 327–331
tct_12157.indd 330
7/7/2014 8:29:53 PM
3.00 2.50
REFERENCES PRE
1.
Law S. Using narratives to trigger reflection. Clin Teach 2011;8: 147–150.
2.
Frei J, Alvarez SE, Alexander MB. Ways of seeing: Using the visual arts in nursing education. J Nursing Ed 2010;49:672–676.
3.
Fish BJ. Response art: The art of the art therapist. Art Therapy: Journal of the American Art Therapy Association 2012;29:138–143.
4.
Moon BL. The role of metaphor in art therapy: Theory, method, and experience. Springfield, IL: Charles C. Thomas; 2007.
5.
Kelly M, Bennet D, O’Flynn S, Foley T. A picture tells 1000 words: learning teamwork in primary care. Clin Teach 2013;10:113–117.
6.
Kramer E. On quality in art and art therapy. American Journal of Art Therapy 2002;40:218–218.
7.
Moon CH. Studio art therapy: Cultivating the artist identity in the art therapist. Philadelphia, PA: Jessica Kingsley; 2002.
8.
Potash JS, Ho RTH. Drawing involves caring: Fostering relationship building through art therapy for social change. Art Therapy: Journal of the American Art Therapy Association 2011;28:74–81.
9.
Coke JS, Batson CD, McDavis K. Empathic mediation of helping: A two-stage model. Journal of Personality and Social Psychology 1978;36:752–766.
POST
2.00 1.50 1.00 0.50 0.00
Figure 4. Mean scores on state empathy scale by item, and by index, before and after workshop Likert scale: 0, not at all; 4, extremely
CONCLUSION Making art may offer medical students an opportunity not only for increased awareness regarding their own and their patients’ emotions, but also to educate each other on the important role that empathy plays in the medical profession. Through creating art, viewing art and creating additional art in response, the arts become a structure for continuous
dialogue. One student’s learning may become the impetus for another student, thereby forging a connection between peers. As an additional application, this process does not have to end in medical school. Such exhibitions and art-making workshops may be extended to practising doctors, nurses and other health care professionals for their own professional development, and to enhance patient empathy.
One student’s learning may become the impetus for another student, thereby forging a connection between peers
Corresponding author’s contact details: Dr Jordan Potash, Centre on Behavioral Health, The University of Hong Kong, 2/F Hong Kong Jockey Club for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong. E-mail: [email protected]
Funding: Development Fund for Medical Humanities, Li Ka Shing Faculty of Medicine, The University of Hong Kong. Conflict of interest: None. Ethical approval: The Human Research Ethics Committee for non-clinical faculties at The University of Hong Kong granted ethical approval (ref. no. EA150811). doi: 10.1111/tct.12157
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 327–331 331
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7/7/2014 8:29:56 PM
