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Original article
Teaching medical humanities in the digital world: affordances of technology-enhanced learning Sandra Joy Kemp,1 Giskin Day2 1
Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 2 Centre for Co-Curricular Studies, Imperial College London, London, UK Correspondence to Dr Sandra Joy Kemp, Lee Kong Chian School of Medicine, Novena Campus, 11 Mandalay Road, 308232, Singapore; [email protected] Accepted 26 June 2014 Published Online First 16 July 2014
ABSTRACT Medical humanities courses are typically taught in face-to-face teaching environments, but now medical humanities educators, alongside educators from other disciplines, are facing shifts in higher education towards online (and sometimes open) courses. For the medical humanities educator, there is limited guidance regarding how technology-enhanced learning design can support the learning outcomes associated with medical humanities. This article aims to provide useful direction for such educators on how digital technologies can be used through learner-focused pedagogies. Specific examples are provided as to how the affordances of Web 2.0 and other tools can be realised in innovative ways to help achieve skills development within the medical humanities. The guidance, alongside the practical suggestions for implementation, can provide important conceptual background for medical humanities educators who wish to embrace technology-enhanced learning, and reconceptualise or redesign medical humanities for an online or blended teaching environment.
INTRODUCTION
To cite: Kemp SJ, Day G. Med Humanit 2014;40:125–130.
A paradigm shift in pedagogy across higher education is imminent. There is a growing demand for university courses in blended, online and distance learning environments. Medical humanities courses, along with other disciplines within medical education, will be expected to adapt to meet this demand. The advent of Massive Open Online Courses (MOOC) also points towards shifts in higher education that may disrupt the hitherto firmly entrenched tradition of face-to-face teaching in the medical humanities. As noted by others, many medical students are already involved in virtual spaces through social networking, video sharing and blogging.1 Contributing to, and producing digital content will be familiar to many educators and students in medicine. Given this, the use of technology in mediating students’ learning is becoming a critical area for educators. Ensuring that medical educators and students are knowledgeable about emerging ethical issues associated with participating in online communities and creating digital content, is becoming increasingly important. Although some educators have experimented with e-modules in the medical humanities (see, eg, Giordano2), guidance for medical humanities educators is sparse. It is clear that how the medical humanities community responds to anticipated new demands for virtual learning, and the changes involving the use of digital technologies, is an important concern. Pederson3 and Shapiro et al,4 among others, have called for humanities to be situated inside the
‘hard core’ of medicine, rather than being seen as a ‘soft add-on’. In an already overcrowded medical curriculum, technology-enhanced learning provides a useful opportunity to integrate humanities with the teaching of science, where humanities-type sources (eg, patient pathographies, artworks, fiction and graphic novels) are made available as core learning materials alongside medical texts, possibly accompanied by assessment that calls for nuanced interpretations. This article aims to outline technology-enhanced learning design considerations, and puts forward practical suggestions for medical humanities educators who want to, or need to, reconceptualise or redesign medical humanities for learning and teaching in online environments. We briefly discuss some underpinning concepts and approaches to learning associated with different general learning objectives in medical humanities, and then offer suggestions for technology-enhanced learning activities that can be conducted in online environments. We also consider some of the challenges associated with introducing technology-enhanced learning in the medical humanities. As this article is primarily concerned with practical suggestions for educators, space precludes an in-depth consideration of theoretical perspectives, although this is not to suggest that these are not important in any consideration of technologyenhanced learning contexts. Our suggestions are grounded in a belief that new ways of thinking about skills in the digital age are now required due to contexts for learning and changes in creative, participation, and production practices enabled by Web 2.0. Theories of learning with technologies, such as situated learning (in the context of video gaming),5 a learning ecologies perspective,6 and the community of inquiry framework,7 highlight different ways of understanding and thinking about learning and digital pedagogies. In particular, Web 2.0 capabilities such as: simultaneous involvement in many settings; creation of personalised learning contexts; and, permeability of boundaries online are some of the factors that have had an impact on the ways in which educators and researchers now think about knowledge, expertise and learning.6 8 From the educator perspective, well-designed technology-enhanced learning must aim to move beyond merely placing the student in information retrieval roles vis à vis the web,9 commonly depicted in information transmission conceptualisations of teaching. The affordances of Web 2.0 tools (such as social networking sites, blogs, wikis, video sharing sites, etc.) in terms of encouraging sharing of work, promoting creativity and stimulating collaboration, have the potential to creatively enhance
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Original article learning in innovative ways. For medical humanities educators in higher education institutions, access to a VLE (Virtual Learning Environment) and Web 2.0 tools, as well as the growing popularity of tablet devices, opens many opportunities for stimulating and effective virtual learning activities—activities that will shape practices and output of medical humanities students.
reflectivity using this method than with other reflective writing.18 Social media has also been advocated as a means of helping students to explore ‘social reflection’ which could helpfully improve interactions with patients.19 Blog tools within an e-portfolio (eg, software applications such as Myprogress by MyKnowledgeMap) allow students and faculty to share and view contributions individually or collectively.
Digital pedagogies and approaches to learning in the medical humanities
Encouraging collaborative learning
Effective technology-enhanced learning design should be consonant with learner-focused pedagogy, a familiar concept to experienced educators. One of the fundamental underlying principles of learner-focused pedagogy is ‘constructive alignment’.10 That is, the learning experiences should be appropriate for achieving the learning objectives and for completing assessment tasks. Embedded in the concept of constructive alignment is the idea that educators should be concerned with how students engage in tasks that are structured to challenge, change or add to existing beliefs and knowledge.11 Such tasks should be aimed at developing students’ understandings of their own cognitive and learning processes. Attention to the individual student’s understandings of knowledge in the discipline is important for teaching and learning that is learner-focused.12 A simple example of learner-focused pedagogy would include facilitation of group dialogue where the purpose of dialogue is to explore an element of the domain/discipline which leads to deeper understanding of a topic.13 This is a common approach in medical humanities contexts. Although the features of learner-focused pedagogy are well recognised in face-to-face teaching environments, achieving this in online learning environments requires leveraging on the affordances of digital technologies. The features and uses of technology are seen as different to the affordances for teaching. A tool, such as a blog, may have the features of image upload and text input. It could be used by students to record an event that day. However, the affordances for teaching could be that the blog is used as a mechanism for creating opportunities for students to document their changing thinking over time in relation to, for example, personal/professional boundaries, end-of-life issues or resource allocation in healthcare. Learning can be enhanced by peer and educator feedback on individual blog entries. The emphasis is on how required skills and knowledge of the discipline inform learning design and its implementation in ways that mean the affordances for teaching can change student learning. We now consider two examples of how digital pedagogies can contribute to key approaches to learning often associated with medical humanities courses: enhancing reflective learning,14 and encouraging collaborative learning.15
Enhancing reflective learning Reflective learning is a high priority in medical education, and medical humanities is considered to be an effective means of advancing ‘reflective habits of mind’.4 E-portfolios have been shown to develop reflective capabilities and encourage selfdirected learning.16 The advantage of an e-portfolio for the medical humanities is that students are able to demonstrate interdisciplinary learning through including humanities sources in their reflective writing. A JISC report identified the opportunity to be creative as important to students and calls for future research into the use of digital stories as artefacts to complement text-based material in e-portfolios.17 Using a class blog can be an effective means of promoting reflection, with one study finding a higher incidence of 126
Bleakley and Marshall15 have recently criticised curriculum designs that “refuse to place collaboration at the heart of learning”. [p 128] They have called for ‘democratic habits’ to be given more emphasis. These aim to challenge the powerful culture of autonomy and heroic individualism that contribute to high rates of medical error through dysfunctional teamwork, poor communication and a decline in empathy. Technology can be used as a medium through which collaborative learning can be developed away from pre-existing classroom hierarchies. Teamwork is an essential skill that can help reduce medical error, improve patient care and reduce workload issues that contribute to burnout.20 Although it may not be a desired substitute for face-to-face collaboration in clinical settings, academic medical humanities teaching can be facilitated using virtual groups. Given stimulus material such as a pathography to read, students can use a wiki to create a collective response. Upon completion, the wiki could be opened to other groups and shared with them. Students could also rate the response they consider to be the most useful. Alternatively, wikis could form the basis of a summative assessment task as wiki tools allow for contributions by individual students to be viewed and graded.
LEARNING IN MEDICAL HUMANITIES We consider three illustrative broad areas related to learning that may be fostered by medical humanities teaching. Each of these areas offers opportunities for educators in medical humanities to leverage on the affordances of technology-enhanced learning. The three areas and the associated learning outcomes considered in this article are where medical humanities is seen as important for ▸ Enhancing understanding of patients’ experiences of illness21 ▸ Developing a tolerance of ambiguity22 ▸ Fostering development of creativity through engagement with the arts23 24 These three different areas and common general learning outcomes associated with each will be considered in turn.
Enhancing understanding of patients’ experiences of illness An online environment can easily provide access to texts not normally given emphasis in traditional curricula but which are increasingly important in the lives of patients, for example, blogs and online support forums. This would go some way to meeting the call by Shapiro et al4 for the inclusion of more types of narratives in addition to the restitution narrative (which refers to the idea that illness is temporary and a restoration of health is taken for granted) that dominates in medicine, so that students can gain a more holistic sense of the impact of illness on the human condition. In online environments, the use of personalised learning pathways can draw upon the feature of certain software applications to release ‘adaptively’ each step in a sequence of learning activities in a pathway. That is, an activity must be completed before the next activity is released. Often software allows for certain criteria to be preset. This means that different students experience different learning activities, depending on their responses. Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
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Original article This is commonly used in many web-based Virtual Patient software applications in medicine, where the medical student is typically presented with a case, and makes decisions about the treatment of the patient in a simulated environment. Some VLEs allow simple branching options, and this mechanism can be used to develop a set of activities which guide the student through a patient’s experience of, for example, the healthcare pathway or a treatment protocol. In medical humanities courses, students often are provided with books and movies recommended for reading or viewing. When this type of material is used, learning is enhanced if activities are structured around the book-reading/movie-viewing task, so that the student’s attention is directed to key features, understandings and interpretations. Typically, this is achieved through ‘chunking’ of the larger task (of reading the whole book) into excerpts. Then, activities are used to prompt and check for understanding. In an online environment, these can range from mini-tasks, such as short paragraph writing in response to specific questions, participation in online discussions facilitated by the teaching staff/peers, posting of reflections on a blog, and keeping a journal while reading the book. Shapiro et al4 point out the value of the tradition of critical inquiry in humanities that can encourage reflective habits in students. Students then can appreciate the perspectives of others and develop ‘humanistic competencies’ that focus on values, helping medicine to move beyond algorithms and checklists. If time constraints preclude students reading the entire book, and it is not desirable to use selective excerpts, different students can be allocated different parts of the book to read. Student 1 reads chapter 1, student 2 reads chapter 2 and so on. Each student could provide a short précis of each chapter. These can then be converted to PDF format, and combined into one document, as a PDF portfolio. This document can be distributed online to the students so that they can be exposed to other chapters in the book. A variation of this would be to allocate different chapters to students in pairs or students in small groups. The benefit of work in pairs is that it increases the feeling of ‘presence’ in the online environment.
Developing understandings of the viewpoints of others In medical humanities, the different perspectives of the humanities disciplines can be used by students to engage with problems from different viewpoints. Sometimes this is seen as a way to help medical students communicate better with patients, or develop humane judgement, or as ‘solace’ from the demands of medicine.25 To develop students’ understandings of the viewpoints of others, completing a reading/viewing task in a self-directed manner with follow-up tasks for formative feedback can be used. This allows the educator to check that students have completed the reading activity and have begun thinking about relevant issues. The questions should be predominantly open-ended, allowing for divergent responses by the students. For example, in reference to Jean-Dominique Bauby’s The diving bell and the butterfly,26 a commonly prescribed text in medical humanities: Why do you think the incident, which triggered the protagonist’s condition, was not described until the end of the book? As a reader, which incident described in the book had an impact on you and why? How could the health care providers described in the book have acted differently? Closed questions will prompt students to search for the ‘correct’ answer. For example: Which symptoms led to the protagonist being admitted to hospital? In medical humanities, the emphasis should be more on thinking about and understanding Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
differing perspectives. Open-ended questions will create an environment where this is more likely. Tasks that foreground the subjective experience of illness, in which students can themselves set questions that stimulate further discussion and reflection, are likely to lead to rewarding and useful discussion.
Encouraging different ways of theorising, interpreting and recording human experiences Some proponents claim that the study of the theoretical structure of the humanities helps students understand and interpret human experience with, for example, illness, disability and medicine. Developing an understanding of the boundaries of the different epistemologies (theories of knowledge) of the humanities and the biomedical sciences is emphasised, and it is suggested that this can help medicine develop a more complete conception of human nature.27 It is also argued that this may help to handle uncertainty in medical practice.28 The online environment could be used to expose students to different interpretations of empirical data and the idea of ‘underdetermination’ of scientific theory.29 Developing skills in how different conceptual knowledge frameworks influence the interpretation of data can begin through encounters with published research in other disciplines that can inform medicine. It would be fruitful to focus on research that analyses qualitative data, as this is likely to be less familiar to medical students. Examples could include research work on different societies/cultures (which could link to understanding other ethnic groups/ cultures) from the discipline of anthropology, or the analysis of communication discourse (which could link to communicating with patients) from the discipline of linguistics. An example for when students study epilepsy is that they could read, alongside clinical texts, extracts from Anne Fadiman’s acclaimed book The spirit catches you and you fall down30 which documents the profound effects of cultural differences in conceptions of epilepsy in the Hmong community in Merced, and those of healthcare professionals. Students could also view online Susan Aldworth’s series of prints ‘The portrait anatomised’.31 The portraits explore the neuroscience and the lived experience of patients with epilepsy through brain scans, drawings, photographs and interviews. These sources also lend themselves well to creative tasks. For example, students could create their own ‘portrait anatomised’ based on case studies they have encountered, or write short narratives from the points of view of the different ‘characters’ from Anne Fadiman’s book. A related activity could be one where the students are presented with a qualitative dataset. In the context of epilepsy, for example, interpretive phenomenological research on people’s seizure experiences could be accessed online.32 In pairs, students contribute to a wiki, which describes how the different approaches taken in the stimulus materials have enhanced their understanding of epilepsy. After completion, each pair then reviews and critiques, or contributes to the wiki of another pair with the same set of data. The final step is that all pairs working on the same dataset compare and contrast answers through an online discussion forum. Another activity could be to provide students with a task brief to create three parallel narratives which tell the historical story of a disease from, variously, the perspectives of a patient, a doctor and policymakers. Using photos and text, students can create an e-book to present the project which can be then displayed (as described in the preceding discussion). Students could also engage in peer evaluation of each e-book, through the use of a criteria-marking scheme (or rubric) which describes the criteria and standards for evaluation. If students do not have 127
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Original article e-book software, students can create the book as a Microsoft Word document and save it in PDF format.
Developing a tolerance of ambiguity Medical education often emphasises problem solving and knowledge as empowering decision making. Luther and Crandall22 use Schön’s33 metaphor of professional practice as ‘the high, hard ground overlooking a swamp’. They argue that, in medicine, the high, hard ground is the scientific zone, which is ‘fact based, predictable and consists of solvable problems’ [ p 800]. By contrast, the artistic or indeterminate (messy) zone is characterised by conflict and ambiguity. Students are often anxious about operating in the artistic zone, leading to calls for dedicating time to address ambiguity and uncertainty as a formal part of medical school curricula.15 22 The arts, for which uncertainty and ambiguity are intrinsic, are an obvious conduit for developing skills in dealing with situations in which multiple interpretations are possible, focusing attention on strengths and weaknesses of competing explanations rather than arriving at a single ‘solution’.
Developing narrative competence Poetry is one type of narrative that lends itself well to increasing a tolerance of ambiguity, as well as developing students’ narrative competence. In an online environment, poems on a topic relevant to a particular clinical area can be displayed side by side in tools, such as LAMS (Learning Activity Management System) or a VLE (eg, applications such as Blackboard, Moodle and Sakai). Students can be asked to list commonalities between the two poems, as well as differences. The advantage of comparison is that it requires analysis. Students who lack confidence in poetic analysis might be tempted to search for established readings of well-known poems, but requiring compare-and-contrast analyses means that they must approach the poems with some originality of thinking. Short open-ended questions to be completed by students can focus on differences, such as imagery, narrative voice, tense and tone. The purpose is to develop their skills in narrative attentiveness to the poet as well as the topic. If LAMS is used, the student is able to submit her/his answer to each question, and then view the answers of other students. This supports learning from peers and promotes online dialogue if further iterations are designed. An online learning environment has the advantage of allowing all students to contribute on their own terms in the first iteration, whereas in face-to-face groups, there is always the possibility of the most confident students dominating the conversation at the expense of a plurality of participating voices.
Developing ethical competence Scenarios involving ethical dilemmas involve high levels of ambiguity and uncertainty. In the online environment, each group of students can be presented with a problem scenario describing an authentic ethical dilemma in a medical context (eg, how to treat epileptic patients whose cultural beliefs oppose standard treatment protocols). Students are asked to plan what they will do, and how they will handle the ethical dilemma, using a group wiki. The students work collaboratively on their group response via the wiki. Groups can then open their completed response to other groups for sharing and/or peer evaluation. Other advantages afforded by an online environment include easy access to legal and professional guidance that can help to justify decisions. 128
Fostering development of creativity through engagement with the arts Medical humanities teaching tends to emphasise the study of artistic work, such as literature, poetry, sculpture, painting and film. The rationale for this approach is that such study of artistic work (sometimes work that relates to experiences of doctors and/or patients) provides the medical student with insight into human experience and human emotions, often with a focus on the patient’s perspective and experiences of living with disease. The medical student is exposed to these experiences as an observer and it is suggested that this helps to develop empathy and skills for handling ambiguity.34 A review by Perry et al23 which focused on the effectiveness of arts-based interventions in medical education found a relatively high-quality evidence base for the use of the visual arts to improve clinical observation skills. There has been a recent emphasis on improving public access to art collections, such as Google Art, resulting in a hitherto unprecedented ability to view digitised versions of fine art. Empirical work cited by Perry et al23 suggested that groups of medical students who engaged with the arts were able to see patients as more than a collection of symptoms, to appreciate multiple perspectives, be attuned to body language, and to question initial assumptions.
Participation in the artistic process Medical humanities is a route by which many medical schools encourage direct engagement with the artistic process. This approach is grounded in beliefs that: creativity is an important skill; medical students/practitioners may find artistic creation beneficial; that participation in creative activities helps them to explore their own feelings and understandings, and to question them; it will enrich the education of medical students; it will enhance wellbeing later in life; and it promotes self confidence in artistic endeavour (or broader self-confidence).35 These various beliefs then connect with engaging students in learning activities which are likely to centre on creative writing, drawing, taking part in theatrical performance, composing music, or keeping a reflective journal. In technology-enhanced learning environments, students can engage in some of these artistic processes in ways that mirror the face-to-face environments. However, some artistic processes can be transformed so that affordances of technology can be capitalised upon to fundamentally change the way in which students engage in the process.
Developing creativity using creative writing The benefits of creative and expressive writing in medical education are well documented.36 Again, poetry is a useful medium through which to introduce students to creative writing. Students could be provided with prompts, or a published poem could be used as a template for students’ own writing. Poems could, for example, reflect on their development as medical students (see, eg, Ref. 37) or be written from the perspective of a patient with a particular disease/syndrome. On an individual basis, students could use a poetry creation application (app) designed for mobile devices to write the poem, for example, Poet’s Pad by Paragoni, Poetry Creator by Tiny Mobile, or PortaPoet by Artisan Engineering. Poems written by students could be collated and used for different purposes. Online environments allow easy display of creative work. Some possibilities include ▸ Poetry from each cohort could be collected and shared with other students, future students or interested audiences. This Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
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Original article could be via an app for mobile devices which ‘pushes’ a poem daily to subscribers. Poetry could also be displayed on a student portal page. ▸ Poetry and other creative work could be shown to other students, visitors and interested parties via a digital slideshow projected on an LED screen or electronic photo frames, and displayed in the library or other venues. ▸ Pairs/groups of students could film each other (or themselves) reading or ‘performing’ (eg, as a rap) the poem using video capability on mobile devices. The video can then be uploaded to a video-sharing website. Some universities have institution-specific video-sharing channels.
Developing creativity using drawing and photography Medical illustration has a long tradition in medical schools,38 but the materials and logistics of organising drawing classes may act as a disincentive for educators to encourage drawing skills in medical education. As well as developing hand-eye coordination, drawing, accurately or impressionistically, can usefully develop ‘critical-looking’ skills.24 The growing use of tablet computers in medical education could provide an opportunity to make use of the many excellent apps to encourage drawing. Although the surface area of a tablet limits the physical drawing area, the ability to share easily, electronically exhibit and archive drawings, are advantages over traditional (and often expensive) art materials. The selection of drawing tools and other options available on drawing apps may help less artistically confident students to overcome anxieties about a perceived lack of talent. A danger with using features of apps to ‘perfect’ drawing techniques, however, does run the risk of the product being emphasised over process. Drawing sessions, whether face to face or through distance learning, need to be well facilitated in order to prioritise the process of mark-making rather than, necessarily, the final artwork. Image-capturing devices have also improved in cost effectiveness and quality in recent years. Although there are important ethical considerations to take into account when taking photographs in clinical settings, nevertheless, developing photo-stories using fellow students as actors, or using photography to explore visual homologies, are creative approaches to encouraging insight into the contexts of medical encounters. Graphic novels, too, are a fast-growing area, and so-called ‘graphic pathologies’ (illness narratives in graphic form) are gaining ground in medical education.39 40 Asking students to devise their own comic strips that illustrate particular scenarios in medicine are a good way of encouraging students to consider both verbal and visual elements of a narrative. Apps like Flipbook by Anon Arts, Draw a Cartoon by Winlink and Strip Designer by Vivid Apps help to provide an aesthetic framework for developing graphic elements.
Digital storytelling Digital storytelling is an expanding area of interest that allows users to combine various digital media (text, photography, video, music, etc) to provide an online narrative. The Patient Voices programme (see http://www.patientvoices.org.uk/ accessed 10 June 2014) developed to support e-learning courses in clinical governance, is an example of how storytelling by different stakeholders in healthcare can contribute to medical education. Students’ own creative work can be compiled and shared online through apps like Storyrobe by Storyrobe, and Storehouse by Storehouse Media. An example is the University of Michigan Medical School which hosts an online exhibition of students’ interpretive projects. First-year students work in Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
groups to identify common themes in patients’ stories and then create an artwork that illustrates their understandings of patients’ illness experiences (see http://www.med.umich.edu/lrc/ fce/ accessed 10 June 2014).
CHALLENGES ASSOCIATED WITH INTRODUCING TECHNOLOGY-ENHANCED LEARNING For educators, moving from familiar face-to-face pedagogies to digital pedagogies can be daunting. Implementing digital pedagogies in ways that are ‘transforming’ can require profound changes to teaching practice.41 Those currently involved in teaching medical humanities are likely to feel defensive about the value of face-to-face interaction with students. Indeed, it may seem somewhat perverse for a discipline which is often viewed as a corrective to the dehumanising effects of scientific medicine to endorse technology-mediated learning. Although there may be a danger technology could become fetishised at the expense of more appropriate learning methods, this can be countered by including only learning activities that enhance pedagogy. Concerns about intellectual property need to be addressed when using technology-mediated teaching. Some of these are instrumental: university libraries need to be aware of rights issues pertaining to uploading copyrighted material on VLEs, but once rights have been secured, digitised books can be made available and films can be viewed from a video streaming server. Although permission for use is required for copyrighted works, photos of sculptures in public places taken by students or educators, for example, can be freely used. Students and educators need to be aware that intellectual property, in collaborative work made by students, and in digital materials, needs to be properly attributed. Challenges may also arise in the context of personal/professional identity in online environments. The use of social media in education allows a blurring of professional and personal boundaries in a way that students and educators may find difficult to negotiate.19 A study by Chretien et al18 found that many US medical schools have taken disciplinary action against students for patient confidentiality violations, and use of discriminatory and profane language. An alternative to adopting draconian or coercive measures in response to students’ use of social media is for educators to play a role in encouraging students to reflect on the nature of prudent and ethical practice as it relates to privacy and professionalism online. To this end, the General Medical Council has produced guidance for doctors using social media.42
CONCLUSION Mennin43 has drawn attention to the need for understanding medical curricula as complex adaptive systems in which knowledge results from the open-ended exchange between participants rather than existing objectively ‘out there’. The widening use of the affordances of technology to enhance education in the broadest sense, and medical education in particular, is an adaptation that medical humanities educators should embrace to embed and strengthen the integration of medical humanities into medical curricula. Leveraging on online environments is an opportunity for medical humanities educators to enhance the teaching of skills related to understanding patients’ experiences, tolerance of ambiguity and developing creativity. With rapidly changing shifts in functionality and possible uses in education of different tools in online environments, it is a challenge for all educators 129
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Original article to remain abreast of changes and alert to opportunities for contextualising these in medical humanities education. Although at first the use of technology might seem to be timesaving, educational institutions should resist merely digitising existing content in the misapprehension that it is a cost-effective, easy way of providing technology-enhanced learning. The preparation and implementation of high-quality technology-enhanced learning is resource-intensive and requires careful consideration of the affordances for teaching and constructive alignment with learning outcomes. Web 2.0 has also fundamentally altered views of knowledge and learning, which creates an opportunity for online education to enhance, and strengthen, learning relationships between educators and students. This paper has presented some practical suggestions for educators on how medical humanities teaching could use digital technologies for teaching and learning. Underpinning these ideas are fundamental concepts related to learner-focused pedagogy which can be used to reconceptualise medical humanities for a changing higher education world. The online environment offers limitless opportunities for enhancing medical education. It is hoped that educators in the medical humanities will embrace these opportunities, while not losing sight of the humanistic, critical, and intellectual values that underpin the discipline. Contributors SJK and GD have met the following conditions: (1) substantial contributions to conception and design; (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
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Cobb P, Perlwitz M, Underwood-Gregg D. Individual construction, mathematical acculturation, and the classroom community. In: Larochelle M, Bednarz N, Garrison J, eds. Constructivism and education. Cambridge: Cambridge University Press, 1998:63–80. Kirklin D. Creating space to reflect and connect. In: Kirklin D, Richardson R, eds. Medical humanities: a practical introduction. London: Royal College of Physicians, 2001:7–14. Bleakley A, Marshall R. Can the science of communication inform the art of the medical humanities? Med Educ 2013;47:126–33. O’Sullivan AJ, Howe AC, Miles S, et al. Does a summative portfolio foster the development of capabilitiies such as reflective practice and understanding ethics? An evaluation from two medical schools. Med Teach 2012;34:e21–8. JISC. Reflect 2.0—using digital storytelling to develop reflective learning by the use of Next Generation Technologies and practices, 2009. http://www.jisc.ac.uk (accessed 10 Jun 2014). Chretien K, Goldman E, Faselis C. The reflective writing class blog: using technology to promote reflection and professional development. J Gen Intern Med 2008;23:2066–70. Brown AD. Social media: a new frontier in reflective practice. Med Educ 2010;44:744–5. Lerner S, Magrane D, Friedan E. Teaching teamwork in medical education. Mt Sinai J Med 2009;76:318–29. Kirklin D, Richardson R, eds. Medical humanities: a practical introduction. London: Royal College of Physicians, 2001. Luther VP, Crandall SJ. Ambiguity and uncertainty: neglected elements of medical education curricula? Acad Med 2011;86(7):799–800. Perry M, Maffulli N, Willson S, et al. The effectiveness of arts-based interventions in medical education: a literature review. Med Educ 2011;45:141–8. Lyon P, Letschka P, Ainsworth T, et al. An exploratory study of the potential learning benefits for medical students in collaborative drawing: creativity, reflection and ‘critical looking’. BMC Med Educ 2013;13:86. Brody H. Defining the medical humanities: three conceptions and three narratives. J Med Humanit 2011;32:1–7. Bauby J-D. The diving bell and the butterfly. London: Fourth Estate, 2002. Macnaughton J. Medical humanities’ challenge to medicine. J Eval Clin Pract 2011;17:927–32. Evans M. Reflection on the humanities in medical education. Med Educ 2002;36:508–13. Quine WV. From a logical point of view. Cambridge, MA: Harvard University Press, 1980. Fadiman A. The spirit catches you and you fall down. New York: Farrar Straus & Giroux, 1998. Aldworth S. The portrait anatomised. 2013. http://susanaldworth.com (accessed 13 Jul 2013). Featherstone V, Sandfield A. The coconut day: a poetic interpretation of seizure experiences. Forum Qual Sozialforschung/Forum: Qual Soc Res 2013;14. http:// www.qualitative-research.net/index.php/fqs/article/view/1942/3540 (accessed 13 Jul 2013). Schön D. Educating the reflective practitioner. San Francisco, California: Jossey-Bass, 1987. Skelton JR, Thomas CP, Macleod JAA. Teaching literature and medicine to medical students, part 1: the beginning. Lancet 2000;356(9245):1920–2. Weisz GM, Albury WR. The medico-artistic phenomenon and its implications for medical education. Med Hypotheses 2010;74:169–73. Bolton G. Boundaries of the humanities: writing medical humanities. Arts Humanit High Educ 2008;7:131–48. Shapiro J. The inner world of medical students: listening to their voices in poety. New York: Radcliff Publishing, 2009. Hajar R. Medical illustration: art in medical education. Heart Views 2011;12:83–91. Green MJ, Myers KR. Graphic medicine: use of comics in medical education and patient care. BMJ 2010;340:574–7. McNicol S. Humanising illness: presenting health information in educational comics. Med Humanit 2014;40:49–55. UNESCO. Information and communication technology in education. Paris, 2002. General Medical Council. Doctors’ use of social media. 2013. http://www.gmc.uk. org (accessed 9 Jun 2014). Mennin S. Self-organisation, integration and curriculum in the complex world of medical education. Med Educ 2010;44:20–30.
Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
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Teaching medical humanities in the digital world: affordances of technology-enhanced learning Sandra Joy Kemp and Giskin Day Med Humanities 2014 40: 125-130 originally published online July 16, 2014
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Original article
Teaching medical humanities in the digital world: affordances of technology-enhanced learning Sandra Joy Kemp,1 Giskin Day2 1
Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 2 Centre for Co-Curricular Studies, Imperial College London, London, UK Correspondence to Dr Sandra Joy Kemp, Lee Kong Chian School of Medicine, Novena Campus, 11 Mandalay Road, 308232, Singapore; [email protected] Accepted 26 June 2014 Published Online First 16 July 2014
ABSTRACT Medical humanities courses are typically taught in face-to-face teaching environments, but now medical humanities educators, alongside educators from other disciplines, are facing shifts in higher education towards online (and sometimes open) courses. For the medical humanities educator, there is limited guidance regarding how technology-enhanced learning design can support the learning outcomes associated with medical humanities. This article aims to provide useful direction for such educators on how digital technologies can be used through learner-focused pedagogies. Specific examples are provided as to how the affordances of Web 2.0 and other tools can be realised in innovative ways to help achieve skills development within the medical humanities. The guidance, alongside the practical suggestions for implementation, can provide important conceptual background for medical humanities educators who wish to embrace technology-enhanced learning, and reconceptualise or redesign medical humanities for an online or blended teaching environment.
INTRODUCTION
To cite: Kemp SJ, Day G. Med Humanit 2014;40:125–130.
A paradigm shift in pedagogy across higher education is imminent. There is a growing demand for university courses in blended, online and distance learning environments. Medical humanities courses, along with other disciplines within medical education, will be expected to adapt to meet this demand. The advent of Massive Open Online Courses (MOOC) also points towards shifts in higher education that may disrupt the hitherto firmly entrenched tradition of face-to-face teaching in the medical humanities. As noted by others, many medical students are already involved in virtual spaces through social networking, video sharing and blogging.1 Contributing to, and producing digital content will be familiar to many educators and students in medicine. Given this, the use of technology in mediating students’ learning is becoming a critical area for educators. Ensuring that medical educators and students are knowledgeable about emerging ethical issues associated with participating in online communities and creating digital content, is becoming increasingly important. Although some educators have experimented with e-modules in the medical humanities (see, eg, Giordano2), guidance for medical humanities educators is sparse. It is clear that how the medical humanities community responds to anticipated new demands for virtual learning, and the changes involving the use of digital technologies, is an important concern. Pederson3 and Shapiro et al,4 among others, have called for humanities to be situated inside the
‘hard core’ of medicine, rather than being seen as a ‘soft add-on’. In an already overcrowded medical curriculum, technology-enhanced learning provides a useful opportunity to integrate humanities with the teaching of science, where humanities-type sources (eg, patient pathographies, artworks, fiction and graphic novels) are made available as core learning materials alongside medical texts, possibly accompanied by assessment that calls for nuanced interpretations. This article aims to outline technology-enhanced learning design considerations, and puts forward practical suggestions for medical humanities educators who want to, or need to, reconceptualise or redesign medical humanities for learning and teaching in online environments. We briefly discuss some underpinning concepts and approaches to learning associated with different general learning objectives in medical humanities, and then offer suggestions for technology-enhanced learning activities that can be conducted in online environments. We also consider some of the challenges associated with introducing technology-enhanced learning in the medical humanities. As this article is primarily concerned with practical suggestions for educators, space precludes an in-depth consideration of theoretical perspectives, although this is not to suggest that these are not important in any consideration of technologyenhanced learning contexts. Our suggestions are grounded in a belief that new ways of thinking about skills in the digital age are now required due to contexts for learning and changes in creative, participation, and production practices enabled by Web 2.0. Theories of learning with technologies, such as situated learning (in the context of video gaming),5 a learning ecologies perspective,6 and the community of inquiry framework,7 highlight different ways of understanding and thinking about learning and digital pedagogies. In particular, Web 2.0 capabilities such as: simultaneous involvement in many settings; creation of personalised learning contexts; and, permeability of boundaries online are some of the factors that have had an impact on the ways in which educators and researchers now think about knowledge, expertise and learning.6 8 From the educator perspective, well-designed technology-enhanced learning must aim to move beyond merely placing the student in information retrieval roles vis à vis the web,9 commonly depicted in information transmission conceptualisations of teaching. The affordances of Web 2.0 tools (such as social networking sites, blogs, wikis, video sharing sites, etc.) in terms of encouraging sharing of work, promoting creativity and stimulating collaboration, have the potential to creatively enhance
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Original article learning in innovative ways. For medical humanities educators in higher education institutions, access to a VLE (Virtual Learning Environment) and Web 2.0 tools, as well as the growing popularity of tablet devices, opens many opportunities for stimulating and effective virtual learning activities—activities that will shape practices and output of medical humanities students.
reflectivity using this method than with other reflective writing.18 Social media has also been advocated as a means of helping students to explore ‘social reflection’ which could helpfully improve interactions with patients.19 Blog tools within an e-portfolio (eg, software applications such as Myprogress by MyKnowledgeMap) allow students and faculty to share and view contributions individually or collectively.
Digital pedagogies and approaches to learning in the medical humanities
Encouraging collaborative learning
Effective technology-enhanced learning design should be consonant with learner-focused pedagogy, a familiar concept to experienced educators. One of the fundamental underlying principles of learner-focused pedagogy is ‘constructive alignment’.10 That is, the learning experiences should be appropriate for achieving the learning objectives and for completing assessment tasks. Embedded in the concept of constructive alignment is the idea that educators should be concerned with how students engage in tasks that are structured to challenge, change or add to existing beliefs and knowledge.11 Such tasks should be aimed at developing students’ understandings of their own cognitive and learning processes. Attention to the individual student’s understandings of knowledge in the discipline is important for teaching and learning that is learner-focused.12 A simple example of learner-focused pedagogy would include facilitation of group dialogue where the purpose of dialogue is to explore an element of the domain/discipline which leads to deeper understanding of a topic.13 This is a common approach in medical humanities contexts. Although the features of learner-focused pedagogy are well recognised in face-to-face teaching environments, achieving this in online learning environments requires leveraging on the affordances of digital technologies. The features and uses of technology are seen as different to the affordances for teaching. A tool, such as a blog, may have the features of image upload and text input. It could be used by students to record an event that day. However, the affordances for teaching could be that the blog is used as a mechanism for creating opportunities for students to document their changing thinking over time in relation to, for example, personal/professional boundaries, end-of-life issues or resource allocation in healthcare. Learning can be enhanced by peer and educator feedback on individual blog entries. The emphasis is on how required skills and knowledge of the discipline inform learning design and its implementation in ways that mean the affordances for teaching can change student learning. We now consider two examples of how digital pedagogies can contribute to key approaches to learning often associated with medical humanities courses: enhancing reflective learning,14 and encouraging collaborative learning.15
Enhancing reflective learning Reflective learning is a high priority in medical education, and medical humanities is considered to be an effective means of advancing ‘reflective habits of mind’.4 E-portfolios have been shown to develop reflective capabilities and encourage selfdirected learning.16 The advantage of an e-portfolio for the medical humanities is that students are able to demonstrate interdisciplinary learning through including humanities sources in their reflective writing. A JISC report identified the opportunity to be creative as important to students and calls for future research into the use of digital stories as artefacts to complement text-based material in e-portfolios.17 Using a class blog can be an effective means of promoting reflection, with one study finding a higher incidence of 126
Bleakley and Marshall15 have recently criticised curriculum designs that “refuse to place collaboration at the heart of learning”. [p 128] They have called for ‘democratic habits’ to be given more emphasis. These aim to challenge the powerful culture of autonomy and heroic individualism that contribute to high rates of medical error through dysfunctional teamwork, poor communication and a decline in empathy. Technology can be used as a medium through which collaborative learning can be developed away from pre-existing classroom hierarchies. Teamwork is an essential skill that can help reduce medical error, improve patient care and reduce workload issues that contribute to burnout.20 Although it may not be a desired substitute for face-to-face collaboration in clinical settings, academic medical humanities teaching can be facilitated using virtual groups. Given stimulus material such as a pathography to read, students can use a wiki to create a collective response. Upon completion, the wiki could be opened to other groups and shared with them. Students could also rate the response they consider to be the most useful. Alternatively, wikis could form the basis of a summative assessment task as wiki tools allow for contributions by individual students to be viewed and graded.
LEARNING IN MEDICAL HUMANITIES We consider three illustrative broad areas related to learning that may be fostered by medical humanities teaching. Each of these areas offers opportunities for educators in medical humanities to leverage on the affordances of technology-enhanced learning. The three areas and the associated learning outcomes considered in this article are where medical humanities is seen as important for ▸ Enhancing understanding of patients’ experiences of illness21 ▸ Developing a tolerance of ambiguity22 ▸ Fostering development of creativity through engagement with the arts23 24 These three different areas and common general learning outcomes associated with each will be considered in turn.
Enhancing understanding of patients’ experiences of illness An online environment can easily provide access to texts not normally given emphasis in traditional curricula but which are increasingly important in the lives of patients, for example, blogs and online support forums. This would go some way to meeting the call by Shapiro et al4 for the inclusion of more types of narratives in addition to the restitution narrative (which refers to the idea that illness is temporary and a restoration of health is taken for granted) that dominates in medicine, so that students can gain a more holistic sense of the impact of illness on the human condition. In online environments, the use of personalised learning pathways can draw upon the feature of certain software applications to release ‘adaptively’ each step in a sequence of learning activities in a pathway. That is, an activity must be completed before the next activity is released. Often software allows for certain criteria to be preset. This means that different students experience different learning activities, depending on their responses. Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
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Original article This is commonly used in many web-based Virtual Patient software applications in medicine, where the medical student is typically presented with a case, and makes decisions about the treatment of the patient in a simulated environment. Some VLEs allow simple branching options, and this mechanism can be used to develop a set of activities which guide the student through a patient’s experience of, for example, the healthcare pathway or a treatment protocol. In medical humanities courses, students often are provided with books and movies recommended for reading or viewing. When this type of material is used, learning is enhanced if activities are structured around the book-reading/movie-viewing task, so that the student’s attention is directed to key features, understandings and interpretations. Typically, this is achieved through ‘chunking’ of the larger task (of reading the whole book) into excerpts. Then, activities are used to prompt and check for understanding. In an online environment, these can range from mini-tasks, such as short paragraph writing in response to specific questions, participation in online discussions facilitated by the teaching staff/peers, posting of reflections on a blog, and keeping a journal while reading the book. Shapiro et al4 point out the value of the tradition of critical inquiry in humanities that can encourage reflective habits in students. Students then can appreciate the perspectives of others and develop ‘humanistic competencies’ that focus on values, helping medicine to move beyond algorithms and checklists. If time constraints preclude students reading the entire book, and it is not desirable to use selective excerpts, different students can be allocated different parts of the book to read. Student 1 reads chapter 1, student 2 reads chapter 2 and so on. Each student could provide a short précis of each chapter. These can then be converted to PDF format, and combined into one document, as a PDF portfolio. This document can be distributed online to the students so that they can be exposed to other chapters in the book. A variation of this would be to allocate different chapters to students in pairs or students in small groups. The benefit of work in pairs is that it increases the feeling of ‘presence’ in the online environment.
Developing understandings of the viewpoints of others In medical humanities, the different perspectives of the humanities disciplines can be used by students to engage with problems from different viewpoints. Sometimes this is seen as a way to help medical students communicate better with patients, or develop humane judgement, or as ‘solace’ from the demands of medicine.25 To develop students’ understandings of the viewpoints of others, completing a reading/viewing task in a self-directed manner with follow-up tasks for formative feedback can be used. This allows the educator to check that students have completed the reading activity and have begun thinking about relevant issues. The questions should be predominantly open-ended, allowing for divergent responses by the students. For example, in reference to Jean-Dominique Bauby’s The diving bell and the butterfly,26 a commonly prescribed text in medical humanities: Why do you think the incident, which triggered the protagonist’s condition, was not described until the end of the book? As a reader, which incident described in the book had an impact on you and why? How could the health care providers described in the book have acted differently? Closed questions will prompt students to search for the ‘correct’ answer. For example: Which symptoms led to the protagonist being admitted to hospital? In medical humanities, the emphasis should be more on thinking about and understanding Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
differing perspectives. Open-ended questions will create an environment where this is more likely. Tasks that foreground the subjective experience of illness, in which students can themselves set questions that stimulate further discussion and reflection, are likely to lead to rewarding and useful discussion.
Encouraging different ways of theorising, interpreting and recording human experiences Some proponents claim that the study of the theoretical structure of the humanities helps students understand and interpret human experience with, for example, illness, disability and medicine. Developing an understanding of the boundaries of the different epistemologies (theories of knowledge) of the humanities and the biomedical sciences is emphasised, and it is suggested that this can help medicine develop a more complete conception of human nature.27 It is also argued that this may help to handle uncertainty in medical practice.28 The online environment could be used to expose students to different interpretations of empirical data and the idea of ‘underdetermination’ of scientific theory.29 Developing skills in how different conceptual knowledge frameworks influence the interpretation of data can begin through encounters with published research in other disciplines that can inform medicine. It would be fruitful to focus on research that analyses qualitative data, as this is likely to be less familiar to medical students. Examples could include research work on different societies/cultures (which could link to understanding other ethnic groups/ cultures) from the discipline of anthropology, or the analysis of communication discourse (which could link to communicating with patients) from the discipline of linguistics. An example for when students study epilepsy is that they could read, alongside clinical texts, extracts from Anne Fadiman’s acclaimed book The spirit catches you and you fall down30 which documents the profound effects of cultural differences in conceptions of epilepsy in the Hmong community in Merced, and those of healthcare professionals. Students could also view online Susan Aldworth’s series of prints ‘The portrait anatomised’.31 The portraits explore the neuroscience and the lived experience of patients with epilepsy through brain scans, drawings, photographs and interviews. These sources also lend themselves well to creative tasks. For example, students could create their own ‘portrait anatomised’ based on case studies they have encountered, or write short narratives from the points of view of the different ‘characters’ from Anne Fadiman’s book. A related activity could be one where the students are presented with a qualitative dataset. In the context of epilepsy, for example, interpretive phenomenological research on people’s seizure experiences could be accessed online.32 In pairs, students contribute to a wiki, which describes how the different approaches taken in the stimulus materials have enhanced their understanding of epilepsy. After completion, each pair then reviews and critiques, or contributes to the wiki of another pair with the same set of data. The final step is that all pairs working on the same dataset compare and contrast answers through an online discussion forum. Another activity could be to provide students with a task brief to create three parallel narratives which tell the historical story of a disease from, variously, the perspectives of a patient, a doctor and policymakers. Using photos and text, students can create an e-book to present the project which can be then displayed (as described in the preceding discussion). Students could also engage in peer evaluation of each e-book, through the use of a criteria-marking scheme (or rubric) which describes the criteria and standards for evaluation. If students do not have 127
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Original article e-book software, students can create the book as a Microsoft Word document and save it in PDF format.
Developing a tolerance of ambiguity Medical education often emphasises problem solving and knowledge as empowering decision making. Luther and Crandall22 use Schön’s33 metaphor of professional practice as ‘the high, hard ground overlooking a swamp’. They argue that, in medicine, the high, hard ground is the scientific zone, which is ‘fact based, predictable and consists of solvable problems’ [ p 800]. By contrast, the artistic or indeterminate (messy) zone is characterised by conflict and ambiguity. Students are often anxious about operating in the artistic zone, leading to calls for dedicating time to address ambiguity and uncertainty as a formal part of medical school curricula.15 22 The arts, for which uncertainty and ambiguity are intrinsic, are an obvious conduit for developing skills in dealing with situations in which multiple interpretations are possible, focusing attention on strengths and weaknesses of competing explanations rather than arriving at a single ‘solution’.
Developing narrative competence Poetry is one type of narrative that lends itself well to increasing a tolerance of ambiguity, as well as developing students’ narrative competence. In an online environment, poems on a topic relevant to a particular clinical area can be displayed side by side in tools, such as LAMS (Learning Activity Management System) or a VLE (eg, applications such as Blackboard, Moodle and Sakai). Students can be asked to list commonalities between the two poems, as well as differences. The advantage of comparison is that it requires analysis. Students who lack confidence in poetic analysis might be tempted to search for established readings of well-known poems, but requiring compare-and-contrast analyses means that they must approach the poems with some originality of thinking. Short open-ended questions to be completed by students can focus on differences, such as imagery, narrative voice, tense and tone. The purpose is to develop their skills in narrative attentiveness to the poet as well as the topic. If LAMS is used, the student is able to submit her/his answer to each question, and then view the answers of other students. This supports learning from peers and promotes online dialogue if further iterations are designed. An online learning environment has the advantage of allowing all students to contribute on their own terms in the first iteration, whereas in face-to-face groups, there is always the possibility of the most confident students dominating the conversation at the expense of a plurality of participating voices.
Developing ethical competence Scenarios involving ethical dilemmas involve high levels of ambiguity and uncertainty. In the online environment, each group of students can be presented with a problem scenario describing an authentic ethical dilemma in a medical context (eg, how to treat epileptic patients whose cultural beliefs oppose standard treatment protocols). Students are asked to plan what they will do, and how they will handle the ethical dilemma, using a group wiki. The students work collaboratively on their group response via the wiki. Groups can then open their completed response to other groups for sharing and/or peer evaluation. Other advantages afforded by an online environment include easy access to legal and professional guidance that can help to justify decisions. 128
Fostering development of creativity through engagement with the arts Medical humanities teaching tends to emphasise the study of artistic work, such as literature, poetry, sculpture, painting and film. The rationale for this approach is that such study of artistic work (sometimes work that relates to experiences of doctors and/or patients) provides the medical student with insight into human experience and human emotions, often with a focus on the patient’s perspective and experiences of living with disease. The medical student is exposed to these experiences as an observer and it is suggested that this helps to develop empathy and skills for handling ambiguity.34 A review by Perry et al23 which focused on the effectiveness of arts-based interventions in medical education found a relatively high-quality evidence base for the use of the visual arts to improve clinical observation skills. There has been a recent emphasis on improving public access to art collections, such as Google Art, resulting in a hitherto unprecedented ability to view digitised versions of fine art. Empirical work cited by Perry et al23 suggested that groups of medical students who engaged with the arts were able to see patients as more than a collection of symptoms, to appreciate multiple perspectives, be attuned to body language, and to question initial assumptions.
Participation in the artistic process Medical humanities is a route by which many medical schools encourage direct engagement with the artistic process. This approach is grounded in beliefs that: creativity is an important skill; medical students/practitioners may find artistic creation beneficial; that participation in creative activities helps them to explore their own feelings and understandings, and to question them; it will enrich the education of medical students; it will enhance wellbeing later in life; and it promotes self confidence in artistic endeavour (or broader self-confidence).35 These various beliefs then connect with engaging students in learning activities which are likely to centre on creative writing, drawing, taking part in theatrical performance, composing music, or keeping a reflective journal. In technology-enhanced learning environments, students can engage in some of these artistic processes in ways that mirror the face-to-face environments. However, some artistic processes can be transformed so that affordances of technology can be capitalised upon to fundamentally change the way in which students engage in the process.
Developing creativity using creative writing The benefits of creative and expressive writing in medical education are well documented.36 Again, poetry is a useful medium through which to introduce students to creative writing. Students could be provided with prompts, or a published poem could be used as a template for students’ own writing. Poems could, for example, reflect on their development as medical students (see, eg, Ref. 37) or be written from the perspective of a patient with a particular disease/syndrome. On an individual basis, students could use a poetry creation application (app) designed for mobile devices to write the poem, for example, Poet’s Pad by Paragoni, Poetry Creator by Tiny Mobile, or PortaPoet by Artisan Engineering. Poems written by students could be collated and used for different purposes. Online environments allow easy display of creative work. Some possibilities include ▸ Poetry from each cohort could be collected and shared with other students, future students or interested audiences. This Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
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Original article could be via an app for mobile devices which ‘pushes’ a poem daily to subscribers. Poetry could also be displayed on a student portal page. ▸ Poetry and other creative work could be shown to other students, visitors and interested parties via a digital slideshow projected on an LED screen or electronic photo frames, and displayed in the library or other venues. ▸ Pairs/groups of students could film each other (or themselves) reading or ‘performing’ (eg, as a rap) the poem using video capability on mobile devices. The video can then be uploaded to a video-sharing website. Some universities have institution-specific video-sharing channels.
Developing creativity using drawing and photography Medical illustration has a long tradition in medical schools,38 but the materials and logistics of organising drawing classes may act as a disincentive for educators to encourage drawing skills in medical education. As well as developing hand-eye coordination, drawing, accurately or impressionistically, can usefully develop ‘critical-looking’ skills.24 The growing use of tablet computers in medical education could provide an opportunity to make use of the many excellent apps to encourage drawing. Although the surface area of a tablet limits the physical drawing area, the ability to share easily, electronically exhibit and archive drawings, are advantages over traditional (and often expensive) art materials. The selection of drawing tools and other options available on drawing apps may help less artistically confident students to overcome anxieties about a perceived lack of talent. A danger with using features of apps to ‘perfect’ drawing techniques, however, does run the risk of the product being emphasised over process. Drawing sessions, whether face to face or through distance learning, need to be well facilitated in order to prioritise the process of mark-making rather than, necessarily, the final artwork. Image-capturing devices have also improved in cost effectiveness and quality in recent years. Although there are important ethical considerations to take into account when taking photographs in clinical settings, nevertheless, developing photo-stories using fellow students as actors, or using photography to explore visual homologies, are creative approaches to encouraging insight into the contexts of medical encounters. Graphic novels, too, are a fast-growing area, and so-called ‘graphic pathologies’ (illness narratives in graphic form) are gaining ground in medical education.39 40 Asking students to devise their own comic strips that illustrate particular scenarios in medicine are a good way of encouraging students to consider both verbal and visual elements of a narrative. Apps like Flipbook by Anon Arts, Draw a Cartoon by Winlink and Strip Designer by Vivid Apps help to provide an aesthetic framework for developing graphic elements.
Digital storytelling Digital storytelling is an expanding area of interest that allows users to combine various digital media (text, photography, video, music, etc) to provide an online narrative. The Patient Voices programme (see http://www.patientvoices.org.uk/ accessed 10 June 2014) developed to support e-learning courses in clinical governance, is an example of how storytelling by different stakeholders in healthcare can contribute to medical education. Students’ own creative work can be compiled and shared online through apps like Storyrobe by Storyrobe, and Storehouse by Storehouse Media. An example is the University of Michigan Medical School which hosts an online exhibition of students’ interpretive projects. First-year students work in Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
groups to identify common themes in patients’ stories and then create an artwork that illustrates their understandings of patients’ illness experiences (see http://www.med.umich.edu/lrc/ fce/ accessed 10 June 2014).
CHALLENGES ASSOCIATED WITH INTRODUCING TECHNOLOGY-ENHANCED LEARNING For educators, moving from familiar face-to-face pedagogies to digital pedagogies can be daunting. Implementing digital pedagogies in ways that are ‘transforming’ can require profound changes to teaching practice.41 Those currently involved in teaching medical humanities are likely to feel defensive about the value of face-to-face interaction with students. Indeed, it may seem somewhat perverse for a discipline which is often viewed as a corrective to the dehumanising effects of scientific medicine to endorse technology-mediated learning. Although there may be a danger technology could become fetishised at the expense of more appropriate learning methods, this can be countered by including only learning activities that enhance pedagogy. Concerns about intellectual property need to be addressed when using technology-mediated teaching. Some of these are instrumental: university libraries need to be aware of rights issues pertaining to uploading copyrighted material on VLEs, but once rights have been secured, digitised books can be made available and films can be viewed from a video streaming server. Although permission for use is required for copyrighted works, photos of sculptures in public places taken by students or educators, for example, can be freely used. Students and educators need to be aware that intellectual property, in collaborative work made by students, and in digital materials, needs to be properly attributed. Challenges may also arise in the context of personal/professional identity in online environments. The use of social media in education allows a blurring of professional and personal boundaries in a way that students and educators may find difficult to negotiate.19 A study by Chretien et al18 found that many US medical schools have taken disciplinary action against students for patient confidentiality violations, and use of discriminatory and profane language. An alternative to adopting draconian or coercive measures in response to students’ use of social media is for educators to play a role in encouraging students to reflect on the nature of prudent and ethical practice as it relates to privacy and professionalism online. To this end, the General Medical Council has produced guidance for doctors using social media.42
CONCLUSION Mennin43 has drawn attention to the need for understanding medical curricula as complex adaptive systems in which knowledge results from the open-ended exchange between participants rather than existing objectively ‘out there’. The widening use of the affordances of technology to enhance education in the broadest sense, and medical education in particular, is an adaptation that medical humanities educators should embrace to embed and strengthen the integration of medical humanities into medical curricula. Leveraging on online environments is an opportunity for medical humanities educators to enhance the teaching of skills related to understanding patients’ experiences, tolerance of ambiguity and developing creativity. With rapidly changing shifts in functionality and possible uses in education of different tools in online environments, it is a challenge for all educators 129
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Original article to remain abreast of changes and alert to opportunities for contextualising these in medical humanities education. Although at first the use of technology might seem to be timesaving, educational institutions should resist merely digitising existing content in the misapprehension that it is a cost-effective, easy way of providing technology-enhanced learning. The preparation and implementation of high-quality technology-enhanced learning is resource-intensive and requires careful consideration of the affordances for teaching and constructive alignment with learning outcomes. Web 2.0 has also fundamentally altered views of knowledge and learning, which creates an opportunity for online education to enhance, and strengthen, learning relationships between educators and students. This paper has presented some practical suggestions for educators on how medical humanities teaching could use digital technologies for teaching and learning. Underpinning these ideas are fundamental concepts related to learner-focused pedagogy which can be used to reconceptualise medical humanities for a changing higher education world. The online environment offers limitless opportunities for enhancing medical education. It is hoped that educators in the medical humanities will embrace these opportunities, while not losing sight of the humanistic, critical, and intellectual values that underpin the discipline. Contributors SJK and GD have met the following conditions: (1) substantial contributions to conception and design; (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
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Kemp SJ, et al. Med Humanit 2014;40:125–130. doi:10.1136/medhum-2014-010518
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Teaching medical humanities in the digital world: affordances of technology-enhanced learning Sandra Joy Kemp and Giskin Day Med Humanities 2014 40: 125-130 originally published online July 16, 2014
doi: 10.1136/medhum-2014-010518 Updated information and services can be found at: http://mh.bmj.com/content/40/2/125
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