2014, 1–8, Early Online
Teaching professionalism to first year medical students using video clips ALLISON HALEY SHEVELL1, ALIKI THOMAS2,3,4 & ABRAHAM FUKS1 1
McGill University, Canada, 2Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Canada, 3School of Physical and Occupational Therapy, McGill University, Canada, 4Centre for Medical Education, McGill University, Canada
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Abstract Background: Medical schools are confronted with the challenge of teaching professionalism during medical training. The aim of this study was to examine medical students’ perceptions of using video clips as a beneficial teaching tool to learn professionalism and other aspects of physicianship. Methods: As part of the longitudinal Physician Apprenticeship course at McGill University, first year medical students viewed video clips from the television series ER. The study used qualitative description and thematic analysis to interpret responses to questionnaires, which explored the educational merits of this exercise. Results: Completed questionnaires were submitted by 112 students from 21 small groups. A major theme concerned the students’ perceptions of the utility of video clips as a teaching tool, and consisted of comments organized into 10 categories: ‘‘authenticity and believability’’, ‘‘thought provoking’’, ‘‘skills and approaches’’, ‘‘setting’’, ‘‘medium’’, ‘‘level of training’’, ‘‘mentorship’’, ‘‘experiential learning’’, ‘‘effectiveness’’ and ‘‘relevance to practice’’. Another major theme reflected the qualities of physicianship portrayed in video clips, and included seven categories: ‘‘patient-centeredness’’, ‘‘communication’’, ‘‘physicianpatient relationship’’, ‘‘professionalism’’, ‘‘ethical behavior’’, ‘‘interprofessional practice’’ and ‘‘mentorship’’. Conclusions: This study demonstrated that students perceived the value of using video clips from a television series as a means of teaching professionalism and other aspects of physicianship.
Introduction
Practice points
First hand clinical experience is a meaningful and effective way of learning professionalism as these experiences are rooted in authenticity and have direct relevance to trainees’ future practice as clinicians (Cruess et al. 2011). These clinical opportunities are likely to occur during trainees’ clerkship and residency rotations. However, many experiences may not be encountered with sufficient frequency within these timeframes. Therefore, there is a need to supplement authentic experiences with simulated situations, which can take the form of case vignettes, role-play, simulation exercises and videos of scenarios (Cruess et al. 2011). The Royal College of Physicians and Surgeons of Canada accredits and sets standards for the education of medical specialists in Canada. The Royal College has endorsed the CanMEDS framework, which outlines the knowledge, skills and abilities expected of physicians for optimal patient outcomes. According to the CanMEDS framework, there are seven core roles that all physicians are required to fulfill to be better doctors: medical expert, communicator, collaborator, manager, health advocate, scholar and professional (Frank 2005). Professionalism is highlighted in the CanMEDS framework and as a result, is emerging as an important part of medical training and is part of an evolving pedagogical stream
Physicianship is a term used in McGill’s Faculty of Medicine to refer to the physician as healer and professional. Medical Schools are confronted with the challenge of explicitly teaching the competencies encompassed by this term. Students perceive the value of using video clips from a television series as a means of teaching professionalism and aspects of physicianship.
(Cruess & Cruess 1997). Therefore, medical schools have recently been faced with the responsibility of teaching students professionalism (Steinert et al. 2005). The concept of ‘‘Physicianship’’ was introduced by the Faculty of Medicine at McGill University in 2005. Physicianship encompasses the physician’s dual role as a healer and a professional (Cruess & Cruess 1997; Boudreau et al. 2008, 2011). As healer, the physician demonstrates several core attributes, such as compassion and openness (Boudreau et al. 2008) that enhance and optimize the physician-patient relationship (Boudreau et al. 2007). Professionalism describes the competencies and behaviors that relate to the physician’s
Correspondence: Abraham Fuks, MDCM, Professor of Medicine, McGill University, 3647 Peel Street, Rm 105, Montreal, Canada. Tel: 514-398-4400, ext 0279; Fax: 514-398-8568; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–8 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.970620
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responsibility to the patient, to other healthcare professionals and to the broader society (Cruess & Cruess 1997; Boudreau et al. 2007). The goal of introducing the term ‘‘Physicianship’’ into the medical curriculum at this University was to allow the core values and roles of the healer and professional to be taught explicitly and permeate through medical students’ educational experience and medical training (Boudreau et al. 2011). Even though many medical schools have begun to implement formal curricula related to professionalism, few studies have evaluated the effectiveness of pedagogical approaches to teaching this content. Several studies have contemplated the use and educational merits of videos in medical education and some studies found that students and facilitators perceive that videos were helpful in generating discussion and learning concepts relating to professionalism (Blasco et al. 2006; Lim & Seet 2008; Lumlertgul et al. 2009). Lumlertgul et al. (2009) argue that movies can be an entertaining and effective way of learning professionalism. Their study demonstrated that the movies prompted discussion of ethical issues amongst students (Lumlertgul et al. 2009). This feature of stimulating group and individual reflection may reflect an advantage of such teaching experiences and distinguish them from handson direct patient learning in busy clinical settings. The purpose of this paper is to report the results of a qualitative descriptive study examining medical students’ perceptions of the quality of their learning when viewing video clips from the television series ER. The study participants were first-year medical students at McGill University. As part of their medical training, students participate in a mandatory longitudinal 5.5 credit course called Physician Apprenticeship, which spans the four years of the undergraduate medical curriculum. Students in each medical class are divided into groups, called Osler groups, typically comprised of six students that meet regularly with an attending physician, called an Osler fellow, and two senior medical students (either in third or fourth year), called Osler co-leaders. The Osler fellows and Osler co-leaders serve as mentors to the group of medical students and meetings are designed to provide a supportive setting to reflect on clinical experiences as students proceed through their medical training (Steinert et al. 2010).
Methods Study design The study used a qualitative descriptive methodology. Qualitative description aims to describe experiences, events and perceptions (Neergaard et al. 2009). This methodology typically uses semi-structured interviews, open-ended questionnaires and/or focus groups to gather data and qualitative content analysis or thematic analysis using coding systems to analyze the data. Our study used open-ended questionnaires as the data source.
Ethical approval The McGill institutional review board (IRB) reviewed and approved the study. It also judged that the study fell under the 2
rubric of educational evaluation and that written consent from each participant was not required. Student confidentiality was maintained, as questionnaires were entirely anonymous with no attached identifiers. Furthermore, participation was voluntary.
Participants During the 2010–2011 academic year, 30 Osler groups and 175 first year students participated in the mandatory Physician Apprenticeship course. The sample for our study is drawn from this group.
Procedures As part of a pilot project for first-year medical students in the 2010–2011 academic year, the Physician Apprenticeship course included the use of multimedia teaching modules, designed to portray various elements of physicianship, namely, the physician’s dual role as a healer and a professional. The multimedia teaching modules contained selected brief, less than 5 minute, video clips from the television series ER accompanied by written teaching guides. The content and format of all video and learning materials were prepared by one of the authors of this paper (A.H.S). Twenty-nine video clips were initially prepared, and of these, 12 were chosen for use in this project, with different combinations of video clips randomly assigned to each Osler group. Osler groups watched one or two video clips per session. The vignettes showcased a variety of interactions amongst clinicians, medical trainees, patients and families. The video clips were chosen to demonstrate either positive or negative elements of physicianship, namely, the skills, attitudes and behaviors of clinicians. These videos emphasized ethical behavior and practice and were meant to promote critical thinking, problem solving, and clinical and ethical reasoning. The pedagogical intent of the videos was to encourage reflection by the students and to stimulate a discussion with peers and mentors in a small group setting. Each video clip was accompanied by a series of questions meant to facilitate discussion. Specifically, the questions explored what the students observed in the video clips and prompted group discussion on the attitudes and behaviors of the characters portrayed in the clinical scenarios. Each video clip was accompanied by a description of anticipated observations, interpretations and teaching points. These were provided as a guide only to the Osler fellows and their use was optional. The video clips were selected by the first author (A.H.S) and approved by another author (A.F), a McGill faculty member and contributor to the Physicianship curriculum with significant knowledge and expertise in professionalism. Osler fellows were requested to incorporate this educational exercise into one of the Physician Apprenticeship meetings. To do so, Osler fellows were instructed to play the video clip with its embedded question prompts and then to open the discussion to the student learners. They were prompted to ask the students what they observed in each clip, how they interpreted their observations, and what they learned from the video scenario. The students were asked to describe how the content of the video was relevant to
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Box 1. Student evaluation form questions.
1. Did the video clips illustrate elements of Physicianship? Please explain 2. Did you find the clips thought provoking? (e.g., by encouraging critical thinking, problem solving, clinical reasoning, self-reflection, ethical behavior) 3. Did the clips serve as a springboard for discussion in your group? 4. Would you like to see this type of teaching material used in the future? 5. If similar video clips were made available next semester on WebCT, would you participate in a moderated online discussion group?
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WebCT: online virtual learning environment system used by universities and other institutions
physicianship and were probed regarding the relevance of these qualities to the practice of medicine. The Osler fellows were permitted to use the materials in the written handouts and/or their own insights and prior experiences to facilitate group discussion. In a written introductory letter, it was stressed to all Osler fellows that they should use the written material as a guide and at their discretion. The Osler fellows were encouraged to replay the video after the discussion to consolidate the teaching points.
Box 2. Transcript for Osler Group B, clip #3, question #1.
Student 1: Yes – how to interact with patients, including eye contact; observational skills Student 2: Learning how to quickly build a rapport, paying more attention to patients initially, be more humane about people’s issues. Student 3: Yes, they illustrated some elements emphasized during Physicianship (to ‘‘do’s’’ and ‘‘don’ts’’). Student 4: Yes, the importance of putting the patient at ease, being open to discuss the patient’s problem, the fact that the physician has to earn the trust of his patients. Student 5: Yes – being there for the patient, eye contact, establishing a rapport with the patient, making them feel comfortable to confide in you. Student 6: Yes – body language and non-verbal communication; proper interviewing technique and patience and persistence.
List of key words/phrases from transcript for Osler group B, clip #3, question #1 Clip 3: 1
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Data sources The data consisted of students’ responses to open-ended questions included in an evaluation form. This evaluation form, developed by two of the authors (A.H.S and A.F), was comprised of five open-ended questions. The questions (Box 1) were designed to explore the elements of physicianship depicted in the videos, determine whether the video clips functioned as an effective springboard for discussion and ascertain whether students would like to use this type of teaching tool in future learning. As this was a trial of a new teaching strategy, Osler fellows and students were told at the time of evaluation form distribution that their feedback would be important in determining the usefulness of the video clips for future classes. The evaluation forms were distributed and completed immediately after viewing the video clips and the group discussion with the Osler fellow and co-leaders. This paper focuses on the students’ responses to the questionnaire.
Data analysis An administrator at the Physicianship Curriculum Development office transcribed the students’ handwritten responses to the questionnaire. Each transcript consisted of all student responses from one session where an Osler group viewed video clips. There were a total of 25 transcripts. We conducted a qualitative thematic analysis of all transcripts using a staged approach. The first author and a co-author (AT) with expertise in qualitative analysis were involved in all stages of the analysis. The first author (A.H.S) read through all the transcripts, to get a general sense of the content. A process of open coding followed which consisted of highlighting excerpts that were deemed to have some meaning. All highlighted excerpts were then included in a table and organized by the Osler group, video clip (if more than one was used) and question (an example can be found in Box 2). Words and phrases that appeared to convey a similar concept were
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how to interact with patients eye contact observational skills how to quickly build a rapport more attention to patients humane ‘‘do’s’’ and ‘‘don’ts’’ importance of putting patient at ease open to discuss physician has to earn the trust being there for the patient eye contact rapport making them fell comfortable to confide in you body language non-verbal communication interviewing technique patience persistence
grouped into preliminary categories. For example, ‘‘eye contact’’, ‘‘body language’’ and ‘‘non-verbal communication’’ were grouped together to refer to the capacity of the video clips to illustrate non-verbal aspects of communication. This iterative process of coding and grouping continued until all the highlighted words and phrases were organized into categories. The categories were then further synthesized into major themes. Two authors (AHS and AT) discussed all categories and major themes. Disagreements regarding categories and themes were resolved through discussion. The authors initially coded student responses and began analyzing data by specific question. However, once they observed that major themes emerged across questions, they no longer made the distinction between individual questions in compiling the final results.
Results Completed evaluation forms were submitted by a total of 112 students from 21 (of the 30) Osler groups (response rate: 112/175 (64%)). Of the 21 Osler groups, 17 groups had a single session using videos and 4 groups had 2 sessions, resulting in 25 sets of completed evaluations. Students’ responses were organized into two main themes, each with a number of nested categories (Box 3).
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Box 3. Themes and categories.
Utility of video clips as a teaching tool in medical education
Authenticity & believability Thought provoking Skills & approaches Setting Medium Level of training Mentorship Experiential learning Effectiveness Relevance to practice
Attributes of physicianship portrayed in the video clips
Patient-centeredness Communication Physician-patient relationship Professionalism Ethical behavior Interprofessional practice Mentorship
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THEME 1: Utility of video clips as a teaching tool in medical education. The first category, ‘‘authenticity and believability’’, is comprised of comments that relate to the accuracy of video clips with respect to real clinical encounters. Some students thought that the video clips accurately portrayed clinical situations. For example, one student reported that the videos showed ‘‘relevance to real-life situations’’ and another student said that the videos provided a ‘‘chance to analyse [sic] a ‘real world’ situation using the principles we’ve learnt ’’. By contrast, other students felt that the clips were exaggerated and portrayed an over-dramatization of clinical encounters that rendered the scenario unrealistic, as reflected in the following quote ‘‘clips targeted for dramatic effect and the general public’’ and another student said, ‘‘It’s a TV show, not the real thing ’’. Words like ‘‘hollywoodesque’’, ‘‘stage-like’’, ‘‘caricature’’ and ‘‘theatrical’’ were used to describe the videos in a number of student comments. The second category, ‘‘thought provoking’’, consisted of comments relating to the video clips’ ability to encourage reflection. Many students reported that after viewing the video clips, they thought about how they would, or should, act in similar situations and debated what they could do differently. One student expressed that the videos ‘‘provided foodfor-thought’’. Other students viewed the exercise as an ‘‘out-of-classroom chance to reflect’’ and that the videos ‘‘made us think’’. The third category, ‘‘skills and approaches’’, is comprised of comments regarding the video clips’ utility in the demonstration of important clinical interactions and skills. Many students appreciated that the videos showcased aspects of the patient interview, including appropriate verbal and non-verbal communication techniques. One student commented that the videos prompted students to ‘‘discuss different ways to approach patients’’. Many student comments highlighted the notion that the video clips portrayed the ‘‘dos and don’ts’’ of medicine by demonstrating positive and negative behaviors and interactions; as one student commented, ‘‘how a physician should or should not act in different situations’’. The fourth category, ‘‘setting’’, consisted of comments about the video clips’ effectiveness in a small group setting. Many students agreed that the video clips generated group discussion. As one student wrote, ‘‘clips provoked a very animated discussion’’, and another stated, ‘‘clips brought 4
deeper discussions’’. Most students enjoyed the direct, live discussions with other Osler group members. One student shared, ‘‘Interesting part of these clips is watching them with other people. . . more interactive and easier to stimulate a conversation’’. There was consensus that this in-person setting was preferred to an online forum. One student reported that showing the videos in a small group setting ‘‘allowed everyone in the group to share their viewpoints’’. The fifth category, ‘‘medium’’, is comprised of comments reflecting the value of learning physicianship content using audiovisual materials. Many students felt that the video clips were an entertaining, engaging, interesting and interactive medium. One student wrote, ‘‘exciting way to integrate and reinforce the physicianship material’’. Another student reported that the video clips were a ‘‘nice change to the curriculum’’. Two students compared this medium to more commonly used methods of teaching in medical curricula by stating, ‘‘allows us to evaluate something more dynamic than theoretical material’’ and ‘‘more interesting method than reading cases’’. The positive reception of this form of educational medium hints that this type of method would be welcomed in the curriculum. As one student suggested, ‘‘please continue with this type of learning’’. The sixth category, ‘‘level of training’’, contained comments surrounding the timing of this material in medical teaching. Several students raised the concern that the situations in the video clips may be difficult for students to relate to when presented at an early point in their medical training. As one student stated, ‘‘sometimes hard for Med 1s to relate to, given the limited clinical experience’’. The seventh category, ‘‘mentorship’’, reflected comments pertaining to the value of having input from Osler fellows and Osler co-leaders. Many students noted that a major benefit of watching these videos in a small group setting was having a physician or senior medical student present to give advice and provide examples from their own clinical experiences. One student wrote that the Osler fellow ‘‘place [sic] the scenario in a real life setting and explain [sic] how situations such as these are handled’’. The eighth category, ‘‘experiential learning’’, reflected comments about the video clips’ capacity to draw on students’ own prior experiences. Many students affirmed that an added benefit of watching the video clips was sharing personal narratives from their own life experiences. One student wrote of ‘‘examples from around the table’’, which reflected that many small group members contributed personal anecdotes after viewing the scenarios. The ninth category, ‘‘effectiveness’’, consisted of comments about the video clips’ ability to effectively (or not) transmit knowledge to students. Many students agreed that the video clips were helpful in communicating information. One student wrote that the scenarios in the video ‘‘makes you think about certain things. . . you can’t learn from a textbook’’. However, some students felt that the video clips were not useful in imparting teaching points. Two students’ comments reflected this opinion in noting, ‘‘more effective to write unique scenarios encompassing the ideas’’ and ‘‘more interesting to go see real patients’’.
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The tenth category, ‘‘relevance to practice’’, included comments about the video clips’ role in preparing students for future clinical encounters. One student reported that the scenarios ‘‘primes us for the difficulties. . . in the clinical setting’’ and another said that the videos were ‘‘very helpful in preparing us how to deal’’.
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THEME 2: Attributes of physicianship portrayed in the video clips. The first category ‘‘patient-centeredness’’ stresses the importance of patient advocacy, patient autonomy and the provision of collaborative health care that reflects the patient’s values, needs and individual preferences. One student, for example, said ‘‘what may not be important for the doctor may be very important to the patient’’, while another student commented on the ‘‘difference between what we think is best for them as health care professionals and what they actually want in their care’’. Many students made the distinction between the patient and his/her disease, which demonstrated an emphasis on holistic care. One student highlighted this by stating, ‘‘treating the disease versus treating the patient and illness as a whole’’. The second category ‘‘communication’’ reflects the meaningful and open exchange between healthcare provider and patient with the ultimate goal of understanding diagnosis and the chosen management plan. Students’ comments suggest that communication is viewed as a shared interaction, with contributions from the health care professional and the patient, as exemplified by one student’s comment, ‘‘how to speak to a patient or their[sic] family, make sure they understand what message you are trying to get across’’ and another student’s comment, ‘‘how to listen to a patient’’. Some students felt it was important to tailor communication to the individual patient, as shown by one student’s comment, ‘‘adjusting your communication level/tone depending on your audience’’. The third category ‘‘physician-patient relationship’’ embraces the delivery of compassionate and supportive healthcare. The emphasis was on how positive rapport is crucial in creating a therapeutic and trustworthy alliance as indicated by two students who stated, ‘‘taking the time to build a relationship is important’’ and, ‘‘how important it is for the patient to trust their[sic] physicians’’. The fourth category ‘‘professionalism’’ represents the set of values, competencies, attitudes and behaviors that a society expects from a medical professional. One student expressed that the videos demonstrated ‘‘how to conduct yourself in a professional manner’’. Another student wrote that the videos sparked a ‘‘good discussion about professionalism’’. Professionalism is reflected by core values, such as responsibility, respect and empathy and these values were illustrated in many of the students’ comments. The fifth category ‘‘ethical behavior’’ reflects the moral issues and dilemmas that are frequently encountered in healthcare settings. One student asserted that the videos ‘‘sparked discussions on ethical behavior’’. Another student found that the scenarios in the video clips, ‘‘provoke a lot of ethical concerns and issues’’.
The sixth category ‘‘interprofessional practice’’ demonstrates interactions amongst colleagues, which promote a collaborative health care model in a multidisciplinary practice setting. One student appreciated from the videos ‘‘appropriate interactions with colleagues’’. Another student felt the videos showed ‘‘how to deal with other doctors’’. The seventh category ‘‘mentorship’’ illustrates the value of direct teaching in medical training and the benefit of having positive clinical role models. One student’s comments exemplified this, as this student described the ‘‘importance of learning from senior physicians’’.
Discussion The present study examined the use of video clips as a teaching tool in the Physician Apprenticeship course at McGill University’s Faculty of Medicine. This course setting revolves around meetings of groups of six first year medical students and a faculty mentor and is designed to provide a forum for discussion and reflection. First year medical students viewed video clips from the television series ER that showcased aspects of clinical interactions and chosen to portray positive or negative elements of physicianship. After viewing these video clips and engaging in group discussions, students responded in writing to open-ended questions that examined their perceptions of these video clips of clinical scenarios as a means of teaching physicianship, and explored the aspects of physicianship that they thought were featured in the videos. Physicianship is the term we have used in our curricular planning and content to refer to the skills, behaviors and attitudes of the doctor as a healer and as a professional. The various competencies encompassed by this term continue to emerge as important aspects of the education of medical students (Cruess & Cruess 1997). There is a concomitant need to develop and evaluate methods to teach these crucial aspects of clinical medicine. Case-based learning is a well-established method of teaching in the education of health professionals (Thistlethwaite et al. 2012) and we therefore chose to exploit this approach but with two variations. Case-based teaching materials are, for the most part, written texts. We reasoned, however, that visual movie presentations might be more appealing and engaging to current first year students. Second, the widespread introduction of simulation-based teaching would be better reflected in materials that provide simulacra of lived patient and physician experiences (Cruess et al. 2011). Finally, medical students are likely to be familiar with the popular television series, ER, and would thus be asked to view the material from a new vantage point. The students found that the video clips were useful teaching tools insofar as they demonstrated important clinical competencies and interactions. They appreciated that the videos showcased aspects of the patient interview, illustrated the patient-doctor relationship and portrayed the ‘‘dos and don’ts’’ of clinical interactions. The students found that the video clips displayed this educational content in a manner that was interesting, entertaining and engaging. Furthermore, they believed this method of presentation is effective in transmitting knowledge and communicating information. It is
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easy to conceive that video clips would appeal to recent cohorts of medical trainees. For example, Pavlov and Dahlquist (2010) note that medical trainees may already be fans of the television series from which the clips are derived and thus, the clips are more likely to capture and maintain trainees’ interest and attention (Pavlov & Dahlquist 2010). Blasco et al. (2006) claim that students often identify with the characters in the films they watch and Lumlertgul et al. (2009) postulate that videos ‘‘make abstract and dry content become alive and understandable’’ (Blasco et al. 2006; Lumlertgul et al. 2009). Blasco et al. (2006) assert that video clips provide easy access to situations with high emotional intensity. Emotions make learning ‘‘more memorable and more pleasurable’’, which could lead us to expect that video clips would succeed in an educational milieu (Blasco et al. 2006). Another important concept highlighted in our study was the capacity of the video clips’ to encourage reflection and critical thinking. This was consonant with the objectives of the Physician Apprenticeship course and also suited the small group teaching setting. A concern raised in the literature is that if a scene portrays unethical behaviors, would these behaviors be endorsed and is there a fear that students would be more likely to mirror these negative qualities? (Wicclair 2008; Czarny et al. 2010). From the student responses in our study, it seems that the videos prompted students to engage in reflection and moral reasoning and to think about how they would, or should, act in similar situations. They readily appreciated the videos that showcased inappropriate attitudes and behaviors for their heuristic value. Similar results emerged from Lumlertgul et al.’s (2009) pilot project, where medical students in Thailand viewed movies with depictions of professionalism conflicts and were asked to reflect on what they learned. The students in that study stated that a benefit of their learning was that it fostered critical thinking, not simple acceptance (Lumlertgul et al. 2009). There was some disparity amongst the student responses regarding the authenticity of video clips, reflecting the existing debate in the literature. Some students thought that the clips accurately portrayed clinical situations and underscored their ‘‘relevance’’. This position is supported by Blasco et al. (2006), who claim that movie clips are grounded in medical students’ familiar and daily lives (Blasco et al. 2006). Other students in our study criticized the video clips for being overly dramatic and exaggerating reality and used words such as ‘‘hollywoodesque’’ and ‘‘theatrical’’ to emphasize their unrealistic content. Lim and Seet (2008) acknowledge this critique by stating that the medical-based drama, House, contains ‘‘inconsistencies’’ and ‘‘reality breaks’’ (Lim & Seet 2008). Most students thought that the video clips’ benefit was enhanced by the small group setting. They enjoyed the inperson, live discussion with colleagues and mentors and began to appreciate the diversity of perceptions of a given situation. In Weber and Silk’s (2007) report of a family medicine elective at the University of Connecticut, which used film to emphasize how families cope with illness, they highlight the power of the small group setting to deepen students’ understanding of important themes (Weber & Silk 2007). In our study, the medical students valued input from peers, senior medical student and physician mentors and 6
appreciated hearing examples from their colleagues and mentors’ own clinical experiences. This was further supported by the overwhelming consensus that this in-person setting was preferred to an online forum. Several students stressed the capacity of the video clips to draw on students’ own previous experiences and to facilitate the exchange of stories from their personal lives. However, some comments from students in our study debated the appropriate timing of this educational experience. Students raised the concern that certain situations portrayed in the video clips may be difficult to relate to when presented early in training. This concern is mirrored in other studies, which argue that video clips shown at different levels of medical education and training can offer different perspectives as students’ transition from the classroom to the clinic (Ber & Alroy 2002; Lumlertgul et al. 2009). Nonetheless, most students in our study commented that the video clips ‘‘prime’’ students and help trainees ‘‘prepare’’ for future clinical encounters. Lumlertgul et al. (2009) echo this finding by stating that the video clips prepare medical students for situations that they will face in their future practice (Lumlertgul et al. 2009). Blasco et al. (2006) report that movie clips function as an ‘‘alarm’’ and make trainees more aware when similar scenarios occur in their professional lives (Blasco et al. 2006). In addition to obtaining a range of responses on the pedagogical aspects of this educational format, we were interested in the content imparted, namely, what features and attributes of physicianship were identified by the students as portrayed and exemplified in the clips. The students noted a diverse array of qualities, many of them very relevant to the objectives of the Physician Apprenticeship course specifically and to appropriate physician behaviors more broadly. After viewing the video clips, the students described a patient-centered and patient-directed approach to medical care. Many comments made reference to the dichotomy between treating the disease and treating the person, a frequent subject of discussion in physicianship courses, reflecting an effort to evolve toward a holistic approach to care. The students understood the importance of the physicianpatient relationship and commented on the relevance of a positive rapport and trust in the clinical dyad in an effort to establish and maintain a therapeutic alliance. The students understood that a critical aspect of the physician-patient relationship is effective communication between the healthcare provider and the patient and commented on the significance of listening to patients and their families. The students reported many enlightening discussions on ethical clinical behaviors provoked by the content and narratives of the video clips. They commented that the video vignettes triggered discussions on professional conduct. Moreover, the students expressed that a collaborative health care model was portrayed in the video clips. Within this model, students stressed the importance of interprofessional practice, whereby healthcare professionals work together in an interdisciplinary practice setting. The students reported on the value of teaching, mentorship and clinical role models within this care model.
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Limitations This study is not without limitations. The students in our sample are from one medical school class at one University, which constrains our ability to generalize our findings to other institutions and settings. In addition, the medical students surveyed in this study were first year students, in the preclinical phase of their medical training. We anticipate that showing the video clips to more senior medical students might stimulate more complex and nuanced discussions - however, we have not yet tested this notion empirically. Another limitation, and an area worthy of further research, is that this study did not look at efficacy, namely, whether this methodology is effective at teaching physicianship.
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Contributions To our knowledge, although many medical schools have instituted formal curricula to teach professionalism and other aspects of physicianship, there are very few studies that have evaluated the impact of the various approaches to teaching this content. Therefore, the major strength of this study is that it examined students’ perceptions of the use of video clips as a beneficial teaching tool to understand and apply the qualities of physicianship. Another strength of this study is that it directly explored medical student opinions and reflections, rather than the views of educators and administrators.
Conclusion This study, which examines the perspectives of first year medical students on using video clips of clinical scenarios from a popular television series as a means of teaching physicianship qualities, has elucidated some of the benefits of this teaching tool in medical education. The findings offer insights into the value of this innovative educational tool and support the continued use of video clips to teach professionalism in medical curricula.
Glossary Professionalism: Physician’s responsibility to the patient, to other healthcare professionals and to society. Boudreau JD, Cassell EJ, Fuks A. 2007. A healing curriculum. Med Educ 41:1193–1201. Physicianship: Physician’s dual role as healer and professional. Boudreau JD, Cruess SR, Cruess RL. 2011. Physicianship: Educating for professionalism in the post-Flexnarian era. Perspect Biol Med 54:89–105.
Notes on contributors Dr. ALLISON HALEY SHEVELL, MDCM, Department of Pediatrics, McGill University, Montreal, Quebec, Canada. Dr. ALIKI THOMAS, PhD, OT(c), erg., is an Assistant Professor, School of Physical and Occupational Therapy and Research Scientist,
Centre for Medical Education, Faculty of Medicine, McGill University, and Emerging Researcher, Centre for Interdisciplinary Research in rehabilitation, Jewish Rehabilitation Hospital, Montreal, Quebec, Canada. Dr. ABRAHAM FUKS, MDCM, is a Professor, Department of Medicine, Pathology and Oncology, in the Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
Acknowledgments The authors are grateful for the continuous support from the Physicianship Curriculum Development Office at McGill University and would like to specifically acknowledge Anne Briggs for her administrative assistance. The authors wish to thank Dr Barry Slapcoff for his leadership role in the Physician Apprenticeship course and specific endorsement of this program as well as the individual Osler fellows for implementing this teaching tool in their Osler group sessions. Declaration of interest: The authors report no conflicts-ofinterest.
References Ber R, Alroy G. 2002. Teaching professionalism with the aid of trigger films. Med Teach 24:528–531. Blasco PG, Moreto G, Roncoletta AF, Levites MR, Janaudis MA. 2006. Using movie clips to foster learners’ reflection: Improving education in the affective domain. Fam Med 38:94–96. Boudreau JD, Cassell EJ, Fuks A. 2007. A healing curriculum. Med Educ 41: 1193–1201. Boudreau JD, Cruess SR, Cruess RL. 2011. Physicianship: Educating for professionalism in the post-Flexnarian era. Perspect Biol Med 54: 89–105. Boudreau JD, Jagosh J, Slee R, Macdonald ME, Steinert Y. 2008. Patients’ perspectives on physicians’ roles: Implications for curricular reform. Acad Med 83:744–753. Cruess RL, Cruess SR, Snell L, Ginsburg S, Kearney R, Ruhe V, Ducharme S, Sternszus R. 2011. Teaching, learning and assessing professionalism at the post graduate level. Members of the FMEC PG consortium. Available from https://www.afmc.ca/pdf/fmec/ 20_Cruess_Professionalism.pdf. Cruess SR, Cruess RL. 1997. Professionalism must be taught. BMJ 315: 1674–1677. Czarny MJ, Faden RR, Sugarman J. 2010. Bioethics and professionalism in popular television medical dramas. J Med Ethics 36: 203–206. Frank JR, editor. 2005. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada. Lim EC, Seet RC. 2008. In-house medical education: Redefining teleeducation. Teach Learn Med 20:193–195. Lumlertgul N, Kijpaisalratana N, Pityaratstian N, Wangsaturaka D. 2009. Cinemeducation: A pilot student project using movies to help students learn medical professionalism. Med Teach 31: e327–e332. Neergaard MA, Olesen F, Andersen RS, Sondergaard J. 2009. Qualitative description – the poor cousin of health research? BMC Med Res Method 9:1–5. Pavlov A, Dahlquist GE. 2010. Teaching communication and professionalism using a popular medical drama. Fam Med 42: 25–27. Steinert Y, Boudreau JD, Boillat M, Slapcoff B, Dawson D, Briggs A, Macdonald ME. 2010. The Osler Fellowship: An apprenticeship for medical educators. Acad Med 85:1242–1249.
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Steinert Y, Cruess S, Cruess R, Snell L. 2005. Faculty development for teaching and evaluating professionalism: From programme design to curriculum change. Med Educ 39:127–136. Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, Purkis J, Clay D. 2012. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach 34:421–444.
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Weber CM, Silk H. 2007. Movies and medicine: An elective using film to reflect on the patient, family, and illness. Fam Med 39: 317–319. Wicclair MR. 2008. The pedagogical value of House, M.D. – Can a fictional unethical physician be used to teach ethics? Am J Bioethics 8:16–17.
Teaching professionalism to first year medical students using video clips ALLISON HALEY SHEVELL1, ALIKI THOMAS2,3,4 & ABRAHAM FUKS1 1
McGill University, Canada, 2Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Canada, 3School of Physical and Occupational Therapy, McGill University, Canada, 4Centre for Medical Education, McGill University, Canada
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Abstract Background: Medical schools are confronted with the challenge of teaching professionalism during medical training. The aim of this study was to examine medical students’ perceptions of using video clips as a beneficial teaching tool to learn professionalism and other aspects of physicianship. Methods: As part of the longitudinal Physician Apprenticeship course at McGill University, first year medical students viewed video clips from the television series ER. The study used qualitative description and thematic analysis to interpret responses to questionnaires, which explored the educational merits of this exercise. Results: Completed questionnaires were submitted by 112 students from 21 small groups. A major theme concerned the students’ perceptions of the utility of video clips as a teaching tool, and consisted of comments organized into 10 categories: ‘‘authenticity and believability’’, ‘‘thought provoking’’, ‘‘skills and approaches’’, ‘‘setting’’, ‘‘medium’’, ‘‘level of training’’, ‘‘mentorship’’, ‘‘experiential learning’’, ‘‘effectiveness’’ and ‘‘relevance to practice’’. Another major theme reflected the qualities of physicianship portrayed in video clips, and included seven categories: ‘‘patient-centeredness’’, ‘‘communication’’, ‘‘physicianpatient relationship’’, ‘‘professionalism’’, ‘‘ethical behavior’’, ‘‘interprofessional practice’’ and ‘‘mentorship’’. Conclusions: This study demonstrated that students perceived the value of using video clips from a television series as a means of teaching professionalism and other aspects of physicianship.
Introduction
Practice points
First hand clinical experience is a meaningful and effective way of learning professionalism as these experiences are rooted in authenticity and have direct relevance to trainees’ future practice as clinicians (Cruess et al. 2011). These clinical opportunities are likely to occur during trainees’ clerkship and residency rotations. However, many experiences may not be encountered with sufficient frequency within these timeframes. Therefore, there is a need to supplement authentic experiences with simulated situations, which can take the form of case vignettes, role-play, simulation exercises and videos of scenarios (Cruess et al. 2011). The Royal College of Physicians and Surgeons of Canada accredits and sets standards for the education of medical specialists in Canada. The Royal College has endorsed the CanMEDS framework, which outlines the knowledge, skills and abilities expected of physicians for optimal patient outcomes. According to the CanMEDS framework, there are seven core roles that all physicians are required to fulfill to be better doctors: medical expert, communicator, collaborator, manager, health advocate, scholar and professional (Frank 2005). Professionalism is highlighted in the CanMEDS framework and as a result, is emerging as an important part of medical training and is part of an evolving pedagogical stream
Physicianship is a term used in McGill’s Faculty of Medicine to refer to the physician as healer and professional. Medical Schools are confronted with the challenge of explicitly teaching the competencies encompassed by this term. Students perceive the value of using video clips from a television series as a means of teaching professionalism and aspects of physicianship.
(Cruess & Cruess 1997). Therefore, medical schools have recently been faced with the responsibility of teaching students professionalism (Steinert et al. 2005). The concept of ‘‘Physicianship’’ was introduced by the Faculty of Medicine at McGill University in 2005. Physicianship encompasses the physician’s dual role as a healer and a professional (Cruess & Cruess 1997; Boudreau et al. 2008, 2011). As healer, the physician demonstrates several core attributes, such as compassion and openness (Boudreau et al. 2008) that enhance and optimize the physician-patient relationship (Boudreau et al. 2007). Professionalism describes the competencies and behaviors that relate to the physician’s
Correspondence: Abraham Fuks, MDCM, Professor of Medicine, McGill University, 3647 Peel Street, Rm 105, Montreal, Canada. Tel: 514-398-4400, ext 0279; Fax: 514-398-8568; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–8 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.970620
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responsibility to the patient, to other healthcare professionals and to the broader society (Cruess & Cruess 1997; Boudreau et al. 2007). The goal of introducing the term ‘‘Physicianship’’ into the medical curriculum at this University was to allow the core values and roles of the healer and professional to be taught explicitly and permeate through medical students’ educational experience and medical training (Boudreau et al. 2011). Even though many medical schools have begun to implement formal curricula related to professionalism, few studies have evaluated the effectiveness of pedagogical approaches to teaching this content. Several studies have contemplated the use and educational merits of videos in medical education and some studies found that students and facilitators perceive that videos were helpful in generating discussion and learning concepts relating to professionalism (Blasco et al. 2006; Lim & Seet 2008; Lumlertgul et al. 2009). Lumlertgul et al. (2009) argue that movies can be an entertaining and effective way of learning professionalism. Their study demonstrated that the movies prompted discussion of ethical issues amongst students (Lumlertgul et al. 2009). This feature of stimulating group and individual reflection may reflect an advantage of such teaching experiences and distinguish them from handson direct patient learning in busy clinical settings. The purpose of this paper is to report the results of a qualitative descriptive study examining medical students’ perceptions of the quality of their learning when viewing video clips from the television series ER. The study participants were first-year medical students at McGill University. As part of their medical training, students participate in a mandatory longitudinal 5.5 credit course called Physician Apprenticeship, which spans the four years of the undergraduate medical curriculum. Students in each medical class are divided into groups, called Osler groups, typically comprised of six students that meet regularly with an attending physician, called an Osler fellow, and two senior medical students (either in third or fourth year), called Osler co-leaders. The Osler fellows and Osler co-leaders serve as mentors to the group of medical students and meetings are designed to provide a supportive setting to reflect on clinical experiences as students proceed through their medical training (Steinert et al. 2010).
Methods Study design The study used a qualitative descriptive methodology. Qualitative description aims to describe experiences, events and perceptions (Neergaard et al. 2009). This methodology typically uses semi-structured interviews, open-ended questionnaires and/or focus groups to gather data and qualitative content analysis or thematic analysis using coding systems to analyze the data. Our study used open-ended questionnaires as the data source.
Ethical approval The McGill institutional review board (IRB) reviewed and approved the study. It also judged that the study fell under the 2
rubric of educational evaluation and that written consent from each participant was not required. Student confidentiality was maintained, as questionnaires were entirely anonymous with no attached identifiers. Furthermore, participation was voluntary.
Participants During the 2010–2011 academic year, 30 Osler groups and 175 first year students participated in the mandatory Physician Apprenticeship course. The sample for our study is drawn from this group.
Procedures As part of a pilot project for first-year medical students in the 2010–2011 academic year, the Physician Apprenticeship course included the use of multimedia teaching modules, designed to portray various elements of physicianship, namely, the physician’s dual role as a healer and a professional. The multimedia teaching modules contained selected brief, less than 5 minute, video clips from the television series ER accompanied by written teaching guides. The content and format of all video and learning materials were prepared by one of the authors of this paper (A.H.S). Twenty-nine video clips were initially prepared, and of these, 12 were chosen for use in this project, with different combinations of video clips randomly assigned to each Osler group. Osler groups watched one or two video clips per session. The vignettes showcased a variety of interactions amongst clinicians, medical trainees, patients and families. The video clips were chosen to demonstrate either positive or negative elements of physicianship, namely, the skills, attitudes and behaviors of clinicians. These videos emphasized ethical behavior and practice and were meant to promote critical thinking, problem solving, and clinical and ethical reasoning. The pedagogical intent of the videos was to encourage reflection by the students and to stimulate a discussion with peers and mentors in a small group setting. Each video clip was accompanied by a series of questions meant to facilitate discussion. Specifically, the questions explored what the students observed in the video clips and prompted group discussion on the attitudes and behaviors of the characters portrayed in the clinical scenarios. Each video clip was accompanied by a description of anticipated observations, interpretations and teaching points. These were provided as a guide only to the Osler fellows and their use was optional. The video clips were selected by the first author (A.H.S) and approved by another author (A.F), a McGill faculty member and contributor to the Physicianship curriculum with significant knowledge and expertise in professionalism. Osler fellows were requested to incorporate this educational exercise into one of the Physician Apprenticeship meetings. To do so, Osler fellows were instructed to play the video clip with its embedded question prompts and then to open the discussion to the student learners. They were prompted to ask the students what they observed in each clip, how they interpreted their observations, and what they learned from the video scenario. The students were asked to describe how the content of the video was relevant to
Teaching professionalism
Box 1. Student evaluation form questions.
1. Did the video clips illustrate elements of Physicianship? Please explain 2. Did you find the clips thought provoking? (e.g., by encouraging critical thinking, problem solving, clinical reasoning, self-reflection, ethical behavior) 3. Did the clips serve as a springboard for discussion in your group? 4. Would you like to see this type of teaching material used in the future? 5. If similar video clips were made available next semester on WebCT, would you participate in a moderated online discussion group?
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WebCT: online virtual learning environment system used by universities and other institutions
physicianship and were probed regarding the relevance of these qualities to the practice of medicine. The Osler fellows were permitted to use the materials in the written handouts and/or their own insights and prior experiences to facilitate group discussion. In a written introductory letter, it was stressed to all Osler fellows that they should use the written material as a guide and at their discretion. The Osler fellows were encouraged to replay the video after the discussion to consolidate the teaching points.
Box 2. Transcript for Osler Group B, clip #3, question #1.
Student 1: Yes – how to interact with patients, including eye contact; observational skills Student 2: Learning how to quickly build a rapport, paying more attention to patients initially, be more humane about people’s issues. Student 3: Yes, they illustrated some elements emphasized during Physicianship (to ‘‘do’s’’ and ‘‘don’ts’’). Student 4: Yes, the importance of putting the patient at ease, being open to discuss the patient’s problem, the fact that the physician has to earn the trust of his patients. Student 5: Yes – being there for the patient, eye contact, establishing a rapport with the patient, making them feel comfortable to confide in you. Student 6: Yes – body language and non-verbal communication; proper interviewing technique and patience and persistence.
List of key words/phrases from transcript for Osler group B, clip #3, question #1 Clip 3: 1
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Data sources The data consisted of students’ responses to open-ended questions included in an evaluation form. This evaluation form, developed by two of the authors (A.H.S and A.F), was comprised of five open-ended questions. The questions (Box 1) were designed to explore the elements of physicianship depicted in the videos, determine whether the video clips functioned as an effective springboard for discussion and ascertain whether students would like to use this type of teaching tool in future learning. As this was a trial of a new teaching strategy, Osler fellows and students were told at the time of evaluation form distribution that their feedback would be important in determining the usefulness of the video clips for future classes. The evaluation forms were distributed and completed immediately after viewing the video clips and the group discussion with the Osler fellow and co-leaders. This paper focuses on the students’ responses to the questionnaire.
Data analysis An administrator at the Physicianship Curriculum Development office transcribed the students’ handwritten responses to the questionnaire. Each transcript consisted of all student responses from one session where an Osler group viewed video clips. There were a total of 25 transcripts. We conducted a qualitative thematic analysis of all transcripts using a staged approach. The first author and a co-author (AT) with expertise in qualitative analysis were involved in all stages of the analysis. The first author (A.H.S) read through all the transcripts, to get a general sense of the content. A process of open coding followed which consisted of highlighting excerpts that were deemed to have some meaning. All highlighted excerpts were then included in a table and organized by the Osler group, video clip (if more than one was used) and question (an example can be found in Box 2). Words and phrases that appeared to convey a similar concept were
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how to interact with patients eye contact observational skills how to quickly build a rapport more attention to patients humane ‘‘do’s’’ and ‘‘don’ts’’ importance of putting patient at ease open to discuss physician has to earn the trust being there for the patient eye contact rapport making them fell comfortable to confide in you body language non-verbal communication interviewing technique patience persistence
grouped into preliminary categories. For example, ‘‘eye contact’’, ‘‘body language’’ and ‘‘non-verbal communication’’ were grouped together to refer to the capacity of the video clips to illustrate non-verbal aspects of communication. This iterative process of coding and grouping continued until all the highlighted words and phrases were organized into categories. The categories were then further synthesized into major themes. Two authors (AHS and AT) discussed all categories and major themes. Disagreements regarding categories and themes were resolved through discussion. The authors initially coded student responses and began analyzing data by specific question. However, once they observed that major themes emerged across questions, they no longer made the distinction between individual questions in compiling the final results.
Results Completed evaluation forms were submitted by a total of 112 students from 21 (of the 30) Osler groups (response rate: 112/175 (64%)). Of the 21 Osler groups, 17 groups had a single session using videos and 4 groups had 2 sessions, resulting in 25 sets of completed evaluations. Students’ responses were organized into two main themes, each with a number of nested categories (Box 3).
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Box 3. Themes and categories.
Utility of video clips as a teaching tool in medical education
Authenticity & believability Thought provoking Skills & approaches Setting Medium Level of training Mentorship Experiential learning Effectiveness Relevance to practice
Attributes of physicianship portrayed in the video clips
Patient-centeredness Communication Physician-patient relationship Professionalism Ethical behavior Interprofessional practice Mentorship
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THEME 1: Utility of video clips as a teaching tool in medical education. The first category, ‘‘authenticity and believability’’, is comprised of comments that relate to the accuracy of video clips with respect to real clinical encounters. Some students thought that the video clips accurately portrayed clinical situations. For example, one student reported that the videos showed ‘‘relevance to real-life situations’’ and another student said that the videos provided a ‘‘chance to analyse [sic] a ‘real world’ situation using the principles we’ve learnt ’’. By contrast, other students felt that the clips were exaggerated and portrayed an over-dramatization of clinical encounters that rendered the scenario unrealistic, as reflected in the following quote ‘‘clips targeted for dramatic effect and the general public’’ and another student said, ‘‘It’s a TV show, not the real thing ’’. Words like ‘‘hollywoodesque’’, ‘‘stage-like’’, ‘‘caricature’’ and ‘‘theatrical’’ were used to describe the videos in a number of student comments. The second category, ‘‘thought provoking’’, consisted of comments relating to the video clips’ ability to encourage reflection. Many students reported that after viewing the video clips, they thought about how they would, or should, act in similar situations and debated what they could do differently. One student expressed that the videos ‘‘provided foodfor-thought’’. Other students viewed the exercise as an ‘‘out-of-classroom chance to reflect’’ and that the videos ‘‘made us think’’. The third category, ‘‘skills and approaches’’, is comprised of comments regarding the video clips’ utility in the demonstration of important clinical interactions and skills. Many students appreciated that the videos showcased aspects of the patient interview, including appropriate verbal and non-verbal communication techniques. One student commented that the videos prompted students to ‘‘discuss different ways to approach patients’’. Many student comments highlighted the notion that the video clips portrayed the ‘‘dos and don’ts’’ of medicine by demonstrating positive and negative behaviors and interactions; as one student commented, ‘‘how a physician should or should not act in different situations’’. The fourth category, ‘‘setting’’, consisted of comments about the video clips’ effectiveness in a small group setting. Many students agreed that the video clips generated group discussion. As one student wrote, ‘‘clips provoked a very animated discussion’’, and another stated, ‘‘clips brought 4
deeper discussions’’. Most students enjoyed the direct, live discussions with other Osler group members. One student shared, ‘‘Interesting part of these clips is watching them with other people. . . more interactive and easier to stimulate a conversation’’. There was consensus that this in-person setting was preferred to an online forum. One student reported that showing the videos in a small group setting ‘‘allowed everyone in the group to share their viewpoints’’. The fifth category, ‘‘medium’’, is comprised of comments reflecting the value of learning physicianship content using audiovisual materials. Many students felt that the video clips were an entertaining, engaging, interesting and interactive medium. One student wrote, ‘‘exciting way to integrate and reinforce the physicianship material’’. Another student reported that the video clips were a ‘‘nice change to the curriculum’’. Two students compared this medium to more commonly used methods of teaching in medical curricula by stating, ‘‘allows us to evaluate something more dynamic than theoretical material’’ and ‘‘more interesting method than reading cases’’. The positive reception of this form of educational medium hints that this type of method would be welcomed in the curriculum. As one student suggested, ‘‘please continue with this type of learning’’. The sixth category, ‘‘level of training’’, contained comments surrounding the timing of this material in medical teaching. Several students raised the concern that the situations in the video clips may be difficult for students to relate to when presented at an early point in their medical training. As one student stated, ‘‘sometimes hard for Med 1s to relate to, given the limited clinical experience’’. The seventh category, ‘‘mentorship’’, reflected comments pertaining to the value of having input from Osler fellows and Osler co-leaders. Many students noted that a major benefit of watching these videos in a small group setting was having a physician or senior medical student present to give advice and provide examples from their own clinical experiences. One student wrote that the Osler fellow ‘‘place [sic] the scenario in a real life setting and explain [sic] how situations such as these are handled’’. The eighth category, ‘‘experiential learning’’, reflected comments about the video clips’ capacity to draw on students’ own prior experiences. Many students affirmed that an added benefit of watching the video clips was sharing personal narratives from their own life experiences. One student wrote of ‘‘examples from around the table’’, which reflected that many small group members contributed personal anecdotes after viewing the scenarios. The ninth category, ‘‘effectiveness’’, consisted of comments about the video clips’ ability to effectively (or not) transmit knowledge to students. Many students agreed that the video clips were helpful in communicating information. One student wrote that the scenarios in the video ‘‘makes you think about certain things. . . you can’t learn from a textbook’’. However, some students felt that the video clips were not useful in imparting teaching points. Two students’ comments reflected this opinion in noting, ‘‘more effective to write unique scenarios encompassing the ideas’’ and ‘‘more interesting to go see real patients’’.
Teaching professionalism
The tenth category, ‘‘relevance to practice’’, included comments about the video clips’ role in preparing students for future clinical encounters. One student reported that the scenarios ‘‘primes us for the difficulties. . . in the clinical setting’’ and another said that the videos were ‘‘very helpful in preparing us how to deal’’.
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THEME 2: Attributes of physicianship portrayed in the video clips. The first category ‘‘patient-centeredness’’ stresses the importance of patient advocacy, patient autonomy and the provision of collaborative health care that reflects the patient’s values, needs and individual preferences. One student, for example, said ‘‘what may not be important for the doctor may be very important to the patient’’, while another student commented on the ‘‘difference between what we think is best for them as health care professionals and what they actually want in their care’’. Many students made the distinction between the patient and his/her disease, which demonstrated an emphasis on holistic care. One student highlighted this by stating, ‘‘treating the disease versus treating the patient and illness as a whole’’. The second category ‘‘communication’’ reflects the meaningful and open exchange between healthcare provider and patient with the ultimate goal of understanding diagnosis and the chosen management plan. Students’ comments suggest that communication is viewed as a shared interaction, with contributions from the health care professional and the patient, as exemplified by one student’s comment, ‘‘how to speak to a patient or their[sic] family, make sure they understand what message you are trying to get across’’ and another student’s comment, ‘‘how to listen to a patient’’. Some students felt it was important to tailor communication to the individual patient, as shown by one student’s comment, ‘‘adjusting your communication level/tone depending on your audience’’. The third category ‘‘physician-patient relationship’’ embraces the delivery of compassionate and supportive healthcare. The emphasis was on how positive rapport is crucial in creating a therapeutic and trustworthy alliance as indicated by two students who stated, ‘‘taking the time to build a relationship is important’’ and, ‘‘how important it is for the patient to trust their[sic] physicians’’. The fourth category ‘‘professionalism’’ represents the set of values, competencies, attitudes and behaviors that a society expects from a medical professional. One student expressed that the videos demonstrated ‘‘how to conduct yourself in a professional manner’’. Another student wrote that the videos sparked a ‘‘good discussion about professionalism’’. Professionalism is reflected by core values, such as responsibility, respect and empathy and these values were illustrated in many of the students’ comments. The fifth category ‘‘ethical behavior’’ reflects the moral issues and dilemmas that are frequently encountered in healthcare settings. One student asserted that the videos ‘‘sparked discussions on ethical behavior’’. Another student found that the scenarios in the video clips, ‘‘provoke a lot of ethical concerns and issues’’.
The sixth category ‘‘interprofessional practice’’ demonstrates interactions amongst colleagues, which promote a collaborative health care model in a multidisciplinary practice setting. One student appreciated from the videos ‘‘appropriate interactions with colleagues’’. Another student felt the videos showed ‘‘how to deal with other doctors’’. The seventh category ‘‘mentorship’’ illustrates the value of direct teaching in medical training and the benefit of having positive clinical role models. One student’s comments exemplified this, as this student described the ‘‘importance of learning from senior physicians’’.
Discussion The present study examined the use of video clips as a teaching tool in the Physician Apprenticeship course at McGill University’s Faculty of Medicine. This course setting revolves around meetings of groups of six first year medical students and a faculty mentor and is designed to provide a forum for discussion and reflection. First year medical students viewed video clips from the television series ER that showcased aspects of clinical interactions and chosen to portray positive or negative elements of physicianship. After viewing these video clips and engaging in group discussions, students responded in writing to open-ended questions that examined their perceptions of these video clips of clinical scenarios as a means of teaching physicianship, and explored the aspects of physicianship that they thought were featured in the videos. Physicianship is the term we have used in our curricular planning and content to refer to the skills, behaviors and attitudes of the doctor as a healer and as a professional. The various competencies encompassed by this term continue to emerge as important aspects of the education of medical students (Cruess & Cruess 1997). There is a concomitant need to develop and evaluate methods to teach these crucial aspects of clinical medicine. Case-based learning is a well-established method of teaching in the education of health professionals (Thistlethwaite et al. 2012) and we therefore chose to exploit this approach but with two variations. Case-based teaching materials are, for the most part, written texts. We reasoned, however, that visual movie presentations might be more appealing and engaging to current first year students. Second, the widespread introduction of simulation-based teaching would be better reflected in materials that provide simulacra of lived patient and physician experiences (Cruess et al. 2011). Finally, medical students are likely to be familiar with the popular television series, ER, and would thus be asked to view the material from a new vantage point. The students found that the video clips were useful teaching tools insofar as they demonstrated important clinical competencies and interactions. They appreciated that the videos showcased aspects of the patient interview, illustrated the patient-doctor relationship and portrayed the ‘‘dos and don’ts’’ of clinical interactions. The students found that the video clips displayed this educational content in a manner that was interesting, entertaining and engaging. Furthermore, they believed this method of presentation is effective in transmitting knowledge and communicating information. It is
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easy to conceive that video clips would appeal to recent cohorts of medical trainees. For example, Pavlov and Dahlquist (2010) note that medical trainees may already be fans of the television series from which the clips are derived and thus, the clips are more likely to capture and maintain trainees’ interest and attention (Pavlov & Dahlquist 2010). Blasco et al. (2006) claim that students often identify with the characters in the films they watch and Lumlertgul et al. (2009) postulate that videos ‘‘make abstract and dry content become alive and understandable’’ (Blasco et al. 2006; Lumlertgul et al. 2009). Blasco et al. (2006) assert that video clips provide easy access to situations with high emotional intensity. Emotions make learning ‘‘more memorable and more pleasurable’’, which could lead us to expect that video clips would succeed in an educational milieu (Blasco et al. 2006). Another important concept highlighted in our study was the capacity of the video clips’ to encourage reflection and critical thinking. This was consonant with the objectives of the Physician Apprenticeship course and also suited the small group teaching setting. A concern raised in the literature is that if a scene portrays unethical behaviors, would these behaviors be endorsed and is there a fear that students would be more likely to mirror these negative qualities? (Wicclair 2008; Czarny et al. 2010). From the student responses in our study, it seems that the videos prompted students to engage in reflection and moral reasoning and to think about how they would, or should, act in similar situations. They readily appreciated the videos that showcased inappropriate attitudes and behaviors for their heuristic value. Similar results emerged from Lumlertgul et al.’s (2009) pilot project, where medical students in Thailand viewed movies with depictions of professionalism conflicts and were asked to reflect on what they learned. The students in that study stated that a benefit of their learning was that it fostered critical thinking, not simple acceptance (Lumlertgul et al. 2009). There was some disparity amongst the student responses regarding the authenticity of video clips, reflecting the existing debate in the literature. Some students thought that the clips accurately portrayed clinical situations and underscored their ‘‘relevance’’. This position is supported by Blasco et al. (2006), who claim that movie clips are grounded in medical students’ familiar and daily lives (Blasco et al. 2006). Other students in our study criticized the video clips for being overly dramatic and exaggerating reality and used words such as ‘‘hollywoodesque’’ and ‘‘theatrical’’ to emphasize their unrealistic content. Lim and Seet (2008) acknowledge this critique by stating that the medical-based drama, House, contains ‘‘inconsistencies’’ and ‘‘reality breaks’’ (Lim & Seet 2008). Most students thought that the video clips’ benefit was enhanced by the small group setting. They enjoyed the inperson, live discussion with colleagues and mentors and began to appreciate the diversity of perceptions of a given situation. In Weber and Silk’s (2007) report of a family medicine elective at the University of Connecticut, which used film to emphasize how families cope with illness, they highlight the power of the small group setting to deepen students’ understanding of important themes (Weber & Silk 2007). In our study, the medical students valued input from peers, senior medical student and physician mentors and 6
appreciated hearing examples from their colleagues and mentors’ own clinical experiences. This was further supported by the overwhelming consensus that this in-person setting was preferred to an online forum. Several students stressed the capacity of the video clips to draw on students’ own previous experiences and to facilitate the exchange of stories from their personal lives. However, some comments from students in our study debated the appropriate timing of this educational experience. Students raised the concern that certain situations portrayed in the video clips may be difficult to relate to when presented early in training. This concern is mirrored in other studies, which argue that video clips shown at different levels of medical education and training can offer different perspectives as students’ transition from the classroom to the clinic (Ber & Alroy 2002; Lumlertgul et al. 2009). Nonetheless, most students in our study commented that the video clips ‘‘prime’’ students and help trainees ‘‘prepare’’ for future clinical encounters. Lumlertgul et al. (2009) echo this finding by stating that the video clips prepare medical students for situations that they will face in their future practice (Lumlertgul et al. 2009). Blasco et al. (2006) report that movie clips function as an ‘‘alarm’’ and make trainees more aware when similar scenarios occur in their professional lives (Blasco et al. 2006). In addition to obtaining a range of responses on the pedagogical aspects of this educational format, we were interested in the content imparted, namely, what features and attributes of physicianship were identified by the students as portrayed and exemplified in the clips. The students noted a diverse array of qualities, many of them very relevant to the objectives of the Physician Apprenticeship course specifically and to appropriate physician behaviors more broadly. After viewing the video clips, the students described a patient-centered and patient-directed approach to medical care. Many comments made reference to the dichotomy between treating the disease and treating the person, a frequent subject of discussion in physicianship courses, reflecting an effort to evolve toward a holistic approach to care. The students understood the importance of the physicianpatient relationship and commented on the relevance of a positive rapport and trust in the clinical dyad in an effort to establish and maintain a therapeutic alliance. The students understood that a critical aspect of the physician-patient relationship is effective communication between the healthcare provider and the patient and commented on the significance of listening to patients and their families. The students reported many enlightening discussions on ethical clinical behaviors provoked by the content and narratives of the video clips. They commented that the video vignettes triggered discussions on professional conduct. Moreover, the students expressed that a collaborative health care model was portrayed in the video clips. Within this model, students stressed the importance of interprofessional practice, whereby healthcare professionals work together in an interdisciplinary practice setting. The students reported on the value of teaching, mentorship and clinical role models within this care model.
Teaching professionalism
Limitations This study is not without limitations. The students in our sample are from one medical school class at one University, which constrains our ability to generalize our findings to other institutions and settings. In addition, the medical students surveyed in this study were first year students, in the preclinical phase of their medical training. We anticipate that showing the video clips to more senior medical students might stimulate more complex and nuanced discussions - however, we have not yet tested this notion empirically. Another limitation, and an area worthy of further research, is that this study did not look at efficacy, namely, whether this methodology is effective at teaching physicianship.
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Contributions To our knowledge, although many medical schools have instituted formal curricula to teach professionalism and other aspects of physicianship, there are very few studies that have evaluated the impact of the various approaches to teaching this content. Therefore, the major strength of this study is that it examined students’ perceptions of the use of video clips as a beneficial teaching tool to understand and apply the qualities of physicianship. Another strength of this study is that it directly explored medical student opinions and reflections, rather than the views of educators and administrators.
Conclusion This study, which examines the perspectives of first year medical students on using video clips of clinical scenarios from a popular television series as a means of teaching physicianship qualities, has elucidated some of the benefits of this teaching tool in medical education. The findings offer insights into the value of this innovative educational tool and support the continued use of video clips to teach professionalism in medical curricula.
Glossary Professionalism: Physician’s responsibility to the patient, to other healthcare professionals and to society. Boudreau JD, Cassell EJ, Fuks A. 2007. A healing curriculum. Med Educ 41:1193–1201. Physicianship: Physician’s dual role as healer and professional. Boudreau JD, Cruess SR, Cruess RL. 2011. Physicianship: Educating for professionalism in the post-Flexnarian era. Perspect Biol Med 54:89–105.
Notes on contributors Dr. ALLISON HALEY SHEVELL, MDCM, Department of Pediatrics, McGill University, Montreal, Quebec, Canada. Dr. ALIKI THOMAS, PhD, OT(c), erg., is an Assistant Professor, School of Physical and Occupational Therapy and Research Scientist,
Centre for Medical Education, Faculty of Medicine, McGill University, and Emerging Researcher, Centre for Interdisciplinary Research in rehabilitation, Jewish Rehabilitation Hospital, Montreal, Quebec, Canada. Dr. ABRAHAM FUKS, MDCM, is a Professor, Department of Medicine, Pathology and Oncology, in the Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
Acknowledgments The authors are grateful for the continuous support from the Physicianship Curriculum Development Office at McGill University and would like to specifically acknowledge Anne Briggs for her administrative assistance. The authors wish to thank Dr Barry Slapcoff for his leadership role in the Physician Apprenticeship course and specific endorsement of this program as well as the individual Osler fellows for implementing this teaching tool in their Osler group sessions. Declaration of interest: The authors report no conflicts-ofinterest.
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