Jordi Loscos1, Josep-E. Baños2, Francisco Loscos3 and Julio de la Cámara1
1Servicio de Oftalmología. Hospital Universitari “Germans Trias i Pujol”. Departamento de Cirugía. Universitat Autónoma de Barcelona. 2Departament de Ciencias Experimentales y de la Salud. Universitat Pompeu Fabra. Barcelona. 3Departamento de Dirección de Recursos Humanos. ESADE. Barcelona (Spain).
Correspondence: Jordi Loscos Arenas. Balmes 334, 1º, 4. 08006 Barcelona (Spain).
Received 15 September 2006; accepted 24 October 2006
In Spain, it is commonly held that medical students spend the entire time of their degree courses obsessed with the MIR (Post-graduate Medical Training/ Medical Residency) exam and, when they have sat and passed this, the health system itself together with excessive professional activity foster what is tantamount to a “hyperspecialisation”, in many cases in detriment to “learning to read” the patient as a complete entity. Upon exercising their profession, physicians should understand patients in their entirety since medicine –when considered as ethical humanism- fails if the patient is merely slotted into the “specialist” pigeon-hole. At the Teaching Unit of the Hospital Universitari Germans Trias i Pujol of the Universitat Autónoma de Barcelona we were prompted to incorporate a subject in the syllabus that would allow students to “both read and see medicine” to an extent far beyond the diagnostic level, that would provide them with a broader view of diseases, and one that that would become an emotional complement to the material studied in their degree course (and as a direct consequence, to their future profession), which tends to be excessively “biologistic”. What, then, could be better than literature and the cinema to teach students to “read and see medicine”? From previous knowledge that we had culled from other university programs, this would not only be a novel subject per se but should also offer a completely different learning model from traditional teaching contents in the field. This would thus approach the situation in other degree courses, such as in business studies, where similar subjects and models are used.
Keywords: Medical Training, Cinema, Literature.
The physician should observe, touch and smell the patient and should also attendto his or her psychic state and social surroundings. If this is not ensured, failure will ensue
Dr. Ciril Rozman
Scrutiny of any university programs aimed at the award of a degree in medicine shows that it is easy to find perfectly defined conceptual bases concerning all the learning aspects necessary to respond to the scientific aspects of medicine (the medical condition per se), but that it is very difficult to find scenarios of conceptual learning oriented to responding to emotion (worry, anxiety, clinical surroundings, the patient’s family) deriving from the patient’s condition. This prompted our interest in compiling an academic program that could give an overarching response to such issues. For the design of the subject discussed here, we initially incorporated an instructor versed in the field of the behaviour/attitude of working people and together we began to posit an objective, a focus, and the most suitable method for attaining our goals. We defined the objectives of the subject to be taught on the basis of certain gaps, apparent both in university programs and in the later professional activities of physicians. Our focus was based on the notion of an essential interrelationship with and interdependence on what we would call the three axes of the medical profession: (i) Disease, patient and Treatment; (ii) System (development of the profession within a given health system implying a specific working model), and (iii) Surroundings (the whole environment surrounding the professional activities of physicians) (Figure 1). Finally, we had to decide on the method. We wished to find a tool that would allow us to gain that knowledge about the basis of the emotional impact generated in illness, since it was not possible to engage in the exploration of the parameters of the emotional aspects involved through a purely theoretical subject. In light of the promising references found in specialist journals to the benefits of using this method as a generic teaching tool1, in instruction in medical microbiology and infectious diseases2,3, in pharmacology4, in studies of human biology5, and in publications about literature and medicine6, we concluded that, together, literature and the cinema could offer a good teaching tool. We also considered the public’s interest in films, owing to their universal language, their accessibility, their recreational nature, their versatility and their capacity for extrapolation to different aspects of professional life. Underpinning all this is the fact that Universities must incorporate new teaching methods that are more in accordance with the technological and social changes currently ongoing that will “break down the educational stagnation brought about by tradition”2.
Essentially, we considered that the cinema would justify its teaching role from four different perspectives: (i) the disseminatory function of medical situations; (ii) the development of a critical standpoint; (iii) the stimulation of emotional knowledge of illness, and (iv): knowledge of the social and individual consequences of illness. Initially, we ruled out the idea of insisting on the exclusively disseminatory aspects of illness and made attempts not to see the cinema from a merely medical or disseminatory point of view. Instead, we focused our interest more on the emotional aspects: reflections about the individual and social consequences brought about by medical conditions. All that remained was to consider the ways of learning we wished to build and equip each of them with a message, an invited contributor, and a film and a book. This was unknown ground and bore its own risks.
The experiment was carried out at the Germans Trias i Pujol Teaching Unit at the School of Medicine of the Universitat Autónoma de Barcelona, where some 60 students per course are taught from the third to the sixth years of the degree in medicine. From the academic point of view, we took advantage of the offer of an elective subject of the same (Literature, medicine and the cinema) that was included in the study plan but that until that moment had still not been taught or exploited (Table 1).
1.- Introduction to the subject: instruction method
2.- The value of literature in the training of medical students
First module: The patient, illness, and treatment
3.- Communication of the diagnosis
4.- Consequences of the illness
5.- Are there bases for belief in the existence of the soul?
Second module: The surroundings
6.- Individual responsibilities in illness
7.- Collective responsibilities in illness
Third module: The system
8.- The public health system
9.- Dramatised readings
10.- Reflections about the application of the course to the practice of medicine: Emotion and rationality in the practice of medicine.
Program of the subject “Literature, medicine and the cinema”
Owing to the characteristics of the subject we intended to teach, the “lure” of the cinema and its immediacy provide this medium with some advantages over literature. We therefore decided to create two different modules involving, on one hand, the cinema and, on the other, literature. The aim of both was to arrive at the same point along different but very similar pathways (Figure 2).
With a view to involving the students from the very first day of the experiment, it was first necessary to check up on their expectations: i.e., was this merely a chance to gain extra academic credits for having watched a few films? To our great surprise we found that the students valued the subject much more than we had anticipated and were pleased that “at last somebody is doing something to humanize medicine”. They understood the subject to be an exercise in empathy aimed at making them better prepared to face up to the problems that they would encounter in their future professional careers. They found the framework of reflection and debate about current issues linked to medicine made available to them through the cinema and literature to be very stimulating. They were also highly critical of their own previous academic training, which seemed to have placed exclusive emphasis on aspects related to the profession, neglecting aspects related to illness beyond its strictly biological considerations. The original idea was to have a small group of 25 students but the success of the course meant that we had to allow in as many students as the facilities could hold; a total of 67. Distribution by academic years was fairly homogeneous, with a predominance of students in the fifth year of their medical degree. Although this was very probably biased by schedule constraints (subjects pending from the third and fourth years), in the comments and attitudes garnered from the “old-timers” we did detect greater interest in these issues and better insight into their own lack of knowledge, and indeed failures, in certain areas as they were approaching the end of their undergraduate training.
A film was shown on each day of class devoted to the cinema, followed by a debate between an invited speaker, sparking lively contributions from the students. At the end of the sessions the students were requested to hand in a short stating their personal conclusions about each session. Along the course, films addressing the following issues were shown: “The consequences of illness”, “Are there any bases for belief in the existence of the soul?”, “Individual responsibilities in illness” and “The health system” (Table 2).
My Life without Me (Isabel Coixet, 2002)
Trainspotting (Danny Boyle, 1996)
Invasion of the Barbarians (Denys Arcand, 2003)
21 grams (Alejandro González, 2003)
Darwin's Nightmare (Hubert Sauper, 2004)
Dancer in the Dark (Lars von Trier, 2000)
The Doctor (Randa Haines, 1991)
Films shown along the subject
Optionally, the students were offered the possibility of making a short film about some topic related to medicine. The response was highly positive and they filmed “Don’t give me that line” which tackled the problem of drug addiction and was shown on the last day of class within the context of the closing lecture, under the title “Emotion and rationality in the medical profession”.
Literature was addressed from a dual standpoint. In a first session, which lasted a whole afternoon, one of the instructors gave a lecture entitled “The value of literature in the training of medical students”. During that session, students debated about how literature might contribute to their knowledge of illness, basing themselves on previous publications addressing the matter6-8. The lecture was interspersed with readings of extracts from literary works ranging from “Love in the time of cholera”, by Gabriel García Márquez, to “Perder la Piel” by Marta Allué (Table 3). At the end of the session, the students were given a list of recommended works that they could consult and use to prepare the next activity.
Fiction by literary authors
Gabriel García Márquez. Love in the time of cholera. New York: Knopf; 1988 (original title: El amor en los tiempos del cólera, 1987).
Marguerite Yourcenar. Memoirs of Hadrian. New York: Farrar, Straus and Giroux; 1963 (original title: Mémoires d’Hadrien, 1951).
Fictional works by physician authors
Martin Winckler. The Case of Dr. Sachs. New York: Seven Stories Press; 2000 (original title: La maladie de Sachs).
William Carlos Williams. The Collected Stories of William Carlos Williams. New York: New Directions; 1996.
Illness in the first person
Rafael Argullol. Davalú o el dolor. Barcelona: Quaderns Crema; 2001.
Kay R Jamison. An Unquiet Mind - A Memoir of Moods and Madness. New York: Vintage Books; 1997.
Marta Allué. Perder la piel. Barcelona: Planeta/Seix Barral; 1996.
José Luis Sampedro. Monte Sinaí. Barcelona: Plaza y Janés; 1995.
Jean-Dominique Bauby. Diving bell and the butterfly. London: Fourth Estate; 1998 (original title: Le scaphandre et le papillon, 1997).
Physicians describing illness
Oliver Sacks. The man who mistook his wife for a hat. Carmichael, CA: Touchstone Books; 1998.
Arthur Kleinman. The illness narratives. Suffering, healing and the human condition. New York: Basic Books; 1988.
Bernard Lown. The lost art of healing. Boston: Houghton Mifflin Co; 1996.
Ricard Ruiz Garzón. Las voces del laberinto. Historias reales sobre la esquizofrenia. Barcelona: Random House Mondadori; 2005.
Literary works commented during the course
The second part of the module dedicated to literature was given over completely to the students. In groups of 4-5 students each, they were asked to freely choose an extract from a work included within the recommended reading list -or from any other source- to prepare a dramatised reading. For this, they had the help of a company specialised in scenography. For one day, the lecture hall became a stage on which the students offered some excellent interpretations of texts by Pío Baroja, Lev Tolstoi, Elisabth Kubler-Ross, Samuel Shem, Martin Winkler, Marta Allué, Isabel Allende, Ramón Sampedro, Carl Sagan. Ann Druyann and Paulo Coelho, among others.
Assessment of the students’ performance took into account class attendance, the presentation of a paper reporting the student’s personal conclusions drawn from each session, participation in debates, and their attitude during the course.
The first salient conclusion was the high level of satisfaction of the students in a subject designed to introduce them to fundamental aspects of their future profession, to which (to date) the University has paid little attention. From the point of view of the instructors, the high degree of motivation and involvement, the number of students who signed up for the course (the highest in any of the elective studies offered by the Teaching Unit), the good attendance in class, and the quality of the students’ work were promising rewards that more than covered the input in terms of the time and energy dedicated to the matter. The students’ own assessment of the results revealed that the experiment was completely successful, which also confirms that the current system neglects these aspects of medicine. For example, in the conclusions of one student in the last year of the degree course the following appeared “It is very encouraging to think that after such a long degree course we have finally received some idea about patient treatment, patient-physician relationships and respect for our patients, none of which has been tackled in the more than 40 subjects we have been taught since we have been here and which in the future we shall have to use routinely in our professional careers”.
These words should lead us to reflect upon the current model of instruction received by our students, in which the most important physician-patient aspects are sadly overlooked and in which students are not taught how to cope with the type of situation that they will surely meet on the very first day of their professional activities. In other countries, there is great interest in the inclusion of such aspects in the medical syllabus9,10, but in Spain, only some physicians have begun to express their concern that novice doctors may be unaware of the important notions underlying empathy or lack thereof in physician-patient relationships11. We believe that experiments such as the one described here can help medical students to reflect upon the emotional and psychosocial aspects implicit in the medical profession that academics from Medical Schools should not overlook. The humanitarian aspects of medicine, such as those reflected in films or novels, may offer strong support to students in that they posit many problems that are difficult to understand from within the traditional scenario of our lecture halls.
The authors would like to thank the following for their advice, enthusiasm, and collaboration: Dr. David Andreu, Dr. Xavier Cardona, Miguel Cubero, Dr. Jordi Delás, Rodrigo Rama, Pilar Delas (Delás?) and María de la Cámera, together with the administrative staff and the students of the Teaching Unit at the Hospital Universitari Germans Trías i Pujol, without whom this teaching experiment would not have been possible.