Perspective
Images and Cultures
A Web-based Approach to Teaching Humanism
By Glenn Nordehn, D.O., Fred Hafferty, Ph.D., S. Klar, D. Collins, E. Vilen, and A. Foss
Medical students use images to consider the less clinical side of medicine.
The humanities have long been associated with medicine. Hippocrates’ grasp of and esteem for philosophy is part of medicine’s historical record. Ibn Sina, who introduced the concept of peer review, wrote volumes on theology, geometry, astronomy, and metaphysics as well as medicine. Many physician-authors such as Anton Chekhov have drawn upon both medicine and the humanities. Over time, however, an emphasis on technology and science almost eliminated the humanities from medical training.
The need to reunite science and the humanities was highlighted by the launch of the Arnold P. Gold Foundation, which was formed in 1988 to promote humanism in medical education. In 1993, the foundation introduced the White Coat Ceremony, in which medical students dedicate themselves to the nurturing of patients as individuals. Medical schools around the country quickly adopted the ceremony to both formalize and re-emphasize the importance of humanism.
Since then, the pendulum in medical education has continued to swing toward the human side of doctoring with the influence of physician-educators such as Rita Charon, M.D. Charon pioneered the art of “narrative medicine” at Columbia University’s medical school, encouraging students and residents to write about the victories they experience, their fear of mistakes, and their sense of anger and loss when patients die.1 A 2006 survey of American Medical Colleges found 94 of 125 medical schools now include medical humanities in the required curriculum.2
Despite this renewed focus on the humanities, getting overly taxed students to invest time and effort in exploring the more human aspects of medicine has been a challenge for instructors. Especially during the first two years, students are immersed in other information—important facts about the current version of scientific truth. Thus, discussion of the humanities, values, and cultures often is marginalized. Students and some faculty believe that there simply is not enough time during those years to adequately cover both the scientific and humanistic aspects of medicine. Or—is there?
Our Attempts at Engaging Students
Previously, faculty at the University of Minnesota Medical School, Duluth campus, attempted to engage first- and second-year students in discussions about the human side of medicine—such things as cultural values, compassion, empathy, and respect—through literature-based discussion groups and book clubs as part of the Family Medicine course. Students read books about the delivery of medicine in diverse cultures and discussed the issues they raised. For most students, these sessions were valuable. But faculty found that some came to class unprepared and were unable to participate in the discussions.
Another way we attempted to get students to reflect on the human side of doctoring was by encouraging them to report on their international experiences. Typically, students would show pictures from their trip and talk about what they learned. Although the photographs generated discussion and the presentations were always interesting, they didn’t always lead to cross-cultural analysis or personal reflection.
We realized we were missing an opportunity to promote a deeper discussion about the human condition and about practicing medicine. We felt we needed another way to engage students in subjects they might not immediately see as relevant to practicing medicine.
A New Approach
This led us to develop a teaching and workshop format we call “Images and Cultures.” The format requires students to use the Internet to quickly find and display images (both photographs and artwork) that then become the focal point of conversation. We consider the approach especially useful for fostering discussions about varied cultural values as well as students’ feelings about caring for diverse patients and being in medical school.
In our first attempt at bringing technology into the classroom in 2005, we used a free electronic bulletin board to which each student submitted one photograph along with their comments about the image. This achieved our goal of getting students talking and thinking about issues that go beyond what they were learning in class. But the online discussion board we used was cumbersome. There were too many registration requirements, and it was difficult to upload photographs. So we developed our own website.
Now, students are assigned topics such as “How I see myself in medicine.” They search online for an image or submit an original photograph that speaks to the topic and upload it temporarily to our website. They then submit short written statements explaining why they selected the image and what it conveys about the topic.
We talk about culture as a set of values, norms, and artifacts, defining those terms as the ideals held by individuals or groups about what is desirable, proper, good, or bad; culturally established rules prescribing appropriate social behavior; and tangible products or any physical remains of human activity, respectively.3 After reviewing these definitions, participants are asked to think of words describing the values, norms, and artifacts they believe are represented in the photograph they’ve selected and are relevant to the topic. These terms become part of the uploaded record.
Students review each others’ images and writings and respond to those they find most compelling. For example, when students were asked to find photos and illustrations that depicted the delivery of medicine in a place other than Minnesota, Daryn Collins submitted a photo of a wrought-iron lawn ornament displaying the Chinese symbol for “to dance.” He explained that he took the picture during a spring break trip to the Mississippi Gulf Coast to help with the cleanup following Hurricane Katrina. The photo was taken on the site where an elderly couple’s home once stood.
Collins wrote: “This image is important to me in that it represents the hope displayed not only by this couple but by many of the people we met during our experience in Mississippi. In the face of great devastation, there remains a palpable sense of hope that things will get better. A parallel can be drawn to the lives of patients faced with debilitating illness. A sense of hope often makes an important difference in determining the quality of life of patients with chronic disease. By focusing on the elements of life that we can control, we allow ourselves ‘to dance,’ regardless of the circumstances. In life, we can ask for strength to change the things we have the ability to change, the courage to accept the things we cannot change, and the wisdom to know the difference. True serenity is found in our ability ‘to dance,’ even when faced with disease. …”
Collins also identified peace, love, and nature as the values the photograph most illustrated; work, rest, and ponder as the norms represented; and nature and tools as artifacts in the image.
The photograph stimulated considerable discussion about the level of passion a physician should have for his or her career, and whether caring too much for their patients can become a problem for medical providers. The students also talked about how they can work in challenging situations where needs are great and still retain compassion for others.
Surprising Pictures and Words
Students repeatedly surprise us with the types of images they find to illustrate medical concepts or themes. And we are even more surprised by the quality of the discussions those images evoke. For example, one student chose a photograph of an elephant’s foot raised over a mouse to illustrate compassion. Although most students and faculty thought the elephant was compassionate for not squashing the mouse, one student cleverly noted that the mouse was showing compassion by scratching the elephant’s itchy foot. This led to a discussion about the ways physicians can show compassion and how their position in society affects whether or not they or their patients interpret an act as compassionate.
Erik Vilen chose a photo of a mountain rescue to illustrate the idea that medical education does not develop well enough one’s ability to form continuous, healing relationships with patients. He wrote: “As health care providers, we struggle to provide many of our patients with care within their means. Thus, much like the provider and patient in the picture, we are dangling precariously over a health care abyss which we both may fall into. How can we prevent our patients from hanging by a thread?”
In response to the assigned theme “How I see myself in medicine,” Adam Foss chose an image of a hand silhouetted against a lit, blue screen, explaining that the image represented pureness of actions, caring, gentleness, and calmness. “A physician’s motto should be ‘First do no harm,’” he wrote. “To me, pureness in actions is the main component of ‘First do no harm.’ This exemplifies what my goal is for my practice, do no harm to the patients, but also to be very caring, gentle, and calming.”
Driving Discussion
Because our Images and Cultures approach does not require students to do reading or research ahead of time, all actively participate. Each student submits a photograph and writes about it; thus, each student is inherently engaged in thought and discussion.
We have found this approach to be efficient, although the time spent on a topic may vary depending on the aim of the instructor and the size of the class. We have successfully worked with a group of 60 students, all of whom submitted photos during a 50-minute class period.
Most important, we have found that because students are simultaneously searching for images, looking at the images others have selected, and reading and writing comments, they are engaged in discussions about integrity, excellence, compassion, empathy—topics that sometimes get marginalized in medical school curricula. We have found some enjoy the discussions so much that they voluntarily stay after class to continue them. Student feedback in the form of class evaluations has been overwhelmingly positive.
Conclusion
Images and Cultures is a unique teaching tool developed by faculty at the University of Minnesota, Duluth campus, to foster reflection about cultural values and norms and evoke discussion. It could be used to explore any topic. But we have found it particularly valuable for stimulating discussion about practicing medicine in the context of culture. Students appear comfortable using the website to explore a variety of topics. The pictures help them make connections between what they know and what might be new to them, and thus, promote learning.
Because images convey so much information and because the technology we’ve developed streamlines the process of finding images and writing about them, the Images and Cultures approach is an especially effective way to foster discussion about issues that might otherwise be overlooked in the traditional medical school classroom. MM
Glenn Nordehn is an assistant professor in the department of family medicine and community health; Fred Hafferty is a professor in the department of behavioral sciences; S. Klar is a graduate student in the College of Science and Engineering’s department of electrical and computer engineering; and D. Collins, E. Vilen, and A. Foss are medical students at the University of Minnesota Medical School, Duluth campus.
References
1. Charon R. Narrative Medicine: A model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-902.
2. “Doctors Who Wield the Pen to Heal the Profession.” New York Times. May 15, 2007.
3. Giddens A. Sociology. London: Polity Press. 1997:586