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The use of abstract paintings and narratives to foster reflective capacity in medical educators: a multinational faculty development workshop
  1. Khaled Karkabi1,2,
  2. Hedy S Wald3,
  3. Orit Cohen Castel2,4
  1. 1Department of Family Medicine, Clalit Health Services, Haifa and Western Galilee District, Haifa, Israel
  2. 2The Division of Family Medicine, The Ruth & Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel
  3. 3Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
  4. 4The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
  1. Correspondence to Dr Khaled Karkabi, Family Medicine, Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Pob 8273, Haifa 31082, Israel; khaledka{at}clalit.org.il, khaled.karkabi{at}gmail.com

Abstract

Reflective capacity is integral to core healthcare professional practice competencies. Reflection plays a central role in teacher education as reflecting on teaching behaviours with critical analysis can potentially improve teaching practice. The humanities including narrative and the visual arts can serve as a valuable tool for fostering reflection. We conducted a multinational faculty development workshop aiming to enhance reflective capacity in medical educators by using a combination of abstract paintings and narratives. Twenty-three family physicians or physicians-in-training from 10 countries participated in the workshop. Qualitative assessment of the workshop showed that the combined use of art and narrative was well received and perceived as contributing to the reflective exercise. Participants generally felt that viewing abstract paintings had facilitated a valuable mood transformation and prepared them emotionally for the reflective writing. Our analysis found that the following themes emerged from participants’ responses: (1) narratives from different countries are similar; (2) the use of art helped access feelings; (3) viewing abstract paintings facilitated next steps; (4) writing reflective narratives promoted examination of educational challenges, compassion for self and other, and building an action plan; and (5) sharing of narrative was helpful for fostering active listening and appreciating multiple perspectives. Future research might include comparing outcomes for a group participating in arts–narrative-based workshops with those of a control group using only reflective narrative or in combination with figurative art, and implementing a combination of qualitative and quantitative methods of assessment.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

https://doi.org/10.1136/medhum-2013-010378

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    Introduction

    Reflective capacity in medical education

    Reflective capacity, that is, the critical analysis of knowledge and experience to achieve deeper meaning and understanding, guiding future behaviour1 is integral to core healthcare professional practice competencies (eg, the Accreditation Council for Graduate Medical Education (ACGME) of the USA2 and the General Medical Council (GMC) of the UK3). Schon's fundamental processes of reflection in- and on-action4 integrated with affective experience5 for deeper learning are essential for mindful practice.6 The use of reflection fosters empathy7 and practical wisdom6 and can help guide healthcare practitioners as they encounter the complexity inherent to clinical practice.8 Reflection is associated with effective use of feedback in medical education9 and the value of training faculty as ‘reflective coaches’ has been emphasised.10 ,11 Reflection in general has a central role in teacher education12 as the art of ‘paying attention’,13 and reflecting on teaching behaviours with critical analysis can potentially improve teaching practice.12 Reflection is not necessarily intuitive for learners or teachers, thus medical educators and faculty development programme developers are challenged to devise innovative pedagogy to promote reflective capacity development.8 The humanities including narrative literature14 and reflective writing,15–17 and the visual arts18–20 can serve as valuable avenues for fostering reflection.21

    Narrative and reflection in medical education

    Under the umbrella of narrative medicine, the study of literature (with narrative skills training) and reflective writing17 can promote reflection, building the skills of observation and interpretation and nurturing empathic attention to patients.22 Through the use of physician and student-generated texts, narrative competency processes of attention, representation and affiliation (with colleagues and patients) can be developed, mirroring clinical practice.17 Thinking with stories can teach phronesis or “constant self-awareness as a moral actor”.23 The use of the written word to represent perceptions, with narrative described as an “edifice”,17 provides an opportunity for deeper reflection.15 The development of emotional self-reflective ability within medical education has been described in memoirs and poetry.24 ‘Interactive’ reflective writing with integration of written feedback from faculty has been described as fostering learners’ development of more sophisticated reflection skills.25 ,26 In addition to cultivating insights into the process of patient care and promoting student-practitioner well-being, reflective writing in small group process within medical education can promote reflective self-assessment, a component of professional development.27 Furthermore, the relationship between reflective writing and professional development during the process of teacher education is well documented.28 The process of narrative reflective practice (physician-trainees and physicians sharing stories and peer group narrative inquiry; narrative ‘triggers’ for reflection)29 facilitates meaning-making within clinical and teaching experience for shaping professional identity.30

    Arts and reflection in medical education

    Within medical education, the visual arts serve to enhance observational skills,31 ,32 improve diagnostic skills,33 ,34 increase the span of listening to the patient,35 and deepen compassion for suffering.36 The formal implementation of arts curricula—as a component of medical humanities—for enhancing reflection in medical education is increasing in prevalence.18 ,37–39 According to Hurwitz, the arts help “order, illuminate, and deepen experience”, by working through “reflective and imaginative processes”.40

    Various arts modalities and combinations of modalities have been employed for fostering reflection. An interactive exhibition of photographs (of an ambiguous nature) was used as a catalyst for healthcare professionals’, patients’ and families’ reflection on feelings, spirituality, the illness process, and views of mortality in a healthcare context.20 Multimedia including use of visual methodologies in digital storytelling was found to stimulate reflection learning in medical students.41 Images of older adults were found to evoke emotional responses and foster critical reflection in a nursing education study of photo elicitation.42 The combination of viewing paintings and writing a short story to enhance understanding of human suffering has been successfully implemented in workshops for healthcare providers and medical educators.43 These combined modalities (writing narratives based on paintings) were found to stimulate students to reflect on their own experience with patients and to examine their emotions, feelings and actions.18

    The viewer's experience

    The arts involve the viewer directly, stretch the imagination, increase emotional self-awareness, and deepen affective resonance.43 In general, when Downie was posed the question: “How do we learn from arts?”, he responded: “We learn from arts by imaginative identification with the situations or characters depicted, and by having our imaginations stretched through being made to enter into unfamiliar situations or to see points of view other than our own”.44 Individuals look at art and react to it, each in his/her own way. The manner in which people look at art is affected by a whole series of learnt assumptions about art with regard to beauty, truth, genius, civilisation, form, status, taste, etc.45 Our reaction to art may vary with age, place, time and state of mind. The process of looking at paintings engages the intellect and emotions, that is, cognitive and affective components. Aesthetic experiences, in general, have been described as providing cognitive and affective processing, hypothesised to be art-specific, and in many cases both pleasing and self-rewarding.46 The emerging discipline of neuroesthetics47 may offer some insights into the neurological bases of the aesthetic experience, such as the blurred imagery of impressionist paintings affecting the brain's amygdala, a phenomenon which may contribute to viewers pervasively finding such pieces to be moving (given the amygdala's crucial role in emotions).48

    As we embarked on designing a faculty development programme to enhance reflection, we deliberately selected the medium of abstract art in contrast to prior work (and more popular use) with figurative paintings in medical education.31–33 In its purest form in Western art, abstract art is “one without a recognizable subject, one which doesn't relate to anything external or try to ‘look like’ something. Instead the color and form are the subject of the abstract painting. It's completely non-objective or non-representational”.49 While the reaction of the viewer to abstract painting might vary widely (as with figurative art), the viewer is not directed to an image or subject, and she/he has the liberty to flow with her imagination and emotions. Interestingly, the emotional state associated with aesthetic experiences has been hypothesised, at least in some cases, to extend to an experience of flow,50 described as a strong, positive emotional state which bears strong, intrinsic motivational potential.46

    Our decision to use abstract paintings was based on the idea that such viewing can facilitate viewers’ connecting with the self and their own inner worlds, thus engaging both cognitive and affective abilities. We hypothesised that such an exercise would facilitate the transition to the next step, writing a reflective narrative.

    Faculty development to promote reflection

    Faculty development for optimising facilitated reflection within medical education has been advocated.51 Such initiatives include building a community of reflective practice through faculty development for enhancing feedback to medical students’ reflective narratives52 and through sessions which incorporate peer group collaborative reflection on interprofessional faculty's self-generated reflective narratives.38 Engaging in the process of guided reflection on students’ reflective narratives can facilitate faculty's capacity to serve as reflective role models through an intersubjective process of transformative growth17 since “the student is no longer the person who wrote the reflective narrative, neither is the teacher who responded to it”.39 With regard to professional development, medical education faculty workshop participants have recognised the value of reflective writing as a vehicle for learning about their teaching practice and development,53 and a faculty development workshop on narrative medicine for reflecting on the use of narrative in professional practice has had measureable impacts.54 Recently, a faculty development programme using guided reflective writing promoted reflection and empathy among practicing physicians55 and the integration of written narratives (on meaningful clinical experiences) for reflection within a continuing education programme on mindful communication for primary care physicians helped cultivate intrapersonal and interpersonal mindfulness and improve their sense of well-being.56

    While both the arts and narrative can foster reflection and cultivate aesthetic ways of knowing57 within medical education, their combined use within a faculty development paradigm has not, to the best of our knowledge, been reported in the literature. Our described workshop design, therefore, is offered as an innovative approach to facilitating reflection through the combined use of art and narrative within faculty development.

    Workshop description

    Building on our foundational work on a previous occasion with integrating medical humanities in medical education,18 we (KK and OCC) designed a workshop for the 2012 WONCA (World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians) Conference (Vienna, Austria) to enhance the reflective competence of family medicine educators in the context of the educator–learner relationship. At the conclusion of the workshop, it was anticipated that participants would be able to identify challenges in educator–learner relationships, describe emotions emerging during an educational interaction with a learner, and utilise reflective writing as a strategy for addressing and managing challenges in educator–learner relationships.

    At the beginning of the workshop, the facilitators (KK and OCC) presented the rationale and plan for the workshop, and requested and obtained the verbal informed consent of the participants for potential publication of the results of the workshop. Participants were free to engage in the workshop, and all of them agreed to take part and gave their consent verbally for potential publication of the results, including anonymous citations of their responses (which were openly and visibly transcribed by facilitator OCC throughout the workshop).

    In the first part of the workshop, three abstract paintings were presented to the group using PowerPoint slides. The paintings presented were: ‘Red and Orange’ by Mark Rothko, ‘Full Fathom Five’ by Jackson Pollock, and ‘Composition number 6’ by Vassily Kandinsky. After observing the paintings one by one, participants were asked to choose one of the paintings to focus on. Each participant was provided with a small photograph of his or her selected painting (10 cm × 7 cm). They were then instructed to observe the painting again and to let the painting ‘work’ on them, allowing emotions to emerge spontaneously, rather than asking themselves what they saw in the painting.

    After several minutes of quiet contemplation, participants were invited to describe the emotions that emerged while observing the painting. Next, while gazing at the painting and allowing their emotional response to accompany the writing exercise, participants were asked to write a personal narrative either in their native language or in English, describing a meaningful or challenging situation with a student or a resident. Participants were then asked to share their narratives in pairs. After hearing the narrative, the listener was instructed to ask reflection-inviting questions to promote depth and breadth of reflection. The participant pairs then switched roles. Questions promoting reflective thinking included:

    1. What ambiguity or contradiction, if any, was reflected in the narrative?

    2. Where does this narrative take us? What challenges emerged within the narrative?

    3. How did the narrative contribute to meaning-making?

    4. How might you do things differently in the future?

    5. What could be an action plan?

    Results

    Twenty-three family medicine physicians or physicians-in-training from 10 countries participated in the workshop: 13 women and 10 men. Countries represented included Austria, Ireland, Israel, the Netherlands, New Zealand, Norway, Romania, Singapore, Spain and the UK.

    In the final part of the workshop, the participants were asked to share their feedback and take-home messages with the group. The discussion was recorded and transcribed. Emerging themes were coded by the authors independently and discussed to achieve mutual agreement. Themes are presented below with accompanying exemplars of workshop participants’ responses.

    1. Narratives from different countries are similar: “Same stories. The relations with trainees—giving feedback—put stress in relations”.

    2. The use of art helped access feelings: “The paintings gave us the right mood, the right words to talk about challenges”, “The colors make balanced emotions and free your mind”.

    3. Viewing abstract paintings facilitated next steps: “Looking at abstract paintings—it is like you have pushed a button which opens a door that leads to the story. It has opened the right side of the brain which allowed your left side to work better”.

    4. Writing reflective narratives promoted examination of educational challenges, compassion for self and other (regarding challenging feedback sessions), and building an action plan “The writing helped me organize and find a solution”, and “Very therapeutic. I wrote on a bad experience but at the end we were laughing at it”.

    5. Sharing of narrative was helpful for fostering active listening and appreciating multiple perspectives: “Listening was a challenge. Trying to see another point of view. The experience was a lesson to me”.

    Discussion

    We designed and conducted an innovative faculty development workshop to foster reflective capacity using art and narrative. We hypothesised that the combined use of abstract art and writing reflective narratives would have an added value in achieving the goal of facilitated reflection. While the value of reflective writing within medical education is now widely recognised and successfully implemented within curricula,14–16 we were uncertain about the acceptability of an intervention utilising abstract paintings and its impact. To the best of our knowledge, our innovation of using abstract paintings to foster reflection within faculty development is novel. However, we can only speculate how the use of this innovative approach in addition to the complexity of viewing and appreciating abstract painting, is perceived by workshop participants.

    Several themes emerged from the workshop discussion and are discussed below.

    Participants felt that narratives from different countries were similar

    While teaching methods in the context of educator–learner relationships in family medicine/general practice may differ, it was not surprising that the narratives were similar given that most countries represented in the workshop have Western cultural and medical education orientations.

    The use of art helped access feelings and viewing abstract paintings facilitated next steps

    Physiologically, it is unclear how looking at abstract paintings contributes to reflection. In his book ‘The Age of Insight’, the neuroscientist and Nobel Prize winner Eric Kandel explains how our brains perceive and engage with art, and how we are moved by it. He cites the Swiss-German art historian Wilhelm Worringer, who argues that two sensitivities are required of the viewer: empathy, which allows the viewer to lose herself in a painting and be at one with the subject, and abstraction, which allows the viewer to retreat from the complexities of the everyday world and follow the symbolic language of the forms and colours in a painting.58 Kendel cites Solso, who argues that in viewing abstract paintings, the viewer is trying to find a “deeper” meaning in each of the limited number of features, and thus spends more time on each.59 This could conceivably relate to the viewing of abstract paintings in the workshop facilitating participants’ ‘right mood’ and transition to reflective writing.

    Writing reflective narratives promoted examination of educational challenges, and compassion for self and other

    Reflection—fostered through the vehicle of reflective writing—can contribute to the professional development of teachers60 including “examination of educational challenges”. Reflection-in-action helps maintain flexibility during teaching and reflection-on-action promotes thoughtful analysis of the teaching experience for an ongoing iterative process of observing, reflecting and experimenting. Critical reflection can help teachers avoid being “trapped in unexamined judgments, interpretations, assumptions, and expectations”61 and thus potentially enrich teaching practice. In addition, cultivating awareness of self and other through reflective writing can nurture empathy55 and self-compassion, which includes recognition of shared humanity.62

    Sharing of narrative was helpful for fostering active listening and appreciating multiple perspectives

    Reflective writing in small group process within medical education can promote reflective self-assessment for personal and professional development.27 The sharing of narratives within a small group has been described as a “springboard to deeper discussion and reflection”.15 A core process of the reflection construct fostered through reflective writing in small group process is appreciating multiple perspectives (within a disorienting dilemma), contributing to meaning-making.63

    To summarise, qualitative assessment of the workshop indicated that the combined use of art and narrative was well received and perceived as contributing to the reflective exercise. Participants generally felt that viewing abstract paintings had facilitated a valuable mood transformation and prepared them emotionally for the reflective writing and the reflective exercise.

    At this level of evaluation, we cannot judge the long term impact of this faculty development session on the reflective capacity of medical educators. In line with participants’ workshop experiences and their feedback, we may speculate that some impact on their personal and professional development and on skills as ‘reflective role models’ within teaching has been achieved.

    Our study has several limitations. We conducted a single arts-narrative-based intervention on a relatively small number of participants. In addition, we did not use a control group receiving a non-arts-based or a figurative arts-based intervention. Neither attitude nor behavioural changes arising from our workshop using a combination of validated qualitative methods were assessed.

    Conclusion

    A faculty development workshop using art and reflective narrative to foster reflective capacity in medical educators in the context of educator–learner relationships is feasible and valuable. Faculty participants felt that the use of abstract paintings had contributed to facilitating the reflective writing and the reflective exercise. The study shows that such a workshop can be easily conducted for faculty development by facilitators without formal education in the arts or literature. Recommendations for future research might include comparing arts-narrative-based workshops with a control group using only reflective narrative or in combination with figurative art and implementing a combination of qualitative and quantitative methods of assessment.

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    Footnotes

    • Contributors All authors meet the ICJME requirements for authorship. Namely, all three have met the following conditions: (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.