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Teaching reflective competence in medical education using paintings
  1. Khaled Karkabi,
  2. Orit Cohen Castel
  1. Department of Family Medicine, The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Clalit Health Services, Haifa and Western Galilee District, Haifa, Israel
  1. Correspondence to Dr Khaled Karkabi, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, POB 8273, Haifa 31082, Israel; khaledka{at}

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Medical authorities around the world are increasingly focusing on the role of reflection in enabling doctors to mature as practitioners. Reflection has been recognised as an important competency in medical education, valuable for effective communication, good physician–patient relationships and accurate gathering of clinical information.1

Although different methods are used for teaching reflection, it remains a challenge for every medical educator. However, over the past 2 decades, the arts have been incorporated into medical humanities programs. For instance, paintings have served to enhance observational skills,2 improve diagnostic skills,3 increase attention span when listening to patients4 and deepen compassion for suffering.5

The standard Israeli medical school program consists of a traditional 6-year curriculum with an additional year of rotating internship. The program is usually composed of 3 years of basic sciences followed by 3 years of clinical clerkships. Internal medicine is a part of the clinical sciences curriculum in the Rappaport Faculty of Medicine in the Technion and is part of the 4th year course.

A 3-h workshop was designed to enhance students' reflective competence in the context of the physician–patient relationship. All 4th year medical students (n=100) were required to participate in one of three similar workshops as part of an initial learning module during their clinical rotations in internal medicine wards. It was intended that by the end of the class participants would be able to:

  1. Describe emotions experienced during an encounter with a patient

  2. Write an account describing their experience during the encounter

  3. Identify, in their own and in others' accounts, the feelings and emotions arising during the encounter.

In the first part of the workshop, paintings portraying scenes with patients were used as sensitisers to elicit students' descriptions of emotions and feelings. Three well known paintings were presented one by one: Francisco de Goya's Self-portrait with Dr. Arrieta, Luke Fildes' The Doctor and Pablo Picasso's Science and Charity.

After observing each painting and briefly describing the portrayed scene, students were asked to choose one of the characters depicted in the painting and write a short account from a first-person perspective. Volunteers were welcome to read their stories out loud. In their accounts students expressed a wide spectrum of emotions and ideas, ranging from feeling unsure and anxious to empathic and compassionate, while others expressed a degree of sarcasm. Telling the story of the physician in Goya's painting, one student explained that he resented the patient (Goya) for repeatedly complaining, and thought that giving him a glass of water might help. Another student, relating to the doctor in Fildes' painting, said that he felt helpless, unconfident and uncertain of his ability to help. He thought that the child and his parents were pitiful and badly in need of assistance. A third student, regarding Picasso's Science and Charity, thought the ill woman was a hypochondriac, which made him feel irritated and unable to identify with her.

Next, students were asked to write an account of a true encounter with a patient and share it with their peers in groups of three or four. In the last part of the workshop, students and their teachers discussed the emotions and feelings expressed in the imaginary characters' accounts and in their own accounts as trainees. In their own accounts students conveyed anxiety, lack of confidence, fear of making mistakes, and a sense of helplessness and frustration. Some were overwhelmed by the despair and anxiety of the patients. They identified with them, felt they somehow contributed to their well-being and had a good feeling by the end of the encounter.

Writing narratives based on paintings stimulated students to reflect on their own experience with patients and to examine their emotions, feelings and actions. This contributed to the next step: writing an account of a true encounter with a patient.

Eighty-four students attended the workshops, of whom 73 completed workshop evaluation forms. Fifty-eight per cent of respondents (n=41) thought that using paintings as an educational tool definitely helped their experiential learning of reflection. Writing narratives based on a painting was appreciated by 54% (n=40) as contributing to the development of their competency to reflect on emotions. Seventy-eight per cent of respondents (n=56) thought that the workshop had achieved its goal.

The majority of the students praised the workshop in their take home messages:

To look at the whole picture, and develop your understanding, not on the small details. The whole picture gives the best understanding.

In my opinion, the piece with paintings where we were asked to tell what's going on was excellent! It showed how much everybody's approach to the picture was linked to his own background.

We conducted an educational case study aimed at enhancing the reflective competence of medical students, whereby paintings and writing accounts served as facilitating tools, even though teaching students ‘non-scientific’ subject matter at the beginning of their clinical education might meet with scepticism and cynicism. Our students come from diverse cultural, ethnic and religious backgrounds and include Jews, Arabs; Muslims, Christians and Druze. This presents an additional challenge when using arts that have, by definition, cultural connotations, as an educational tool; paintings depicting patient–doctor interactions are hard to find in Jewish and Islamic culture, due to limited volume of work in the first, and absence in the latter for religious reasons.

The use of painting in teaching reflective competence was well received. Our students found it an innovative and useful educational tool, an exciting ‘out of the box’ teaching modality. Moreover, students appreciated the plot, creativity and imagination employed in their fellow students' accounts.



  • Competing interests None.

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

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