Empathy is an essential attribute for medical professionals. Yet, evidence indicates that medical learners' empathy levels decline dramatically during medical school. Training in evidence-based observation and mindfulness has the potential to bolster the acquisition and demonstration of empathic behaviours for medical learners. In this prospective cohort study, we explore the impact of a course in arts-based visual literacy and mindfulness practice (Art of Seeing) on the empathic response of medical residents engaged in obstetrics and gynaecology and family medicine training. Following this multifaceted arts-based programme that integrates the facilitated viewing of art and dance, art-making, and mindfulness-based practices into a practitioner-patient context, 15 resident trainees completed the previously validated Interpersonal Reactivity Index, Compassion, and Mindfulness Scales. Fourteen participants also participated in semistructured interviews that probed their perceived impacts of the programme on their empathic clinical practice. The results indicated that programme participants improved in the Mindfulness Scale domains related to self-confidence and communication relative to a group of control participants following the arts-based programme. However, the majority of the psychometric measures did not reveal differences between groups over the duration of the programme. Importantly, thematic qualitative analysis of the interview data revealed that the programme had a positive impact on the participants' perceived empathy towards colleagues and patients and on the perception of personal and professional well-being. The study concludes that a multifaceted arts-based curriculum focusing on evidence-based observation and mindfulness is a useful tool in bolstering the empathic response, improving communication, and fostering professional well-being among medical residents.
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The training and practice of medicine demands a special blend of skill and understanding. As medical educators, we invest heavily in teaching the fundamentals of clinical practice, but have until very recently minimised the importance of fostering empathy. Yet, empathy is the foundation from which care is delivered. Empathy is the quality that allows the physician to experience vicariously the feelings, thoughts, viewpoints and values of a patient.1–3 It involves an interaction between affective processes, which mediate a passive response to the emotions of another, and cognitive processes, which permit active perspective-taking and the understanding of others' experiences through intellect.4 ,5 It is through the vicarious empathic experience that a physician is able to recognise patients within their own context and to generate healthcare plans that are appropriately patient-centred. In this regard, empathy in medicine is also clearly intertwined with the related constructs of compassion and mindfulness.
In many medical specialties, such as family medicine and obstetrics and gynaecology, the need to understand a patient's personal context is crucial, and as such the interactions associated with patient care can be particularly demanding. Young physicians in these disciplines that do not develop a strong foundation in empathic caring are less likely to build and sustain a truly rewarding and successful career,6–9 as the empathetic practitioner is more likely to have better patient adherence to therapy,10 ,11 experience greater patient satisfaction,10 ,12 and improved clinical outcomes,13 ,14 while encountering fewer medicolegal challenges.15 Currently, medical schools and residency programmes select trainees with consideration for their empathic attributes, however, once training starts educators often fail to follow that lead.16 This is particularly troubling when considered in the light of recent research that shows that medical trainees' levels of empathy decay steadily as they encounter the stress and fatigue associated with learning and professional caring, and reach their lowest levels during residency training.2 ,4 ,17–22 As a result, learners may begin to feel that the work is more mechanical and transactional, and that patients are ‘problems’ rather than people. Taken together, the question of how medical teachers can help trainees retain their empathy in order to see patients more clearly and effectively is raised.
Of particular interest, is mounting evidence that the traits associated with empathy can be nurtured and taught through guided observation and facilitated discussion around works of visual art.23 ,24 This educational approach is based on the results of qualitative, stream-of-consciousness interview research that describes how observational ability improves with experience.25 ,26 The idea is through facilitated exposure to art, trainees develop strategies that optimise attention to detail and improve the quality of the perceptions formed via observation. In this way, facilitated arts-based exercises purport to have a positive impact on the cognitive aspects of empathic processing.3 ,23 ,27–31
With these benefits in mind, the Department of Family Medicine (DFM) at McMaster University and the McMaster Museum of Art (MMA) launched a programme in 2010 called the Art of Seeing, which seeks to nurture empathy and the ability to perceive meaning in imagery among family medicine residents.3 ,23 The programme represents an enrichment opportunity for residents, which augmented the viewing of art with guided reflective writing exercises. Psychometric measures of interpersonal reactivity—an index of empathy—taken before and after participation in the programme showed that residents left the Art of Seeing programme as more empathic observers.23 The programme was subsequently offered as an enrichment programme to Bachelor of Health Science students (ie, premedical students), and was again found to have a significant positive impact on participants' empathic response; however this investigation highlighted a particular impact on the cognitive perspective-taking processes that contribute to empathy.3
Recently, the DFM and MMA engaged in an expansion of the Art of Seeing programme to include a wider range of reflective and creative activities to postgraduate medical trainees. In doing so, the programme developers hoped that these developments further fostered the maintenance and development of empathy through two additions. First, the new programme exposes participants to formal analysis and mindfulness exercises in the artistic domain of dance. In doing so, the programme aimed to foster in participants an embodied understanding of the patient experience. By including dance, the programme's observational training was extended to include a specific consideration for the non-verbal communication that occurs between patients and healthcare providers. Taken together, the addition of dance was designed to help learners see and feel the patient experience more vicariously, understand the movement cues that reveal aspects of patient affect and state of being, and realise the potential messages that they convey to patients through their own movements.27–31 Second, the new iteration of the programme engages students in art-making exercises (ie, collage, sculpture) as a way to reflect upon their experiences, both within the educational and clinical contexts. These activities are conceived as an augment to the expressive writing assignments, which serve as a foundational component of the original iterations of the Art of Seeing. These exercises provide learners and educators a valuable means to access the conceptualisations that underpin empathic behaviour. This is important because while most behaviours are observable, the thought processes that lead to them are typically not. Through writing and art-making, these thought processes are revealed and help educators generate appropriate learner-specific feedback.32 ,33
During the most recent offering of the Art of Seeing, we were interested in evaluating the way in which the new programme configuration maintained and/or improved the impacts that previous versions have had for trainees. To do so, we employed two concurrent methodological approaches—a psychometric approach and a qualitative approach. First, in the psychometric approach, we administered an independent and previously validated scale that is concerned with the measurement of participant empathy to programme participants and an appropriately matched control group of learners. We also administered psychometric tools designed to measure the constructs of compassion and mindfulness within our study participants. We chose to do this because of the strong relationship that exists between definitions of empathy, compassion and mindfulness. Compassion, for instance, refers to the motivation to help upon witnessing another's suffering,34 ,35 while mindfulness describes the self-regulation of attention to one's experiences while adopting an attitude of openness and acceptance.36 Specifically, these tools were the Interpersonal Reactivity Index Empathy Scale (IRI),37 the Compassion Scale,38 and the Mindfulness Scale.39 Given the results of our previous investigations,3 ,23 our hypothesis was that these measures would reveal the new programme to promote the development and/or maintenance of empathy, compassion and/or mindfulness, potentially with particular relevance in the cognitive dimensions. Second, given the inherent challenges associated with the valid and reliable measurement of empathic concern through psychometric means,40–43 we also conducted semistructured interviews with the programme participants to elicit their impressions of the programme's impact. In conducting these interviews, we were particularly interested in the way responses confirmed or refuted the survey findings, and also how they revealed emergent perceptions of programme effectiveness.
The new Art of Seeing programme
The Art of Seeing sessions were held in the gallery exhibition spaces of the MMA and were cofacilitated by an art gallery educator from the MMA, an academic family physician-educator, an art therapist, a mindfulness instructor and two professional dancers. The programme began with the introduction of formal art analysis and included each of the components described below. Each subsequent session was organised so as to build on skills learned in previous sessions.
Week 1: introduction to formal art analysis
At the foundation of the programme are the skills of formal art analysis and practices of mindfulness. At the start of each session the residents were led through a guided mindfulness practice, including awareness of breath or body scan as a way of settling into the afternoon activities, while at the same time ‘leaving behind’ the business and stress of their clinical practice.
The residents were then introduced to, and provided with, a checklist of the elements and principles of art analysis, which included approaches to recognising and describing colour, line, shape and form, space and texture, emphasis, and movement and balance used in a piece of artwork. Following the introduction they moved into the gallery to apply these principles of formal analysis to works of art from the MMA collection and exhibition programming. The artwork selected ranged from traditional and representational pieces to conceptual and contemporary pieces. Canadian artist George Reid's The Call to Dinner (1886–1887), Illustrations from Sebastian Brant's Ships of Fools (1487) and English artist William Hogarth's print etching, The Reward of Cruelty (1751), are examples of some of the works of art used. The art gallery educator guided the observation and facilitated discussion using a series of graded questions intended to encourage the participant to look, and look again, and to consider what evidence exists within the works of art to back up their observable interpretations. The goal of this exercise is to analyse artwork using the analysis domain descriptors in a way that elucidates all possible meanings of the artwork.
The residents then moved to an art-making activity led by the art therapist. With the use of simple art tools such as watercolour pencils, pastels, coloured paper, scissors and glue the residents created personal and reflective collage-based artworks in response to the gallery activity as a complement to the lessons learned. For example, in this session the residents were asked to ‘create a scene’ accompanied by a two-to-three sentence story about their work. The session ended with a short guided mindfulness mediation practice.
Equipped with their own take-home art supplies and a journal, the residents were encouraged to create a drawing or write short prose daily about something they were grateful for throughout the duration of the Art of Seeing programme. They were also asked to write a short narrative description about a patient encounter in which they incorporated the skills of observation learned in the introductory session.
Week 2: introduction to symbols in art
Once again, beginning with a short guided mindfulness mediation, the learners shared their narrative writing homework that described a clinical encounter drawn from the past week. The residents then moved into the gallery to learn about how artists use visual symbols to convey meaning in their work. Building on the techniques of the previous session the participants were challenged to examine the use of symbolism as a means of communication between the artist and the viewer. Connections manifestations of tattoos as personal symbols and their potential meanings for the patient context were made. This session also paid specific attention to the assumptions, judgements and biases often made when observing and interpreting certain stereotypical images. In this session, ancient Athenian silver coins (449 BC) and Dutch Baroque paintings Still Life with Pike, Barbel, and Vegetables (Philips Breughel, mid-17th century) and Scene at the Inn (Egbert van Heemskerck, 17th century) were used as relevant examples. The residents then created their own personal symbols based on ideas and images that help personal and professional significance. The assigned homework at the end of the session was a daily mindfulness practice.
Week 3: mindful movement workshop
Local professional dancers worked with the residents to provide a dance workshop. In this novel element of the programme, the residents engaged in a range of dance-based activities; such as, analysing gestures and non-verbal communication, sculpting medical case reports in three dimensions, engaging in mindful movement (ie, walking, standing, mirroring) and observing the body to recognise how physicians use their bodies to communicate, connect and care. The session was designed to enhance the resident's understanding of patients' non-verbal cues. Using a traditional medical case study relevant to both family practice and obstetrics and gynaecology residents, the dancers facilitated exploration of the embodied dimensions of the patient experience and non-verbal communication between patients and healthcare providers. The narrative homework assignment at the end of this session asked residents to write a description of a particular instance when their body ‘showed up’ in their work as a physician. This writing prompt was intended to increase awareness of the use of the body in clinical work. As always, the session started and finished with a guided mindful meditation.
Week 4: looking beyond: introduction to conceptual and contemporary art
The final session again opened with a guided mindful meditation followed by the sharing of the assigned narrative homework from the previous session. This session focused on the notion that what one observes is not always immediately recognisable. Using contemporary works of art (eg, the work of Canadian artists John Noestheden and Thelma Rosner) this session attempted to enhance the resident's tolerance of ambiguity and challenge them to consider how their own personal experiences might bias their observations and interpretations. The final art creation activity was an art directive in which they had to visualise a healing space. The residents were asked to visualise and create an image based on self-care and resiliency, and then organise visually their personal repertoire of skills, behaviours, resources and supports to recognise balance in their personal and professional lives. Working in dyads the residents completed a formal analysis and interpretation of each other's artwork, pulling together all the skills learned over the past four sessions.
Fifteen residents (6 family medicine; 9 obstetrics and gynaecology; 14 women; 1 man; mean age=30.56 years) across a range of postgraduate years (year 2–year 5) from the McMaster University community volunteered to participate (ie, self-selected) in the Art of Seeing educational intervention. Twenty obstetrics and gynaecology residents acted as controls for our analysis (14 women; 6 men; mean age=27.65 years). All participants provided informed consent according to guidelines set out by the Hamilton Integrated Research Ethics Board and the Declaration of Helsinki (2013).
This prospective cohort study took place between October 2013 and February 2014. The intervention group participated in the four 3-hour Art of Seeing sessions at the MMA over the course of 1 month. These residents attended these sessions in lieu of four 3-hour didactic academic educational sessions, which were attended by the residents comprising the control group. These didactic educational sessions represent standard teaching of core components of the respective McMaster University Family Medicine and Obstetrics and Gynecology curricula. As such, the residents in the intervention group had participated in these sessions with equal regularity to the control group in the months preceding the intervention.
All participants completed three validated psychometric scales on the first and last days of the programme: the IRI,5 ,37 the Compassion Scale38 and the Mindfulness Scale.39 The IRI aims to measure the respondent's empathy with specific respect to the contributions of cognitive and affective components. In particular, the scale measures empathy along four dimensions—two cognitive: perspective-taking and fantasy; and two affective: empathic concern and personal distress. It is a 28-item questionnaire, each item of which is scored using a 5-point Likert Scale spanning a continuum of responses that reflect the degree to which the respondent believes the statement contained in the item relates to him/her.5 ,37 The Compassion Scale is a 24-item questionnaire using a 5-point Likert Scale, that asks respondents to rate how they act typically towards others. The scale includes items that probe expressions of compassion across three pairs of factors: kindness-versus-indifference, common humanity-versus-separation and mindfulness-versus-disengagement.38 The Five-Facet Mindfulness Scale is a 39-item scale, which is scored using a 5-point Likert Scale and prompts respondents to rate the general ‘truth’ of each of the statements on a range from ‘never or very rarely true’ to ‘very often or always true’. It is built on a comprehensive analysis that yielded five factors that are most representative of current constructs of mindfulness: observing, describing/self-expression, acting with awareness, non-judgement of inner experience and non-reactivity to inner experience.39 For all three scales, some items required reverse scoring. This was carried out prior to collation and analysis. The data collected from each scale, including overall scores and subscores, were analysed in separate two-group (control, intervention) by two-test (pre, post) analyses of variance (ANOVAs) with repeated measures on the second factor. All significant findings (p<0.05) involving more than two means were decomposed by way of Tukey's honest significant difference post hoc methodology.
The residents in the intervention group also participated in either a focus group (n=9 obstetrics and gynaecology residents) or telephone interview (n=5 family medicine residents), as was convenient after the programme, in order to capture programme experiences and changes in perception. The interviews explored specifically the participants' overall impression of the programme as well as their impressions of each component of the curriculum: formal art analysis, art creation, mindfulness and dance. These interviews were anonymised, transcribed verbatim and coded for the emergence of themes using an iterative process. This activity was conducted within a general qualitative approach without a sensitising theory and involved cycles of open coding by which themes were identified, defined and developed. Coding was conducted by three members of the research team (JZ, MS and LEMG) and areas of disagreement were identified and resolved through consensus discussion and refinement.
The IRI analyses yielded no significant group or test effects for either the Total Score analysis (grand mean (±SE)=65.7±1.9 out of a possible 96), or the four-subscale analyses (grand means out of 4: perspective-taking=2.61±0.09; fantasy=2.45±0.12; empathic concern=2.91±0.08; personal distress=1.42±0.10).
Compassion Scale analysis
The analysis of Compassion Scale responses yielded no significant group or test differences for either the Total Score (grand mean (±SE)=95.8±1.6 out of a total of 120) or the six-subscale analyses (grand means out of 5: kindness=4.21±0.08, indifference=3.85±0.09, common humanity=4.13±0.10, separation=3.92±0.08, mindfulness=3.89±0.09, disengagement=3.94±0.09).
Analysis of the Mindfulness Scale
While the overall mindfulness scores did not show any group or test effects (grand mean (±SE)=123.18±3.30 out of a possible 195), analysis of the subscales revealed significant effects for the ‘non-judgment of inner experiences’ subdomain, F(1,23)=10.78, p=0.003 (figure 1), and the ‘describe/self-expression’ subdomain, F (1,23)=5.43, p=0.03 (figure 2). Post hoc decomposition of these effects revealed that the intervention group scored lower initially on both domains but showed improvement following participation in the curriculum. Analysis of the scores for the mindfulness subscales of ‘act with awareness’ (3.07±0.12), ‘non-react’ (3.06±0.11) and ‘observation capabilities’ (3.09±0.11) revealed no significant differences.
Analysis of focus group/telephone interview data
Three major themes emerged from the interviews: personal and professional well-being, increased personal empathy and greater awareness of other professions. Each theme is discussed in the foregoing sections with illustrative quotes included.
Personal and professional well-being
The analysis of interviews revealed that participation in the Art of Seeing programme influenced participants' sense of personal and professional well-being in a number of ways. Many residents commented that the programme rekindled past interests—pursuits in art and music—that had been put aside when they began devoting time to medical training. Particularly interesting was that participants indicated that they felt the programme helped decrease their sense of personal isolation.
In the sessions we learned how to relax and to interact in a different way, to find other ways to express ourselves. So, it was really awesome.
Similarly, many residents commented that the programme provided them with skills to deal with the stress of residency training in a more effective way. This included incorporating the mindfulness, focus and reflection practices covered in the curriculum into their day-to-day work. For example, one resident indicated that the mindfulness teaching helped him/her to be more aware of patients in a holistic way.
Just observing patients and people in their lives a little bit more openly, not just jumping to the clinical information so quickly.
Increased personal empathy
Several of the residents commented directly on improved observational skills, which were perceived as leading to a deeper understanding of the patient they encountered. That is, they learned to ‘look beyond the obvious’ with patients. In particular, the residents reported the session on dance to be specifically beneficial in increasing awareness of the importance of personal and professional space in a clinical encounter and how patients might feel during physical exams.
I feel that it helps me look at patients in a new way… I find that maybe some things that were there subconsciously have been brought to the surface.
Now I think I'm more aware not only about the patient's disease but patient as a person, as a kind of a whole.
Greater awareness of other professions
In addition to the new curricular components, this iteration of the programme was opened to learners from two different medical professional training programmes. Interestingly, the participant residents reflected uniformly on the value of working together with residents from a different medical specialty. In essence, it was described as an opportunity to build empathy for colleagues. Even though there was a smaller number of family practice residents in the programme, and the inherent scheduling challenges, all the obstetrics and gynaecology residents commented on the benefit of the family practice outlook during to the programme. Likewise, the family practice residents felt similarly about their interactions with the obstetrics and gynaecology residents.
It was quite nice because I knew a lot of the obstetrics and gynaecology (OB) residents from being on my OB rotation and just from medical school as well…I think it's a fresh outlook, different input, it was very nice
In this regard, the participants strongly endorsed extending the Art of Seeing to other medical specialties. They expressed that offering the programme to other medical trainees would build rapport and foster respect between specialties, particularly the specialties with which they often consulted.
I was going to say gen surgery and urology because those are often services that we're consulting part way through in operating room and you know you've got rapport and respect. It would be interesting because it's a different mindset
This study was designed to evaluate the impacts of the multifaceted Art of Seeing curriculum on the development of empathic, compassionate and mindful behaviour in resident-level trainees from two different medical specialties. To explore this effectively, a broad scope of evaluation tools were used including the IRI, Compassion Scale, Mindfulness Scale and interviews designed to explore qualitatively the facets of empathy that participants took forward into their professional training. Our hypothesis was that this enriched programme would have a positive impact on self-reported empathy, compassion and mindfulness as measured by the previously validated psychometric tools. However, significant differences were elicited only in the Mindfulness Scale and in particular in the non-judgement and describe/self-expression subdimensions of the scale. The non-judgement facet of this scale reflects one's reactivity to inner experiences.39 With respect to clinical empathy, this is relevant insofar that it suggests that programme participants are more prepared to handle experiences that leave one feeling anxious or inadequate, as is often the case in clinical practice, without judgement or self-criticism. This, in turn, may lead physicians to refrain from impulsive reactions to others. The describe/self-expression facet refers to the ability to label internal experiences and feelings with words. The positive improvement for programme participants in this facet suggests that the Art of Seeing is effective in nurturing awareness of one's own reactions to situations—another purported benefit to empathy. This is supported by a number of studies showing the positive impact of mindfulness training for healthcare professionals.44–50
Importantly, however, the general lack of significant findings across the psychometric measurements again raises the question of the appropriateness of this approach to identifying changes in empathy, compassion and/or mindfulness. While the IRI is used widely to measure empathic behaviour,40 the validation work surrounding its use has yielded mixed results. In particular, although there is substantive agreement that empathy should be conceptualised as comprised of both cognitive and affective components,51 ,52 some studies have revealed factor structure that is consistent with the four IRI subscales,53 while others have not.40–43
Given the potential limits of psychometric research in the domain of empathic development, we were encouraged in the way that the qualitative analyses supported our previous findings. In particular, the interviews pointed to the new programme's perceived positive impact on stress and sense of relaxation. These qualitative findings highlight a relationship between the curriculum and improvements to the residents' perceptions of psychological functioning and well-being. The thematic analysis, however, highlighted many other findings in favour of the programme's impact on empathic development beyond improved sense of well-being through stress reduction. Specifically, participants lauded the programme for renewing their outlooks on patient care and rekindling their personal interests in the arts. Resident participants also reported that a deeper understanding of empathy helped increase their awareness of the use of personal and professional space during clinical encounters. We acknowledge that physical and group interaction may elicit potential differences in the responses provided by those participants that engaged in focus groups as opposed to telephone interviews; however, given the consistencies of responses, our overall position is that the evaluation supports the Art of Seeing as a facilitator of the cognitive components of empathic behaviour such as improved abilities to describe internal experiences, judge personal reactions and understand the views of others.3 ,23
Importantly, this iteration of the programme included both obstetrics and family medicine residents and, as such, provided an opportunity to understand the interactions between trainees from across both specialties. In this regard, the results indicate that participation was beneficial to the relationships and understanding that underpin interprofessional practice. In this way, the programme's greatest impact may have been on the nurturing of empathy for colleagues and stands as a strong foundation for extending the Art of Seeing programme to other medical and health professional trainees. If co-participation is indeed a major driver of empathic development, then this finding may suggest that empathy for patients may be best improved through arts-based curricula when the patients are also invited to participate.
Overall, the revised Art of Seeing was successful in terms of expanding the curriculum to bring together dance and arts-based visual literacy training, art-making and mindfulness practice through new relationships between the Department of Family Medicine and Department of Obstetrics and Gynecology at McMaster University (Hamilton, Ontario, USA). Indeed this evaluation will fuel future efforts in humanities-based training for other healthcare professions at McMaster University. This work offers a good platform for future research into the specific aspects of art-making and dance that promote empathic development. In particular, we are interested in whether empathic responses derive from the development of improved observational skills, a deeper sense of embodied understanding or a combination of both. In conclusion, we feel confident that a non-traditional learning approach involving visual art interaction within an art gallery space can improve trainee empathy, physician well-being and, as a result, patient care. It reminds us of the importance of empathy at a time when scarce resources and increased demands may lead physicians to see patients, and perhaps colleagues, as ‘problems’ rather than people.
Contributors JZ and MS led the study, facilitated data collection and wrote the manuscript. AF, EH, ET and NK participated in the critical formation of the research design. EH facilitated the participation of obstetrics and gynaecology residents. AF facilitated the dance portions of the programme. ET and NK facilitated the art observation portions of the programme. LEMG supervised all aspects of the project. All authors contributed to the critical revision of the paper, approved the final manuscript for publication, and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved.
Funding This project was generously supported through the Associated Medical Services (AMS) Phoenix Project Call to Caring Grant.
Competing interests None declared.
Ethics approval Hamilton Integrated Research Ethics Board.
Provenance and peer review Not commissioned; externally peer reviewed.
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