A fresh perspective on medical education: the lens of the arts

There is a mismatch between the broad range of learning theories offered in the wider education literature and a relatively narrow range of theories privileged in the medical education literature. The latter are usually described under the heading of 'adult learning theory'. This paper critically addresses the limitations of the current dominant learning theories informing medical education. An argument is made that such theories, which address how an individual learns, fail to explain how learning occurs in dynamic, complex and unstable systems such as fluid clinical teams. Models of learning that take into account distributed knowing, learning through time as well as space, and the complexity of a learning environment including relationships between persons and artefacts, are more powerful in explaining and predicting how learning occurs in clinical teams. Learning theories may be privileged for ideological reasons, such as medicine's concern with autonomy. Where an increasing amount of medical education occurs in workplace contexts, sociocultural learning theories offer a best-fit exploration and explanation of such learning. We need to continue to develop testable models of learning that inform safe work practice. One type of learning theory will not inform all practice contexts and we need to think about a range of fit-for-purpose theories that are testable in practice. Exciting current developments include dynamicist models of learning drawing on complexity theory.

Humanities form an integral part of undergraduate medical curricula at numerous medical schools all over the world, and medical journals publish a considerable quantity of articles in this field. The aim of this study was to determine the extent to which the literature on humanities in undergraduate medical education seeks to provide evidence of a long-term impact of this integration of humanities in undergraduate medical education. Medline was searched for publications concerning the humanities in undergraduate medical education appearing from January 2000 to December 2008. All articles were manually sorted by the authors. Two hundred forty-five articles were included in the study. Following a qualitative analysis, the references included were categorized as "pleading the case," "course descriptions and evaluations," "seeking evidence of long-term impact," or "holding the horses." Two hundred twenty-four articles out of 245 either praised the (potential) effects of humanities on medical education or described existing or planned courses without offering substantial evidence of any long-term impact of these curricular activities on medical proficiency. Only 9 articles provided evidence of attempts to document long-term impacts using diverse test tools, and 10 articles presented relatively reserved attitudes toward humanities in undergraduate medical education. Evidence on the positive long-term impacts of integrating humanities into undergraduate medical education is sparse. This may pose a threat to the continued development of humanities-related activities in undergraduate medical education in the context of current demands for evidence to demonstrate educational effectiveness.

Observation, including identification of key pieces of data, pattern recognition, and interpretation of significance and meaning, is a key element in medical decision making. Clinical observation is taught primarily through preceptor modelling during the all-important clinical years. No single method exists for communicating these skills, and medical educators have periodically experimented with using arts-based training to hone observational acuity. The purpose of this qualitative study was to better understand the similarities and differences between arts-based and clinical teaching approaches to convey observation and pattern recognition skills. A total of 38 Year 3 students participated in either small group training with clinical photographs and paper cases (group 1), or small group training using art plus dance (group 2), both consisting of 3 2-hour sessions over a 6-month period. Students in both conditions found value in the training they received and, by both self- and instructor-report, appeared to hone observation skills and improve pattern recognition. The clinically based condition appeared to have been particularly successful in conveying pattern recognition concepts to students, probably because patterns presented in this condition had specific correspondence with actual clinical situations, whereas patterns in art could not be generalised so easily to patients. In the arts-based conditions, students also developed skills in emotional recognition, cultivation of empathy, identification of story and narrative, and awareness of multiple perspectives. The interventions studied were naturally complementary and, taken together, can bring greater texture to the process of teaching clinical medicine by helping us see a more complete 'picture' of the patient.