Using Movie Clips to Promote Reflective Practice: a Creative Approach for Teaching Ethics
To teach ethics implies setting rules, guidelines, and rational decision-making but it also requires creativity and acknowledgement of the affective aspects of our decision-making processes. Usually, ethical inquiries become involved in emotions that cannot be ignored but included in the learning process. The authors relate their experience with a pedagogic model involving film clips to prompt and frame discussions that might foster a more holistic approach to ethics education. Teaching with movies is also an innovative method for promoting the sort of engaged learning that education requires today. By allowing reflections on emotions, participants in these sessions can learn to develop their reflective abilities and attitudes. Life stories derived from movies fit well with the learners’ context and expectations and could serve as a launching point for discussions of both the emotions and ethical scenarios. Using film clips in a structured way allows for new opportunities in ethics education.
KeywordsTeaching ethics Emotions Affective education Cinema education Reflective practice
Increasing Technology Challenging Traditional Ethics Teaching
Nowadays, outcomes, guidelines, and clinical trials are at the forefront of medical training. We observe well-trained technological physicians with reduced humanistic perspective which leads to attitudes that lack ethics and professionalism. Nevertheless, the frequent dissatisfaction of patients points more to the human deficiencies of medical professionals than to their technical shortcomings. Maybe this is because objective knowledge is considered scientific and valuable, whereas subjective information is thought to be “soft” and second-rate. For the relief of suffering, that conflict is not only false but an impediment (Cassell 1999). Doctors exist to care for patients. To care implies having an understanding of the human being and the human condition. Empathy has to do with deeply understanding the other and is a path to bridge scientific knowledge with compassion for better caring. The constant question is always if empathy can be taught? (Bayne 2011; Moreto et al. 2014).
On the other hand, to teach ethics implies setting rules, guidelines, and rational decision-making. But it also requires creativity and acknowledgement of the affective aspects of our decision-making processes. We need, as teachers, to go beyond instructions and perform a caring model pursuing excellence. Is it possible to get together prudence, wisdom, and creativity for a new ethics teaching model? (Christianson et al. 2007)? Usually, ethical inquiries become involved in emotions, and those emotions cannot be ignored. Actually, they should be included in the learning process as an essential tool. To share emotions, in an open discussion surrounded by a friendly learning scenario, creates the path for affective education and foster empathy that empowers patient care (Marcus 1999).
There is a growing concern about the human dimension of the future physician and how it can be taught or reinforced in the educational environment (Moyer et al. 2010). Emerging technology tends to monopolize students’ attention and learning efforts, often at the expense of other important aspects of medicine. In addition, medical students are, in general, young people who are learning to be physicians at the same time as they are developing their adult personas. Medical educators must recognize this and provide ways for students to reflect on general subjects related to culture and the humanities from the medical perspective. Although technical knowledge and skills can be acquired through training with little reflective process, it is impossible to refine attitudes, acquire virtues, and incorporate values without reflection. Learning through humanities stimulates a reflective attitude in the learner.
Teaching reflection is a goal for educators who want to move beyond transmitting subject matter content. These teachers believe that they will better understand their students and the nature and processes of learning if they can create more supportive learning environments. Effective teaching is often both an intellectual creation and a performing art (Bain 2004). Excellence in teaching requires innovation and risk taking in dealing with sometimes unanticipated learner response. This is at the core of education and where the humanities and the arts have a place in responding to the challenge of teaching.
This is when the movie teaching scenario takes place, as the authors address afterwards: a model involving film clips might foster a more holistic approach to ethics education. Using films, specifically short clips of films, to prompt and frame discussions would be of value for medical ethics education. By allowing reflections on emotions, participants in these sessions can learn to develop their reflective abilities and attitudes. These skills and attitudes, in turn, can help create more humanistic, and presumably more ethical, physicians.
Humanities in Medical Education: from Emotions to Ethical Attitudes
The humanities help in building an anthropologic perspective of doctoring, enabling doctors to understand patients in their whole context. For this reason, arts and humanities are not just appendages of medical knowledge but necessary tools and sources of information for proper doctoring. They should be as much a part of medical education as training in differential diagnosis or medical decision-making (Mullangi 2013). Without humanism, doctors would not be physicians but simply mechanics (Blasco 1997) (technicians who try to fix the immediate presenting problem, and nothing else). Teaching how to effectively take care of people requires creating methods that address the human aspects of medicine (Blay Pueyo 2006). Humanities also offer a counterpart to the necessary reductions of the natural sciences. The unit of medicine is the particular patient, always irreducible. We know that medicine runs into trouble when individual persons are examined only with instruments that reduce specific meanings to simplistic data (Belling 2010). A new balance is needed for incorporating a modern perspective in medical humanism.
Arts and humanities, because they enhance an understanding of human emotions, are useful resources when incorporated into medical education. The students’ emotions easily emerge through arts like movies, music, and poetry; teachers can impact student learning by broadening their perspectives of student development. In life, the most important attitudes, values, and actions are taught through role modeling and example, a process that acts directly on the learner’s emotions (Ruiz Retegui 1999). Because people’s emotions play a specific role in learning attitudes and behavior, educators cannot afford to ignore students’ affective domain. Certain types of learning have more to do with the affection and love teachers invest in educating people than with theoretical reasoning (Ruiz Retegui 1999). Usually feelings arise before concepts in the learners. Understanding emotionally through intuition comes in advance. First, the heart becomes involved; then, rational process clarifies the learning issue. Thus, the affective path is a critical way to the rational process of learning.
To educate through emotions does not mean that learning is limited to values and attitudes exclusively in the affective domain. Rather, it comes from the position that emotions usually come before rational thinking, especially in young students immersed in a culture where feelings and visual impact prevail. Thus, medical educators need to recognize that learners are immersed in a popular culture largely framed through emotions and images (Ferres 2000). Since emotions and images are privileged in the popular culture, they should be the front door for learners’ educational processes. Emotions are a kind of bypath to better reach the learners, a type of track for taking off and moving more deeply afterwards, which requires fostering reflection on the part of learners. The point is to provoke students to reflect on those values and attitudes (Blasco and Alexander 2005), with the challenge here to understand how to effectively provoke students’ reflective processes.
Life stories and narratives enhance emotions and, therefore, lay the foundation for conveying concepts. When strategically incorporated into the educational process and allowed to flow easily into the learning context, emotions facilitate a constructive approach to an understanding that uses the learners’ own empathetic language. Furthermore, in dealing with the students’ affective domain, the struggle in learning comes close to the pleasure felt, and it is possible to take advantage of emotions to point out attitudes and foster reflection over them (Shapiro and Rucker 2004) Consequently, it is not all about emotions, since emotions alone are not enough for providing experiences through reflection. The emotional impact caused by emotions should be utilized to foster reflection and this experience generates possibilities for incorporating stable attitudes.
That is the teacher’s role. For instance, in cinema education as discussed afterwards, the educational outcomes do not materialize simply from watching movies. People go to the cinema all the time and see the same scenes, and while they might have similar emotions, the reflective process is lacking. This is where the competence and the teaching skills of the facilitator come into play, that is, by putting all the scenes together and fostering reflection through comments and personal thoughts, even as unanswered open questions are introduced.
The instructor’s role consists not just in pouring out emotions, but in catalyzing the process by which the audience moves from the emotions to immerse themselves in personal reflection and begins to generate concrete ideas for how, in specific and concrete ways, they can incorporate the lessons they have learned from the emotional experience into their daily lives. These experiences are real educational footprints and become open doors for generating attitudes that modulate behavior (Blasco et al. 2013). The first step in humanizing medical education is to keep in mind that all humans, including medical students, are reflective beings. They need an environment that supports and encourages this activity to refine attitudes, construct identities, develop well-rounded qualities, and enrich themselves as human beings.
Likewise, faculty members use their own emotions in teaching, so learning proper methods to address their affective side is a complementary way to improve their communication with students. Therefore, excellent teachers develop their teaching skills through constant self-evaluation, reflection, the willingness to change, and the drive to learn something themselves (Palmer 1998). Faculty members face challenges when they teach and have few opportunities to share them and reflect with their peers. Usually, when teachers discuss educational issues with their colleagues, they often spend most of the time talking about problems instead of nurturing themselves. As teachers, we need to state new paradigms in education, learn how to share our weaknesses and frustrations, and find resources to keep up the flame and energy for a better teaching performance. Humanities could be incorporated in faculty development strategies because they provide useful peer reflective scenarios (Blasco et al. 2015).
The inclusion of humanities in the curriculum occasions deep rethinking of what it means to be sick and what it means to take care of the sick. They also portray a tremendous spectrum of attitudes required for building ethics and professionalism. We need to be creative in using arts and humanities for effectively reaching our students. This is why brief readings, pieces of art, music, and movie clips have a proper place in medical educating. They illustrate complex moral choices and stimulate comments and reflection. A well-known researcher in medical humanities quotes, “we are midwifing a medicine that makes contact with the mysteries of human experience along with its certainties—a medicine that appreciates the deep beauty of health, the silence of health, the wisdom of the body, and the grace of its genius. It is an arch to far times and places, a site for all the living and the dying that go on; it is a link to what it means to be human”(Charon 2010).
Teaching through humanities includes several modalities in which art is involved (Ousager and Johannessen 2010). Literature and theater (Shapiro 2000), poetry (Whitman 2000), and opera (Blasco et al. 2005) are all useful tools when the goal is to promote learner reflection and construct what has been called the professional philosophic exercise (Decourt 2000). Teaching with movies is also an innovative method for promoting the sort of engaged learning that education requires today (Baños and Bosch 2015; Self and Baldwin 1990). For dealing with emotions and attitudes, while promoting reflection, life stories derived from movies fit well with the learners’ context and expectations. Teaching with films engages the emotions and could serve as a great launching point for discussions of both the emotions and ethical scenarios (Colt et al. 2011; Self et al. 1993; Searight and Allmayer 2014). The crucial role of teaching is to help frame these discussions in such a way as to foster reflective practice among clinicians and clinicians-in-training.
Movies and the Cinema Teaching Methodology to Promote Reflective Practice
As film is the favored medium in our current culture, teaching with moveis is particularly well-suited to the learning environment of medical students and residents. Movies are the audiovisual version of storytelling. Movies provide a narrative model framed in emotions and images that is also grounded in the student’s familiar, everyday universe and stimulate a reflective attitude in the learner. We know that in the clinical setting, the life histories of patients are a powerful resource in teaching. Similarly, when the goal is promoting reflection that includes both cognitive and emotional components, life histories derived from the movies are well matched with the student desires and expectations.
Life stories are a powerful resource in teaching. In ancient cultures, such as classical Greece, the art of storytelling was often used to teach ethics and human values (McIntyre 1984). Stories are one reasonable solution to the problem that most people, especially young people, can only be exposed to with a limited range of life experiences. Storytelling, theater, literature, opera, and movies all have the capacity to supplement learners’ understanding of the broad universe of human experience. Exposure to life experience—either one lived, or one lived through story—provides what Aristotle called catharsis. Catharsis has a double meaning, each of which deals with human emotion. Catharsis literally means to “wash out” the feelings retained in the soul. It also implies an organizing process in which the person sorts through, orders, and makes sense of emotions. In short, in the normal course of events, people keep their feelings inside, storing them in an untidy fashion, but do not think about them. Catharsis helps empty one’s emotional drawers and reorganizes them in ways that provide a pleasant sense of order and relief.
Cinema is useful in teaching the human dimension of medicine (Blasco 2011a) because it is familiar, evocative, and non-threatening for students. Movies provide a quick and direct teaching scenario in which specific scenes point out important issues, emotions are presented in accessible ways where they are easy to identify, and students are able to understand and recognize them immediately.
In addition, students have the opportunity to “translate” life histories in movies into their own lives, and into a medical context, even when the movie addresses a non-medical subject. Movie experiences act like emotional memories for students’ developing attitudes and remain with them as reflective reference points while proceeding through their daily activities, including those related to their role as future doctors. Students identify easily with film characters and movie “realities,” and through a reflective attitude gain new insights into many important aspects of life and human relationships. The educational benefit also is expanded by the phenomenon of students “carrying forward” into their daily lives the insights and emotions initially generated in response to cinema experience. In other words, the movie teaching scenario acts like “an alarm” to make learners more aware when similar issues and situations occur in their daily lives.
Using medical movies is similar to presenting a specific case—like problem-based-learning—and discussing it. This is valuable, but not what we are trying to achieve. In our method (Blasco 2002), what matters is not the case or the situation that demands a particular answer. Our goal is to move beyond a specific medical solution to reach a human attitude in life that requires integrity and wholeness. We move from technical responses to deep reflection on how to call forth the best that learners have inside themselves. The specific translational process is intentionally left up to learners as they encounter their own lives as doctors and as people.
Fostering reflection stimulates discussion about the interaction of health with the breadth of human experience and this discussion often elicits profound conflicts and concerns about their future professional roles and as human beings. A new learning process is created, and through it, the students are involved in an ongoing process of learning spread into their daily life. The movie teaching methodology stimulates their reflection, and, through accessing learners’ emotions, offers new paths to the rational process of learning. This is how we can foster reflective practice for the future doctors. A process that is at the core of ethical decisions: never giving up reflection, and never giving in to mediocrity, which in Hannah Arendt’s words would lead to the banality of evil (Blasco 2016).
Dealing with cinema education is also useful to lead clinicians and students in getting familiar with their own emotional responses, an issue often neglected in medical education. Little effort is exerted to develop emotional honesty in medical students or residents, either in terms of their own affective responses, or in terms of their awareness of others’ emotions. When students experience negative emotions and nothing is done to construct a real affective education, learners sometimes decide to adopt a position of emotional detachment and distance, and this comes to attitudes lacking professionalism (Shapiro 2011). Narrative films can provide valuable access to viewers’ affective lives by “lighting up” disruptive or disturbing parts of the self that might otherwise be ignored or neglected. Because the characters portrayed in movies are “not real,” learners can be more honest about their reactions than if they were discussing actual patients. This emotional honesty becomes a starting point for exploring emotional responses.
Movies allow us to go beyond the illustrations of theories and principles, so that we might develop not only a range of rational and analytic skills, but also a range of emotional and interpretative ones, including those habits of the heart. The standard models of ethical decision-making so commonly taught in medical school classrooms—the step-by-step approach seeking for an answer, maybe one answer to a particular dilemma—are someway disrupted by the films, opening doors to multiple questions and may never fully resolve an issue (Blasco 2011b). Discussions among and with students and colleagues, independent of their level of knowledge and experience, are thought-provoking and can be intensely personal, transforming ethics education into a pendulous experience that oscillates from scientific debate to an exciting and often uneasy voyage of moral inquiry. This educational scenario forces us to reflect on who we are, who we have become, and who we long to be.
In this sense, film, as art, can affect the root of our being. Using film clips in a structured way allows for new opportunities in ethics education. We now consider the specific methodology using movie clips.
The Movie Clip Methodology
Young people today live in a dynamic and sensitive environment of rapid information acquisition and high emotional impact. In this context, it makes sense to use movie clips because of their brevity, rapidity, and emotional intensity. Bringing clips from different movies, to illustrate or intensify a particular point, fits well with the dynamic and emotional nature of students’ experience. Nevertheless, the purpose is not to show students how to incorporate a particular attitude, but rather to promote students’ reflection.
Because our goal is to promote reflection on attitudes and human values from a broad perspective, in our teaching, we use clips from non-medical films. The intention is to expose students to life events, not to specific medical situations. For this purpose, in our experience, teaching with clips with several rapid scenes taken from different movies, works better than viewing the whole movie. The effect is a rich generation of perspectives and points of view, which in turn trigger multiple, often, contradictory emotions and thoughts in the viewers. In this context, learners have an intensely felt need for reflection about what they have just seen. Our experience affirms the effectiveness of using the movie clip methodology in which multiple movie clips are shown in rapid sequence, along with facilitator comments while the clips were presented (Blasco et al. 2006).
The value of facilitator commentary during the viewing of clips is based on our own experience. Although the sudden changing of scenes in the clips effectively evoke participants’ individual concerns, and fosters reflection on them, making comments while the clip is playing acts as a valuable amplifier to the whole process. Because learners are involved in their personal reflective process, they may at times disagree with the facilitator’s comments and form their own conclusions. But this does not matter and may even be desirable. This point-counterpoint deepens reflection, while still enabling participants to draw their own conclusions.
In fact, participants note that divergent comments are particularly useful to facilitate the reflection process. The effect is a rich generation of perspectives and points of view, which in turn trigger multiple, often, contradictory emotions and thoughts in the viewers. In this context, learners’ have an intensely felt the need for reflection about what they have just seen. A comment coming from the learner elucidates this process: “Your commentary on the clip is quite useful. Something happens inside of us. It is neither the movie, nor your comments. It is something in between.”
The movie clip approach opens the door toward working with learners’ emotions and explores how to turn them into a useful educational resource. For teaching the human matters of doctoring, one can employ the purely rational method favored by ethics lectures and deontology courses. But movies offer another path: exposing learners to particular examples with strong emotional consequences to either follow or reject. The movie clips lead the learners to reflect on where their own attitudes and responses will lead, not only intellectually but emotionally, both for themselves and others. In this way, bringing examination of emotional responses and their consequences into the discussion serves as an effective shortcut that helps reconnect learners with their original idealistic aspirations and motivations as physicians.
The purpose of the film-clip methodology is not only to evoke emotions but to help the learners to reflect on them and figure out how to translate what they learn into attitudes and action. Reflection is the necessary bridge to move from emotions to behavior. The whole process—quick movie clips along with facilitator comments—is responsible for this outcome.
The roller coaster of feelings that arises trough this methodology generates a learning environment that consistently brings debates about core assumptions in medical education to the fore. Teaching reflection through film clips goes beyond watching movies, mastering subject matter, evoking emotions, or teaching new skills, to considering the emotional and moral issues that contextualize so much of actual medical practice.
We can still consider a couple of questions: What scenes and clips should be used in this methodology? Do we need to teach explicit topics through specific scenes? Although some educators follow this topic-scene method, the experience of the movie clip methodology suggests that this is not always required. How to decide what scenes could be grouped together in a specific presentation? It depends on which is the audience, what they are looking for, and what the main message the teacher wants to deliver. When the objective is to address specific issues (empathy, leadership, commitment, vocation), a variety of movie scenes in some way related to the main topic could be put together. In our experience, in most cases of applying this methodology, we found no specific topic or theme that linked all the film clips. There was only life, human beings acting, feeling and living. And the facilitator’s comments—always looking at the faces in the audience—need to bring sense to the whole presentation.
Readers would also ask about what happens when using clips coming from movies that part of the audience have not yet seen? Another comment, coming from a professor who attended one of our presentations brings a wonderful insight on this issue: “Maybe the clip is good, because we don’t lose the focus trying to remember the whole movie. I never go to the movies myself. And maybe because of this, I get the results about this, without distracting myself trying to bring up the script. Now I am focused on your comments and on what is going on at the screen, and not trying to remember the movie theme, or the characters, or the whole story. So, this is straight to the point, the teaching point I mean”. (Blasco et al. 2010)
A broad range of movie clips is available trough the authors’ reference. An extensive list of clips can be found on http://sobramfa.com.br/eng/articles/movies-in-medical-education/.
Getting to a Conclusion: Does this Work? What about Appraisal?
The value in teaching with movies is reinforced through the audience’s feedback. Analyzing data from participants (comments through field notes and session evaluations, interviews and written assignments) shows the value of teaching with movie clips. As pointed out in the literature, “The researcher is the primary research tool, so it is essential to include his/her feelings and reflections over the analysis. The experience had in the field is not merely observed and recorded, but is also felt. Reflection on feelings is essential.” (Crabtree and Miller 1999).
The qualitative perspective in analyzing such data is especially useful for teachers who understand their discipline as more empirical and craft-based than theoretical. This is especially true when the learning objective deals with emotions, attitudes, and professional values. For example, in medical education, to emphasize compassion, commitment, empathy, or teamwork, and to portray them through the screen, is more effective than theoretical models (Blasco et al. 2011).
When the audience is comprised of teachers, they shift to the core and focus on their roles as educators. By the end of these sessions, we have had the opportunity to discuss in a profound sense how we are educating people. Do we foster learners’ motivation and help them to grow as human beings? Do we really care about their feelings, emotions, and barriers to learning, or do we just keep to the official curriculum content?
Inevitably, hidden issues arise, the kind of concerns that traditional education never seems to have time for: deception from bad role models, inspiration from good models, application of this learning to real life, and the missing pieces. A comment from one student at the end of a session clarifies this subject: “Yes, I want to be a doctor, but all I don’t want is to forget what I learned with my grandmother.” For sure, we need time to listen to students addressing these unexpected topics.
The academic community requires proof of the effectiveness of a new technique before advocating or even supporting its widespread application. Educators have long ago learned that the measurement of success in teaching remains an elusive, controversial, and at the very least a quite ambiguous goal. We should not confuse quality teaching with successful teaching, one that produces learning as is understood exclusively in terms of its achievements. At this point, we can envision why those “intangibles” topics, difficult to teach and to assess, in which ethics, empathy, compassion, and commitment are included, could be taught through cinema education methodology (Blasco and Moreto 2012). What we can say is that acquiring a taste for the esthetic provides an additional dimension to medical learning, and that even when morality is at issue, this humanistic perspective is an ideal tool for understanding. Maybe, in Pascal’s (1670) words, this has something to do with “The heart has its reasons which reason knows not of.”
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