Peer Reviewed Research

 

Teaching empathy through role-play and fabric art:  An innovative pedagogical approach for end-of-life health care providers

André Smith1, Jane Gair2, Phyllis McGee3, Janice Valdez4, Peter Kirk5

  1. Department of Sociology, University of Victoria, Cor A333, 3800 Finnerty Road, Victoria BC V8W 3P5

  2. Division of Medical Sciences, Island Medical Program, University of Victoria and The University of British Columbia, Victoria, British Columbia, Canada

  3. Centre on Aging, University of Victoria, Sedgewick A104 3800 Finnerty Road, Victoria, British Columbia, Canada V8P 5C2

  4. Director, Imago Wellness and Education Canada, Vancouver, British Columbia, Canada, website: http://janicevaldez.com

  5. Department of Family Practice, University of British Columbia, 3rd Floor David Strangway Building, 5950 University Boulevard Vancouver, British Columbia, Canada V6T 1Z3

Correspondence: André Smith, Department of Sociology, University of Victoria, Cor A333, 3800 Finnerty Road, Victoria BC V8W 3P5. Email: apsmith@uvic.ca

Abstract

This paper explores the experiences of first- and second-year medical students who participated in a learning intervention that used fabric art and role-playing to foster the acquisition of empathy skills for end-of-life care. The intervention centers on students' engagement with artwork by renowned artist Deidre Scherer, who depicts the processes of aging, dying, and grieving in her work. We collected data from qualitative interviews with students and from observations of students' participation in the intervention. The students reported experiencing intense feelings of empathy toward the patients depicted in the artwork. Based on these experiences, they successfully formulated empathetic responses that took into account the imagined perspectives of these patients. We conclude that this learning intervention effectively cultivated empathy in the medical students who took part in the study.

Keywords: empathy, death and dying, role playing, fabric art

Introduction

Caring for elderly individuals who are dying constitutes a pivotal but often largely unacknowledged aspect of the health care system. Given increases in life expectancy and the proliferation of life prolonging treatments, the majority of deaths now occur in old age and take place in hospital or long-term care facilities (Northcott & Wilson, 2008). Palliative care in such settings focuses on reducing pain and discomfort rather than on halting or delaying the progress of disease (World Health Organization, 2007). Because older adults often experience vulnerable states, health care providers also find themselves needing to respond to older patients' emotional needs (Roter et al., 1997; Halpern, 2003; Shapiro & Hunt, 2003; Larson & Yao, 2005). Being empathetic under such circumstances may prove demanding for health care providers, but it can also yield important benefits for patients' quality of end-of-life care. Research on empathy in the clinical relationship suggests considerable benefits which can transfer to the context of palliative care. For example, empathetic physicians are more successful at making patients adhere to prescribed drug treatments, thus improving therapeutic outcomes, such as pain management (Piette, Heisler, Krein, & Kerr, 2005). Empathetic physicians also elicit more complete medical histories from their patients, thus improving diagnostic accuracy and treatment decisions (Halpern, 2003; Larson & Yao, 2005). Additionally, they are less likely to be sued for malpractice (Meryn, 1998) and more likely to be perceived as trustworthy (Butow, Maclean, Dunn, Tattersall, & Boyer, 1997). Finally, empathetic physicians report high levels of professional satisfaction, derive more meaning from their work, and are less likely to experience burn-out, which is a constant concern in palliative care (Roter et al., 1997).

Unfortunately, health care providers are often ill-equipped to address the psychosocial needs of older dying patients and their families, in part because the teaching of empathetic skills is underdeveloped in medical and paramedical curricula (Halpern, 2001; Price, 2004; Nordgren & Olsson, 2004). As Kidd and Connor (2008) found in their survey of medical humanities and arts-based activities across Canada, instructors of medical humanities feel their field is marginalized in Canadian medical schools partly because instruction tends to be voluntary and rarely extends beyond the pre-clinical years. Another reason is that medical education tends to privilege scientific knowledge of body systems and diagnostics at the expense of interpersonal skills and psychological awareness (Starr, 1982; Wilkes, Milgrom, & Hoffman, 2002).1 Yet, as Garden (2007) remarks, "learning about the way an individual patient experiences and makes meaning from illness and the social context of that suffering is vastly different from the way students are tested on knowledge about the organ systems and disease" (p. 564). As a result, health care providers learn to manage patients' physical symptoms systematically and efficiently but tend to neglect the existential and experiential aspects associated with death and dying (Kirk, 2011).

Teaching empathy: A brief survey of the literature

A strong proponent of improving empathy training in medicine is Jodi Halpern, a psychiatrist, philosopher, and Professor of Bioethics and Medical Humanities at the University of California, Berkeley. In From Detached Concern to Empathy: Humanizing Medical Practice, Halpern (2001) rejects outdated notions of scientific objectivity that discourage empathy training and claims that "empathy requires experiential, not just theoretical, knowing" (p. 72). According to Halpern, learning to be empathetic requires physicians to "imagine how it feels to experience something, in contrast to imagining that something is the case" (p. 85). Unfortunately, existing programs that teach empathy typically lack the sophistication needed to reflect Halpern's pedagogical vision. Students learn about empathy primarily in the classroom, although evidence suggests that experiential learning (e.g. modeling the responses of an empathetic mentor in a clinical setting) is more effective (Henry-Tillman, Deloney, Savidge, Graham, & Kilmberg, 2002; Larson & Yao, 2005; Stepien & Baerstein, 2006). Didactic approaches to teaching empathy are also less effective in securing students' enthusiastic participation than alternate approaches, such as viewing a painting depicting illness or engaging in role-playing (Hoffman, Brand, Beatty, & Hamill, 1985; Wikström, 2003).

Recognizing the limitations of didactic teaching methods, researchers over the past two decades have developed pedagogical approaches centered on the use of "works of narrative, the visual arts, anthropology, history, and journalism [to] encourage reflection and critical thinking about the human body and mind" (Kidd and Connor, 2008, p. 47). These researchers argue that including the medical humanities in medical and paramedical curricula can serve a corrective role for the reductionism of biomedicine and contribute to the training of reflective practitioners with an empathic understanding of the patient (Bleakey, Marshall, & Brömer, 2006; DasGupta & Charon, 2004; Ousager & Johannessen, 2010). Students' reading of literature or reflecting on paintings that depict illness circumstances can enhance their understanding of the doctor-patient relationship and their ability to express themselves in non-technical language (e.g., Calman & Downie, 1996; Calman, 1997; Elizur & Rosenheim, 1982; McManus, 1995; Moyle, Barnard, & Turner, 1995; Stowe & Igo, 1996; Smith, 1998; Skelton, Macleod, & Thomas, 2001). For example, in one pedagogical intervention, fourth-year medical students learned to care for patients in a more humane and thoughtful manner during a one-month humanities elective (Anderson & Schiedermayer, 2003). This intervention combined an artist presenting drawings of a cancer patient, a teacher leading a tour of an art museum, and discussion of selected readings. The students kept a journal and were asked to write a poem and either an essay or a short story. Similar pedagogical interventions were successfully used with medical residents (Barnard, 1994; Risse, 1992) and nurses and midwives (Begley, 1996; Castledine, 1998). Several studies report similar success in engaging students to assess the experiences, feelings, and activities of ill individuals depicted in artwork (e.g., Brett-MacLean & Yiu, 2006; Blomquist, Pitkala & Routasalo, 2007; Wikström, 2001). Medical students taking part in art appreciation classes significantly improved their observational skills (Bardes, Gillers, & Herman, 2001; Dolev, Friedlander, & Braverman 2001) and at least one study reports that students considered their personal and professional development to be enhanced by studying the arts (Lazarus & Rosslyn, 2003).

Another pedagogical innovation in empathy education involves the use of theatre performance and role-playing (Shapiro & Hunt, 2003). Theatre performance provides opportunities for students to identify with imagined roles and situations either as viewer or participant. This process can prove effective in fostering empathy by requiring health care providers to take on a patient's point of view in seeking to understand their illness circumstances (DeVito, 1999). In this manner, theatre performance can foster deeper understanding of the interactional dynamics involved in a caring and empathetic relationship (Lewis & Johnson, 2000; Welch & Welch, 2008). One example that illustrates this process is Deloney and Graham's (2003) study in which first-year medical students viewed Margaret Edson's Pulitzer Prize-winning play, Wit, as part of an experiential learning module. The play relates the personal story of a patient dying from ovarian cancer and depicts her experiences of medical care, from diagnosis to death. Surveying students' responses after they had viewed Wit, the authors concluded that the play improved students' empathy and understanding of the lived experience of end-of-life care.

Role playing can similarly allow students to imagine illness from the patient's perspective (Booth, 2003). More specifically, performing a dramatic role can engage students in empathetic reasoning by requiring they put themselves in another person's psychological frame of reference and imagine that person's thoughts, feelings, and behaviors, which are important aspects of empathic communication (Suchman, Markakis, Beckman, & Frankel, 1997). For this reason, role playing represents an effective experiential technique for developing empathy skills (Bolton, 1984), a view confirmed by several studies of this technique (Denny, Johnson, Boore, Leyden, & McCaughan, 2001; Ekebergh, Lepp, & Dahlberg, 2004; Wasylko & Stickley 2003).

Description of the teaching intervention

Despite the advent of innovative empathy pedagogies, researchers have paid little attention to their potential usefulness in teaching empathy skills to providers of end-of-life elder care. Our pilot study addresses this gap in knowledge with a unique approach that combines appreciation of fabric art and role-playing techniques adapted from drama therapy (see Bolton, 1984). Our aim is to investigate how combining fabric art appreciation and role-playing can help students empathize with older patients at the end of life. For this reason, we planned the study to coincide with an exhibit at the University of Victoria's Maltwood Art Museum and Gallery by well-known American fabric artist Deidre Scherer (1998). Scherer has been praised for the honesty and respect with which she explores the processes of aging, dying, and grieving (see http://www.dscherer.com/Reviews.asp [examples of Deidre Scherer's work can be found at the website]). She addresses the issues of aging and mortality by building a series of images based on elders and mentors in her community, drawing her inspiration from actual situations and models in hospices and nursing homes.

The exhibit featured fifteen fabric scenes depicting end-of-life scenarios among patients and their loved ones. One series, Surrounded by Family and Friends, consisted of six life-sized scenes involving intergenerational and non-traditional families from culturally diverse groups. The other series, The Last Year, featured nine scenes documenting the final year in an elderly woman's life (see www.dscherer.com for sample images of some of the artwork viewed by medical students). Using cotton, linen, and silk, Scherer combines the techniques of cutting, layering, and machine stitching to lend a narrative quality to her scenes. She also draws on other art media techniques, including painting, collage, portraiture, quilting, mosaic, and stained glass.

Our intervention's role-playing component involved asking students to take on alternate roles of physician and patient. A learning facilitator trained in drama therapy (J. Valdez) asked participants to focus on selected scenes from Scherer's work and to imagine how patients in those scenes would feel about their circumstances. We also used role-playing to help participants imagine how, as physicians, they would establish a therapeutic alliance and understand the circumstances of their patients' illnesses (Stepien & Baerstein, 2006). This goal of this technique was to help students acquire the "ability to understand the patient's inner experiences and perspective and a capability to communicate this understanding" (Hojat et al., 2002, p. 1563).2 Next, we asked students to once again assume the role of care provider and think of how they would respond using specific communicative strategies (e.g., comfort, reassurance) and language to express their feelings and understandings of the imagined concerns of the patients (Charon, 2001; Morse, Bottorff, Anderson, O'Brien, & Solberg, 1992).

Methods

Five medical students from the University of British Columbia's Island Medical Program (based at the University of Victoria) volunteered for the study after attending an information session open to all students in the program. We introduced the study as an investigation of how art could improve empathy and communication skills between physicians and patients. The criteria for inclusion in the study were full-time enrolment in the Island Medical Program and a willingness to participate in an intervention involving the arts. The sample included one first-year student and four second-year students; four students were female and one was male. The mean age was 26 years. This sample was drawn from a pool of 24 first-year and 24 second-year students. The ratio of male to female students in this pool was approximately 50:50.

We are aware that this sample is too small to make generalizable claims about the intervention and that it is skewed towards female second-year students. Obtaining generalizable results from this intervention would require a different research design with a larger sample of students who could be assigned to either an intervention or a control group. Such a study would also involve the use of standardized measures of empathy before and after the intervention—and, ideally, several times afterwards to measure the intervention's lasting effects. However, such a design is ill-suited for the in-depth exploration of students' learning experiences that interested us in this pilot study. A quantitative quasi-experimental study will constitute a subsequent step in investigating the effectiveness and applicability of this intervention.

Our design is inspired by the principles of phenomenographic research, a widely used qualitative approach in the field of higher education research. Phenomenography "is an empirically based approach that aims to identify the qualitatively different ways in which different people experience, conceptualize, perceive, and understand various kinds of phenomena" (Richardson, 1999, p. 53). Within such a framework, learning is conceptualized as a qualitative change from one conception about some particular aspect of reality to another conception of reality (Marton, 1988). In phenomenography, researchers aim to describe variations in how people understand a particular phenomenon (Johansson, Marton, & Svensson, 1985). To achieve this aim, researchers systematically explore participants' experiences, classifying them into categories according to their similarities and differences (Marton & Pong, 2005). This approach is compatible with two key concepts in learning and teaching empathy: 1) learning empathy as a process of understanding suffering from the patient's perspective; and 2) teaching empathy as a process of engaging the patient's experiences in a critical and reflexive manner.

Sample size in phenomenographic research varies depending on the phenomenon's complexity. For studying broad and complex phenomena, a sample size of between 15 and 20 is considered sufficiently large to reveal variations in viewpoints (Trigwell, 2000). However, for a more circumscribed phenomenon such as this intervention, a smaller sample size is considered adequate. Although we desired a slightly larger sample size for this study, the small number of participants we recruited nevertheless yielded rich enough data to provide useful insights into the various experiences and benefits of our intervention.

Data Collection

A brief interview with students before the intervention allowed us to familiarize ourselves with their views on empathy in the physician-patient relationship. After the intervention, we interviewed students about their learning experiences, their reactions to the fabric artwork, how they felt the exercises helped them to formulate empathetic responses, and how peer-to-peer interactions and the group session facilitated their learning. We collected further data by observing students during the intervention.

All interviews were audio recorded and transcribed verbatim for analysis by the investigators, according to the principles of phenomenographic research. We read the transcribed interviews to identify significant statements related to the phenomenon of learning empathy. These statements were grouped into themes, themes into clusters, and clusters into categories on the basis of shared meaning (Spencer, Ritchie, & O'Connor, 2003). At several points during the process, we assessed the findings' trustworthiness by having two investigators code transcripts independently and by comparing the significant statements they independently identified. Consistent inter-investigator agreement obtained on these comparisons indicates good trustworthiness for our analysis. Because participants came from a tightly knit cohort of medical students, we determined that the best way to protect their anonymity was to remove all identifying information from the narrative account. Because the study had only one male student, we also decided to use the gender neutral term "student" instead of pseudonyms as a further measure to protect anonymity.

Findings

Effective teaching of empathy is facilitated by students having a baseline understanding of why empathy is important. If they do not value empathy, they will not likely be motivated to learn about it. Learning empathy occurs more effectively when students having some basic conceptual understanding of empathy as a human response and can connect learning with their own real-life experiences (Bereiter, 1992; Bereiter & Scardamalia, 1996). If students lack a notion of what empathy entails in practical terms, trying to teach them specific skills for empathizing with patients will likely present significant challenges. However, as Morse et al. (1991) note, students typically begin their training by equating empathy with alternative responses (e.g. sympathy, pity and commiseration), which are judged non-beneficial or even harmful in the clinical setting. The goal of empathy training is therefore to teach students empathy strategies that allow them to solve practical issues in the patient-physician relationship--such skills involve controlled emotive engagement and communication that address and respond to the specific needs and concerns of patients (ibid.).

On this basis, we conducted baseline interviews before the intervention to determine if students met these necessary preconditions for effective empathy teaching. The results from these interviews confirmed that students perceived empathy as a valuable feature of the patient-physician relationship, although their responses understandably indicated vagueness in their conceptualization of empathy as clinical practice. One student remarked, "The physician must have compassion and a high level of empathy in relating to what the patient is experiencing;" another student said, "I think the physician has to be able to understand their patients, where they are coming from, what their fears, their hopes are." Additionally, students commented on the importance of "intuition" in determining how best to address the concerns and emotional needs of their patients:

We also have to be very intuitive...know how to take what they are saying and understand what they are really saying, or what they are leaving out and what they are saying because they think they should be saying that.

Finally, students emphasized the role of reflexivity in empathetic communication, with one student commenting:

I think it is important to be thoughtful and reflective as a physician. If you can't reflect on your own experiences and your own prejudices and opinions about things then you probably won't be able to identify issues in your own interactions with the patients.

Another student articulated how one's own life experiences with loss and grief could enhance one's ability to understand the needs of suffering and dying patients:

I can relate to suffering because I have suffered. If you are in touch with your emotions and know what that is like, you can identify with someone in a similar situation and know what it feels like to want to be comforted and wanting to have that suffering relieved.

Students also critiqued the inadequate instruction about empathy they received in problem-based learning (PBL) lectures, a venue "not really meant for empathy," which they described as better suited to the "nuts and bolts of physiology." As one student succinctly remarked, "Having someone tell you about empathy is a lot different than feeling empathy." Students expressed a desire to learn experientially--by observing preceptors with an empathetic predisposition, for example. As one student noted, "There is just something about strong role models that gives you a feeling that you would want to imitate; an inspiration that gives you the drive to learn better skills."

Overall, these students valued empathy as an important aspect of the patient-physician relationship. The students also had some personal experiences which gave them grounds for conceptualizing empathy in the context of palliative care. They were motivated to learn empathy skills and appreciated the opportunity to do so—an opportunity they felt their medical training had thus far denied them. Our findings about students' valorization of empathy are not unexpected: several studies report that first- and second-year medical students generally begin their education valuing empathy but that empathetic concern for patients drops as their education progresses, an effect that is especially marked during their residency (Bellini, Baime, & Shea, 2002; Newton et al., 2000; Wolf, Balson, Faucett, & Randall, 1989). Having ascertained students' receptiveness to empathy training, we then focused on helping them acquire more specific skills in the context of palliative care. In the next section, we report on the students' experiences with this intervention, for which we coined the acronym REAL (Reflecting and Engaging with the Arts to Learn).

Reflecting and engaging with the arts

The first stage of the intervention was designed to encourage students to imagine vividly the circumstances of adults depicted at end-of-life. In the first exercise, the facilitator asked the students to walk around the art gallery, to reflect on the various scenes depicted in the fabric artwork, to note their reactions, and to share these reactions with one another. One student described the evocative nature of the artwork in this way:

It was going to a place in my mind that I don't know if I could have gone to without having an image to take me there. It was connecting to a moment of someone's life, or the end of their life. Through art is a really interesting way to do it, rather than having a real patient in front of you. Just to tell a story about someone in that moment I don't think could be as powerful as actually just seeing an image.

When asked to elaborate on these emotional reactions, the students said they were touched by the vivid colours and varied fabric textures of the artwork. These comments were typical: "A lot of the colours and the tones and the images added to the emotion of them. They could really strike something inside that just made you connect to what that person, or that image, was experiencing at that moment." Another student added, "I felt very strongly that they were real people who I was looking at, who had something to say." Another student specifically remarked on how the artwork helped facilitate empathetic engagement with the troubling circumstances of death and dying:

There was a catalyst to trigger emotions with the art. We have had a lot of lectures on palliative care, but they have been really dry and almost superficial about how to manage patients. But the art kind of gets right to that level of emotion, where there are a lot of things that are happening at that present moment. I felt it was a connection with that.

These comments suggest the artwork's effectivity in helping students transpose the represented illness circumstances into vividly experienced internal emotions.

In the next phase of the intervention, the facilitator engaged the students in role-playing. This technique required students to select a patient from one of the scenes and to begin imagining what that patient was experiencing. The intention was to prompt students to imagine the patient's perspective before responding empathetically to the patient's concerns. Students did indeed find this technique valuable in helping them appreciate the unique circumstances of the patients depicted in the artwork, as this comment makes clear:

It was just nice to just think about the feelings of the people in the pictures, their situation. There was an interesting picture called "At Night." It was an elderly man, and it just showed his face and it was at night. I hadn't thought about that before, about night time being such a difficult time for these patients and what we can we do for them during this time. Because often sleep is disrupted and if you wake up and no one is around, it is really lonely.

Another student spoke about gaining a better grasp of end-of-life care as a lived experience:

I guess the sadness just comes from knowing that these people are inside. Like looking at people inside, and feeling empathy for them. I can think of certain women in those pictures just looking at me, and feeling "Oh, it must be really hard to be you." It is almost like they were saying, this is what my life is, and I felt that I was communicating with them.

One student felt attuned to the patients' despair: "They were lonely. I felt they were alone, a hopeless situation;" another remarked, "With making a story about the person, it became about the family member. It was really close to me. So it was feelings associated with thinking about my own death or about the death of people that are close to me."

In the next phase, the facilitator asked students to assume the role of the physician comforting that patient. This time, we intended to give students the opportunity to consider how they would express empathy in the context of end-of-life care. In this exercise, students were asked to focus their attention on strategies that would address the specific needs and concerns of the patients in the artwork. Students identified several useful techniques, including "taking your time to listen to the patient," "being with the patient," and "not imposing your feelings on the patient's care." Students also learned to develop strategies based on what they would expect others to do for them if they themselves were patients, as illustrated by the following comment:

I would want to receive news not with my family. But that comes from me not being a person who likes to share emotion. If somebody is really emotional, it depends on the circumstances. But I would want to deal with it myself and then face my family or my friends. I don't know for sure if I would [want] to do that. I guess I am clearer on how I would feel than on what I would do.

As part of this exercise, the facilitator asked students to imagine a life history for a patient of their choice (including details about the patient's family life, work history, and hobbies) and to speculate about how these details would affect the patient's experience of palliative care. This exercise helped students to humanize patients as individuals with unique biographies beyond their medical histories. In reflecting on this exercise, one student astutely remarked,

Being a physician means being around a lot of patients all the time and I wonder if a lot of doctors do feel that after a while they become desensitized to death or to the patients. They see a lot of older dying patients as the same. But I think it is important to remember that every one of them has had a full life and that they are someone's mother or someone's father and to make sure that every patient remains kind of a human with a whole story to them.

Group debriefing and post-intervention interviews

In the final stage of the intervention, the students participated in a group debriefing session in which they shared their learning experiences; their views on empathy, death, and dying; and their concerns about communicating empathy in the context of challenging end-of-life scenarios. We included this group session in the intervention because research suggests that peer-to-peer interactions can help practitioners learn from one another how best to respond to patients in the sensitive situations often encountered in palliative care (Elizur & Rosenheim, 1982; Lancaster, Hart, & Gardner, 2002).

The students credited the group session for helping them appreciate the diverse ways of responding to patients with empathy. As one student revealed,

I could just see that they had picked up on different things from the art, and what we saw wasn't tied to art only but also to history and our own experiences with death and our own natural feelings of it. So that helped me to understand how they saw death differently than I did.

Students also appreciated the trust that developed in the group, expressing how this trust allowed them to disclose personal thoughts and feelings:

It is kind of liberating to share what you are feeling with others [and] really valuable to be vulnerable with them. That is not something that we get to do very much and I would really like to do that more often, because I think it really changes my attitudes about other people. I felt that I got to be closer to them for doing it.

Other students added that the competitive climate of medical school discouraged them from engaging in such supportive exchanges. Participants also appreciated how the group session allowed them to forge a sense of community among themselves as learners and future health care providers. Participants felt that medical practitioners would benefit from taking part in such an intervention, regardless of their appreciation for the arts:

I think that everyone should have to do it if they are going to be practicing medicine. Even if it makes them uncomfortable, you have to face it if you are going to be in medicine, whether you are doing palliative care or not. I don't think that anyone would lose anything.

In reflecting on their learning experiences in post-intervention interviews, the students lauded the intervention for providing them with specific ways to assess the personal dimensions of patients' end-of-life needs. This approach proved a welcome counterpoint to the diagnostic emphasis that typically characterizes patient-physician encounters. As one student remarked, "You start to lose focus, you do other things, and I think it is really good to just redirect your attention every once in a while. I think that is more what it has done for me." Another student similarly underlined, "Being competent is more than just focusing on the relevant details and science and I think this is one way of just bringing me back to the bigger picture." Finally, one student expressed how the type of experiential learning fostered by the intervention could translate into life-long self-exploration:

I really enjoyed the process and I think in the future it will probably give me another method of processing things. I hope that, if I have time in my life where I need to think more about a certain subject, that maybe I will consider using art to do that.

Overall, the students reported the intervention to be effective in enhancing their awareness of the palliative care circumstances depicted in the artwork. They also considered the guided reflection and role-play exercises to be instrumental in helping them develop skills in formulating empathetic responses that were specifically geared toward the needs and concerns of patients at end of life.

Discussion

Death and dying constitute difficult aspects of medical care, particularly in the context of geriatric care. End of life introduces unique challenges for health care providers: they must not only care for patients' physical health, but also grapple with patients' and families' emotional pain—and with patients' and families' unresolved issues. Such emotional issues often pose as communication barriers between patients and health care providers. While health care providers likely enter their discipline favourably predisposed to empathy, they do not necessarily possess the specific empathy skills needed to effectively manage patient encounters, particularly in challenging palliative care scenarios. Current clinical training poorly prepares providers to deal with these kinds of scenarios where treatment options are few and empathetic communication is crucial in fostering quality care (Dickinson, 2007). Without proper training, providers may later resort to coping strategies such as distancing themselves emotionally from their patients (Ross, 1978).

Yet, as Halpern (2001) argues, medical judgement cannot be based on such complete detachment--rather, some level emotional engagement can enable health care providers to understand more completely the "particular meanings that a symptom or a diagnosis has for an individual" (p. 40). Our intervention provides an initial step to empower health care providers with emotional sensitivity to older adults at end of life. We sought to make students' learning centred on the palliative care circumstances depicted in the artwork and prompted them to construct their own responses to these circumstances. The guided reflection and role-playing exercises gave them an opportunity to learn to manage their own emotions while appraising patients' circumstances. We also encouraged students to share and examine each other's responses in an effort to foster learning as a co-operative knowledge-building experience.

Our findings also underscore the value of combining art appreciation with role-playing techniques. Deidre Scherer's fabric art lends itself well to this type of intervention: reviewers of Scherer's work have commented on her ability to use fabric art to express profound human emotions, imbuing her subjects with a sense of human presence and representing grief and love in a powerful manner. As Cohen remarks (2001, p. 2524), "the viewer is swept into the scene. One only pulls back to marvel at her technical mastery and the surprise that the medium is fabric and not acrylic or oil paint." The aesthetic qualities of the fabric artwork are therefore crucial in enhancing students' learning experiences. Students spoke at length about the qualities of and the manner in which they were drawn in by the vibrant colours and sophisticated quilting techniques (layering, piecing, and machine sewing) that lent a three-dimensional quality to the depicted end-of-life scenes. We doubt that the same learning benefits could be obtained by using pictures of artwork in a book.

The results we obtained from this intervention may also be explained by recent research on mirror neurons, which neuroscientists newly perceive as the seat of empathy in the brain (e.g. Carr, Iacoboni, Dubeau, Mazziotta, & Lenzi, 2003; Gallese, 2003). These mirror neurons are brain cells "specialized in understanding our existential condition and our involvement with others" (Iacoboni, 2008, p. 267) and they facilitate the establishment of empathetic bonds between people. Freedberg and Gallese (2007) argue that artwork produces physiological reactions as these mirror neurons facilitate "the direct experiential understanding of the intentional and emotional contents of images" (p. 202). They cite neuroimaging evidence shows these empathetic responses to have "a precise and definable material basis in the brain" (p. 202). Similarly, Jeffers (2009) discusses "the mirror neuron system that can explain how students connect to and are connected by their interactions with objects of art, the artists producing them, and the classmates with whom they share a 'we-centered' space." (p. 11). This research suggests that empathetic engagement could be effectively triggered by observing works depicting scenes that elicit an empathetic response. Our findings therefore lend credence to these neuroesthetic arguments that effective learning is more likely to occur when powerful sensory experiences are triggered in the limbic system, the part of the brain that regulates emotional response (Hinton, Miyamoto, & Della-Chiesa, 2008; Ingleton, 2002).

One caveat of our study is that students viewed original artwork in an art gallery; the immediacy of this experience arguably provides a greater impact than would viewing reproductions of the same artwork in a classroom. However, this disparity in impact could be overcome by displaying artwork on high-definition computer monitors or TV screens, thus enhancing its vividness and emotional force. Using visual art in this manner is both pedagogically advantageous and convenient because the images can be uploaded from scanned prints, digital pictures, or searchable educational databases. Furthermore, instructors could design interventions around works representing specific medical conditions, patient populations, or illness circumstances (Murray, 2000). Many websites also feature readily searchable databases containing downloadable annotated pictures. One well-known example is the Literature, Arts, and Medicine Database maintained by the Division of Educational Informatics at New York University School of Medicine (Holden, 2007). Additionally, several artists have produced work on specific illnesses (Murray, 2000): Robert Pope's (1991) Illness and Healing series of paintings famously chronicles his struggle with Hodgkin's disease, for example. Pope's work has been used in medical schools across Canada and the United States to teach students how to engage empathetically with cancer patients. In this way, the flexibility and focus afforded by reproduced artwork may in fact represent a pedagogical advantage over students' attendance at an independent gallery exhibit.

Others caveats include sampling self-selection, sample representativeness and sample size. Although self-selection is unavoidable in qualitative research, it is possible that this study involved participants with an above-average appreciation of the arts; students with a lesser appreciation might respond less successfully to the exercises. A second concern is that our sample included four women and one man; our findings thus over-represent the experiences of women in regard to this intervention. However, we did not detect a gender difference in the data: the male student and female students reported similar appreciation of the artwork and we observed them to be equally engaged in the role-playing exercises. A final issue is the small size of our sample. While having only five medical students partake in this pilot study proved ideal for gathering in-depth data about their experiences, our findings are obviously limited by their lack of generalizability to a larger population. Further research based on a larger, representative sample of medical students would help gauge more accurately the effectiveness of this intervention. These caveats aside, we want to emphasize that while this intervention involved medical students, it is by no means discipline-specific. Further research on the intervention's applicability across a variety of disciplines would help establish protocols for adapting the intervention to serve the learning needs of students and health care providers in all disciplines.

Conclusion

Until recently, the issue of empathy training was hampered by "decades-old arguments in the literature voicing the concern that empathy interferes with scientific and medical objectivity" (Garden, 2007, p. 553). The consequences of dismissing empathy in medical education have been well-documented: medical students learn to suppress their emotions and find it increasingly difficult to empathize with patients as their clinical training progresses (Beaudoin et al., 1998; Bellini, Baime, & Shea, 2002; Newton et al., 2000; Sinclair, 1997; Wilkes, Milgrom, & Hoffman, 2002). In his analysis of physicians' first-person accounts of their medical school experiences, Conrad (1988) concludes:

Medical education emphasizes disease, technical procedures, and technological medicine, with scant attention to "caring" aspects of doctoring. Students struggle to learn medicine and to maintain a humanistic or patient-oriented perspective, but the social environment of medical training militates against humanistic doctoring. (p. 323)

Empathy's devaluation as a clinical skill means that training programs in empathy are often insufficiently supported, forcing students to rely on lectures, which are convenient but do not give students the opportunity to practice empathetic techniques (Henry-Tillman, Deloney, Savidge, Graham, & Kilmberg, 2002; Stepien & Baernstein, 2006). Shapiro (2008) notes that medical education still "does not include sufficiently thorough preparation to reflect on, be present with, and come to terms with [students'] fear and anxiety about being contaminated by patients' confusion, loss, vulnerability, helplessness, powerlessness, and suffering – and their own" (p. 5).

Our intervention addresses this paucity of training with an experiential and convenient protocol designed to encourage students in developing empathy skills early in their training. First- and second-year medical students participating in this study experienced empathetic responses to the circumstances of illness, death, and dying depicted in the artwork they viewed under the guidance of an applied arts facilitator. The peer-to-peer interactions and group session helped students share their views and experiences of empathy. The results suggest this intervention represents an important first step in prompting students to cultivate emotional self-awareness and empathetic responses to patients in end-of-life health care situations. The intervention also marks a point of departure for further cultivation of empathy skills, which, as Halpern (2001) notes, can only be refined over a lifetime of clinical work with self-education and self-awareness.

In conclusion, we suggest that empathy training would be even more beneficial if it also integrated learning about how social inequities mediate patients' experiences of illness (e.g. Link & Phelan, 1995; Wilkinson, 1997). Much empathy training literature focuses almost exclusively on ways to improve clinical communication skills. However, as Garden (2007) notes, truly effective empathy needs to "extend beyond the individual relation to address socially determined inequities in health care" (p. 563). Similarly, Wear and Aultman (2005) recommend a more critical approach to teaching in medical settings that deepen "students' willingness to imagine what it is like to be someone who is suffering, and to work against oppressive social structures that sustain such suffering" (p. 1056). This expansion of empathy training would involve students in examining how illness impacts individuals differently, depending on their economic status. In the case of our intervention, training would require the use of suitable artwork to illustrate how the poorest patients are at a higher risk of illness (Wilkinson, 1997) and the least likely to have access to adequate health services (Chappell & Penning, 2001; Denton, Prus, & Walters, 2004; Nazroo, 2003). The intention would be to give students the opportunity to empathize with patients by understanding how disadvantageous socio-economic circumstances can contribute to their ill health.

Acknowledgements

We would like to acknowledge Deidre Scherer for her exceptional skill in depicting palliative care scenes through fabric art. We would also like to acknowledge the Greater Victoria Eldercare Foundation for supporting Embrace Aging Month in Victoria, BC by arranging for this art exhibit to be showcased at the University of Victoria. Funding was received from Canadian Institutes of Health Research (CIHR) New Emerging Team Grant ("Overcoming Barriers to Effective Communication in the Transition to Palliative/End of Life Care"). The New Emerging Team (NET) grants component of the Palliative and End-of-Life Care initiative is designed to build capacity and to promote the formation of new research teams or the growth of small existing teams. We received further support from the Centre on Aging, University of Victoria, and their Research Unit Infrastructure Grant from the Michael Smith Foundation for Health Research.

Footnotes

  1. The scientific turn in medicine can be traced to the 1910 Flexner Report, which resulted in American and Canadian medical schools enacting higher training standards based on the principles of human physiology and biochemistry (Beck, 2004). The Flexner Report is credited with improving medical training, but it also diminished interest in the interpersonal component of medical practice (Hays and DiMatteo, 1984, p.6).

  2. This conceptualization of empathy originates from German philosopher Robert Vischer's work on aesthetics. In 1873, he coined the term "einfühlung" ("in-feeling" or "feeling-into") to capture the process by which human beings project feelings onto the natural world (Montag, Gallinat, & Heinz, 2008). Theodor Lipps, a fellow philosopher, popularized the concept by using it to explain the human ability to imagine another's perspective. The term "einfühlung" was translated to English in 1909 as "empathy" by famed British psychologist Edward Titchener in an effort to distinguish it from the then-popular notion of sympathy (Jahoda, 2005).

  3. Phenomenographic and phenomenological research share similarities: both approaches are relational, experiential, content-oriented, and qualitative (Marton, 1986). However, phenomenography also differs substantively from phenomenology. The latter constitutes a philosophical method that seeks to capture a phenomenon's essence (Creswell, 2007). By contrast, phenomenographers adopt a more modest empirical orientation toward phenomena, seeking to articulate participants' reflections on experience as completely as possible (Marton & Booth, 1997).

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