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Art as Sanctuary

A Four-Year Mixed-Methods Evaluation of a Visual Art Course Addressing Uncertainty Through Reflection

Gowda, Deepthiman, MD, MPH, MS; Dubroff, Rachel, MD; Willieme, Anna, MFA; Swan-Sein, Aubrie, PhD, EdM; Capello, Carol, PhD, MSEd

doi: 10.1097/ACM.0000000000002379
The Emerging Learning Environment
Free

Purpose Engagement with visual art is a promising modality for addressing issues of uncertainty via reflective practice, one that is being increasingly used in health science education. An elective museum-based course for first-year medical students was created by two medical schools and led by an art educator experienced in medical education. The course, Observation and Uncertainty in Art and Medicine, sought to help students explore experiences of uncertainty and to develop reflective capacity through engagement with visual art.

Method The course was run and evaluated from 2014 to 2017, with 47 students participating over the 4 years, with 12 students enrolled per year. Before and after the course, students were given the Groningen Reflection Ability Scale (GRAS) for reflective ability, the Tolerance for Ambiguity scale for ambiguity, and Best Intentions Questionnaire for personal bias awareness, and 35 students (74%) completed all of the scales. Focus group interviews and narrative postcourse evaluations were conducted, coded, and thematically analyzed.

Results Statistically significant improvement was found in GRAS scores. Qualitative themes included student enhancement of observational skills, awareness of the subjectivity and uncertainty of perception, exploration of multiple points of view, and recognition of the course as a place for restoration and connection to classmates.

Conclusions Incorporating visual art into medical education is an effective pedagogical method for addressing competencies central to training, including observation, reflection, and self-care.

D. Gowda is director of clinical practice, Program in Narrative Medicine, director, Foundations of Clinical Medicine, and associate professor of medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; ORCID: http://orcid.org/0000-0001-7124-7615.

R. Dubroff is assistant professor of clinical medicine, Weill Cornell Medical College, New York, New York.

A. Willieme is founder and director, ArtMed inSight, Cambridge, Massachusetts.

A. Swan-Sein is director, Center for Education Research and Evaluation, and assistant professor of educational assessment in pediatrics and dental medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York; ORCID: http://orcid.org/0000-0002-3139-4626.

C. Capello is associate director, Office of Curriculum and Educational Development, director, Office of Academic Assistance, and associate professor of geriatrics education in medicine, Weill Cornell Medical College, New York, New York.

Funding/Support: None reported.

Other disclosures: Anna Willieme is founder and director of ArtMed inSight, a for-profit educational organization that uses art to enhance perceptual skills.

Ethical approval: Institutional Review Boards at Columbia University Medical Center (IRB no. AAAN5500; approval date April 1, 2014) and at Weill Cornell Medical Center (IRB no. 1209013010; approval date May 1, 2013).

Previous presentations: Early versions of this work were presented at the Ottawa Conference Biannual Meeting in March 2016 in Perth, Australia, and at the Association for Medical Education in Europe Annual Meeting in August 2016 in Barcelona, Spain.

Correspondence should be addressed to Deepthiman Gowda, Hammer Health Sciences Building, Suite 201, 701 W. 168th St., New York, NY 10032; e-mail: dg381@columbia.edu.

The ability to tolerate uncertainty has been increasingly recognized as a core capacity for effective medical practice.1 Indeed, intolerance of uncertainty has been associated with higher burnout among physicians2 and even linked to anxiety.3 It is also associated with overtesting, which is noted as an important driver of overdiagnosis and increased health care costs.4 Some researchers also link the inability to tolerate uncertainty with certain cognitive biases, which in turn can lead to delayed or missed diagnoses.5 Because it is a central attribute of medical practice, educators have argued that uncertainty training should be explored in health science education6 and that reflective practice should be a central feature of such curricula.7

Several scholars note that the humanities, a field that grapples with uncertainty at its core, can have an important role in exploring this concept in health science education.8,9 Engagement with visual art is a promising modality for addressing issues of uncertainty via reflective practice, one that is being increasingly used in health science education. Though methodological rigor varies, educators have employed diverse teaching methods to enhance observation skills, increase tolerance of ambiguity, improve reflection, and enhance teamwork.10–14 Notably, one exploratory qualitative study showed that medical students grapple with uncertainty when engaging in a general visual art curriculum.15 To our knowledge, however, no study has been published that uses a rigorous mixed-methods evaluation of a visual arts program specifically designed to address issues of uncertainty through promoting reflection.

We created a museum-based course, Observation and Uncertainty in Art and Medicine (OUAM), that sought to explore issues of uncertainty and develop reflective capacity through engagement with visual art. This paper describes the objectives and teaching methods of the course and presents the results of an evaluation that assessed curricular objectives over four years of course administration.

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Method

Study participants

The OUAM course is taught annually to a combined class of first-year medical students from Columbia University Vagelos College of Physicians and Surgeons and Weill Cornell Medical College. The average enrollment of 12 students per year (6 students per school) was deemed appropriate for museum-based teaching.

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Course details

The course satisfied a narrative medicine requirement for Columbia students. Students must choose from among 12 different course offerings, 3 of which are museum-based art courses; others explore various creative traditions, ranging from fiction writing to modern dance. All narrative medicine courses were graded pass/fail. The Cornell students participated in the OUAM course as a non-credit-bearing elective on a voluntary basis that did not satisfy a curricular requirement. As many as 25 Cornell students expressed interest annually for 6 spots that were selected by lottery.

Course objectives included (1) strengthening observation skills, (2) recognizing and examining uncertainty, (3) recognizing and examining cognitive biases, and (4) promoting self-awareness through reflection. The course consisted of weekly two-hour sessions over a period of six weeks in Metropolitan Museum of Art galleries in New York City (5th Avenue location). The course was designed and taught by A.W., founder and director of ArtMed inSight, an organization that uses art to train students and health care professionals in perceptual skills. To achieve our course objectives, A.W. paired specific works of art with structured exercises that included reflection. Table 1 describes three examples of exercises, teaching methods, and intended outcomes. Artworks were both figurative and abstract and included painting, photography, sculpture, and drawing; Figure 1 is an image used in one of the described exercises.

Table 1

Table 1

Figure 1

Figure 1

A.W. facilitated the museum sessions during which students observed and interpreted the artworks in structured exercises that included reflecting on their responses to the works. Classes were student centered, focusing on examining students’ experience as opposed to an emphasis on art history. Students completed short weekly outside-of-class assignments that further explored these topics and created a final presentation relating an artwork of their choosing to the practice of medicine.

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Data collection

A mixed-methods approach was used to evaluate the course. Quantitative survey instruments were employed to evaluate outcomes related to course objectives. Qualitative approaches were also used to assess course objectives using an inductive, exploratory approach that remained open to emergent outcomes related to students’ experience in the course.16,17 Data were collected over four years of course administration, annually from April to May, 2014 to 2017.

During each course administration, students completed three pre- and postprogram survey instruments: (1) Groningen Reflection Ability Scale (GRAS) for ability to reflect,18 (2) Tolerance for Ambiguity (TFA) scale for ambiguity,19 and (3) Best Intentions Questionnaire (BIQ) for personal bias awareness.20 The TFA scale, which focuses on ambiguity, was chosen as a proxy for uncertainty. In line with the objectives of the course, we hypothesized that scores on the TFA scale would improve, indicating that students would have a higher tolerance for ambiguity and could better cope with situations of uncertainty. We hypothesized that student responses to the BIQ would also indicate that student awareness of personal biases would improve. Finally, we hypothesized that responses to the GRAS would indicate improvement in student ability to engage in self-reflection, empathetic reflection, and reflective communication.

Qualitative evaluation, performed at the end of the course, included focus group transcripts and written narrative evaluations. Focus groups were conducted after each of the first three course years, with a combined total of 18 participants from the two campuses. C.C. and A.S., who were not involved in teaching the sessions, conducted all focus groups. The interview guide was developed collaboratively by C.C., R.D., and D.G. and was informed by course objectives in addition to an exploratory openness regarding students’ experience in the course. Sample questions from the interview guide included “Through this course, was there anything, if at all, that you learned about yourself?” and “How, if at all, did the art elective influence your observation skills?” All interviews were audio-recorded and transcribed. The end-of-course written evaluation (developed by A.W.) allowed free-text responses to open-ended questions related to students’ experiences in the course (e.g., “Please comment on the time spent in the galleries looking at art”).

To achieve consistency over the four years of data collection, the interview guide and written evaluation questions were not altered after their initial development. Transcripts and written evaluations were anonymized and stored securely by D.G. Consent was obtained from all students included in the study. Students’ participation in focus group interviews or completion of surveys was optional and did not affect course grades. This study was approved by the Institutional Review Boards at Columbia University Medical Center (IRB no. AAAN5500; approval date April 1, 2014) and at Weill Cornell Medical Center (IRB no. 1209013010; approval date May 1, 2013).

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Data analysis

Authors include C.C., an educational researcher with doctoral training in humanities and in qualitative research; R.D., a physician–educator with extensive experience teaching medical students and residents in a museum setting; D.G., a physician who directs a clinical skills course, has experience teaching medical students in museum settings, and has graduate-level training in qualitative research methods; A.S., a medical education researcher with doctoral training in quantitative and qualitative research methods; and A.W. (background described above).

C.C., R.D., and D.G. reviewed focus group transcripts and written course evaluations and performed coding and thematic analysis using a general inductive approach to qualitative evaluation.16,21 In-person and telephone meetings were held approximately monthly from June 2014 to June 2017 to collaboratively review transcripts, iteratively create and apply codes, and conduct thematic analysis. Final codes and themes were agreed on by C.C., R.D., and D.G. Member checks performed at both schools with students who had taken the course confirmed that the identified themes were consistent with their experience.

To encourage critical exchange during data collection and analysis, A.W., who designed and taught the course, did not ask for consent from students to participate in the study, conduct focus group interviews, or analyze the data. All authors participated in manuscript preparation.

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Results

A total of 47 students completed the course over the four years of course administration. Demographic information collected for 44 students is displayed in Table 2. The pre- and postcourse surveys were completed by 35 out of 47 students (74%), through which the TFA, BIQ, and GRAS questions were administered. Paired t tests were performed comparing student scores pre and post intervention for each of the three surveys; Table 3 presents the results. Scores improved significantly on the GRAS inventory, indicating that student personal reflection ability improved over the progression of the course. The effect size for this improvement was d = 0.46, which is close to the standard of 0.50 for a “medium” effect. Though improvements were found on the TFA and BIQ scales, the differences were not statistically significant.

Table 2

Table 2

Table 3

Table 3

A total of 44 out of 47 students who took the class completed the written course evaluation. Eighteen students participated in focus group interviews, which ranged from 30 to 70 minutes in duration. Four major themes were identified from the focus groups and course evaluations: enhancement of observational skills, awareness of the subjectivity and uncertainty of perception, exploration of multiple points of view, and recognition of the course as a place for restoration and connection to classmates.

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Observation skill enhancement

Students frequently remarked on how the course strengthened their observation skills. One student mentioned that the course encouraged “stopping, slowing down, [and] being intentional about seeing, [while] everything in med school is at such a fast pace.” Another student noted that the course strengthened being able to “better perceive easily missed details and better able to describe elements that at first seem indescribable.” One student commented that the course promoted heightened curiosity and more nuanced observation and description. “It might be enough for me to say that ‘the chair is red’ six weeks ago, but now I might look at the chair and say, well, ‘What kind of red is it?’”

Additionally, several students expressed how observation outside of class was affected. One said, “I began to notice subtle details in everyday experiences and began to take more time to consider their meaning and purpose.” Another student commented, “I have noticed being more aware of my surroundings…. I just notice what’s in the park more than I used to when I just walked by.” Several students expressed a desire to leverage these skills of observation in future clinical work, including one who said, “I have definitely learned to be more observant and attentive and will try to cultivate that skill further in my career as a physician.”

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Subjectivity and uncertainty of perception

Students often shared how emotions, biases, and context all affected what was perceived through acts of observation. One stated, “I began to realize how I can directly impact what I am perceiving, whether it be by my own thoughts or emotional state.” Another found that working with art presented opportunities to ponder questions such as, “Why am I disgusted by that sculpture? Or why does it frighten me?”

Students also focused on how recognition of the subjectivity of perception required them to grapple with the discomfort of uncertainty. For one student, subjectivity and uncertainty of perception in art served as “a reminder that … we can’t escape that with the ‘objectivity’ of medicine.” Another student connected the notion of uncertainty with adjusting to medical training in general.

Med school is a long journey through accepting uncertainty.… I think this whole year for me has been a long process of being comfortable with being uncomfortable. I can’t know everything…. I can’t do everything I need to do. I don’t have the time. And accepting that, moving on and not letting it cause so much anxiety. This class added to that.

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Exploration of multiple points of view

Students acknowledged that engagement with art in groups resulted in appreciating the value of multiple points of view. Such insights included recognizing that different people notice varying details and have diverse interpretations and emotional responses, even when looking at the same art object. As one student remarked, “I never noticed the map in the Vermeer painting until [another student] pointed it out.” Another student offered: “An expression on someone’s face that I interpreted as sad, somebody else interpreted as frustrated.… It made me realize how singular my own perspective is and how important it is to really consider multiple interpretations.” Students also noted how others’ observations impacted their own. One student noted, “It was very informative hearing other people’s take on the same image, and that often made me change the way that I thought about it.” Another student noted the benefit of having multiple points of view: “I … really enjoyed the Rodin piece because it was so involved. It took a lot of ‘lifting’ so to speak from the group as a whole.”

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Sanctuary for restoration and connection

One student felt the course “was like a sanctuary away from campus.” In fact, some of the lengthiest and most frequent comments involved descriptions of the restorative aspects of the course. A student noted, “I realized just how exhausted I was and how much I really, really needed this.” The same student went on to say that it “was healing in many ways just to get out of that narrative of being a med student.… It reminded me that I need to take large chunks of time on a regular basis for self-care and it’s okay to do that. It’s healthy to do that. It will make me a better doctor to do that.” The theme of self-care also included comments regarding benefits and support of having deeper connections with classmates. Students experienced strengthened bonds with classmates by learning things about them that might not have come up in typical curricular experiences. As one student put it, “I really enjoyed seeing my peers in this new way.”

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Discussion

Visual observation is a foundational means of knowing one’s world, yet educators cannot assume that students and clinicians know how to skillfully observe. Although it is also the bedrock of medical practice, few, if any, opportunities occur in the traditional medical educational curriculum where skills of observation are explicitly taught.

Students frequently noted enhanced observational skills as a consequence of taking this course. Several described careful observation not as an ever-present, automatic capacity but, rather, as a “tool” to be used purposefully, in the way a stethoscope must be placed on the patient’s body in a particular fashion to appreciate heart sounds. The use of the metaphor suggests that the observer’s skill can be trained and honed. It also suggests that the observer should have an awareness of when careful observation is needed and then have the desire to use it. Discoveries students made in the course about artwork or one’s environment through careful observation may possibly serve as evidence of the benefits of employing such practices. Indeed, several students commented specifically on how skilled observation might enhance their future clinical practices.

The OUAM course was designed specifically to help students grapple with uncertainty of one’s observations and engage in reflection around this issue. Students noted that the course led them to consider how their emotions, personal histories, and situational contexts affected perception. They also recognized the benefits that accompanied the limits of one’s perception. For instance, persons observing the same object may perceive the object differently, and attending to those multiple points of view may lead to a deeper understanding of that object. The application of this insight to the benefits of team-based clinical care are readily apparent. Such comments from students represent considerations about the object (nature of the exterior that is being seen), as well as the subject (nature of the person doing the seeing), and the relationship between the two. This type of negotiation of interior with exterior parallels the important recognition of the self in relation to the other that is deeply characteristic of clinical practice.

Any thoughtful exploration of the subjectivity of perception and the relationality of self with the outside world requires reflection, a foundational habit of the skillful practitioner.22 We observed robust improvements in the GRAS inventory, which measured ability to reflect. This survey includes items such as “I can see an experience from different standpoints,” “I can empathize with someone else’s situation,” and “I reject different ways of thinking” (reverse coded). Though they did not achieve statistical significance, we saw improvements in the scales for tolerance for ambiguity (TFA) and awareness of biases (BIQ). One can postulate that enhancing reflective practice is a necessary step toward becoming aware of one’s emotional responses to uncertainty and becoming aware of one’s inherent biases in thinking. Our hope is that the skillful practitioner would then take stock of those insights to make appropriate clinical decisions. The phenomena of subjectivity of perception, tolerance of uncertainty, and cognitive biases play out at the intimate, personal, and singular level, but when considered collectively, these concepts have relevance to the broad public health concerns of diagnostic error, overtesting, and cost of health care.

A key theme that emerged was that the course was a restorative experience, with one student describing it as a “sanctuary.” Indeed, comments related to this theme were emotional, eloquent, and compelling. The experience of the course as a safe and restorative place is particularly important for exploring uncertainty and bias because these topics may prove to be uncomfortable and even unsettling to learners. Uncertainty, a central feature in clinical practice, is at odds with an educational environment that is populated by multiple-choice questions and the false notion that there is a “right” answer to most clinical situations. Recognizing that one’s perception, and even scientific knowledge generation as a whole, is bounded by a zone of uncertainty can be a troubling notion; this may be particularly disturbing while providing clinical care when the stakes are the highest. Importantly, in courses like OUAM, these lessons are learned through a direct experience and experimentation, and not through theory and detached learning. This embodied learning attends to the emotional dimensions of the topics explored and provides rich opportunity for reflection and discussion; a nonjudgmental and supportive environment will best allow such insights to occur.23

The word sanctuary also points to the course’s role in self-care and connection with classmates. Students noted that they learned things about classmates they might not have discovered through the normal course of medical training in classrooms and hospitals; these types of experiences facilitate a more nuanced understanding of one’s classmates and colleagues and strengthens relationships and community. These attributes of the course, in addition to the practices of reflection mentioned above, have been identified as features that promote resilience.24–26 Given the concerning rates of burnout in medical education, facilitating habits of self-care and providing opportunities for connection with classmates seems a necessary element of a healthy and flourishing training environment.

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Limitations

This program evaluation has limitations. The students from Weill Cornell enrolled in the course electively, and although the course satisfied a curricular requirement for the Columbia students, they still had some choice in selecting our particular art-based course. Thus, participant selection for this study may be biased toward students who have a prior affinity for art and those who may be more receptive to museum-based education. In addition, the total number of participants is relatively small and thus affects generalizability. The lack of a comparison group limits causal inference. Though this study was conducted with students from two different medical schools, both schools are based in New York City with easy access to museums; however, schools in many other settings typically can find access to art in smaller galleries and even within hospital settings. A skilled artist and facilitator led our course, representing a local resource that might not be present in some institutions. Other schools might rely on local experts with whom to partner or seek avenues to train those interested in leading such sessions.

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Conclusions

The findings in this evaluation indicate that art-based education holds promise to explore important competencies critical to medical practice such as observation, reflection, self-care, and tolerating uncertainty. Facilitating such curricula, however, requires schools to dedicate curricular time and devote other necessary resources. More research is needed to assess feasibility at different institutions. Finally, students noted how the lessons regarding close observation impacted their habits outside of the course. Further research examining impact of art education on clinical practice is needed.

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Acknowledgments:

The authors thank Dr. Herbert Chase and Dr. Pablo Tinio for their early consultations on this study and thank Deborah Lutz for teaching some of the sessions in the course.

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