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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. Jo u rn a l o f M e d ica l E th ics a n d H isto ry o f M e d icin e Painting as a reflective method in teaching medical professional values *Corresponding Author Mina Mobasher Address: Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, 22th Bahman Blvd., Kerman, Iran. Postal Code: 7616914115 Tel: (+98) 34 33 25 76 60-4 Email: m.mobasher@kmu.ac.ir Received: 15 Sep 2020 Accepted: 16 Jan 2021 Published: 30 Jan 2021 Citation to this article: Mobasher M. Painting as a reflective method in teaching medical professional values. J Med Ethics Hist Med. 2021; 14: 1. Mina Mobasher Assistant Professor, Department of Medical Ethics and History of Medicine, School of Traditional Medicine, Kerman University of Medical Sciences, Kerman, Iran. Introduction Teaching medical ethics is an effort to deliver the dominant values in the relationship between physicians and their patients, colleagues, and eventually the whole society. Furthermore, medical ethics education requires appropriate methods in addressing these topics for pre-clinical and post- clinical courses. One study showed that the final purpose of medical ethics education is to train medical students and physicians who have acquired the fundamental skills in professionalism, such as responsiveness, altruism, excellence, integrity, respect, and justice (1). In another study, the authors defined the principles of professional commitment, stating that the main purpose is to internalize the meaning of professional commitment and behaviors among medical students and physicians (2). Another author believed that the internalization of ethical concepts can assist doctors in dealing with tough situations and emergencies, since in these circumstances ethical sensitivity and personal feelings substitute ethical reasoning (3). Education plays a vital role in changing these non-cognitive components, which can be presented semi-directly or indirectly in group discussions, or through introducing ethical issues in stories or role modeling. In fact, students should deeply understand the concepts and behavioral values in medical practice and observe the principles of professional conduct through a highly practice-based approach, and not just completely depend upon lectures or theoretical knowledge. Painting as a reflective method in teaching medical professional values 2 J Med Ethics Hist Med. 2021 (Jan); 14: 1. Jo u rn a l o f M e d ica l E th ics a n d H isto ry o f M e d icin e The Importance of Medical Ethics Education and the Associated Challenges When the aim of education is to convey values to the learners, the professors could have a vital role in the academic atmosphere. In fact, medical students and professionals should understand patients’ values and beliefs in their family and cultural contexts. Thus, the main concern of medical education is to introduce humanities to medical practitioners. However, this is not a simple issue, and many studies have investigated the problems of teaching the concepts and values of professionalism. One of the main reasons why conveying behavioral values is difficult is that what students see in the educational setting is in contrast to what is discussed in the medical ethics class about values and behaviors. Sometimes, it seems that students are hesitant to accept such values, and therefore the main question is about the ways that we can teach those topics more effectively. In a study, the author showed that the medical ethics curriculum in the undergraduate level is inclined towards being student-centered, and emphasizes the importance of applying the principles of adult teaching in medical ethics education (4). It is also possible to use other methods such as small group discussion, which can make students sensitive to human values based on professionalism. In one study, the author has emphasized the need for formal education in ethics for students in their clinical training course (5). In this study, the educators used ethical rounds with anonymous cases. This author pointed out that this continuous clinical ethics training could highlight professional behavior and help students to better manage ethical challenges and improve their problem-solving skills. Painting in the Medical Ethics Class Achieving educational goals in this field requires the engagement of learners in the educational process, and this is what I can claim to have achieved based on several years of experience in teaching this course. That is why I have always sought ways to facilitate learning and at the same time make the class intriguing for the students. Therefore, I participated in a workshop named “Ethics Teachers’ Training Course” organized by UNESCO in Malaysia in 2016 and implemented the methods taught in the workshop in my own classes. In that workshop, they explained how to apply various methods such as painting in order to educate adults about ethical concepts. Professionalism and medical humanities play a paramount role in medical ethics curricula, but it is difficult to deliver topics related to professionalism using routine methods such as case presentation and problem-solving. Therefore, I used drawing as an instruction tool for training students in professional behaviors. In this article, I presented this educational method and my students’ viewpoints about it. Also, I explained how they reflected on professional values by illustrating their conceptions about it on a piece of paper. In the university that I currently work for, medical ethics is a mandatory course delivered in two units, which I present in Mobasher M. 3 J Med Ethics Hist Med. 2021 (Jan); 14: 1. Jo u rn a l o f M e d ica l E th ics a n d H isto ry o f M e d icin e fourteen to fifteen sessions each semester. Usually, after five sessions dedicated to ethical analysis tools, informed consent, truth-telling and confidentiality, I start teaching about patient-physician relationship issues. At the beginning of the session, I play a seven-minute clip to the class without any introduction or pre-talk. This thought- provoking clip presents sentiments, values and beliefs that health care providers and clients believe in. Then, I ask the students to paint their feelings and perceptions about the clip in fifteen- to twenty-member groups. Each group receives drawing tools (papers and color markers) and is given 40 minutes to prepare their painting. The drawing of each group is shown to the class and a member of that group gives a short presentation about it. Then, I choose a group that has successfully used drawing to propose a novel idea about the values in medicine and their importance in patient- physician relationships. Nevertheless, as a staple of all team projects, a small number of students usually carry a bolder role in either coming up with an idea or presenting it. After three semesters, in the second semester of 2018 at the Department of Medical Ethics in Kerman University of Medical Sciences of Iran, I interviewed a number of my students about their drawing experiences. Six students participated in a 15-30minute interview. I purposefully selected the students based on their final scores and how effective they were in their groups. A secretary invited them to participate in the interview and obtained informed consent while assuring them that we would keep their information confidential. Also, she explained to them that the risk of this study was minimum. She asked the participants four main questions: What was your experience in the painting session in the medical ethics class? What do you think of this method for teaching behavioral values in the course of medical ethics? Did it help you learning the concepts and goals of this lesson? Do you think that using this approach will improve your performance as an ethical practitioner? In addition, she asked probing questions to guide and continue the interviews. She transcribed each interview immediately after performing to extract the codes. Then, the contents of the interviews were analyzed by the six-step methodology proposed by Braun and Clarke (6). Content analysis showed five main themes related to students’ experiences about this teaching method, including variety in education, pleasant experience, active cooperation among the group members and giving every student a voice, expressiveness and memorable experience, and imagining the values and drawing them. Some samples of the students’ paintings can be found in Figures 1, 2, 3. Painting as a reflective method in teaching medical professional values 4 J Med Ethics Hist Med. 2021 (Jan); 14: 1. Jo u rn a l o f M e d ica l E th ics a n d H isto ry o f M e d icin e Fig 1- Students’ perspective about professional values in patient-physician relationship in this picture: “We drew a tree with our fingertips which were a symbol for our cooperation, and the red color around the tree shows our blood and how we are untied to cure our patients.” Fig 2- Students’ perspective about professional values in patient-physician relationship in this picture: “I wanted to show my assistance and sympathy toward patients, so I drew a hand holding a rope tightly.” Fig 3- Students’ perspective about professional values in patient-physician relationship in this picture: “The painting from the concept in the Quran which read: a person would save one of the people is equal that she/he save the whole life. Humans are the greatest asset.” Mobasher M. 5 J Med Ethics Hist Med. 2021 (Jan); 14: 1. Jo u rn a l o f M e d ica l E th ics a n d H isto ry o f M e d icin e 1- Variety in education: Some students felt good that there was a variation in their class routine. They believed that such methods are better than solely explaining theories in lectures. One student stated, “Painting has a fun factor, and when it is coupled up with education, it will certainly make the class less boring and more effective “. 2- A pleasant experience: Students unanimously considered the painting session as a good experience. A few of the interviewees' comments about this event are as follows: “Painting has an artistic aspect to it which enabled us to illustrate the spirit and feelings of a doctor in a meaningful way. Even after the class, I felt happy to know others’ ideas about medicine…. It was very interesting.” 3- Active cooperation among the group members and giving every student a voice: Many students mentioned the bold teamwork nature of this activity. Although their classes usually include group discussions and supposedly active engagement of everyone, they admitted that utilizing painting to express their thoughts and feelings was much more inclusive and democratic. As one student put it, “It was a wonderful experience in terms of cooperation between classmates and how everyone was trying to achieve a certain goal. “ 4- Expressiveness and memorable experience: The students had a consensus that the painting session was a memorable experience and they would never forget it. Below are some comments by the interviewees: “I clearly remember the painting session and every time I feel unmotivated to study or do my professional duties, remembering what we painted in that session about our values helps me to get back on track.” “This method will help us to internalize the conveyed meanings and values in the unconscious part of our minds.” 5- Imagining the values and drawing them: All the students mentioned that they have to thoroughly think about their duties as physicians and this has caused them to view their profession from a different perspective. Some mentioned that they were reminded of the famous quote in the Quran, “Saving a single life is tantamount to saving the whole humanity”. A few of their responses are provided below: “Painting about the concept in the Quran which says, ‘Saving one person is equal to saving the whole life and existence’ represented an interesting concept of human preservation. Humans are the greatest assets”. “I wanted to show my support and sympathy for patients, so I drew a hand holding a rope tightly”. “There is sorrow and joy in the hospital. It was a tree we drew; the tree could be cut off, and it would crumble away, but it is always saved when an ally is green with green leaves”. “We drew a tree with our fingertips which were a symbol for our cooperation, and the red color around the tree showed our blood and how we are untied to cure our patients”. Painting as a reflective method in teaching medical professional values 6 J Med Ethics Hist Med. 2021 (Jan); 14: 1. Jo u rn a l o f M e d ica l E th ics a n d H isto ry o f M e d icin e A Critical Reflection on Utilizing Painting as a Teaching Method According to what the students expressed about their experience in this class, it seems that painting has been an intriguing method, and they have been participating in this class enthusiastically. Students learn from this event as an experience that will remain with them for the rest of their professional careers and even their lives. Students also emphasized that they have understood the concept of teamwork and cooperation and the values involved in medical settings in this session. Also, they expressed that the sanctity of the medical profession has been pronounced in their minds and their standards. In a study, the author stressed that medical ethics should be taught in flexible and critical ways (7). Another author emphasized the role of art in understanding the human aspects of medicine. When medical professionals are interacting with individual, cultural and social values, arts such as painting, poetry, music, movies, etc., can help them to understand the human aspects of their profession (8). Authors of another study also stated that the arts can help learners and medical professionals to improve their skills for critical thinking and to understand the human aspects of medicine as well as improve their practice (9). I have not been able to find a study that used painting to train professional behaviors. In this study, however, the students contemplated concepts of professionalism by painting, and understood the humanities of medicine when interacting with patients, colleagues, and the society, which was evident in their interviews. The medical students drew down their feelings and understanding regarding the topic in each group and showed their ability to portray professional values by reflecting them in their paintings. They stated that they had acquired a good grasp of professional behaviors such as responsibility, empathy, integrity, etc. in the patient-physician relationship. It seems that painting is a flexible and thought-provoking approach to teaching medical ethics, and can improve critical thinking in students while being effective in achieving the educational goals in medical school. Limitations The groups were relatively large due to a lack of sufficient classroom facilities. If this method is used in smaller groups of students, more students will be encouraged to think about professional values and come up with novel ideas, which will also diversify the shared ideas among students. Also, the study did not examine the effectiveness of this method on the students’ performance in real clinical settings. Acknowledgments The author is grateful to the Medicine Faculty of Kerman University of Medical Sciences for the educational facilities. Also, the author appreciates the participation of medical students in the painting session of the medical ethics class, and Ms. Fatemeh Iranmanesh for interviewing the participants. Conflict of Interests The author reports no conflict of interests. Mobasher M. 7 J Med Ethics Hist Med. 2021 (Jan); 14: 1. Jo u rn a l o f M e d ica l E th ics a n d H isto ry o f M e d icin e References 1. Muller PS. Teaching and assessing professionalism in medical learners and practicing physicians. Rambam Maimonides Med J. 2015; 6(2): e0011 . 2. Cruss SR, Cruess RL. Teaching professionalism- why, what, and how. Facts Views Vis Obgyn. 2012; 4(4): 259–65. 3. Madani M, Larijani B, Madani E, Ghasemzadeh N. Establishment of medical education upon internalization of virtue ethics: bridging the gap between theory and practice. J Med Ethics Hist Med. 2017; 10: 3. 4. Goldie J. Review of ethics curricula in undergraduate medical education. Med Educ. 2000; 34(2): 108-19 . 5. Parker L, Watts L, Scicluna H. Clinical ethics ward rounds: building on the core curriculum. J Med Ethics. 2012; 38(8): 501-5. 6. Braun V, Clarke V. Using thematic analysis in psychology. 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