Using Visual Arts Education and Reflective Practice to Increase Empathy and Perspective Taking in Medical Students

Educational Objectives

By the end of this activity, learners will be able to:

Introduction

Empathy is a critical competency for health care providers.¹ The beneficial impacts of empathy in the care of patients are well documented.² When patients feel heard and supported, they are more likely to adhere to treatment recommendations, leading to better health outcomes.³ Conversely, emotional detachment has been associated with negative consequences for both patients and health care providers.⁴ Despite the importance of empathy in promoting high-quality patient care,⁵ empathy levels in medical students and residents have paradoxically been shown to decrease during training.^6,7 Contributing factors include emotional exhaustion, poor social support, high workload, and the hidden curriculum of medical training.^6–10

The incorporation of humanities into medical education has been recommended as a means of reducing burnout, increasing tolerance for ambiguity, and enhancing empathy.^11–14 Several medical schools have incorporated visual art instruction, often in collaboration with local art museums. A recent review of such programs found evidence for the development of observation skills but insufficient data to demonstrate that art education for medical students promotes empathy or cultural sensitivity, despite anecdotal reports of such effects.¹⁵

Reflective practices are also increasingly integrated into medical education to cultivate compassion and empathy.^16,17 Reflective exercises have been associated with improved empathy in medical trainees, as measured by self-perception, patient feedback, and third-party observation.¹⁸ Such findings align with Gibbs’ reflective cycle framework, which encourages structured reflection about workplace situations using elements of description, feelings, evaluation, conclusions, and action.¹⁹ While not specific to the medical profession, the reflective cycle provides a conceptual model for reflective practice among medical trainees since reflection on feelings or emotions may improve the capacity for empathy.²⁰ The incorporation of reflective practice with visual art observation is an area of increasing interest in medical education.^21,22

Reflective practice has been recommended as one strategy to address implicit bias in health professions education.²³ Prior work has identified connections among reflective practice, mitigation of implicit bias, and the development of empathy.²⁴ Art education has the potential for fostering reflective practice and enhancing learner awareness of bias, especially when educators intentionally select artworks that highlight bias and pair observation with structured discussion of the artwork to facilitate reflective practice (Appendix A).

To date, there has been only one visual arts education publication in MedEdPORTAL.¹³ Residents who participated in this faculty-led session reported improvement in patient communication skills and in viewing art as a wellness activity. Empathy was not explicitly taught or assessed. Similarly, while some publications cite the connection between art education and improved visual diagnosis,^25,26 educators lack clear guidance on the optimal instructional modalities to promote empathy.^15,27 Given the importance of empathy as a clinical competency and the increasing integration of reflective practice into medical education curricula, medical schools need additional instructional tools to promote empathy.

We developed and implemented an elective for first-year medical students incorporating visual arts instruction and reflective practice, with the goal of enhancing empathy by encouraging learners to improve their visual analysis skills and identify how emotions and biases influence observations. We evaluated the impact of the curriculum using both quantitative and qualitative measurements, including the Interpersonal Reactivity Index (IRI),²⁸ a validated assessment of both cognitive and affective empathy, and a student self-assessment survey. By presenting our pedagogical methods and outcomes here, we hope to provide additional insight into how arts education and reflective practice can be used to promote the cognitive, affective, and communicative aspects of empathy among medical trainees.

Methods

Learners

We offered the Art of the Human Body elective to first-year Baylor College of Medicine (BCM) medical students annually between 2017 and 2022. Over the 4-week course, students met weekly for 2 hours at the Museum of Fine Arts, Houston (MFAH), and were taught by BCM faculty and MFAH learning and interpretation staff.

Curriculum Development

BCM faculty met with MFAH staff to create learning objectives and a course syllabus (Appendix B) with the goal of enhancing students’ visual observation and empathic communication skills. Based on the learning objectives, we developed a series of four sessions. In-person sessions are described in Appendices B and C. Due to pandemic-related restrictions on in-person visits, we developed a virtual version of the course (Appendices D–G) that aligned with our overall course objectives. We adapted some activities to fit the virtual environment and added new ones more conducive to online engagement. During the first session (Appendix D), we provided instruction in visual observation principles, such as noticing color, shape, line, and texture. The second session (Appendix E) allowed students to apply skills in visual observation through drawing exercises. Sessions three (Appendix F) and four (Appendix G) focused on bias and empathy, including didactic content (on the components of empathy—emotional, cognitive, and motivational)²⁹ and art interpretation exercises to facilitate reflective practice and dialogue with other students regarding their perspectives.

Curriculum Implementation

For each session, students met at the museum. Following a brief didactic session, we divided the students into groups and traveled with them to different areas of the museum to view selected works of art (as relevant for the session topic) and to participate in designated session activities. MFAH staff and BCM faculty co-led the session activities, including small-group discussions, drawing exercises, and large-group debriefings. Faculty used facilitation techniques to encourage students to share their perspectives and to make connections to clinical practice and their own professional identities. Overall, we designed the curriculum to provide multiple opportunities for students to develop observation and communication skills, reflect on ambiguity, identify biases, and recognize empathic responses as they observed and interpreted works of art.

Notably, we transitioned the course to an online format in 2021 due to the COVID-19 pandemic. We conducted the reflection and discussion aspects of each course session virtually using Zoom conferencing technology.

Evaluation

Grading for the elective was pass-fail, based on mandatory attendance. To assess changes in empathy, students voluntarily completed the IRI (Appendix H) in the first and final classes and a student self-assessment survey (Appendix I) following the final class. Evaluation methods were approved by the BCM Institutional Review Board.

The IRI—a validated questionnaire measuring four components of empathy: perspective taking, fantasy, empathic concern, and personal distress³⁰—had 28 questions, seven per subscale. Questions were scored on a 5-point Likert scale (0 = does not describe me well, 4 = describes me very well). Subscale scores for each empathy component were obtained by summing the points of the respective questions.

The IRI's subscales allowed investigators to measure cognitive empathy (perspective taking and fantasy) separately from affective empathy (empathic concern and personal distress). Perspective taking measured the “tendency to spontaneously adopt the psychological point of view of others” while fantasy assessed students’ “tendencies to transpose themselves imaginatively into the feelings and actions of fictitious characters.”²⁸ Empathic concern quantified “other-oriented feelings of sympathy and concern for unfortunate others.”²⁸ Personal distress assessed “self-oriented feelings of personal anxiety and unease in tense interpersonal settings.”²⁸

The student self-assessment survey included two sections. The first consisted of a questionnaire using a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree) to score three statements about how well the course addressed empathy, raised awareness of biases, and offered strategies to deal with ambiguity. The second section solicited free-text responses to questions related to empathy.

Data Analysis

Single-factor analysis of variance tests showed no statistically significant difference within the pretest and posttest scores on the IRI from the different years’ cohorts, which allowed us to pool the data from the 5 years and use a paired, two-tailed t test to compare the combined pretest and posttest data. Given that the IRI tested four separate components of empathy, Bonferroni corrections were applied, setting statistical significance set at p < .0125 rather than .05.

We analyzed the Likert-scale data from the student self-assessment survey using descriptive statistics, while the qualitative data were analyzed using thematic content analysis. Three independent coders read the transcripts and coded them using a tentative coding scheme.³¹ After reviewing the initial data, we revised the coding scheme with newly discovered categories and recoded the transcripts to confirm interrater agreement. Finally, we analyzed the coded data for identification of themes that emerged as significant to the students as a group.

Results

A total of 128 students enrolled in the course from 2017 to 2022. Due to the pandemic, we did not offer the course in 2020. Thus, between 2017 and 2022, we offered the course five times. Of those enrolled, 89 completed the IRI for a response rate of 70% (Table 1). Incomplete surveys were excluded. The pretests and posttests were pooled across the 5 years, and IRI subscale scores were compared before and after taking the art course (Figure 1). There was no statistically significant change in the fantasy, empathic concern, and personal distress subscales. Perspective taking, however, had a statistically significant mean increase from 19.0 (SD = 4.3) to 20.2 (SD = 4.5), t(88) = 2.61, p < .0125.

Table 1. Completed Pre/Post Intervention Interpersonal Reactivity Index Surveys 2017–2022

The student self-assessment survey had a completion rate of 100% in 2017, 66% in 2018, 96% in 2019, and 90% in 2021. Overall, student feedback was very positive. All three surveyed fields (empathy, bias, and ambiguity) received at least 80% positive scores (5–7 on the Likert scale) each year (Figure 2). The percentage of strongly agree responses (score of 7) increased each year for all three categories, suggesting that the course may have become more effective at achieving its goals and objectives as it matured.

Thematic Analysis

Analysis of qualitative comments revealed insights into the value of observation, development of empathy, awareness of bias, and pedagogical approaches that students found most helpful for reaching their medical and nonmedical goals, as summarized below and in Table 2.

Table 2. Sample Student Comments From the Student Self-Assessment Survey

Students across all years noted that observation was a critical skill that could be consciously improved through facilitated experiences in art interpretation and drawing exercises, particularly uninterrupted contour drawing. Through observation, students learned to recognize situational ambiguity and the need for further inquiry. The effectiveness of taking time to closely observe art also served as a reminder to slow down when observing patients. Holistic observation required taking time, trying on different perspectives, and avoiding hasty conclusions. When describing how they might use empathy in clinical situations, students noted that taking time to closely reflect and observe would likely lead to more empathic responses to the feelings of others.

The theme of bias emerged as a barrier to perspective taking and empathy. Students observed that bias involved adhering too closely to their first impressions or assumptions. Some students saw bias as a personal failing that precluded learning the actual story. Others noted that focused observation or awareness of others’ perspectives could mitigate bias and that overcoming bias involved awareness of one's own assumptions and consideration of alternative viewpoints through communication. Small-group discussions aided understanding of bias and awareness of alternative perspectives. Other students valued the experience of learning to appreciate art and saw any effect on empathy or bias as an indirect benefit.

In 2021, the course briefly shifted to the virtual environment. Educators used videoconferences and virtual whiteboards to create interactive spaces online. Students were asked to comment on the benefits and limitations of the virtual versus in-person experience. They appreciated the ability to search online for information during the session and having more access to artworks. The technology allowed them to change perspectives (e.g., zooming in on an artwork) that would not be possible in person. However, they found that viewing the artwork through a computer screen limited their ability to appreciate different dimensions, particularly the texture of the artworks, and their ability to experience the artworks’ presence. They also noted a lack of freedom to wander around and absorb the atmosphere of the museum. Group discussions came less naturally and were not as engaging as students had anticipated. In-person classes resumed in 2022.

Discussion

We designed this elective to help medical students improve visual observation skills and use reflective practice to identify implicit biases that can affect those observations as a means to improve empathy. The curriculum development drew from existing literature regarding art education to improve observation skills and the use of reflective practice to promote empathy. Curriculum development was enhanced by a collaboration between art education experts at MFAH and BCM faculty trained in clinical medicine and humanities and ethics. The curriculum was designed to engage students with multiple learning styles and preferences; for instance, activities included individual drawing practices and reading assignments, think-pair-share exercises (working with one other student), and small- and large-group discussions. The prompts for reflective practice were also designed to promote thinking about bias and to foster consideration of diverse perspectives. Notably, our curriculum explicitly included instruction in empathy, including defining and distinguishing emotional, cognitive, and motivational empathy. This direct focus on teaching and evaluation of empathy distinguishes our approach from other medical school art education tools available in the literature.

Another unique element of our curricular intervention was the use of the IRI as an evaluation tool, so that we could better understand the impact of the curriculum upon the cultivation of empathy. We found a significant improvement in perspective taking, one of the four subcomponents of empathy. Students’ responses on the student self-assessment survey showed four common themes: (1) observation skills could be improved, (2) close observation and awareness of different perspectives improved empathy, (3) bias was a barrier to empathy, and (4) overcoming bias involved awareness of one's own assumptions and consideration of alternative viewpoints. These themes correspond closely with the increase in perspective taking measured by the IRI.

While medical students often are drawn to humanities-based learning opportunities, they also feel compelled to constantly build clinically relevant skills. We found it challenging to deliver clinically relevant content without diluting the intrinsic value of being exposed to the arts and humanities and sharing these experiences with peers. We struggled to balance making explicit connections to medicine for students to consider and allowing them to make these connections on their own. Ultimately, we found that using reflective practice as part of our pedagogy provided a useful framework for developing clinically relevant skills like visual observation, awareness of bias, and empathetic communication as well as less clinically relevant skills like art appreciation and wellness behaviors.

Our curricular design and evaluation approaches have several limitations. Since the elective was offered only to first-year students in the spring semester, it is unclear whether our model will lead to greater improvement in traits like empathy over the long term. Next, although we used standardized educational methods, the museum's art collections rotated, which may have introduced variation in students’ experiences across iterations of the course. In addition, our curriculum involved a museum–medical school partnership, which may not be widely available. While there is no substitute for subject matter expertise, medical school faculty with art backgrounds may still find this resource helpful in developing strategies for teaching and evaluation of arts education to cultivate empathy. For instance, if collaboration with museum educators is not feasible, medical school faculty can adapt our instructional approach using a virtual museum environment, engaging learners in observation and reflection based on viewing works of art available online.

In terms of our evaluation approach, there are a few additional limitations. First, students self-selected into this elective, and several noted prior exposure to humanities courses. Selection bias may have attenuated the IRI results. The use of pre- and postcourse assessments may have mitigated this impact; however, students who electively enrolled in the art course may have responded more positively to art education than others in their class. Second, we were not able to assess all learning objectives—namely, we did not directly evaluate students’ skills in visual analysis. Rather, we prioritized assessment of skills related to bias and empathy since the connection between art education and improved skills in visual analysis was already well established. Finally, although we only noted a statistically significant change in IRI scores on perspective taking, our relatively small sample size may have been underpowered to appreciate differences in the other subscales. These challenges are similar to those other institutions have faced by primarily relying on single-institution enrollment with small cohorts lacking controls.

Throughout the implementation of this educational initiative, there were several lessons learned that may prove valuable to other educators. Although the instructional methods can be implemented in the absence of a museum collaboration, we found the collaboration with MFAH to be highly beneficial for curriculum development and refinement. For instance, the art educators helped to select works of art that would stimulate conversation regarding bias and diverse perspectives. The collaboration was also fruitful in ensuring that learners appreciated the clinical relevance of arts and humanities education. Some student feedback indicated that including multiple types of learning activities—ranging from individual to large group—helped to maximize learner engagement across a variety of learning styles. We also found it useful to engage learners across multiple sessions (rather than in a single encounter). Although not directly measured, we suspect this approach helped to encourage open discussions as students developed more comfort in sharing reflections with their peers. Although the course was adaptable to a virtual learning environment, learner evaluations suggested a preference for the richness of in-person sessions.

Moving forward, we aim to use visual observation and reflective practice to situate conversations about racial disparities in medicine, in keeping with national efforts to expand diversity, equity, and inclusion initiatives across medical education. For example, we plan to facilitate discussions of empathy and bias using modern art produced by members of historically marginalized populations. Additionally, we hope to incorporate our pedagogical approach longitudinally so that all medical students have a chance to practice these skills. We aim to integrate artistic representations of organ systems, anatomy, and pathophysiology into relevant sections of the medical school curriculum to stimulate thinking about cultural representations of the human body.

In summary, the Art of the Human Body elective was associated with improvement in the perspective-taking component of empathy as measured by a validated assessment tool (the IRI). Our methodologies, including both active learning pedagogies as applied to art observation and reflective practice with consideration of bias, ambiguity, and multiple perspectives in relation to art interpretation and clinical experience, should prove useful to other medical educators interested in adopting these tools for their own curricula.