USING MOVIES IN FAMILY MEDICINE TEACHING: A REFERENCE TO EURACT EDUCATIONAL AGENDA Zalika KLEMENC KETIŠ1,2,3*, Igor ŠVAB2 1University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska 8, 2000 Maribor, Slovenia 2University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana, Slovenia 3Community Health Centre Ljubljana, Metelkova 9, 1000 Ljubljana, Slovenia Received: Apr 6, 2016 Accepted: Sep 13, 2016 Original scientific article Introduction. Cinemeducation is a teaching method where popular movies or movie clips are used. We aimed to determine whether family physicians’ competencies as listed in the Educational Agenda produced by the European Academy of Teachers in General Practice/Family Medicine (EURACT) can be found in movies, and to propose a template for teaching by these movies. Methods. A group of family medicine teachers provided a list of movies that they would use in cinemeducation. The movies were categorised according to the key family medicine competencies, thus creating a framework of competences, covered by different movies. These key competencies are Primary care management, Person- centred care, Specific problem-solving skills, Comprehensive approach, Community orientation, and Holistic approach. Results. The list consisted of 17 movies. Nine covered primary care management. Person-centred care was covered in 13 movies. Eight movies covered specific problem-solving skills. Comprehensive approach was covered in five movies. Five movies covered community orientation. Holistic approach was covered in five movies. Conclusions. All key family medicine competencies listed in the Educational Agenda can be taught using movies. Our results can serve as a template for teachers on how to use any appropriate movies in family medicine education. Uvod. Cinemeducation je metoda poučevanja z uporabo filmov ali filmskih izsekov. Namen te raziskave je bil oceniti, ali filme lahko uporabimo pri poučevanju družinske medicine na osnovi kompetenc družinske medicine, ki jih je predlagala Evropske akademija učiteljev v družinski medicini (EURACT). Metode. Skupina učiteljev družinske medicine je predlagala seznam filmov, ki bi jih lahko uporabili v poučevanju družinske medicine. Dva učitelja družinske medicine sta filme pregledala in na osnovi vsebine ter prizorov iz filmov za vsak film določila seznam kompetenc družinske medicine, ki se lahko s pomočjo določenega filma učijo. Kompetence družinske medicine so vodenje primarne zdravstvene oskrbe, v osebo usmerjena zdravstvena oskrba, zmožnost reševanja specifičnih problemov, celostni pristop, usmerjenost v skupnost in celovito oblikovanje modelov. Rezultati. Končen seznam je obsegal 17 filmov. Devet jih je zajemalo kompteneco vodenja primarne zdravstvene oskrbe. Kompetenca v osebo usmerjene zdravstvene oskrbe je bila zajeta v 13. filmih. Osem filmov je vsebovalo kompetenco zmožnosti reševanja specifičnih problemov. Celovit pristop je bil zajet v petih filmih, prav tako tudi kompetenca usmerjenosti v skupnost. Celosten pristop je bil zajet v petih filmih. Zaključek. Vse kompetence družinske medicine, ki jih je predlagal EURACT, se lahko učijo tudi s pomočjo filmov. Rezultati te raziskave lahko služijo kot predloga učiteljem družinske medicine glede načina uporabe filmov v izobraževanju iz družinske medicine. ABSTRACT Keywords: family practice, medical education, narration, professional competences IZVLEČEK Ključne besede: družinska medicina, medicinska izobraževanja, narativna medicina, profesionalne kompetence *Corresponding author: Tel: ++ 386 3 896 31 22; E-mail: zalika.klemenc@um.si 10.1515/sjph-2017-0013 Zdr Varst 2017; 56(2): 99-106 UPORABA FILMOV V POUČEVANJU DRUŽINSKE MEDICINE NA OSNOVI KOMPETENC DRUŽINSKE MEDICINE Klemenc Ketiš Z, Švab I. Using movies in family medicine teaching: a reference to EURACT educational agenda. Zdr Varst 2017; 56(2): 99-106 99 © Nacionalni inštitut za javno zdravje, Slovenija. 1 INTRODUCTION Family medicine is a unique medical specialty, which does not only provide clinical care, but predominantly focuses on continuing, comprehensive and holistic care that is person-based (1). Family physician should therefore also possess special skills in order to be able to deliver appropriate care, such as communication skills. The Educational Agenda produced by the European Academy of Teachers in General Practice/Family Medicine (EURACT) (2) has become a standard for developing family medicine curricula in Europe. This document is based on the European Definition of General Practice/Family Medicine (1). The European Definition of General Practice/Family Medicine(1) was developed following the need for an authoritative statement which would define both the discipline of family medicine and the tasks of the family physician, and relate them to the context of the health care system (1). It defines six main competencies of family medicine: primary care management, person-centred care, specific problem-solving skills, comprehensive approach, community orientation and holistic modelling. Primary care management includes the ability to manage primary contact with patients, dealing with unselected problems; to cover the full range of health conditions; to co-ordinate care with other professionals in primary care and with other specialists; to master effective and appropriate care provision and health service utilisation; to monitor, assess and improve quality and safety of care; to make available to the patient the appropriate services within the health care system; and to act as an advocate for the patient. Person-centred care includes the ability to adopt a person-centred approach in dealing with patients and problems in the context of the patient’s circumstances; to develop and apply the general practice consultation, so as to bring about an effective doctor- patient relationship, with respect for the patient’s autonomy; to communicate, set priorities and act in partnership; to promote patient empowerment; and to provide longitudinal continuity of care as determined by the needs of the patient referring to continuing and co- ordinated care management. Comprehensive approach includes the ability to manage multiple complaints and pathologies, both acute and chronic health problems in the individual, simultaneously; to promote health and well- being by applying health promotion and disease prevention strategies appropriately; and to manage and co-ordinate health promotion, prevention, cure, care, palliation and rehabilitation. Community orientation includes the ability to reconcile health needs of individual patients with the community in which they live, in balance with available resources. Holistic approach includes the ability to use a bio-psycho-social model, taking into account cultural and existential dimensions. Based on these competencies that every family physician should possess, the Educational Agenda lists, in broad terms, educational objectives of family medicine at different levels of training (2). Usually, medical education is focused on studying diseases and their clinical management (3-5). Due to straightforwardness and rationality of such topics, they are usually relatively easy to teach using traditional teaching methods. On the other hand, medical education is also trying to teach more complex issues, namely comprehensive care, holistic care, multimorbidity, professionalism, ethical dilemmas, family functioning, communication in different situations, community orientation, etc. This requires adoption not only of knowledge and skills, but often also a change of attitudes of learners (4, 6), where traditional teaching methods are less likely to produce the expected results (6-9). Cinemeducation is a relatively new method of medical education where movies or movie clips are used. In recent years, also television series on medical issues are being used in this context (10). Cinema utilises sight and sound, which enhance learners’ ability of watching and listening. Moreover, movies stimulate discussions and reflections, which is a part of an active learning process (11). Cinemeducation is useful in teaching the bio-psycho-social-spiritual approach (12), especially the areas of communication, palliative care, ethical issues, professionalism, family dynamics and doctor-patient relationship (8, 11-14). This is achieved by engaging students in active learning, which is comparable to learning experienced during the actual consultations with patients (11). Therefore, cinemeducation seems a very useful method of teaching a complex area of family medicine. Nevertheless, there are practically no studies that would go beyond the mere description of the topics and movies (11). The aim of this study was to determine whether family physicians’ competencies as listed in the Educational Agenda produced by the European Academy of Teachers in General Practice/Family Medicine (EURACT) (2), can be found in movies, and to propose a template for teaching by these movies. This exercise could then be repeated by different teachers interested in teaching family medicine by the use of cinemeducation. 2 METHODS We asked a group of 41 family medicine teachers to provide us with a list of movies that they would use in cinemeducation. Movies were defined as recordings of moving images that tell a story and that people watch on a screen or television. We only included fictional and/ or narrative movies and excluded documentaries and 10.1515/sjph-2017-0013 Zdr Varst 2017; 56(2): 99-106 100 10.1515/sjph-2017-0013 Zdr Varst 2017; 56(2): 99-106 101 television series. The latter were excluded because we wanted to ensure homogeneity of the methodology. We used full-length movies, but there were no other requests regarding the content, language, or country of production of the movies. In the next step, the authors independently viewed the suggested movies and wrote a short synopsis of each, in which they described their usefulness for family medicine education. The evaluation was based on the learning outcomes of family medicine education proposed in the Educational Agenda (2). The movies were then categorized according to the key family medicine competencies by both authors independently. In practice, it meant that the authors looked for the scenes or clips of a particular movie that would stimulate the discussion and/or reflection upon at least one competency. Both authors afterwards discussed the findings and came to a mutual agreement. There were no disagreements between authors regarding the categorisation of movies. The selection of movies was finished when the learning outcome of every competence was covered by at least five movies. 3 RESULTS The list consisted of 17 movies. Most of the movies covered more than one key competence. Table 1 shows the list of movies and their categorisation according to competencies. Table 2 shows which competencies were covered by which movies. Table 1. The selected movies according to the category, key family medicine competency and key topic. 4 Months, 3 Weeks and 2 Days (2007, Cristian Mungiu) 50/50 (2011, Jonathan Levine) Amour (2012, Michael Haneke) As Good as It Gets (1997, James L. Brooks) Doc Hollywood (1991, Michael Caton-Jones) Dr. T & the Women (2000, Robert Altman) Once Upon a Time Was I, Veronica (2012, Marcelo Gomez) Hannah and Her Sisters (1996; Woody Allen) The Intouchables (2011, Olivier Nakache & Eric Toledano) Person-centred care Community orientation Person-centred care Specific problem- solving skills Primary care management Holistic approach Person-centred care Community orientation Comprehensive approach Primary care management Person-centred care Specific problem- solving skills Comprehensive approach Primary care management Person-centred care Specific problem- solving skills Comprehensive approach Primary care management Primary care management Specific problem- solving skills Comprehensive approach Holistic approach Person-centred care Community orientation Comprehensive approach Social and cultural dimension The effect of poverty on health care utilisation Understanding the patient’s personality and life aims An approach to patients according to prevalence and incidence of diseases in a community Stroke Holistic concept of care Social and cultural dimension The effect of poverty on health care utilisation Multimorbidity Obsessive-compulsive disorder Coordination of health services’ utilization Continuous management of patients Diagnosis and management of an emergency situation The use of complementary and alternative medicine by patients Common conditions Continuous management of patients Uncertainty in medicine Simultaneous management of acute and chronic conditions Gynaecological disorders Depression, anxiety, somatoform disorders Irrational use of investigations Consultation in family medicine Holistic approach to communication Understanding the patient’s personality and life aims Health care management of patients with special needs Consultation in family medicine Movie (year, director) Movie (year, director) The key family medicine competency The key family medicine competency The key topics in the corresponding competence The key topics in the corresponding competence 10.1515/sjph-2017-0013 Zdr Varst 2017; 56(2): 99-106 102 3.1 Primary Care Management Primary care management was covered in nine movies. They mainly focused on clinical topics or clinical dilemmas, and most of them narrated patients’ experiences and their points of view. Some of them also described the coordination of care. 3.2 Person-Centred Care Person-centred care was covered in 13 movies. Those movies depicted the relationship between the doctor and patient, building a partnership, communication, and continuous management of patients. 3.3 Specific Problem-Solving Skills Specific problem-solving skills were covered in eight movies. The movies portrayed specific techniques and problem solving skills of family physicians. 3.4 Comprehensive Approach Comprehensive approach was covered in five movies. The movies depicted doctors dealing with multiple complaints of a patient, health promotion, prevention and lifestyle issues. 3.5 Community Orientation Community orientation was covered in five movies. The movies in this category described the influence of a disease on a community and family, and vice versa. 3.6 Holistic Approach Holistic approach was covered in five movies. The movies portrayed comprehensive solutions to patients’ problems that needed to include negotiations between biomedical solutions and social and cultural realities. Steel Magnolias (1989, Herbert Ross) What’s Eating Gilbert Grape? (1993, Lasse Hallström) Wit (2001, Mike Nichols) Stopped on Track (2011, Andreas Dresen) The Death of Mr. Lazarescu (2005, Cristi Puiu) The Doctor (1991, Randa Haines) The King’s Speech (2010, Tom Hooper) The Last King of Scotland (2006, Kevin McDonald) Person-centred care Primary care management Comprehensive approach Holistic approach Person-centred care Holistic approach Person-centred care Specific problem- solving skills Person-centred care Comprehensive approach Community orientation Primary care management Specific problem- solving skills Person-centred care Community orientation Specific problem- solving skills Primary care management Holistic approach Person-centred care Person-centred care Specific problem- solving skills Primary care management Holistic approach Understanding the patient’s personality and life aims Diabetes Multimorbidity Holistic approach to communication Family-centred approach Practical approach to holistic care Communication Partnership building Ethics of history taking and clinical examination Patients’ and their families’ understanding of a disease House visit Health care organization and its effect on patients’ management outcomes Epidural haematoma, abdominal pain, alcoholism Coordination of emergency services Diagnosis and management of emergency situation Communication Inequalities in health care provision Step-wise decision-making Cancer Ill physician Person-centred communication Partnership building Social and cultural dimension Communication Partnership building Diagnosis and management of an emergency situation Epilepsy Holistic concept of care Movie (year, director) Movie (year, director) The key family medicine competency The key family medicine competency The key topics in the corresponding competence The key topics in the corresponding competence 10.1515/sjph-2017-0013 Zdr Varst 2017; 56(2): 99-106 Table 1. The selected movies according to the category, key family medicine competency and key topic. Primary are management Person-centred care Specific problem solving skills To manage primary contacts with patients dealing with unselected problems To adopt a person-centred approach in dealing with patients and problems in the context of the patient’s circumstances To relate specific decision making processes to the prevalence and incidence of illness in a community To selectively gather and interpret information from history-taking, physical examination and Investigations, and apply it to an appropriate management plan in collaboration with the patient To develop and apply the general practice consultation, so as to bring about an effective doctor-patient relationship, with respect for the patient’s autonomy To communicate, set priorities and act in partnership To provide longitudinal continuity of care as determined by the needs of the patient, referring to continuing and co-ordinated care management To cover the full range of health conditions To co-ordinate care with other professionals in primary care and with other specialists To master effective and appropriate care provision and health service utilisation To make available to the patient the appropriate services within the health care system To act as an advocate for the patient Doc Hollywood (1991, Michael Caton-Jones) The Last King of Scotland (2006, Kevin McDonald) The Death of Mr. Lazarescu (2005, Cristi Puiu) Once Upon a Time Was I, Veronica (2012, Marcelo Gomez) Steel Magnolias (1989, Herbert Ross) What’s Eating Gilbert Grape? (1993, Lasse Hallström) The Last King of Scotland (2006, Kevin McDonald) 4 Months, 3 Weeks and 2 Days (2007, Cristian Mungiu) 50/50 (2011, Jonathan Levine) Intouchables (2011, Olivier Nakache & Eric Toledano) Stopped on Track (2011, Andreas Dresen) The Doctor (1991, Randa Haines) Dr. T & the Women (2000, Robert Altman) Doc Hollywood (1991, Michael Caton-Jones) The Death of Mr. Lazarescu (2005, Cristi Puiu) Amour (2012, Michael Haneke) The Death of Mr. Lazarescu (2005, Cristi Puiu) Wit (2001, Mike Nichols) Wit (2001, Mike Nichols) Steel Magnolias (1989, Herbert Ross) As Good as It Gets (1997, James L. Brooks) The Doctor (1991, Randa Haines) The King’s Speech (2010, Tom Hooper) 50/50 (2011, Jonathan Levine) Dr. T & the Women (2000, Robert Altman) Doc Hollywood (1991, Michael Caton-Jones) Amour (2012, Michael Haneke) Doc Hollywood (1991, Michael Caton-Jones) The Death of Mr. Lazarescu (2005, Cristi Puiu) Once Upon a Time Was I, Veronica (2012, Marcelo Gomez) Dr. T & the Women (2000, Robert Altman) The Death of Mr. Lazarescu (2005, Cristi Puiu) As Good as It Gets (1997, James L. Brooks) The Doctor (1991, Randa Haines) Once Upon a Time Was I, Veronica (2012, Marcelo Gomez) The Death of Mr. Lazarescu (2005, Cristi Puiu) The main competency Learning outcome Movie (year, director) 103 10.1515/sjph-2017-0013 Zdr Varst 2017; 56(2): 99-106 104 4 DISCUSSION To the best of the authors’ knowledge, no study has dealt with the use of movies in teaching key competencies of family medicine (2) so far. In 2007, an article about using movies to teach Accreditation Council for Graduate Medical Education (ACGME) competencies was published (15). The article gives examples of a movie clip appropriate for teaching each of the six ACGME competencies, namely: Patient care, medical knowledge, practice-based learning and improvement, system-based practice, professionalism and communication (16). The article additionally described proposed methods and content areas in order to create a framework for teaching by cinemeducation. Other articles about cinemeducation already published usually offer a narrative view from an author that had used movies or movie clips in teaching, or in some way report on the feedback from learners engaged in cinemeducation (11). In our study, similarly as in the aforementioned article (15), we used a theoretical framework as a basis for the Specific problem solving skills Comprehensive approach Community orientation Holistic approach To adopt appropriate working principles (e.g., incremental investigation), using time as a tool and to tolerate uncertainty To manage multiple complaints and pathologies, both acute and chronic health problems in the individual, simultaneously To reconcile health needs of individual patients and the community in which they live, in balance with available resources To use a bio-psycho-social model, taking into account cultural and existential dimensions To intervene urgently when necessary To manage conditions which may present early and in an undifferentiated way To make effective and efficient use of diagnostic and therapeutic interventions To promote health and well-being by applying health promotion and disease prevention strategies appropriately To manage and co-ordinate health promotion, prevention, cure, care, palliation and rehabilitation The Doctor (1991, Randa Haines) Dr. T & the Women (2000, Robert Altman) Steel Magnolias (1989, Herbert Ross) As Good as It Gets (1997, James L. Brooks) Doc Hollywood (1991, Michael Caton-Jones) As Good as It Gets (1997, James L. Brooks) The Death of Mr. Lazarescu (2005, Cristi Puiu) Intouchables (2011, Olivier Nakache & Eric Toledano) The Doctor (1991, Randa Haines) 4 Months, 3 Weeks and 2 Days (2007, Cristian Mungiu) The Death of Mr. Lazarescu (2005, Cristi Puiu) Amour (2012, Michael Haneke) What’s Eating Gilbert Grape? (1993, Lasse Hallström) The Last King of Scotland (2006, Kevin McDonald) The Doctor (1991, Randa Haines) Steel Magnolias (1989, Herbert Ross) Doc Hollywood (1991, Michael Caton-Jones) The Last King of Scotland (2006, Kevin McDonald) The Death of Mr. Lazarescu (2005, Cristi Puiu) The Death of Mr. Lazarescu (2005, Cristi Puiu) Dr. T & the Women (2000, Robert Altman) The Doctor (1991, Randa Haines) The Doctor (1991, Randa Haines) Dr. T & the Women (2000, Robert Altman) Hannah and Her Sisters (1996; Woody Allen) Hannah and Her Sisters (1996; Woody Allen) Steel Magnolias (1989, Herbert Ross) Dr. T & the Women (2000, Robert Altman) Stopped on Track (2011, Andreas Dresen) As Good as It Gets (1997, James L. Brooks) Dr. T & the Women (2000, Robert Altman) The main competency Learning outcome Movie (year, director) 10.1515/sjph-2017-0013 Zdr Varst 2017; 56(2): 99-106 105 selection of movies. As we wanted to test the template of EURACT Educational Agenda (2) on the case of education with movies, we used a pragmatic method of selection of movies, based on trainers’ opinions. The aim was not to make a reference list of movies that can be used in family medicine by cinemeducation, but to come up with a framework, which could be useful for teachers in their work. Therefore, many very good movies, widely used in education, were not listed. This study showed that movies can be used in teaching all key family medicine competencies as described by the Educational Agenda (2). Most of the movies included in our study covered more than one family medicine competence. These movies could be very useful in teaching family medicine, as the discipline itself is of a holistic and comprehensive nature. Topics, like family dynamics, holistic perception, comprehensive approach, continuous management of patients and person-centred approach are more difficult to teach when compared to clinical themes (7, 17, 18), and the use of movies could be a good addition to conventional teaching. It is understandable that movies cannot be used for teaching practical skills. However, as our study showed, they can be used to demonstrate their importance or to show the appropriate procedure. Since family medicine is a very comprehensive discipline, it should not be taught by only one method. Our study aims to provide a template of how movies could be fitted into a framework of different teaching techniques of family medicine teaching. Cinemeducation in family medicine can be used in different ways, and traditional classroom setting is probably not the best one. Since a lot of teaching of family medicine is done through a process of mentoring, discussions about movies may be a useful method of encouraging discussions with young learners and elucidating dilemmas of different kinds (19, 20). Teaching with movies gives students enough time to reflect on a situation they have seen, discuss about the problems with a supervisor, and find a solution which could help them were they facing similar problems in actual clinical work (8). It is interesting that we have found no descriptions of such use of cinemeducation. It is possible that the potential use of cinemeducation in teaching family medicine in one-to-one setting has been left to tutors’ beliefs, without the use of a structured tool. The strength of this study is the use of a theoretical framework, such as the Educational Agenda (2). We chose not to perform the systematic search for appropriate movies, as we wanted to produce a model for teaching with movies that are available to teachers. Our list of movies serves only as a model for teaching and not as a proposed list of movies to be used in family medicine teaching. Teachers could use any movie (the content of which is appropriate for family medicine teaching) and employ it for teaching on the basis of EURACT Educational Agenda (2), together with their direction and moderation. The only criterion for the choice of an appropriate movie or movie clip is that it covers the teaching aims and that it stimulates discussion/reflection. Our study has also some limitations. The first one is that only two teachers assessed the movies. Other teachers were only asked to provide a list of movies they thought to be appropriate for cinemeducation. The study would have a greater value if also those teachers provided analyses of suggested movies. Another limitation of the study pertains to the fact that we did not assess the usefulness of the movies for teaching, but were merely concerned with whether they are appropriate for teaching family medicine competencies according to the opinions of the teachers and authors. In addition, this study did not test the usefulness of this model in teaching, as no feedback from the teachers was sought. However, this study was only aimed at determining whether family physicians’ competencies can be found in movies, and proposing a template for teaching by means of these movies. We suggest that further studies assess the usefulness of this approach, and also examine where in the educational process movies could be successfully used. 5 CONCLUSIONS This is the first attempt to use the EURACT teaching agenda to provide a systematic approach with an innovative teaching method. It suggested that cinemeducation can map across the different domains proposed in the Educational agenda, and vice versa. Therefore, any appropriate movie that covers at least one family medicine competence can be used in family medicine teaching. Our results can serve as a template for teachers on how to start selecting appropriate movies in the education of family medicine. Further studies are needed to determine the usefulness of such an approach in teaching and the extent of coverage of different areas of medicine in cinema. CONFLICTS OF INTEREST The authors declare that no conflicts of interest exist. FUNDING The study received no funding. 10.1515/sjph-2017-0013 Zdr Varst 2017; 56(2): 99-106 106 ETHICAL APPROVAL The study did not include any persons, so we did not seek ethical approval. REFERENCES 1. Allen J, Gay B, Crebolder H, Heyrman J, Svab I, Ram P. The European definition of general practice/family medicine. Evans P, editor: Wonca Europe, 2011. 2. Heyrman J. EURACT Educational Agenda. Leuven: European Academy of Teachers in General Practice, 2005. 3. 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