The Arts Dispel Medical Students’ Qualms About Dementia

JAMA


By Rebecca Voelker
April 24, 2019
 

Maybe never before had a rendition of “Take Me Out to the Ball Game” had more meaning for Alyssa Vigliotti. As a first-year student at the Penn State College of Medicine, she launched a research project to evaluate whether a creative storytelling program had benefits for people with dementia. Called TimeSlips, the program uses pictures that prompt participants to create stories about the image.

Or, in this case, break into song.

Vigliotti said one of her favorite moments during the 6 months she collected data was watching people in the program—all with mild to moderate or severe dementia living in a rural Pennsylvania retirement community—react to a picture of a young boy at a baseball stadium. “Randomly, out of the blue, some of the residents started singing…and it was just such a cool experience,” she recalled.

It was one of many moments in which the residents, some who had been rather withdrawn, began to reminisce, concoct new stories, or simply smile. “That’s what made it so exciting and impactful on me,” she added.

Vigliotti’s study reported no significant changes in dementia severity, but it demonstrated some benefits in quality-of-life measures such as interactions with other residents and expressing pleasure. Observing the program “showed me these are real people who still have real thoughts and real memories and can communicate, just in a different way,” she said.

Vigliotti isn’t the only medical student to have had that reaction. Research also shows that TimeSlips and other nonclinical arts-centered programs in medical school curricula can improve students’ attitudes about dementia.

Tackling an Important Issue

As the number of people diagnosed with dementia increases and the search for effective treatments appears stymied, experts said that addressing future physicians’ attitudes has become more pressing.

“[T]here’s been a 99% fail rate with drugs in the field,” said Daniel George, PhD, a Penn State College of Medicine assistant professor who teaches fourth-year medical students how to conduct TimeSlips sessions. “[T]hat gives us an imperative to think creatively and think in different ways about what it means to care for people with memory loss.”

George said students have told him they feared that they wouldn’t be able to connect with people who have dementia and that it would be challenging to work with them. Students also worried that they would say the wrong thing or have an epithet shouted at them.

“They had a whole host of assumptions and fears that they were nursing,” George said. However, those fears weren’t realized. Once they got involved with TimeSlips, “I was seeing a dramatic attitude shift in the way my students regarded people with dementia,” George said.

He collected data to validate that observation. His 2013 study in Academic Medicine measured 22 fourth-year medical students’ attitudes toward people with dementia living in a Pennsylvania retirement community. After 8 sessions, students’ scores improved in 19 of 20 items on the Dementia Attitudes Scale (DAS); 12 of the 19 were significant improvements.

“In almost every case and every student I’ve ever had, [their views] shifted dramatically,” George said.

No Longer a Fly on the Museum Wall

In 2008, as a behavioral neurology fellow at Columbia University Medical Center in New York City, James Noble, MD, attended programs for people with dementia and their caregivers at the Metropolitan Museum of Art and the Museum of Modern Art.

“I was curious to understand how art was expressed by those experiencing dementia,” and whether that phenomenon could be measured, he recalled. As he observed from the corner of the room, a facilitator told him to join in. “[B]eing a fly on the wall was not an acceptable role,” Noble said. “I didn’t forget that moment.”

He was given a seat and a brush. Painting alongside those with dementia and their caregivers “was absolutely revelatory,” Noble said. “[T]here were aha moments where a patient would say something quite profound in the reflection of the art they made.”

Two years later, he launched what’s now called Arts & Minds, which runs programs for people with dementia and their caregivers at the Studio Museum in Harlem, the Met, and several other sites. Although they don’t have specific sessions for medical student participation, the programs served as research sites for one of Noble’s students. Hannah Roberts, MD, now a resident physician in the Harvard Radiation Oncology Program, invited 19 of her classmates to participate in the gallery discussions and artwork sessions while she evaluated whether it changed their perceptions of people with dementia.

Each student in Roberts’ study attended one 90-minute museum program. Using the DAS, Roberts also found significant improvements in how her classmates perceived people with dementia after taking part in the program. “This fits into a paradigm of experiential learning,” Noble said.

That’s something with which he’s familiar. As a student at the Emory University School of Medicine in Atlanta, Noble attended Alcoholics Anonymous meetings and visited a halfway house for people who were recently discharged from inpatient psychiatric facilities. “We had to write about it—write poems about it—and really reflect on our experiences,” he said.

Today, poetry programs have become more widespread for people with dementia. Can they also affect medical students’ attitudes? To find out, investigators at the Rowan University School of Osteopathic Medicine in Stratford, New Jersey, studied students’ perceptions about dementia after they participated in a poetry workshop with assisted living facility residents.

After a single 3½-hour program, the investigators found significant improvements in attitudes toward people with dementia among the 11 students who participated. The students said they were surprised at a nonbiomedical approach’s effectiveness and that they were more likely to use the words hope, creativity, and humanness to describe people with dementia.

In fact, a couple of the students said they could see ways to adapt workshop techniques for patients with dementia that they may treat in the future. “I think that I would be able to do some of that in the office if patients were willing to do it with me,” one of the students said after the workshop.

Failure-Free Art

In 2007, Elizabeth Lokon, PhD, was working on a graduate degree in gerontological studies at Miami University in Oxford, Ohio. Her thesis devised a program that combined her background in fine arts and education with gerontology—a fruitful trio. “When I finished in 2008, they hired me to design and implement the program” at Miami, said Lokon, the founder and director of Opening Minds Through Art (OMA).

Through OMA, students and people with dementia work together to produce failure-free art. “Every piece is abstract,” Lokon said. It’s all about the discovery process of creating art rather than an expectation of what the final product should look like. Individuals with dementia determine the aesthetic and students assist by washing brushes or helping with various materials used during the program. “Students are taught how to give autonomy back to the elder,” Lokon noted.

In a study that used the DAS to evaluate 156 Miami undergraduate students who participated in OMA, Lokon and her colleagues found that their attitudes toward and comfort level with people who have dementia improved significantly after a semester’s worth of weekly meetings.

Not all the Miami students who participate in OMA are in health-related fields, but Lokon is launching pilot programs at 8 medical schools. While planning the pilots, Lokon searched the medical literature for articles about how medical schools teach students to have empathy and compassion for older adults.

“They focus on [healthy] older adults because they believe that exposing medical students to people who are frail and sick and have dementia will strengthen their stereotypes and they become more negative toward aging,” Lokon said.

That notion, she added, flies in the face of what she has seen and documented with Miami students. “Our students actually learn a great deal and become more positive,” she said.

Two of the pilot programs are up and running—one at the University of Toledo College of Medicine and Life Sciences and another at the Ohio University Heritage College of Osteopathic Medicine. Lokon has unpublished data showing that among 22 first- and second-year students at Toledo, the overall DAS score and scores on 10 of the 20 items improved significantly after 1 OMA session.

Afterward, the students wrote about their experiences. One student explained that while it’s necessary to master the scientific concepts of neuronal loss, cortical atrophy, and ventricular changes, it’s also important to understand how disease affects patients’ daily lives. “I was grateful to have the chance to develop my clinical communication skills and learn how to best interact with a dementia patient,” the student wrote.

Another student described working with a woman who was reluctant to participate in the session. Encouraging the woman to join in was “an opportunity to practice patience and compassion toward a patient,” the student wrote. A conversation ensued, the woman began to open up, and together they laughed, painted, and chatted.

“I will always keep this experience close to my heart and will make sure to keep the values that I have learned with me as I continue on my path to becoming a physician,” the student concluded.

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Integrating the Arts Into Medical Education

 

Medical educators and experts in the arts and humanities have joined forces to help medical students approach clinical practice with greater empathy for patients and enhanced critical thinking. Some schools use medical improv courses to help students think on their feet and build skills in communication, listening, and teamwork. Others offer opportunities to analyze fine art as a way of improving students’ visual diagnostic skills.

“It’s really fascinating how diverse the programs are,” said Lisa Howley, PhD, senior director of strategic initiatives in medical education at the Association of American Medical Colleges (AAMC).

The AAMC is currently in the second phase of a 3-part initiative that’s taking an in-depth look at the arts in medical school curricula. Launched in 2017, the first phase consisted of focus groups and listening sessions, followed by a forum in which educators, arts professionals, and students strategized ways to integrate the arts and humanities into medical school curricula.

In the second phase, a research team will spend the next year conducting a scoping review, which examines an issue more broadly than a focused literature review. The team will evaluate how and why arts and humanities programs are being used in medical education. Since the initiative began, Howley said the AAMC has collected a lot of information about programs being conducted in medical schools and teaching hospitals.

“[T]hese [methods] are being used to teach a whole variety of things, from dementia and empathizing with patients to diagnostic reasoning and image interpretation to observation skills, and clinician well-being and resilience in their own practice—connecting back to their joy in medicine,” she said.

The key for medical education, Howley noted, is finding ways to integrate arts and humanities into the curricula. An example is a Harvard Medical School course in which students draw parallels between their analysis of works at the Museum of Fine Arts, Boston, and diagnostic approaches in medicine.

Although it’s focusing on medical education, the AAMC also is interested in hearing from physicians who use the arts to improve patient care—either indirectly as artists to circumvent burnout or directly with patients during office visits. Recently, a physician who’s also a photographer relayed a story from his own practice.

He noticed a patient staring intently at a photograph hanging in the waiting room. When he asked what attracted her to it, she replied that her pain went away when she looked at the photograph. He printed a copy of the photograph and gave it to her to take home.

It may be a single anecdote,a but it shows “that the arts can be used to facilitate conversations, help better understand the patient’s experience, and connect with the patient in a different way,” Howley said. [read more]