Introduction

Research suggests that exposure to the humanities during medical training is successful in developing humane doctors (​1, ​2, ​3). The Medical Humanities Group (MHG) of the University College of Medical Sciences (UCMS), Delhi, has been using a variety of humanities tools to explore health and illness from multiple perspectives (​4, ​5). Over the years, our experience, which includes networking with other institutions, led us to develop the attitude, behaviour, communication, diversity, ethics and empathy (ABCDE) paradigm (​5). The ABCDE is an integrated, interdisciplinary medical humanities (MH) approach to the development of appropriate analytical and attitudinal skills, ethical and professional behaviour, effective communication, respect for diversity, and empathy in medical students. We use the theatre of the oppressed (TO), reflective student narratives, disability studies, film, literature, street theatre, performing arts, creative writing, poetry and graphic medicine, among other humanities tools, to hone the ABCDE attributes of medical students.

Having heard of our engagement with MH, the Jorhat Medical College in Assam invited the MHG of the UCMS to collaborate with it and facilitate the establishment of an MH movement in Jorhat. We document our experience with a workshop format and analyse its effectiveness in bringing about change through the use of Kirkpatrick’s model of training evaluation (​6).

Methods

Members of the host institution ​– Jorhat Medical College (JMC), Assam ​– were invited to volunteer. Twenty-eight students and faculty members, with a self-professed curiosity/interest in the medical humanities, did so. The institutional review board of the host institution waived ethical clearance and the participants gave informed consent for the publication of the data provided by them. A month before the onsite workshop, they joined a closed Google group created for online learning.

The online component

A large component of what we seek to do is to build an understanding of how one experiences others (​7). For people to understand each other, it was important for them to overcome communication barriers. The online component was designed specifically to include several ice-breaking exercises, which were conducted in a closed Google group to ensure a safe learning environment. To initiate change in the ABCDE attributes of the learners, we gradually introduced them to various humanities tools, as follows.

The participants were requested to watch Rashomon ​– the famous 1951 Japanese language movie ​– with English subtitles, and then reflect in writing on how they felt after watching it. This movie was chosen because it is recognised as a valuable depiction of the need to respect diverse viewpoints, which are shaped by human experiences and conditioning. The Japanese language version was chosen to demonstrate linguistic diversity.

In addition, to prepare the participants to write narratives, they were introduced to publications in the medical humanities from the online journal of the MHG, UCMS (Research and Humanities in Medical Education; www.rhime.in). Thereafter, they were asked to write and submit reflective narratives on the doctor​–patient interactions they had experienced.

A literary cluster highlighting issues of ethics and professionalism, and comprising medical biographies, poems, graphic narratives on disability and the end of life, and a newspaper cutting of an incident report were shared with the participants. They were requested to read and reflect upon the material. Every experience was scheduled for debrief during the onsite workshop.

Finally, the participants were advised to form three groups for the art/culture component of the workshop, the events of which would be performed by them onsite, in Jorhat. The first group called itself Itihaas (history) and volunteered to stage cultural events on the inaugural evening; Sanskriti (culture) would stage cultural events on day 2 (the first day of the workshop); and the third group chose to convert the college corridors into a “Humanities Lane”, where they would display the art works and poetry of the students and faculty members.

The onsite component

The essence of MH is “reflective practice”. We exposed the participants to Augusto Boal’s TO, which is a powerful tool specifically designed to promote reflection (​7). To this end, the initial part of the workshop consisted of a series of exercises that were intense, interactive, and designed to promote trust and deep reflection in a safe working environment. The exercises were interspersed with debrief sessions to discuss learning from Rashomon, from the narratives submitted, and from the literary cluster.

As a part of the TO, the participants learned to identify themes and stories of immediate and pressing relevance to themselves and their community: stories which presented ethical and existential dilemmas that had lingered in their memories as unfinished business, or stories with unsatisfactory endings, or disturbing, undesirable outcomes.

After one-and-a-half days of exercises, the participants worked in five groups. Each participant shared a personal experience of oppression with the others, following which each group chose one story which they thought best represented their feelings at that time. These five stories, each 5​–10 minutes long, were rehearsed by the respective groups over the next few hours in preparation for Forum Theatre. During rehearsals, it was noticed that the participants were the most animated and natural when delivering their dialogues in the Assamese language. As an experiment, since we had hitherto always performed Forum Theatre in the English language with a smattering of Hindi, we advised the participants to enact their plays using whichever language they felt the most comfortable in ​– Assamese, English or Hindi. Even though we knew no Assamese, we anticipated that the spoken language would be rendered redundant for us in the presence of theatrical body language.

After appropriate rehearsals, the five stories were enacted by the respective groups. The performances were “open to all” from the community in what is called “Forum Theatre” (​7, ​8). The spectators chose one story with which they identified the most strongly; the one they wished to explore further. In this manner, beginning with 28 stories, five were presented, out of which one was chosen by the audience for the Forum.

The Forum Theatre was facilitated by a “Joker” ​– the TO term for the facilitator (​7). The theatre performances were in Assamese, with Hindi and English being used on occasion. Since the Joker (NS) did not know Assamese, one of the authors, a local Assamese-speaking faculty member (PB), offered to interpret if necessary.

Data collection and analysis

The authors collected the participants’ feedback relating to the movie and their feedback on their experience with TO, and took stock of their reflections on the workshop overall. To gauge the effectiveness of the workshop, the reflective narratives submitted by the participants were analysed from the perspective of the ABCDE paradigm (​5), while feedback data were analysed using Kirkpatrick’s model of training evaluation (​6).

Results

The participants included 16 students (14 undergraduates, 1 intern, 1 postgraduate) and 12 faculty members.

Results pertaining to the online activities of the workshop

Rashomon ​– the movie
During the online phase, all participants watched Rashomon together. Nine of them submitted feedback on their feelings after having watched the movie (5 students, 3 faculty members and 1 postgraduate student). The details of the feedback are given in the annexure.

Essentially, the movie was successful in evoking emotions, predominantly those of hope, and promoting an understanding of power equations. It prompted reflection on the issues of gender discrimination, cultural diversity, communication, and biases and prejudices, as well as on the need for respect and trust in interpersonal relationships. The participants demonstrated critical, creative thinking, and reported an understanding of others’ perspectives and of imagined realities.

Reflective narratives
Six reflective narratives pertaining to doctor​–patient interactions were submitted by five students. Thematic analysis of the narratives demonstrated that they highlighted issues, both positive and negative, related to the domains of professionalism, ethical behaviour, communication, empathy and reflective practice (see Annexure).

Art and culture
The three groups created during the online phase were successful in displaying the art and culture of the region. The first group, Itihaas, portrayed the rich history of Assam’s tribal culture through song, dance, drama and instrumental performances. Sanskriti, the second group, took a more contemporary route, presenting tribal dances, folk and classical music, modern art forms, and a ramp walk by participants from the faculty in diverse tribal costumes. The third group took charge of the “Humanities Lane”, which was a long corridor in the college. It had a large array of paintings, photographs, poems and prose on display; these had been contributed by the students and staff members of Jorhat Medical College. The three groups not only showed an interest in and showcased their talent with respect to things outside the medical curriculum, but also displayed a commitment to the humanities, despite their busy academic schedules. The events were evocative and had a strong focus on the appreciation of diversity ​– cultural, linguistic and artistic.

The literary cluster
To round off the online phase, a debrief was conducted onsite. During this, the participants discussed the literary cluster. The discussion was enriching. The participants felt that the use of poetry and graphics was an especially powerful way to examine and to teach empathy and ethics. Further, they were of the view that studying the history of medicine was helpful in finding inspiring role models, and also taught one which errors one should avoid for one’s conduct to be professional.

Results pertaining to onsite activities

As mentioned in the methods, the initial part of the onsite workshop consisted of TO and started with a series of interactive exercises designed to promote trust. The exercises pertained to feeling what we touch (restructuring muscular relations), listening to what we hear, dynamising several senses, seeing what we look at, and memory of the senses (​7).

The participants shared stories about oppression that they had experienced personally and five of these stories were chosen for Forum Theatre. These were as follows.

1. Kolite Moroha Xopoon (a dream nipped in the bud): This story is about an enthusiastic medical student who is humiliated in class by her “insecure” teacher for being too eager to respond to his questions. As a result, she withdraws into a shell and becomes unwilling to be involved in her studies.
2. “Helplessness”: This story pertains to a junior doctor’s feeling of oppression in the work environment. She is evicted from her job for being overtly ethical by refusing to order unnecessary investigations for a patient just to increase the hospital’s income.
3. “Xiya”: This depicts the travails of a student, Xiya, who is compelled by her parents to attend coaching classes for medical entrance examinations. Her tutor makes sexual advances to her and she is unable to talk to anyone about her plight. Since the tutor’s coaching classes are highly reputed, Xiya finds herself unable to escape from her circumstances.
4. “Crisis”: The story portrays a busy emergency department in a crowded hospital. A patient in a life-threatening situation needs the immediate attention of the doctors, who are already overworked. A patient who has a minor injury, and happens to have political connections, loudly and persistently demands that she be attended to first. All the while, she threatens to use her political patronage to have the doctors dismissed from their jobs.
5. “Disowned”: This story is about a pregnant patient who is brought to hospital by her husband and mother-in-law. During testing, it is discovered that she is HIV-positive. The story details how she is disowned and abandoned by her husband and mother-in-law, adding to the responsibilities of the already overburdened doctors.

During Forum Theatre, the stories were enacted one by one before an audience of between 150 and 200 people, who consisted of students, medical faculty members, nurses and anyone who chose to come. The use of the local language lent an air of authenticity to the performances. After a while, translation was redundant because the actors’ body language was so powerful that they rendered speech superfluous. The spectators were asked to choose one of the five stories for the Forum. By a show of hands, the majority opted for “Xiya”.

The spectators were introduced to the concept of Forum Theatre: “Xiya” would be performed again, and anyone from among the audience could stop it at any time by raising a hand and calling out “Stop!” If nobody stopped the play, it would be performed again until someone did. This was meant to demonstrate that, as in real life, unless the oppressor is challenged, the cycle of oppression continues unabated.

The interceptor would be invited to replace the oppressed person and act out the rest of the scene to show how he/she would have changed the script, and thus, the outcome. In TO parlance, the interceptor is called a “spect-actor” (​7). In a Forum performance, when a spect-actor makes an intervention, the oppressors also modify their reactions to counter the new challenges posed by the spect-actor. As often happens in real life, when challenged, the oppression becomes worse. It is axiomatic that in Forum Theatre, it is not possible to replace or change the oppressor.

The ice was broken by the first spect-actor, ironically a male, who wished to replace the protagonist’s mother. Boal describes having encountered a similar situation at a Forum performance in Italy, much to the annoyance of the women in the audience, who felt that no man could understand what it is like to be a woman (​7). In our case, once the idea caught on there was a veritable deluge of spect-actors wishing to try their hand at being Xiya and handling her predicament in their own way. The actors also got worked up enough to deny all solutions by stepping up the oppression. After about two hours of heated Forum Theatre, the process had to be called to an end because it was getting late into the night.

Unexpected results of the workshop
This was, one, a logo designed by the participants (Figure 1), and the other, a newsletter that celebrated their contribution toward developing a medical humanities culture at the institution. The logo is representative of the melding of medicine with the humanities. Appropriately, the maxim is Ars Medicina ​– or the art of healing. The Rod of Asclepius, the historical symbol of the staff carried by ancient physicians, is thought to signify the support that medicine can offer one who is ailing. In this logo, the rod has been replaced by a musical instrument ​– the tanpura ​– an Indian drone instrument with a rich sound. It does not play melody, instead providing a harmonic drone that supports other instruments. Figuratively, then, it is very much like the rod in its supportive role, but also signifies art and music. The snake ​– symbolic of rejuvenation and of sickness and death ​– is coiled around the long neck of the tanpura while a human form plays the instrument. The human appears as one with the snake, the artists perhaps hinting at the inseparableness of health and sickness; life and death; medicine and the humanities.

The inaugural issue of the newsletter showcased interpretations of the term medical humanities and the participants’ expectations from the workshop. Anticipation was high. As a student wrote in the newsletter, “I would say that MH is the ‘Art surrounding Medical Science’. The day after an extensive Google research on the meaning of MH, I woke as if to a new world. MH was everywhere . . . in my friend who had taken a detour to help this old patient pay her bills, in the attendant who was praying in the corner of our ward, in the story of syphilis that our teacher told us, in the doodle on the bench [where] I sat, in the film that we watched [a] few days back. I was surrounded by MH.”

Discussion

While the entire experience ​– both online and onsite ​– was enjoyable and hugely educative for the authors, it also served to bring about a change in the participants. Nineteen participants returned feedback forms in the week following the workshop (response rate 68%; see annexure). The participants examined their own attitudes and behaviour, communicated with their bodies (non-verbal communication), demonstrated and experienced diversity, and were able to appreciate issues related to ethics and professionalism. It would appear that a workshop of this nature, with a mix of TO, art, literature, reflective narratives, movies, history of medicine, graphic medicine, poetry and diversity studies, can be used to discuss and initiate change in the ABCDE attributes of medical professionals.

Using Kirkpatrick’s model of training evaluation and on the basis of the feedback received, the workshop achieved level 1 to a high degree (level 1 ​– reaction: the participants found the workshop relevant and engaging), level 2 to some degree (level 2 ​– learning: the participants acquired an understanding of and skills pertaining to ABCDE), and level 3 to a limited degree (level 3 ​– behaviour: the participants have begun to apply in practice all that they learned during the workshop). We feel that the participants need more opportunities and more time for level 4 to be achieved (level 4 ​– results: the achievement of targeted outcomes that can be attributed to the workshop and to institutional support and accountability).

Our learning from the experience
Pre-workshop asynchronous learning is a good ice-breaker and allows the participants to bond with the resource faculty much faster when they finally meet. Language is no barrier to a workshop such as this one as it depends heavily on non-verbal communication. We feel that the workshop could be extended by at least half a day to accommodate more of Forum Theatre because this would give the participants more time to own and hone their plays.

A limitation of this exercise was that the participants selected themselves for the workshop, indicating that they were highly motivated. Moreover, the workshop was conducted in Jorhat, the cultural capital of Assam, where the participants were more likely to demonstrate an appreciation of theatre and cultural diversity. Our model of workshop may not work as well in other circumstances, eg when participation is made mandatory or when the workshop is conducted in other parts of the country.

The way forward
The participants have succeeded in spreading word of MH through the circulation of their newsletter. Their newly formed MHG has met several times, and some members report that they have used TO exercises and narrative writings in their work. Many new members have joined the MHG. The reflective narratives submitted by the student participants, along with commentaries by experts on the issues raised in the narratives, have been published as “Disarming Dialogues: Ethics and Professionalism” (​9, ​10, ​11, ​12). Three of the student participants presented their humanities work at the Association for Medical Humanities Conference, London, in July 2016 (​13).

Conclusion

The participants were exposed to various humanities tools, including the Theatre of the Oppressed, reflective student narratives, disability studies, the performing arts, creative writing, poetry and graphic medicine. Not only did they participate in the change, they also collaborated in it by contributing reflective narratives, performing arts, visual arts, and Forum Theatre. Their active involvement, facilitated by the experiential design of the workshop, transformed them from mere spectators to spect-actors. The workshop and TO helped to sensitise participants to methods that could be used for understanding problems integral to medical practice The current format of our MH workshop seems to be successful in initiating change across the ABCDE paradigm. The participants felt they had been transformed. In their own words, “. . . it was like being introduced to a part of me that I was unaware of. So familiar, yet so different.”

Competing interests: None

Funding support: The workshop was funded by the Jorhat Medical College, Jorhat, Assam.

This article or similar work has not been submitted for publication elsewhere.

Supplementary materials
The newsletter of the Jorhat Medical College is open-access and is available at: http://medicaleducationunit.yolasite.com/resources/JMC%20Newletter.pdf

Annexure

Exemplary quotes from participant feedback

1. After watching the movie, Rashomon:
• The predominant emotions evoked by the movie were those of hope and power:

“But all we know is, when the storm ends, the rain stops and the sky clears, no matter how much damage has been done, we survive!”

“. . . I feel that a presenter [composer/writer/speaker] can actually influence the other person by the strength of his words and the way he communicates with the listener.”

• The movie prompted reflection:

“. . . I believe the audience was potrayed as the listener in the movie. We, just like him, have prejudices and notions and are always jumping to conclusions. We are judgemental and we like pretending that we know everything when we actually don’t.”

“Another message this movie gives us is that we should not believe what we hear from others or others claim to have seen with their own eyes. Because the truth may be something quite different to what the narrator might say.”

“At the end of 88 minutes, I ended up loathing the woman. I feel that she was the reason behind the entire crime tragedy. She was cunning and misleading, and yet portrayed herself to be a ‘victim’. All the stories (except her own) proved that she was not a lady I would trust or respect.”

• The participants noticed issues of gender discrimination and cultural diversity:

“. . . story of the woman portrays how helpless a woman could be and how important to a husband the ‘shame’ of his wife could be.”

“The component of the oppression of women and helplessness that prevailed then was well projected through all the narrations.”

“The one constant theme throughout the movie is the inferiority of womenfolk, their sorry plight and the need for approval of the male gender to survive in society.”

“Perhaps the calling of spirits was an accepted notion in 1950 in Japan.”

• Participants demonstrated critical, creative thinking:

“The use of words pertaining to colour ​– like ‘blue’ attire . . . and ‘red’ (somewhere in the first story) ​– is astonishing as the director must have known that it was a black-and-white movie. . .”

• There was learning:

“I learned that people need to learn how to interpret things in a different manner rather than believing the obvious explanation ​– which may not be true ​– and then communicate it to others so that they can see the merit in it.”

“. . .need to learn or rather cultivate the habit of interpreting things in a broader way, just as we do differential diagnosis, since these are the traits that we will be carrying forward in the years to come and also teaching our younger generations, to become a better human being rather than just ‘a good doctor’.”

2. Themes identified in the participants’ reflective narratives, with relevant excerpts:
• Professionalism: “Both the baby and the mother were in a bad condition and Ma’am called the husband and explained everything to him, seeking his consent for caesarean section.”
• Ethical behaviour: “The professor asked me to demonstrate that a femoral neck fracture is the most tender in and around the mid-inguinal point. I am no saint but when it comes to choosing between learning and not hurting my patient, I tend to choose the latter even at the cost of not learning at times.”
• Communication: “The old man was back with some postoperative infection that he had acquired. He held my hand, looked at his wife and said, ‘This is the girl I was talking about!’ His wife smiled, her eyes glowing. She told me that all these days back home, he had been talking about me, telling his granddaughters to be like me!”
• Empathy: “That evening I didn’t go for evening tea with my friends. I took up a pile of paperwork, which everyone loathed, and sat with it. I cried quietly in a corner. I didn’t know if I felt sad or angry that she had died needlessly.”
• Reflection: “So, I decided to be more than what I was. I was determined to stand up, to stand up and take it! I told myself, ‘Let them tear everything down, we will rebuild! People don’t decide what I do! I am my own guardian, my own peacemaker. All I need to be is a bigger and a better person.'”
3. Feedback received from 19 participants (response rate 68%) after the workshop
1. Which game/exercise did you like the most and why?
• Glass Cobra: n=11 (built faith, nothing is impossible, calm in the face of a storm, focus, self-dependence, felt euphoric when I connected, bonding, self-discovery, discovery, felt like a child, individuals contribute to the team)
• Gravity exercise: n=4 (detachment, we shall overcome, unencumbered)
• Carnival in Rio: n=3 (gravitate towards positivity)
• Image theatre: n=2 (expressing self, non-verbal communication)
2. What did you think of Forum Theatre?
• Helped in playing a different character
• Spect-actor becomes a part of the theatre
• Develops power of persuasion
• Oppressed needs to bring change
• How combined effort can pave the way forward
• Opens up the mind
• A trigger to give an outlet to oppressed self
• Taught me to notice unnoticed processes
• Learnt how a situation can be perceived differently by different people
• Got rid of my inhibitions
• There are multiple solutions to a single problem
• Can reform many personal, social, real-life problems and maintain equity among individuals
• I could feel the agony of an oppressed human being, the struggle of helplessness and the urge to “let it go”, but FT taught me to resist oppression
• It is not about the situation but how we face and negotiate the event
4. Excerpts from participants’ reflections that demonstrate components of the ABCDE paradigm

Attitude
“Understanding (of MH) helps us step down from the ‘god-like’ image and become more human, and thus establish a better connection to the humanity of the patient.”

Behaviour
“TO games like Columbian hypnosis, and those in which we were asked to ensure that the opponent never lost, helped us discover how our oppressive behaviour affects patients and how we ought to behave to make the burden light.”

Communication skills
“It was immensely enjoyable to witness our teachers and seniors break out of their cocoon of inhibition and participate with us. The kids within us were set free to communicate.”

Respect for diversity
“I have a strong urge to look for every possible perspective of any situation I come across . . .as if ‘Rashomon’ was a replay of our own lives!”

Empathy
“. . .medicine teaches us detachment over empathy. It is a double-edged sword. In a profession where empathy might cloud judgment regarding patient care, one must learn to empathise within the boundaries of detachment. It is the only way to proper patient care.”