Using movies in family medicine teaching: A reference to EURACT Educational Agenda

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 coordinated 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 wellbeing 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.

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 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.

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.

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 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.

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.