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Palliative care and the arts: vehicles to introduce medical students to patient-centred decision-making… Centeno, Carlos; Robinson, Carole; Noguera-Tejedor, Antonio; Arantzamendi, María; Echarri, Fernando; Pereira, José Dec 16, 2017

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RESEARCH ARTICLE Open AccessPalliative care and the arts: vehicles tointroduce medical students to patient-centred decision-making and the art ofcaringCarlos Centeno1,2,3, Carole Robinson4, Antonio Noguera-Tejedor1,2,3* , María Arantzamendi2,3,Fernando Echarri5 and José Pereira6,7AbstractBackground: Medical Schools are challenged to improve palliative care education and to find ways to introduceand nurture attitudes and behaviours such as empathy, patient-centred care and wholistic care. This paperdescribes the curriculum and evaluation results of a unique course centred on palliative care decision-making butaimed at introducing these other important competencies as well.Methods: The 20 h-long optional course, presented in an art museum, combined different learning methods,including reflections on art, case studies, didactic sessions, personal experiences of faculty, reflective trigger videosand group discussions. A mixed methods approach was used to evaluate the course, including a) a post-coursereflective exercise; b) a standardized evaluation form used by the University for all courses; and c) a focus group.Results: Twenty students (2nd to 6th years) participated. The course was rated highly by the students. Theirunderstanding of palliative care changed and misconceptions were dispelled. They came to appreciate themultifaceted nature of decision-making in the palliative care setting and the need to individualize care plans.Moreover, the course resulted in a re-conceptualization of relationships with patients and families, as well as theirrole as future physicians.Conclusions: Palliative care decision-making therefore, augmented by the visual arts, can serve as a vehicle to addressseveral competencies, including the introduction of competencies related to being patient-centred and empathic.Keywords: Medical education, Palliative care, ArtsBackgroundThe practice of medicine requires more than inter-viewing and examining a patient, ordering appropriateinvestigations, making the right diagnosis and initiat-ing a treatment plan. While these skills are essentialas is knowledge of sciences such as anatomy, pharma-cology, and biochemistry, they are insufficient tomake an excellent clinician.These skills need to be augmented by a set of attri-butes, attitudes and behaviours that differentiate a medi-ocre or even good doctor from an excellent one. Beingempathic, patient-centred, compassionate, humble andrespectful are essential components of being a wholephysician able to provide wholistic care.Medical Schools are challenged to find ways tocatalyze and nurture these attributes and behaviours.The task is made even more challenging given evidencethat altruism and empathy decline over the course ofmedical school and specialty training [1, 2]. Increasingcynicism and detachment may partly account for thisand hidden curricula that do not make these attributes* Correspondence: anoguera@unav.es1Faculty of Medicine, University of Navarra, Pamplona, Navarra, Spain2ATLANTES Research Programme, Institute for Culture and Society, Universityof Navarra, Edificio Bibliotecas, Campus Universitario, 31009 Pamplona, SpainFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Centeno et al. BMC Medical Education  (2017) 17:257 DOI 10.1186/s12909-017-1098-6explicit and valued across the whole medical school or resi-dency learning experience aggravate the problem [3, 4].A number of strategies and initiatives to reverse thisand to strengthen patient-centredness, empathy, com-passion and whole-person care amongst medical stu-dents and residents (registrars) have been reported. TheHarvard University in Boston, for example, implementedan undergraduate curriculum that was designed toheighten humanitarianism [5]. Zazulak and colleaguesused an arts-based programme to nurture the affectiveand cognitive components of empathic development [6].The University of Navarra in Spain values the attri-butes of empathy, compassion and caring that enhanceshuman dignity and is striving to make these overtthroughout its medical curricula. It is also working tostrengthen the palliative care (PC) related content inthose curricula given the emergence of Palliative careeducation as a priority area in medical undergraduateand postgraduate education [7–9]. A recent WorldHealth Organization (WHO) recommendation, for ex-amples, states that basic training in PC should be inte-grated as a routine element of all undergraduate medicaleducation [10].With these priorities in mind, the University ofNavarra has been seeking appealing ways to engage itslearners in these areas. We posit that palliative care pro-vides an excellent platform and vehicle to nurture em-pathy, compassion, patient-centredness and wholeperson care. By its very definition and practice, thepatient is viewed as a unique individual and person. Itrequires considering where the patient is coming fromand what the patient and his family and loved ones areexperiencing. This is particularly true during thedecision-making process where many different factorsneed to be considered Two patients with advanced dis-ease and with the same diagnosis and burden of diseasemay make very different decisions when faced with acomplication such as pneumonia or deciding on whetherto pursue third- or fourth-line chemotherapy.Moreover, palliative care also provides a platform tosupport other important competencies such asinterprofessionalism, communication, and sensitivityto different cultures, and religious and spiritual needsand viewpoints.In 2005 The University of Navarra in Pamplona, Spain,started integrating palliative care in its six-year medicalschool curriculum by way of an optional course in the6th year. In 2011 the course was made compulsory forall students in their sixth (clinical) year [11]. While theserepresented good initial steps, a need was identified tocomplement the final-year course with an introductionto palliative care and the related competencies its sup-ports (particularly empathy, patient-centeredness anddecision-making) earlier in the curriculum, including thepre-clinical years. This paper describes a pilot coursethat used palliative care, end-of-life decision-making andthe arts to introduce medical students earlier to wholis-tic patient care. This piece is part of the ATLANTES Re-search Program of the Institute for Culture and Society(ICS) of the University of Navarra, where the message ofPalliative Care is researched with a focus from the hu-manities and social sciences.MethodsThe intervention: CurriculumThe curriculum team (CC, JP, AN and MA) felt that thevisual arts warranted exploration as a potential catalystfor some of the learning objectives, particularly those re-lated to keeping an open mind, self-awareness and ap-preciating the different perspectives that make everysituation and patient experience unique [6, 12–15].A decision was therefore made to host the course inthe University’s new modern art museum. In addition tothe artwork, the gallery offered a quiet, reflective ambi-ence and an architecture that underscored how the samething may look very different from different viewing an-gles. Each day started with a thirty to forty minute- longintroduction to pre-selected artworks (paintings, photo-graphs, sculptures or stand-alone displays) by a gallerycurator. Students and faculty were asked to reflect onwhat they saw in each piece and what it represented forthem, and what their emotional responses to each workwere. A facilitated large group discussion followed. Fac-ulty provided clinical examples from their own work ex-periences that connected these discussions with real lifeto underscore the clinical relevance of the exercise.After this daily reflection, learners made their way to amuseum classroom. Several learning methods were usedin the classroom, including case-based small and largegroup discussions and didactic overviews of the topics athand. Faculty members were specifically tasked to sharetheir real-life stories and examples. Short trigger videoshighlighting an issue or communication scenario werealso used. These included trigger Snippets and Doo-dles from Pallium Canada and material from PalliumCanada’s Learning Essential Approaches to PalliativeCare (LEAP) courseware. The course program is sum-marized in Table 1.An interprofessional faculty team made up of doctors,a nurse, a sociologist, and a psychologist/ethicist) wasdeliberately chosen so as to model interprofessional col-laboration and the different perspectives that each pro-fessional brings and how these various perspectives andcompetencies contribute to wholistic care.To connect the course with their other 2nd-yeartopics, opportunities were also sought to highlight therelevance of their other current topics in the decision-making process. These included pharmacology (e.g.Centeno et al. BMC Medical Education  (2017) 17:257 Page 2 of 10mechanism of action and metabolism), anatomy (e.g.pain pathways) and biochemistry (e.g. inflammatory me-diators and cachexia).Given the unique nature of the course and the need tofirst test the concept before broader implementation, itwas decided that it would be an optional course thatwould be presented after the end of the academic yearto volunteers who were interested and available; classeswere held in the evening from 4 pm to 7 pm. The teamrecognized that this approach would likely result in therecruitment of a highly motivated, self-selected group oflearners.Although the course was first intended for 2nd-yearstudents, students in other years also expressed interest.This presented a design challenge as various learningneeds had to be accommodated. The experiences of themore senior students (5th and 6th Years), particularlytheir observations and their clinical experiences, wereharnessed and they were encouraged to share these dur-ing the course. They were also asked to respond to someof the junior students’ questions related to pharmacol-ogy and pathophysiology, thereby providing opportun-ities for them to review these and also to start serving asrole models to their junior colleagues.The course was presented within the school’s Inter-national Stream in which courses, particularly in thepre-clinical years, are presented in English. The studentsreceive 3 ECTS credits for the course.Evaluation frameworkA mixed methods approach was used to evaluate thelearning experience, its impact and the various methodsused in course. This consisted of a) a reflective exercisein which students were invited to write short responsesto three open-ended questions/topics (See Table 2); b) astandardized form used by the University for students toevaluate all the courses they attend (made up largely of aLikert-type 0 to 5 point scales); and c) a focus group(voluntary) of students. Faculty also did a debriefingexercise to share their thoughts and experiences. Par-ticipation in b), and c) required students to sign aninformed consent.We were curious about whether having the course inthe museum and integrating art made a difference to thelearning experience. Since this had not been previouslyassessed, all students were invited to participate in aone-hour focus group, eight months later, to explore thisquestion led by a researcher who was not involved in thecourse design and its delivery (CR). Eight students par-ticipated and all agreed to have the focus group video-recorded. In addition, four students spontaneously com-mented on the usefulness of art in their written re-sponses to the questions above.Data analysisThe students’ written responses were in English (9) andSpanish (11). In order to fully understand the Spanishresponses and inform analysis, one of the authors (AN)made a culturally appropriate translation with CR.The open-ended questions and focus group data wereanalysed using constant comparison to develop an inter-pretive description (Thorne method) [16]. This is an in-ductive analytic approach designed to create ways ofunderstanding clinical and learning phenomena thatyield relevant practical knowledge. The identified themesare presented including pertinent quotes.The responses to the quantitative survey (standardizedcourse evaluation) were analysed and compared to othercourses in the curriculum. Student identifiers wereremoved from the written submissions to ensureanonymity.The evaluation component of the course receivedapproval from the Research Ethic Committee of theTable 1 The Course ProgrammeDAY HOURS TopicsPart 1 Part 2 Part 3Day 1 3 h • Introductions and Course OrientationReflections on museum art works• The Illness Experience • Defining Palliative CareDay 2 3 h • Reflections on museum art works • Suffering• Decision-making frameworks and ethical issues• Hydration at the End of Life• Nutrition at the End of LifeDay 3 3 h • Reflections on museum art works • Dignity & hope• Empathy• Principles of Pain Management• Psychological and Spiritual/Religious CareDay 4 3 h • Reflections on museum art works • Being Aware: connecting with our feelings,viewpoints and biases• Respiratory Symptoms• Delirium• Last days and hoursDay 5 3 h • Reflections on museum art works • Society and Death and Dying • Desire for deathDay 6 2 h • An Introduction to Essential conversations (videos) • Post course reflection and courseevaluationCenteno et al. BMC Medical Education  (2017) 17:257 Page 3 of 10University of Navarra (project 120/2015). Students wereinformed of the study and those interested in participat-ing signed consent. Lack of consent to participate in theevaluation component did not disqualify them from par-ticipating in the course.ResultsA total of 20 medical students (aged 18 to 22 years)participated in the course; 8 were in the 2nd year, 2in the 3rd year, 3 in the 4th year, 6 in the 5th year,and 1 in the 6th year of study. Nineteen were women.All completed the standardized evaluation of thecourse provided by the Faculty. Eight accepted the in-vitation for the focus group, conducted 6 monthsafter the course.Standardized course evaluationThe results of the standardized course evaluation by thelearners are summarized in Table 3. Students confirmedthe relevance of the course content (mean 5/5) and thecourse was rated very positively across a number of pa-rameters. The course also received high scores relativeto other courses that year.Interpretive description of the students’ written and focusgroup responsesWhat did the students learn and how will this influencetheir practice?The students wrote in English (9) or Spanish (11). Theirresponses reflect changes in thinking, feeling, and doing.Their responses were remarkably consistent across the20 students.Prior to the course, the students shared the generalsocietal misconception that PC is end-of-life care andinvolves relatively straightforward, protocol-drivenpharmacological treatment of symptoms. Some evenequated PC with euthanasia.Students identified quality of life as central to pal-liative care; “a way of improving the patient’s life” inalignment with patient and family wishes and bestwhen initiated early in the course of chronic illness.They came to appreciate that palliative care is notjust about end-of- life care. Students expressed aheightened appreciation of the value and role of pal-liative care and its applications in medicine in gen-eral. One student, for example, commented “Palliative[care] should be a close attitude towards life.” In fact,they viewed palliative care as a way to enhance well-being in the context of serious illness.The students saw palliative care as assisting wholis-tic, multi-dimensional person-focused care. Theycame to realize that it can occur alongside treatmentsto control or even cure life threatening illnesses. Thiswas “new news” for some who viewed palliative careas passive rather than active and marked an import-ant shift in perspective away from the idea that whenthere are no further disease altering treatments “noth-ing more can be done.”They came to understand that promoting patient well-being through palliative care includes preserving hopeand dignity. Palliative care values “not only (patients´)physical needs but also their needs as people made up ofmany different dimensions.”The students highlighted the importance of seeingthings through the eyes of the patient and family, which,in their view, requires compassion, listening and dialogue.Table 2 Reflection questions for students post courseCenteno et al. BMC Medical Education  (2017) 17:257 Page 4 of 10I will [engage] them more; not just about their condi-tion and about possible treatment options but aboutwhat they’re feeling, their inner motivations and howthey think I could care for them better. Generally to in-volve myself more in the human aspect of their care.It’s about reasoning…maybe for one patient you chooseone thing and for another patient who might be in asimilar position but who has other things in their life youmight decide something else. So you have to think specif-ically in each case what you would do and you have toreason in each of the cases.Students were able to see the reciprocity between theirown humanity and the humanity of their patients.We live in a rush and we work non-stop, patients be-come cases and thereby we become machines. So beforethis could happen I will always keep in mind the fact oflistening. I have learnt that many times [it] is more use-ful than any anatomy book. The ability of listening givesus humanity and we get closer to the patient and so tothe illness course.Listen to patients in a reflexive and active manner,with great empathy for them to feel accompanied. It isvery important in medical practice and it will make usgrow not only as physicians but also as human beings.Further, they now saw listening as a therapeutic inter-vention in and of itself. Students indicated enhanced ac-ceptance that, in the complex world of living whiledying, there may be times that they do not know whatto say and that “simply listening” may be the very bestthing one can do for the patient.The course successfully challenged the notion thatthere is a formulaic, straightforward decision-makingprocess in palliative care (e.g., several students com-mented specifically about this as it relates to artificialhydration and nutrition at end of life). Instead, it in-volves individualized, personalized solutions to prob-lems that are uniquely defined by the particularcircumstances, values, and desires of both patient andfamily, which may be different. Decision-making wasunderstood to be more ambiguous than the studentsrealized; taking into account multiple factors, and per-spectives that requires the physician to engage in dia-logue and reflection from a position of self-awareness.They became aware that there may be no clear rightand wrong answers.I’ll consciously try to be more self-aware because dur-ing the course…I’ve realized that the way I originallythought of prospective patients and what I would do inTable 3 Evaluation of the Palliative Care Decision Making course and comparisons with other courses offered the same year(Original survey is in Spanish; 0 to 5 scales are used- the higher the score the more positive the evaluation positive)COURSE This course (Palliative CareDecision Making)Other optionalcoursesAll subjects Facultyof MedicineSurveys received (total asked) Respone ratio (%) 20 (20) 100% 139 (212) 65% 6.409 (11.758) 54%Mean (*) Mean (*) Mean (*)The classes were well prepared 4,6 4,7 4,1Recommended literature and other materials were useful 4,4 4,0 3,5The faculty roused our interest in the course. 4,9 4,6 3,5Active participation by students was encouraged 5,0 4,6 3,4The faculty used appropriate learning methods 4,6 4,6 3,8The course learning objectives were clear. 4,6 4,3 3,7The Faculty were open to addressingquestions. 5,0 4,8 4,1The Faculty was professional with the learners. 5,0 4,9 4,3The evaluation criteria of the course were clear. 3,4 4,1 3,7The evaluation criteria were appropriate. 4,1 4,3 3,6The faculty enhanced my learning. 5,0 4,7 3,7In this course I learned things that are valuable for my university education 5,0 4,6 3,9The method of teaching/facilitating enhanced my my attendance in the course. 5,0 4,5 3,4The learning activities have helped me improve otherskills (such as oral and written communication skills,teamwork, use of information,and critical appraisal).4,9 4,4 3,2Overall, I am very satisfied with the course [as alearning experience]4,9 4,6 3,5Overall total 4,7 4,5 3,7(*) Only means are shown as only aggregate data (no original data) were provided to the course team; secondary analysis was not possible. For brevity, not allítems are shown but all ítems that scored less than other courses are shownCenteno et al. BMC Medical Education  (2017) 17:257 Page 5 of 10different situations…differs from what I would wish frommy [caregivers] if I were in the same position.We stop being good physicians when we start treatingthe patient as a room number or as a research object. Agood physician must know the patient as a person.Many students applied what they learned to practicingmedicine in general – not just practicing palliative care.They saw palliative care as applicable to all physicians.As physicians we must be advisors and companions inthe way of the illness of our patients.Students indicated that listening and dialogue werepractices that enable better understanding of patientand family values, wishes, and decisions, which sup-ports the physician to make better decisions. Studentsgained appreciation of the value of multiple perspec-tives, exemplified in a team approach. In particularthey remarked on the importance of asking for helpand of having an “open-mind.” They saw teamwork ascritical to best care and decision-making. As one stu-dent noted:When taking a decision, no matter the importance thatit can have for me, always consult with the group ofpeople I will be working with, but also with the familyand the patient [himself].The course invited many students to reconsider theirideas about the practice of medicine, and the role of thephysician. For example, one student remarked on the“power of information” and the importance of “not opt[-ing] for the easiest solutions because I am afraid ofspeaking truthfully with the patient.” Other studentscommented on their new appreciation of the importanceof getting close to patients and families rather than prac-ticing from a distance through the lens of disease andproblems. The shift in perspective is further illustratedin another student’s ideas about death.We are taught to be doctors to save lives so it is normalto think of death as a failure but I just realized thateveryone dies, earlier or not, so I should stop seeing pa-tients like machines to [be] fix[ed] and start seeing pa-tients like persons who deserve a better way of life.Another student noted that much can be done whendisease oriented treatment is no longer effective butcomfort in the dying process is the focus.Previously, before attending the palliative carecourse, I thought that this was a very sad specialty.Now it seems to me that it can be a very gratifyingway of life – to help people in the most importantmoment of their lives.What difference (if any) did it make to have the course inthe museum and to integrate art?There were multiple aspects of how this course wastaught that created an excellent learning experiencefrom the students’ perspective. It was taught in adifferent building than “where you take exams.” Thebuilding, a museum, was spacious and offered freedomto think and move. It helped them “think in a differentway; feel in a different way.” The timing of the coursewas June, outside the usual timetable, which again of-fered students time to prioritize this learning, and timeto think. The students believed that, had it been offeredduring regular class time alongside all the other coursesthey needed to learn, it would have suffered because itwould not have been a priority.Students from across various years of the medical pro-gram joined to take the course. While this was a bit “in-timidating” for the first-year students, they endorsed thisapproach because they learned so much from their class-mates. They also appreciated early introduction of pallia-tive care in their learning.The way the course was taught was completely differ-ent than the theoretical approach taken in other classes.This class was practical and case based; requiring under-standing and reasoning prior to decision making.The students were clear that integrating art in thelearning experience assisted them in one of two ways.For some students, art directly influenced their learning;whereas, for others, it was the discussion about the artthat was influential. The students believed it enabledthem to both see and appreciate the validity and useful-ness of multiple perspectives and the importance of ob-servation. Students who found the art directly helpfulexplained it this way:I also liked the way the teacher tried to compare apicture that they just explained to us, and tried tocompare that to the real patient or the situation inthat moment. So for me it was really useful trying toimagine that picture and trying to comparing withthat situation.I think that to be a good physician you have to be verysensitive to what happens around you and that art helpsto see and promote that sensitivity; to be aware of thingsthat are happening around you.Another student experienced art as a way of connect-ing with and understanding self.There were different rooms of art, there’s one abstractand there’s another one where there’s mountains down-stairs. I made different connections with myself. I like go-ing to mountains, for me it’s different, the emotions I feltwere quite different seeing the different pieces of art.Art also offered a different way of knowing, feelingand expressing than can be captured in words, mirroringthe practice of PC.We have learned the necessity of reflecting about in-trinsic questions of the human being. For example, dig-nity and hope. In the process of expressing ourselves inthe museum in the art, it became clear that words aloneare not able to express things fully.Centeno et al. BMC Medical Education  (2017) 17:257 Page 6 of 10In addition, art enabled the growth of the human be-ing who was becoming a physician.Also I think as a doctor, as a student, we shouldknow about art, we should know about literature, wehave to learn about everything. This is a good way tolearn art in my opinion.Other students did not find the art helpful. But thediscussion about the art provided a unique learning op-portunity. It enabled empathy and facilitated opennessto multiple perspectives.I can’t really see what other people might see. But forme what was more important was to try and understandwhat other people see and how they see it. And try to getinto someone else’s head because it’s not all the same foreveryone. I see the red picture and that’s it. And if some-one else says, ‘I feel whatever when I see that picture,’ Ithink about it and I try to understand why they see thatand where they are coming from.I don’t know anything about art but I like that we hadto put on the other’s shoes. I think that every doctorshould put on the patient’s shoes. So I like that relation.Finally, the students offered ideas about how to makethis course even better. They appreciated the smallgroup setting and the intimacy of the discussions. Theywould have liked to get to know one another better atthe beginning of the course, and to engage in deeper dis-cussion in even smaller groups, sitting in a circle, on thesame level, seeing each other’s faces.In summary, the students deeply appreciated the co-herence of the learning experience, which aligned withthe nature of palliative care. It was a learning experiencethat engaged them as whole persons learning to care au-thentically with and for whole persons in the vulnerablesituation of advanced illness.DiscussionThis course, in addition to introducing medical studentsfrom different years to the principles of palliative care,also exposed them to essential attitudes and behavioursthat contribute to wholistic, shared control, patient-centred care [17]. The students learned about palliativeand end-of-life care, about themselves, and about howthey would like to practice in general. Their understand-ing of palliative care changed and misconceptions weredispelled. They came to understand that palliative care isnot restricted to the end-of-life (terminal) phase of ill-ness, that it represents active care and that it can bedone alongside treatments to control or cure the disease.They came to appreciate the multifaceted nature ofdecision-making in the palliative care setting and theneed to individualize care plans. Palliative care thereforeserved as a vehicle to address several competencies, notonly those related to caring for persons with life threat-ening illnesses.Moreover, the course resulted in a re-conceptualizationof relationships with patients and families, as well asthe role of the physician in palliative and end of lifecare decision-making. For some, there was a broaderreconceptualization of the practice of medicine and agreater appreciation of the components that contrib-ute to empathy, where empathy refers to one’s abilityto experience the feelings, thoughts, viewpoints andvalues of another [6]. Arts (performing, literary andvisual) and the humanities have previously been in-cluded, alongside other approaches such as narrativereflections, in methods to introduce and nurture em-pathy in medical education [18–20].The use of the visual arts for teaching palliative care isstill an uncharted territory. Turton et al. in a recentscoping review described that visual arts, employed as amethod for training palliative care professionals, im-proves the awareness of others, personal developmentand self-awareness [21]. Our study was not designed toassess the specific contribution of the arts relative to theother course components. There is however evidencefrom our course that the use of the visual arts and thesetting (in modern art museum) enhanced the learningexperience for many of the students. In particular, stu-dents came to realize that the same piece of art could beseen and interpreted in different ways by different indi-viduals. Harnessing the arts and humanities to facilitatepalliative care education has previously been reported[12–14, 22]. Johnson and Jackson, for example, have de-scribed the contributions of the arts and humanities asteaching and learning strategies to support palliative careeducation [14]. Lawton and McKie reported a staff sem-inar programme that used art and literature as vehiclesto explore personal and professional dimensions of pal-liative care [12]. A variety of media, including the visualarts, were used to facilitate learners’ expressions of theirlearning reflections [12].Benefits of incorporating the arts and humanities ingeneral medical education have been reported. They can,it has been argued, facilitate the acquisition of a varietyof competencies that range from empathy and culturalsensitivity to clinical observation and diagnostic skills[23–30]. Zazuluk et al. paired family medicine residentswith an art educator and a family physician and requiredthe residents to undertake reflective practice exerciseswith the goal of improving empathy amongst thelearners as well as enhancing their observational skills[18]. Schaff and colleagues explain that art interpretationand daily clinical work share some similarities such asthe importance of observation, multiple interpretations,ambiguity, collaboration between observers and direc-tion to action [31].Debate continues as to the evidence for incorporatingthe arts and humanities in medical education. OusagerCenteno et al. BMC Medical Education  (2017) 17:257 Page 7 of 10and Johannessen, for example, have posited that, basedon their systematic review, evidence on the positivelong-term impacts of integrating humanities into under-graduate medical education is sparse [32]. This, they goon to say, “may pose a threat to the continued develop-ment of humanities-related activities in undergraduatemedical education in the context of current demands forevidence to demonstrate educational effectiveness.” Bel-ling, on the other hand, contended “the value of the hu-manities in educating new physicians can be defendedby demonstrating the need for more complex ap-proaches to knowledge than complete dependence onempirical evidence” [33].This course used a combination of approaches toachieve the learning objectives. These included the visualarts, case studies, stories (narratives by faculty), reflectivetrigger videos, group discussions and an interactive openmilieu. While learners specifically reported the impact ofincorporating the arts and the uniqueness of the setting,the evaluation framework used was not designed to sys-tematically tease out the relative and specific contribu-tions of each of the different methods. The course andits impact on learners therefore need to be viewed col-lectively as a package of different approaches.Several limitations are acknowledged, particularly withrespect to the generalizability of the course design.Firstly, the students were a group of highly motivated,self-identified group of individuals; they volunteered toparticipate outside their usual class-time. They wereopen to the experience and the learning methods, in-cluding the arts, used. Secondly, the course was deliv-ered outside the academic year during the beginning ofsummer holidays. It can therefore be argued that it maybe difficult to incorporate such a class in an already fullcurriculum during normal academic hours.Given the relatively small number of learners, wewere not able to compare the experiences of studentswho are in the pre-clinical years versus those in theclinical years. The impact of experiential learning withpatients to augment this course merits future atten-tion. The imbalance between female and male stu-dents can be largely explained by that fact that in theuniversity of Navarre, between 70 and 80% of medicalstudents are currently women.Strategies could be developed to incorporate thiscourse in the second or third years. With 180 stu-dents per year in the Faculty of Medicine at the Uni-versity of Navarra, it is feasible to hold the coursefour or five times a year during the academic year (inthe evenings), thereby maintaining the intimacy andreflective learning potentials of small learning in thisunique setting (modern art museum). More opportun-ities should be sought to incorporate palliative careeducation and nurturing wholistic, patient-centredand empathic care throughout the six-year curricu-lum. While the arts are not for everyone, as was re-ported by some of the students who participated inthis pilot course, even these students recognized thatit opened their minds and perspectives.This course could be adapted for an interprofessionalaudience. It would require some redesigning so that itaddreses the competences that are common to all par-ticipating professions while also addresing the compe-tencies that are unique to each of the professions.Learning these topics has the capacity of enhancing teamwork.ConclusionsIn this pilot course of 20 h delivered to medical studentsfrom the second to the sixth years of medicine, studentslearned about palliative and end of life care, about them-selves, and about how they would like to practice in gen-eral. Their understanding of palliative care changed andmisconceptions were dispelled. As a main learning ob-jective, they came to appreciate the multifaceted natureof decision-making in the palliative care setting and theneed to individualize care plans. Moreover, the courseresulted in a re-conceptualization of relationships withpatients and families, as well as their role as future phy-sicians. Palliative care decision-making therefore, aug-mented by the visual arts, can serve as a vehicle toaddress several competencies, including those related tobeing patient-centred, empathic and wholistic in the ap-proach to care. These can be incorporated and re-emphasized longitudinally across the whole medical cur-riculum, from the pre-clinical to the clinical years ofmedical school, and beyond into specialization pro-grams. The specific contributions of the different learn-ing methods used in this course, including the arts,needs further study.AbbreviationsAN: Antonio Noguera; CC: Carlos Centeno; CR: Carole Robinson;ECTS: European Credit Transfer and Accumulation System; ICS: Institute ofCulture and Society (ICS); JP: Jose Pereira; LEAP: Learning EssentialApproaches to Palliative Care; MA: Maria Arantzamendi; PC: Palliative Care;WHO: World Health OrganizationAcknowledgementsThis research has been possible thanks to the help and availability of theUniversity of Navarre Museum tour guides, which focus their art knowledgeon the medical students necessities.FundingNo direct funding’ s been received to complete this research. CC, AN andMA work as researchers in the Institute of Culture and Society; JP and CR arevisiting research fellows and their stays were supported by the Institute. FEworks as education director at University of Navarre Museum.Availability of data and materialsData is available from the authors upon request.Centeno et al. BMC Medical Education  (2017) 17:257 Page 8 of 10Authors’ contributionsCC has contributed to course design, study design, information analysis, andwrote the paper. CR has contributed to study design, information analysis,wrote results and revised the draft. AN has contributed to study design,information analysis, wrote discussion and revised the draft. MA has contributedto study design, information analysis, wrote methods, and revised the draft. FEhas contributed to course design, and revised the draft. JP has contributed tocourse design, and revised the draft contributing with important topics andadding new insights. All authors read and approved the final manuscript.Authors’ informationCC is the director of the Palliative Care Unit at University de Navarre Clinicand is the director of the Atlantes Research Program of the Institute ofCulture and Society, University of Navarre. This institute promotes research issocial sciences. Atlantes program is about Medical Humanities and PalliativeCare, and is focus on Palliative Care development, Intangibles (values andessence) in Palliative Care, Palliative Care’s message, and Palliative Care andMedical Education.CR is nurse professor at British Columbia University, and as an expert inqualitative research, supports this research approach in Atlantes program.AN works as palliative care physician in University of Navarre Clinic at and asresearcher in Atlantes program, specifically in medical education andpalliative care research.MA is a research nurse that works as a researcher in the Institute of Cultureand Society, Atlantes Program, investigating the core values and the essenceof Palliative Care (Intangibles).FE is the director of the education unit of the University of Navarre Museum.JP is a palliative care physician and professor in the Division of PalliativeMedicine, Department of Family Medicine, McMaster University. He has leadthe development of Learning Essential Approaches To Palliative and End-of-Life Care (LEAP). He collaborates with Atlantes program supporting palliativecare education research line.Ethics approval and consent to participateThe evaluation component of the course received approval from theResearch Ethic Committee of the University of Navarra (project 120/2015).Students were informed of the study and those interested in participatingsigned consent. Lack of consent to participate in the evaluation componentdid not disqualify them from participating in the course.Consent for publicationNot applicable.Competing interestThe authors declare that they have no competing interest. There isn’t anynon-financial competing interest to declare.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Faculty of Medicine, University of Navarra, Pamplona, Navarra, Spain.2ATLANTES Research Programme, Institute for Culture and Society, Universityof Navarra, Edificio Bibliotecas, Campus Universitario, 31009 Pamplona, Spain.3IdiSNA, Pamplona, Spain. 4Faculty of Health and Social Development, Schoolof Nursing, University of British Columbia, Okanagan, Vancouver, Canada.5Area Educational, University of Navarra Museum, Pamplona, Navarra, Spain.6Department of Family Medicine, University of Ottawa, Hamilton, Canada.7Division of Palliative Medicine, Department of Family Medicine, McMasterUniversity, Ottawa, Canada.Received: 8 November 2016 Accepted: 6 December 2017References1. 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