Educating Medical Students about the Personal Meaning of Terminal Illness Using the Film,“Wit”

Abstract

Background:

Addressing the emotional needs of dying patients is rarely found to have a place in formal medical curriculum and is also a difficult area to teach through classical medical lectures. “Cinemeducation” is a wonderful way to educate health care providers about the magnitude of emotions that arise during those difficult situations.

Objective:

The aims of this study were to test the relevance and usefulness of the movie ‘Wit’ in teaching medical students about the personal meaning of terminal illness and to assess the impact of this teaching method on students' attitudes toward palliative care.

Design:

This was an education study using qualitative and quantitative data analysis of 518 first-year medical students in a single medical faculty in Turkey. Students watched the entire film, filled out an evaluation questionnaire, and answered questions about the film. Students also expressed their own feelings and thoughts about palliative care.

Results:

Overall, 88% rated the film as excellent, very good, or good. According to 54% of the students, the emotions of terminally ill patients were fully portrayed in the film and in a very realistic way. Approximately 61.4% of the students found this film emotional. Most students (80.5%) stated that this film made them think about the emotional and spiritual suffering that dying patients go through and found this learning approach about palliative care more useful than didactic lectures and journal article readings but not more useful than bedside rounds. It was thought that caring for dying patients would be very or fairly personally satisfying for 65.3% of the students.

Conclusions:

The film ‘Wit’ gave the students an opportunity to explore their beliefs, values and attitudes in terms of the bio-psycho-social-spiritual aspects of health care and encouraged them to think more about the humanitarian issues of the medical profession.

Death, be not proud, though some have called thee

Mighty and dreadful, for thou art not so;

For those whom thou think'st thou dost overthrow,

Die not, poor Death, nor yet canst thou kill me.

From rest and sleep, which but thy pictures be,

Much pleasure; then from thee much more must flow,

And soonest our best men with thee do go,

Rest of their bones, and soul's delivery.

Thou art slave to fate, chance, kings, and desperate men,

And dost with poison, war, and sickness dwell;

And poppy or charms can make us sleep as well

And better than thy stroke; why swell'st thou then?

One short sleep past, we wake eternally,

And death shall be no more; Death, thou shalt diet

—John Donne

January 25, 1572–March 31, 1631

London, England

Introduction

The first article about the use of films in medical education was published in 1979.¹ This article addressed cinema as an untapped resource for psychiatric education and found this teaching format useful and enjoyable in residency training programs. Since then this innovative teaching method has received a consistent level of interest from medical professionals, and the number of published papers about this subject has increased.² In 1994, Alexander et al.³ described the use of cinema to teach psychosocial aspects of medicine to family medicine residents and used the word “cinemeducation” for the first time. As written by Alexander et al.⁴ in their book Cinemeducation: “Lights, camera, action!!! Or, we should say ‘Lights, camera and educational action!’” because today we are to be exposed to over 200 movies that can be used to teach the doctor–patient relationships, communication skills, grief and bereavement, ethical issues, palliative care, medical humanities, mental health issues, family and marriage counseling, some social determinants of health such as alcohol, poverty, and domestic violence.² Movies allow us to be an inhabitant of a conscious dream state, and escape from the real world for a short period and during this time we learn our feelings, behaviors, and thoughts from the characters of the films. We build bridges between us and them; we learn to perform empathy, to trigger discussions, to become emotionally involved in a situation but also to keep enough distance to maintain objectivity and we learn to be more honest about analyzing our reactions. Furthermore, movies are fun, entertaining, and enjoyed by everyone. Therefore, movies are adaptable to the educational context. The most common strategy in cinemeducation is the use of an entire movie or movie clips to stimulate group discussion and ask trigger questions which are tailored to the teaching goals.^5–19 The teaching goals could be the emotional reactions of the viewer, diagnostic and therapeutic decisions, and the balancing of professional life with personal life.^5–21

One of the most used movies in cinemeducation is the film ‘Wit’ directed by Mike Nichols and adapted from a Pulitzer Prize-winning stage play written by Margaret Edson.^20–23 This movie tells the very personal story of an English literature professor, dying of metastatic ovarian cancer, from her first encounter with the diagnosis to her death. Her approach to her illness is aggressively probing and intensely rational, but during the course of her illness she changes dramatically and begins to reassess her life and work. She feels isolated and in need of friendship, forgiveness, and compassion. During her journey, she loses her dignity, which she might previously have thought was based on her title and appearance but both of these are lost. Her title subtly migrates from “Doctor” to “Ms.,” and eventually to “Vivian” and her appearance changes from that of a beautiful woman to a poor, powerless human who is hairless and pale, vomiting into a plastic bowl and in pain.

The objectives of this study were to test the relevance and usefulness of the movie ‘Wit’ in teaching medical students about the personal meaning of terminal illness and to assess the impact of this teaching method on students' attitudes toward palliative care.

Materials and Methods

This was an education study using qualitative and quantitative data analysis from 518 first-year medical students in a single medical faculty in Turkey. All of the first-year students in the academic years 2011–2012 and 2012–2013 participated in the study, which was took place during the professional skills course that takes approximately 14 weeks (2 hours per week) in the second semester and is compulsory for every student. Due to the large number of students, the student group was divided into 8 subgroups of 25–30 students each and these subgroups took the course on a rotation basis. For this study, the students in each of the 8 subgroups watched the entire movie during their first visit to the skills laboratory. Before showing the movie a short explanation was given about the purpose of the study, about the movie, and about its characters. The movie was shown in the original language with Turkish subtitles. After watching it, students filled out a printed questionnaire to evaluate the film. This evaluation questionnaire was the Turkish translation of the questionnaire that had been used in the ‘Wit’ Film Project.²¹ A list of open-ended questions was then distributed for the students to answer. On the next skills laboratory day the students read and discussed their answers and the movie. After the discussion a short presentation regarding palliative care was given.

The quantitative data from this study were derived from the printed questionnaires whereas the qualitative data were gathered from the answers given by the students to the open-ended questions. Statistical analyses of the quantitative data were performed using the SPSS program (SPSS Inc., Chicago, IL). Descriptive statistics and χ² analyses were used. Qualitative data were evaluated by reading the answers.

Results

All of the study participants were first-year medical students. The mean age was (mean±standard deviation [SD]) 19.4±0.9 years and gender distribution was 48.8% male and 51.2% female. Table 1 shows the distribution of students in terms of gender and the overall rating degree of the movie. Most of the students rated the movie ‘Wit’ as “good” and no statistical difference was found between male and female students in terms of overall rating.

Table 1.

Distribution of Students According to Gender and the Overall Rating of the Film “Wit”

	Excellent+very good	Good	Fair+poor	Total
Male	88 (34.8%)	133 (52.6%)	32 (12.6%)	253
Female	113 (42.6%)	122 (46.0%)	30 (11.4%)	265
Total	201 (38.8%)	255 (49.2%)	62 (12.0%)	518

χ²=3.37; df=2; p=0.32.

Table 2 shows the distribution of students in terms of emotional experience of the movie. Most of the students found this movie “somewhat emotional.” More male students than female found it “slightly or not at all emotional” and this difference was statistically significant.

Table 2.

Distribution of Students According to Gender and their Emotional Experience Gained by Watching the Film “Wit”

	Extremely+very emotional	Somewhat emotional	Little+not at all emotional	Total
Male	46 (18.2%)	92 (36.4%)	115 (45.4%)	253
Female	65 (24.5%)	115 (43.5%)	85 (32.0%)	265
Total	111 (21.4%)	207 (40.0%)	200 (38.6%)	518

χ²=10.04; df=2; p=0.04.

Table 3 shows the distribution of students in terms of positive and negative emotional impact. Most students reported neither a positive nor negative impact of the film. More female students than male reported a negative impact and this difference was statistically significant.

Table 3.

Distribution of Students According to Gender and the Emotional Impact of the Film “Wit”

	Very+somewhat positive	Neither positive nor negative	Very+somewhat negative	Total
Male	96 (38.0%)	103 (40.7%)	54 (21.3%)	253
Female	38 (14.3%)	123 (46.4%)	104 (39.3%)	265
Total	134 (25.9%)	226 (43.6%)	158 (30.5%)	518

χ²=42.44; df=2; p=0.000.

Table 4 shows the usefulness of the film ‘Wit’ compared to the other approaches to learning about caring for dying patients. Students found the film ‘Wit’ as a tool for learning about caring for dying patients much more useful than lectures and journal readings but not more useful than bedside rounds. Table 5 shows to what degree the film Wit made the students think about the care that they will give to dying patients.

Table 4.

The Usefulness of the Film as a Tool for Learning About Caring for Dying Patients Compared to Other Approaches

	Much more useful	Somewhat more useful	Equally as useful	Somewhat less useful	Not at all useful
Lectures	127 (24.5%)	271 (52.3%)	62 (12.0%)	41(7.9%)	17 (3.3%)
Journal readings	120 (23.2%)	263 (50.8%)	69 (13.3%)	52 (10.0%)	14 (2.7%)
Bedside rounds	55 (10.6%)	140 (27.0%)	109 (21.0%)	173 (33.4%)	41 (7.9%)

Table 5.

Distribution of the Students in Response to the Question: “To What Degree Did the Film “Wit” Make You Think About the Care That You Will Give to Dying Patients?”

	Very much+a good amount	Somewhat	Not very much+not much at all
How to give bad news	316 (61.0%)	146 (28.1%)	56 (10.9%)
How to talk with patients about prognosis	330 (63.7%)	142 (27.4%)	48 (8.9%)
How physical pain is treated	287 (55.4%)	165 (31.9%)	66 (12.7%)
The emotional and spiritual suffering that dying patients go through	417 (80.5%)	73 (14.1%)	28 (5.4%)
How to talk with patients about their end of life treatment wishes	298 (57.5%)	151 (29.2%)	69 (13.3%)

According to 80.5% of the students, the film ‘Wit’ reflects the emotional and spiritual suffering that dying patients go through to a very great and a considerable degree. Other issues that made students think to a great and considerable degree were: how to talk with patients about prognosis, how to give bad news, how to talk with patients about their end-of-life treatment wishes and how physical pain is treated, respectively. Approximately 65.2% of all students (males, 30.5%; females, 34.7%) reported that they would be very or fairly personally satisfied if they were to care for dying patients.

Table 6 shows the mean response of the students by survey items. As mentioned in the Methods section, on the next skills laboratory day the movie and students' answers to the open-ended questions were discussed. Some questions and their answers are given below:

Table 6.

Mean Response of the Survey Items

Survey items	Mean±SD
How would you rate the film overall?	3.3±0.7
How accurately did the film portray:
Emotions of terminally ill patients?	3.6±0.7
Treatments for terminally ill patients?	2.6±0.8
Doctor–dying patient communication?	2.3±0.9
Nurse–dying patient communication?	3.6±0.8
To what degree did the film move you emotionally?	2.8±0.9
To what degree did the film make you think about:
Giving bad news	3.7±0.9
Talking with patients about their prognosis?	3.7±0.9
Addressing patients' physical pain?	3.6±0.9
Addressing patients' emotional and spiritual suffering?	4.2±0.9
Talking with patients about their end-of-life wishes?	3.6±0.9
How useful was the film as a tool for learning compared to:
Didactic lectures?	3.9±1.0
Journal article readings?	3.8±1.0
Bedside rounds?	3.0±1.2
How relevant was the film with regard to the care that you will provide to your patients in the future?	3.2±0.8
With regard to your future practice how would you rate your interest in:
Breaking bad news to patients	2.8±1.2
Discussing treatment options with patients	3.6±0.9
Controlling symptoms	3.9±0.9
Dealing with patients' emotions	3.6±1.0
How personally satisfying would it be for you to care for dying patients?	3.7±1.0

Ratings based on a 5-point Likert scale, ranging from 1 (the most negative response) to 5 (the most positive response).

SD, standard deviation.

Which scene of this movie affected you most emotionally?

The study group was emotionally affected most by the scene in which Professor Ashford read some paragraphs to Vivian from a children's book, The Runaway Bunny, followed by the scene in which Nurse Susie and Vivian were eating popsicles and talking about life and death.

I was affected not only by one scene but by the whole film. Watching the situation of a person who is so near to death affected me very deeply. I felt a chaos of feelings and as if I were inside the movie.

I was mostly affected by the scene where Vivian Bearing got the bad news. I put myself in her place and also I thought of one of my relatives who was in the same situation as Vivian. It is a very hard situation. There is something in me which grows and grows and it will kill me…without experiencing this it is very difficult to know, but even thinking about it is also so hard and sad.

How has the film affected your personal interest in caring for dying patients and learning more about palliative medicine?

This movie raises awareness about palliative medicine. I think that palliative medicine is an important part of health care. Telling the whole story from the side of the patient was very efficient.

This movie gave me the opportunity to experience the job I have chosen before practicing it. Furthermore, I was stimulated to read more books, watch more movies, and do research about this matter. I have learned the mood of the patients who are at the end of their lives and how we should behave toward them. We could be in the same position. Being a doctor is something completely different from simply diagnosing and treating diseases.

After watching this movie I want to be trained and educated in palliative medicine. Because I understood that being a doctor did not mean only curing the patients. We must also understand the situation of the patient and share her/his feelings and suffering. These are important things. It would be a great honor for me to serve those kinds of patients.

If you were designing a program to improve the environment of the hospital where Vivian Bearing received her care, what features would you change to improve palliative services?

I would turn the palliative care room into a place different from a hospital room. I would change the color of the walls, put some flowers in, and bring books to read. I would have the patients listen to classical music. I would employ caregivers who would look after them with compassion as you would with children and finally I would provide the necessary medical equipment.

Discussion

Understanding the feelings of terminally ill patients and caring for them requires humanistic skills that cannot be taught easily by traditional methods. To promote learner empathy and self-reflection in the care of dying persons an end-of-life educational program called the ‘Wit’ Educational Initiative (WEI) was delivered to medical students and residents at 32 sites in the United States and Canada, between February 2000 and January 2002.^7,8 After the success of WEI in making the experience of Wit widely accessible to medical students and trainees, the Wit Film Project was enabled, which made the film version of ‘Wit’ available to medical schools throughout the United States.²¹ WEI was rated as excellent or very good by 95% of the participants.⁸

In the current study, the percentage of students who gave high ratings to the film ‘Wit’ was lower than in the results of the WEI.⁸ However, the extent to which the patient's emotional and spiritual suffering was addressed was rated as very much or a good amount by 80.5% of respondents in the current study, which was close to the result of WEI (85%).⁸

Most of the current study group (74.0%–76.8%) found the film more useful than didactic lectures or reading journal articles as a learning tool for caring for patients with terminal illness. This percentage was 80%–83% in the WEI.⁸ However, the percentage of students who found the film more useful compared to bedside rounds was lower than that of the WEI.

These differences between our and the results of WEI could be due to cultural differences, which should be further studied. Another reason could be the use of the film ‘Wit’ in our study whereas in the WEI, not the film but the stage performance, and live performances could be more effective than those captured on film. Another reason could be the composition of the study groups. Our study group consisted of first-year medical students whereas the results of the WEI were obtained from clinically experienced medical students. There were several reasons why we used the film in the first year of medical education:

The challenges that medical students face during their long clinical training can lead them to become less emphatic and more detached from their patients^23–26 Although some studies do not support this view,^27–30 we decided to foster empathy and to promote the attribute of altruism at the beginning of their medical education.

Humanistic attitudes should be implemented independently from years of education and the future of the proper and desirable doctor–patient relations in today's technical-, MRI-, CT-, and advanced laboratory tests-based medical care may depend on this implementation. Obviously we recognize that a single viewing of the film ‘Wit’ may not lead to a lasting change in students' attitudes or intentions toward patients. This kind of activity should be regularly repeated throughout the years of medical education and should have a place in the medical curricula at least equal to didactic approaches.

The final reason why we used the film ‘Wit’ with first-year medical students was the limitations of the curriculum. Students in the clinical years had neither time nor space for such an event, which takes a long time together with feedback discussions. However, the results of this study have encouraged us to implement a similar course for the clinical students in the future.

Unfortunately, the concept of palliative care is not well developed in our country. This concept has no place in the medical curriculum. We have no hospice-like institutions for palliative care and there are two options for patients who need this care. Either receive this care from family members in their own home, which is a tradition here as it is in many eastern cultures or receive this care in the intensive care units of hospitals (especially if the patients need technical medical care). Therefore, even the medical students in their clinical years have no or little exposure to palliative care.

The film Wit shows how not to provide optimal care through the roles of Dr. Posner and Dr. Kelekian and how to provide the proper care through the role of Nurse Susie Manohan. Therefore, it gives the audience the opportunity to learn how to and how not to provide optimal care for dying patients.

Teaching students with no or little exposure to palliative care may give rise to potential problems and also may have potential benefits. The potential problems could be not understanding the meaning of palliative care, comparing it with intensive care, undermining its importance, neglecting and refusing palliative care, being confused about their role as a medical doctor as to whether the aim is to preserve life or to help the patient have a good death, and not fully understanding dignity and respect for patients. In this study we recognized that some students do not know the meaning of palliative care, they accept death as a failure and are not aware of the concept of a good death.

The potential benefits of teaching students with no or little exposure to palliative care could be raising awareness of palliative care and reacting without prejudice.

From the results of this study, it can be concluded that movies can be used as an innovative, effective method to provide training about end-of-life issues and doctor–patient communication even in the earlier stages of medical education. Implementation and the use of this approach in medical education in our country depend on progressive educators who advocate the humanities as an educational method.

Footnotes

Acknowledgments

The authors would like to thank to Mrs. Caroline Jane Walker for the editing of the language of this manuscript.

Author Disclosure Statement

No competing financial interests exist.

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