Theater based Learning - TBL

A unique and innovative methodology to learn and understand educational material

Medical Theater

Medical Theatre is the use of TBL for medical and healthcare topics.

 

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Medical Theatre – A Dramatic improvement in Medical education. Our first experiences

May and June 2011

The medical curriculum comprises a vast database of information that a medical student has to understand and apply in order to become a doctor. This on an average takes five to seven years for an undergraduate in various medical institutions across the world. For these reasons medical education has always been thought to have been a long and tedious journey taken up by those who have the perseverance and dedication to become a doctor. (1,2) Added to this, specialization in a particular field has become a necessity for doctors especially in a developing nation such as India.

This adds to stress and the pressure to finish learning the entire curriculum in a speculated period of time which forces many students to learn by rote or skip topics that they fail to understand easily. (1,2) Many resort to suicidal tendencies due to poor coping skills.(2) Dramatics in the form of plays and skits have always been popular amongst children and adults universally. (3,4) Dramatics presents a means to represent elements in multiple sensory dimensions – visual and auditory stimuli being the most common. Surveys have shown that incidences which an individual has experienced are easier to recollect and effortless to remember. (4)

 

In this process we hope to attempt at combining medical education with dramatics and theatre to create an innovative methodology that enables medical and non medical students to learn and understand medical concepts more effectively .

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The Concept The concept involves the ability of an individual to create a theatrical outcome from a selected medical content such that during the process of creating an outcome, the content is well understood. The outcome could be a story, a script for a play, a poem, a prose, a song, a game, a narration/monologue, a group activity, a cartoon/ comic, a clinical scenario or a role play. The type of outcome depends on the content and the discretion of the individual making the outcome. The quality of the outcome is not stressed upon as the outcome only serves the purpose of revision material to that individual alone. So if the individual has created a story from a selected medical content, then that story will be useful as revision material for that individual only. It may or may not serve the same purpose for someone else, but might create inspiration amongst others to try and create something for themselves for their own content.

The understanding behind the conceptFor an individual to make a theatrical presentation or outcome from the selected medical content, the process would automatically involve reading and trying to understand the medical content first. After this the individual tries to create a story or plot using the content to make a final theatrical outcome. This process involves a lot of concentration, imagination and creation where in the individual creates his own words in the story and links the contents such that it forms a sequence of events when trying to remember the topic. The outcome is special and specific to the individual’s thoughts and experiences and hence allows room for excitement, curiosity and challenge to create an interesting outcome which is easy to remember and recollect during revisions. This process need not be performed for every topic in the medical curriculum, but only to those where the student finds it difficult to remember or has to learn by rote.

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The type of intervention selectedIn view of the concept involving individual participation for effective learning, an intervention in the form of a one day workshop was considered appropriate. Subsequent workshops being conducted in the same institution were structured similarly; however the content was entirely new in each of the workshops so as to enable the same participants to lean new topics in a fun and innovative manner at monthly intervals.

Number of ParticipantsWorkshop 1-   23 participants (Medical students from different years)

Workshop 2-   23 participants (Nursing students from different years)

10 participants (Medical students from workshop 1)

Number of facilitators-

For both the workshops the facilitators included the first author of this paper for the medical contnt and conversion of medical topics into stories/scripts. The third author and team of 3 others from a professional and recognized theatre group conducted the entire workshop in between sessions taken by doctors. Two invited guest doctors as facilitators for their sessions and the second author participated mainly in the organization and management of the workshop.

Content–                          

 Workshop 1 – 4 topics

  1. Mechanism of action of penicillin’s (Group activity -converted into story)
  2. Syphilis (Guest doctor- Demonstration of song)
  3. Community survey (Guest doctor- Demonstration of role play)
  4. Meniere’s Disease ( pre written script- performed by participants)

Workshop 2-  6 topics-

  1. Broca’s Aphasia (Demonstration of Monologue)
  2. Temporal Arteritis (Demonstration of theatrical case scenario)
  3. Action of Parathyroid Hormone (Demonstration of story)
  4. Autonomic Nervous System (Group activity by participants)
  5. Rheumatic Fever (pre written script- performed by group A participants)
  6. Cushing’s Syndrome (pre written script- performed by group B participants)

2

The methodology Two workshops were conducted in the span of two months between May and June 2011 in a medical college premises for medical and nursing students. The workshops were structured in a manner to enable learning and understanding of both the medical content and the basics of theatre in the same intervention. The workshop included theatrical games, group building exercises, demonstration sessions showing conversion of a few medical topics into a variety of theatrical outcomes, group activities in which students attempted to convert a topic into a theatrical outcome, sessions by two invited guest doctors who demonstrated how they have been using theatre in their teaching sessions highlighting the benefits that dramatics brings to the quality of a doctors profession and finally the workshop conclusion with a theatrical performance by the participants on pre-written scripts based out of medical content in front of an invited audience. The participants were then instructed to make a theatrical outcome of their own within a week of the workshop so as to apply their learning’s into their own topics of interest. These were submitted before the issue of certificates.  The structure of the two workshops is listed in Table 1.

Table 1Shows the schedule of the workshop for a one day and two day intervention.

ONE DAY WORKSHOPTWO DAY WORKSHOP              DAY 1 TWO DAY WORKSHOP           DAY 2
Introductory session in theatreIntroductory session in theatreTheatre games competitiveness
Theatrical skillsScript writingReading and rehearsing the allotted play with leaders
Script writing sessionScript content and formatTechnical showSuggestive changes
Stage 1 – script reading of topicTheatre games(Bonding, competition , collaboration and understanding using play method)Creating of the performance
Stage 2-  presentation and reviewScript creationPerformance in front of an invited audience
Stage 3- rehearsalDramatic elements of a performancePlayback theatre and closure
Stage 4- performance for an invited Audience.Role play- Dramatic elements and use in medical field 
Circle time- de-briefing sessionLearning’s of the day and forward links 

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Assessment of the workshops-

Both the workshops included a pre-workshop assessment form and a post workshop assessment form. (Table 2 and 3 respectively) These were filled by the candidates and submitted before and after the workshops. In addition to these written assessment forms there was video documentation of the entire intervention.  At the end of the workshop a one hour De- briefing session was carried out in which each participant shared their experiences and gave their individual feedback which was also video recorded. Within a week of the workshop each candidate submitted their script/story which was compiled into a book as a documentation of the outcomes created by these students and demonstrating the efficiency of the intervention.

The content created as scripts submitted by students was utilized in the subsequent workshops for the final performances. Students were also awarded the best scripts award for their efforts.

Workshop 1- May 2011–

The first workshop was a one day intervention conducted for 23 undergraduate medical students.

 Positive feedback –

1.  Creative thought processes were challenged

2.  Learnt a new way to understand and learn

3.  Learning medicine appeared easier and entertaining

4.  Remembering and recollection was easier

5.  Enjoyed the process and interacted with students from different batches

Negative Feedback

1. Need for more demonstrations of how a topic is made into a story

2. More topics need to be covered

3. Some students felt overloaded and tiered

4. Some suggested a two day workshop

Changes Implemented in second workshop-  In view of the negative feedback received , the subsequent workshop was converted into a two day intervention with more topics included. The performances were kept on the second day so as to avoid overloading of content on the participants. There were two performances instead of one, by essentially dividing the group into two.

Workshop 2- June 2011–

The second workshop was a two day intervention conducted for 23 undergraduate nursing students and 10 undergraduate medical students.

Positive feedback –

1.  An innovative learning and teaching methodology

2.  Makes it simpler to understand topics

3.  Increases self confidence and explores creativity

4.  Remarkable improvement from the last workshop

5.  Lot of fun and enjoyment

Negative Feedback

1. Could be conducted for a larger student population

2. Topics must be specific to the group and the workshop must be

conducted for specific years of batches.

 

Table 4 A, B and C summarizes all the data from the feedback forms of both the workshops.

 

Table 4A- Summarizing the reasons for participation assessment for both workshops

Reasons for Attending Medical TheatreWorkshop1 (%)Workshop2 (%)
Attend guest facilitator sessions4010
Learning difficulties3262
Peer pressure183
Curiosity1025

 

Table 4B- Summarizing the pre workshop assessment feedback for both workshops

Pre-workshop AssessmentWorkshop1 (%)Workshop2 (%)
Satisfied with the current teaching methodologies6376
Satisfied with their learning methodologies2724
To learn a way to avoid learning by rote8087
Have a good time and make friends during the workshop2013
Become entertaining teachers7379

 

Table 4C- Summarizing the post workshop assessment feedback for both workshops

Post-workshop AssessmentWorkshop1 (%)Workshop2 (%)
Usefulness of the workshop9296
Enjoyed participating in the workshop100100
Want to attend work regularly5869
Keep up to their expectation9296
Methodology included in the teaching curriculum8589

The medical curriculum comprises a vast database of information that a medical student has to understand and apply in order to become a doctor. This on an average takes five to seven years for an undergraduate in various medical institutions across the world. During this period there are many commonly used methods that a student utilizes to understand medical subjects. Such as in addition to the teaching carried out by doctors in undergraduate classes and clinical case discussions, the student spends a significant amount of time reading the curriculum after college hours. The student might also prepare charts and drawings to remember complicated conditions and stick them up on the walls of their rooms to revise it frequently. Many often come up with interesting mnemonics to remember classifications and differential diagnosis etc. Some make notes from multiple books and read them for revision and most of the students learn by rote for all the difficult to understand medical topics. This often leads to saturation of knowledge and on many occasions confusion amongst similar content. There are a large number of students who do not believe in sacrificing their time on sports and recreation and are further burdened at the time of examinations for the need of leaning large amount of content over a short duration of time. This invariably affects the future of all these students with their career in health care.  For these reasons medical education has always been thought to have been a long and tedious journey taken up by those who have the perseverance and dedication to become a doctor.Added to this, specialization in a particular field has become a requirement for doctors especially in a developing nation such as India. This adds to stress and the pressure to finish learning the entire curriculum in a speculated period of time which forces many students to learn by rote or skip topics that they fail to understand easily.  Many resort to suicidal tendencies due to poor coping skills.

There are newer methodologies for teaching medical subjects that have come to existence in recent times. The most popular concept is the Problem based learning (PBL) wherein the student learns everything entirely with respect to the problem instead of reading various aspects at different stages of the curriculum. (5,6)This is usually carried out in groups where each student reads up a particular aspect about the disease and discusses it amongst their peers. Other methods such as Fish bowl learning , teaching from experiences using memories of being taught (7,8,9) and group discussions have also been attempted. All these however carry a significant amount of seriousness which appeals only to those who would even otherwise be interested to read on their own in order to learn the subjects. For the rest, there is no current existing methodology that gives room for fun and entertainment along with a high quality of learning. The concept of medical theatre reaches out to these group of students who can learn with as much fun and excitement as they would while playing sports or watching a movie and it also challenges their creativity and imagination to help them nurture into doctors with the ability to apply their knowledge instead of learning just for the sake of clearing examinations. Medical theatre is a method which results in learning in the processof a seemingly independent theatre activity.

Dramatics in the form of plays and skits have always been popular amongst children and adults universally.(4) Surveys have shown that incidences which an individual has experienced are easier to recollect and effortless to remember.(3,4) The probable reasons for this can be attributed to the stimulation of the limbic system along with the auditory visual stimuli received along with the information. On regular reading of any topic, no emotions are triggered, however when the entire process is made into a creative challenge to convert a topic into a story or enact in a play, it gives an emotion to the process and helps in remembering this as an experience.(3,4) Knowledge of theatre also helps a doctor to be more expressive and empathetic towards a patient and also trains the improvisational skills that a doctor frequently requires during clinical practice and academic teaching.

 

A classic study by Dr Alexander Luria in 1968 of his patient ‘S’ with five-fold synesthesia presents an extreme case of use of sensory modalities in remembering words or numbers or other elements. ’S’ was synaesthetic and often long row of words became multi-dimensional images. For example he would remember a long sentence by taking a mental walk down a street from his home in Moscow, slowly placing images of houses, gates, trees and people to represent the constituting words. The technique helped him remember sentences even 15 years after the incidents (The Mind of a Mnemonic – A.Luria).

The two workshops conducted for medical and nursing students demonstrated the acceptance of this method in an overwhelming manner and emphasized the need for such a methodology to help improve learning in the medical curriculum. The feedbacks from the first workshop were invaluable in helping us improve it to an acceptable structure that benefits both students and teachers in the subsequent workshops. This methodology also promises benefit in other fields such as dentistry, pharmaceutical companies to train medical representatives with respect to the medications they promote, Medical design and equipment companies to train their team for a better medical understanding in their domain and in awareness programs for non medical population in the community where medical theatre can be utilized to create awareness among various medical elated conditions.

This article highlights the acceptance and benefits of an innovative teaching methodology for the learning and understanding of medical topics that are otherwise difficult to comprehend amongst students. This methodology however does not substitute the conventional teaching and learning methods in any manner, it only provides an option to learn certain topics in a unique manner so as to break the monotonous process of usual methods of studying and to have an enjoyable learning experience in the process.

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From the workshops conducted the following were specific conclusions derived.

  1. The stories and scripts converted by participants are useful as revision material for the participant who created it only. These theatrical outcomes do not promise to improve the understanding of a topic for other readers. In the same manner, if a play is enacted, the participants gain maximum benefit in understanding the subject rather than the viewers.
  2. The process of learning theatrical skills and a new teaching methodology adds to the qualities of a doctor in being a better listener, empathizer and communicator.
  3. These workshops help in relieving stress from the usual routine and works as a very effective group bonding exercise amongst peers and helps train the students to co-ordinate, communicate and function as a team which is very useful in future multidisciplinary approaches to various illnesses.
  4. A two day intervention was much more accepted and useful when compared to a one day workshop.

This methodology needs to continue for a larger number of students with focus on more specific content and must be applied to all possible areas where this methodology can prove beneficial. Further data will be required to establish the efficacy of this methodology in the future. The current data only shares our initial experiences.