Cine-ed: using films to teach medical learners
Authors: Deana Midmer
Publication date: 02 Oct 2004
These days medical students don't have to bunk off lectures if they want to watch a movie; it's part of their training. Deana Midmer explains how the new concept of cine-ed can bring learning to life
Have you ever been to a movie or film and said to yourself, “wow, that's exactly like the patient I saw today”or “that's just like the case we discussed in the seminar”? You'll often recognise the psychosocial components of clinical practice in the movies. Movies show scenes of dying and death, pregnancy and birth, critical and chronic illness, family and intimate partner violence, and problems with the elderly, with teens, and with children. They also portray marital dysfunction, substance use, physician health, and a whole range of other complex but common human problems. As medics we can learn a lot from films; in this article I'll try to show you how.
Using video clips
Using short clips from movies can be an effective way to initiate a discussion with medical students about values and beliefs, behaviours and motivations (see box 1). Cine-ed is an attention grabbing strategy that can highlight the psychosocial issues that often coexist with medical problems.   Manycommercial videos have highly dramatic and graphic content and are often very powerful in their depiction of the behaviours and thought processes of the movie's characters. Because of the intense nature of these videos, and their ability to stimulate strong feelings in viewers, only a short clip is needed to stimulate rich discussions with medical learners.
In a movie, dramatic, tense scenes are often juxtaposed with milder or humorous scenes, which act to buffer the viewer from the intensity of the action and increase psychological comfort. With cine-ed, because only a short clip is shown, this high tension is not diluted and the already highly dramatic effect of the experience is magnified. Viewers should be warned about this, and it is important to ensure that the learner feels psychologically safe during the exercise.
Clips from television programmes can also be used, but because of the wider viewing audience for television there may be less intensity in the scenes. Situation comedies or serialised dramas can often provide interesting footage of human troubles and foibles. Television clips are a great way to determine current societal beliefs about the functioning of the family, including parenting roles; they can depict what it's like to be a working mother, an out-of-work father, or a child with behavioural problems—all good discussion items. Television shows are constructed differently from movies, and the flow is often interrupted because of the commercials. Videotaping television shows can also be difficult: unless a tape is always in the video recorder or you know in advance that a programme on a certain topic will be aired, it is a catch-as-can situation.
With any public viewing of commercial properties there are copyright issues, and taping segments of a video infringes copyright; it is best to buy or rent the video of choice. Using an original video is also better because the picture will be crisp and in full colour. Taping a video often results in a grainy image that can detract from the viewing intensity and the same poor quality is often evident with television clips.
Precautions and caveats
Medical learners, especially undergraduates, often have limited personal life experience. For some students, looking at the life of a character in a video provides a vicarious experience of a world they do not know; other students will have experienced similar problems in their own family. Reflection on the actions of the character often helps students to begin to understand behaviours, motivations, and life choices far beyond their own worldview and to develop an empathetic awareness of the experiences and different realities of others. Foreign films can be used when helping the students to develop cultural competence.
As with any experiential learning, or inductive teaching strategy, there is a possibility that the learner may develop sudden new insights, some of which can be painful. Some precautions are advised:
Box 1: Uses for videos
Signs and symptoms of a medical condition
The impact of the illness/condition on the health and coping strategies of the individual
The impact of the illness/condition on the health and coping strategies of family members
Medical system issues
Community treatment modalities
Alternative medical treatment
Response of medical personnel: behaviours, attitudes, emotions
Relationships between family members
Job related concerns and societal issues
Legal and educational problems
Relationships with children
Relationships with parents and siblings
Impact of the family on adult behaviour
Caring for elderly people
Stereotypes about certain conditions
Normative behaviours in some subcultures, for example, adolescent groups
Social determinants of health
Learners need to be told that the video clip may contain highly dramatic and intense scenes that may be frightening or upsetting or may stimulate memories of past experiences
Learners should only participate in debriefing/processing discussions to a level at which they feel comfortable
Support resources need to be identified and available for students who may find the content of the video unsettling and need further discussion or counselling
Discussions with the same group at a later date allow for further questions that may have arisen after the session.
Preparation before using video clips
Before using videos to teach medical students, or for any other medical learning event, it is best to view the entire video in order to develop a context for the different behaviours depicted in the clips you choose to show. For example, if a graphic clip of someone in severe distress is shown, the viewers may want to know about the final outcome of the video, especially if the end is positive. It is important, however, to refrain from revealing the ending until the event has been thoroughly processed. Knowing the ending in advance might temper the learners' comments and interfere with their spontaneous reactions. Also, anyone in the group who has seen the movie should be asked also refrain from revealing the ending.
Finding good films
As well as going to the movies or renting videos yourself, most video rental companies have reference books where you can easily check on specific topics. Again, video review is important, and you must watch with a “teacher's eye” rather than from a viewer's perspective (see box 2).
You can set up the video to start at the correct place. If you are using a counter, be aware that all machines track differently. This can make it difficult if there are multiple clips you want to show in one video. You may need to keep a watchful eye as the video tracks forward.
Identifying teaching goals
As with all educational events, it is important to identify the learning objectives and your teaching goals before the session. A principal teaching goal may be to clarify values around the topic of interest. Another may be to explore cultural differences with respect to a social problem. Commercial videos, in contrast to medical teaching videos, are emotionally laden and this is why they can be such helpful tools for a range of teaching goals. They are useful for challenging and changing beliefs, clarifying values, and debunking commonly held stereotypes, and can help to discredit personal and societal prejudices, expose biases, and reveal intolerance, by teaching students about character motivation and decision making, and showing ethnic perspectives (see box 1 for more uses).
Ideal viewing conditions
Teaching in small groups is preferred, although a short clip can certainly grab the attention of a large group at a conference session. Whatever the size of the group, the event must be analysed and discussed by students, and this can be accomplished more easily in a small group. If there is a large assembly, small groups can be formed, or participants can debrief with the person sitting next to them, with a large group discussion to follow.
The processing cycle
The debriefing, or processing, of the viewing experience is the key to any successful clarification of values. At least as much time should be spent on the debriefing as was spent on the experience itself. Too often, session faculty will ask a general question, such as, “so what did you think?” after an experiential event. This often results in a low yield of disclosure and diminishes the success of the learner's experience. The processing cycle  leads the participant to discuss what they saw and heard, what they felt about it, what applied to the real world and how it might apply to the practice of medicine.
Box 2: Examples of films
When a Man Loves a Woman (1994). In this movie, a couple with a seemingly charmed life begins to deal with the mother's alcohol dependence. There are very good scenes showing the young children's reaction to their mother's drinking, the dynamics in the marital relationship, and behaviour of the husband that contributed to the drinking. A great teaching clip occurs about 30 minutes into the film. Alice, the mother, comes home drunk and falls in the shower. This clip illustrates the hypervigilance and parentified behaviour common in children who are exposed to alcohol problems in the family.
The Basketball Diaries (1995). This is a brilliant film and a true story about a young boy's escalating misuse of substances. Scenes with the mother show the deterioration of their relationship and the steps she takes to deal with his addiction, including calling the police to have him arrested. This is a great video to explore adolescent issues around substance misuse. Beware: very explicit language, graphic scenes of drug use, teenage prostitution.
Uses with patients
On a final note, it is also effective to suggest that patients watch a particular film or programme if there are elements in it that parallel their lives. At a future visit, you can discuss their impressions and perspectives on how the characters reacted to similar life situations. This can be very effective when used with families, for recommending videos on parent-child issues, divorce or separation, adolescent rebellion or substance misuse, and so on.
- Alexander MM, Hall MH, Pettice YJ. Cinemeducation: an innovative approach to teaching psychosocial medical care. Fam Med 1994;26: 430-3.
- Goldman JD. An elective seminar to teach first-year students the social and medical aspects of AIDS. J Med Educ 1987;62; 557-61.
- Midmer D. The processing cycle. BMJ 2002;325: 140.
Deana Midmer associate professor
department of family and community medicine, University of Toronto, Canada ( firstname.lastname@example.org)