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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 17  |  Issue : 3  |  Page : 540-547

Approaching medical humanities with an interactive tool: Theater of the oppressed


1 Department of Neuroscience Technology, College of Applied Medical Sciences in Jubail, Imam Abdul Rahman bin Faisal University, Dammam, Saudi Arabia
2 Department of Anesthesia Technology, College of Applied Medical Sciences in Jubail, Imam Abdul Rahman bin Faisal University, Dammam, Saudi Arabia
3 Department of Pharmacology, N.C. Medical College and Hospital, Panipat, Haryana, India

Date of Submission15-Aug-2020
Date of Acceptance01-Dec-2020
Date of Web Publication2-Nov-2022

Correspondence Address:
Dr. Manoj Goyal
Department of Anesthesia Technology, College of Applied Medical Sciences in Jubail, Imam Abdul Rahman bin Faisal University, Dammam
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_306_20

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  Abstract 


Introduction and Background: The focus of medical education should not only be the cognitive aspects but also be the qualities and values that make us human. Researchers suggest that the required attitudes and values can be inculcated by exposing the students to medical humanities, which will be helpful in making them not only competent but also ethical and humane doctors. “Theatre of the Oppressed (TO),” which was devised by Augusto Boal, has been used as a tool in medical humanities with positive outcomes. Aim: A study was conceptualized with the aim of sensitizing the students with medical humanities with “Theatre of the Oppressed” and to evaluate the workshop by students' perceptions and reflections. Materials and Methods: A workshop of 7 days, 5 days online and 2 days physical, was conducted for 30 students, in which they participated in TO games and activities, which are based on theoretical framework of Paulo Freire's “Pedagogy of the Oppressed” TO. Results: Students participated very enthusiastically in the workshop. The feedback and reflections of students reveal that they felt more empathetic toward patients and underprivileged, developed mutual trust between their class mates, listened more during the workshop, and developed better understanding on their bodies and emotions. Conclusion: The study documents the experience of exposing the students to TO as an interactive tool to address medical humanities. The feedback of students reflects that TO workshop was successful in bringing deep insights on the role of human values in medicine and they want to participate in more of TO workshops in future.

Keywords: Empathy, ethics, humane doctors, medical humanities, mutual trust, professionalism, Theatre of the Oppressed


How to cite this article:
Bansal M, Goyal M, Bajpai A. Approaching medical humanities with an interactive tool: Theater of the oppressed. J Datta Meghe Inst Med Sci Univ 2022;17:540-7

How to cite this URL:
Bansal M, Goyal M, Bajpai A. Approaching medical humanities with an interactive tool: Theater of the oppressed. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Jan 28];17:540-7. Available from: http://www.journaldmims.com/text.asp?2022/17/3/540/360209




  Introduction and Background Top


”The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” …Sir William Osler

Medicine is both an art and a science[1],[2] and its pursuit is both intellectual and moral,[3] where one's “heart” is equally exercised as the brain. Hence, education of the heart is prudent, which means that the focus of medical education should not only be the cognitive aspects but also all the qualities and values that make us human. Researchers suggest that the required attitudes and values can be inculcated by exposing the students to medical humanities, which will be helpful in making them not only competent but also ethical and humane doctors.[4],[5]

Medical humanities is an interdisciplinary and increasingly international endeavor that draws on the creative and intellectual strengths of diverse disciplines, including literature, art, creative writing, drama, film, music, philosophy, ethical decision-making, anthropology, and history, in pursuit of medical educational goals.[6] One of the challenges of teaching humanities is that it cannot be done effectively by the conventional methods. It needs different approaches, which can address the affective domain. Many researchers have approached medical humanities using various tools: paintings,[7] cinemeducation,[8],[9] narratives,[10] poetry,[11] and street play[12] with favorable outcomes.

One such tool is known as “Theatre of the oppressed”[13] (TO), which is an interactive form of theater consisting of set of games and exercises, which was devised by a Brazilian theater artist Augusto Boal, which was based on the landmark work of the educationist Paulo Freire known as “Pedagogy of the Oppressed”,[14] which advocates participatory and emancipatory education. TO is a creative tool for personal and social transformation and has been used in diverse fields, such as for reducing bullying and victimization among school adolescents[15] and preventing sexual violence.[16] It has been used as a humanities tool in medical education to hone the attributes important in medicine: ethics,[17] empathy,[17],[18] communication,[18] and professionalism.[17]

Considering the diversity of India and the number of medical colleges, at present, the experience of using TO in medical education is limited to some colleges only. Hence, we conceptualized a workshop based on “Theatre of the Oppressed” for our students with the aim of inculcating the values of a humane doctor and to generate more experience of using TO as humanities tool in our setting, which was a newly established medical college.

Aim

The aim of the study was to sensitize the students with medical humanities using TO.

Objectives

  1. To conceptualize and conduct a workshop on TO
  2. To evaluate the workshop by students' perceptions and reflections.



  Materials and Methods Top


Study design and population

It was a quasi-experimental, single-group study. The study participants comprised the 2nd year MBBS students of our institute. Convenient sampling method was used to enroll 30 participants for the program.

Planning of the program

Institutional Ethics Committee approval was obtained before the start of the study. The students of 2nd year of MBBS were informed about the workshop in a brief session and motivated to participate in the workshop. The flyer of the workshop titled, “Theatre workshop for Medical Humanities,” was circulated in the college and hostel notice boards. The cutoff number of the participants was kept as 30, who were enrolled on “first come first served” basis. Written informed consent was obtained from the participants. The workshop had two parts: online part (5 days) and physical workshop (2 days).

Online part of the workshop

Before the physical workshop, the participants were engaged in an online activity for 5 days using WhatsApp medium. The purpose of this group was to develop the sense of comfort and create a safe space for sharing of thoughts and feelings, before the group would meet in the physical workshop. After introductions, one image[19] and a video[20] in succession were shared by the authors to trigger discussion in the group. The participants were encouraged to reflect and respond keeping themselves in the shoes of a health-care professional, using “I” perspective using the following framework: (1) What do I see in this video, (2) What meaning it carries for me, and (3) My learning from this video which can be put to action.

The physical workshop

The physical workshop began with brief introductions, since the group was already a coherent group due to the online activity. Certain agreements were made among participants and the facilitators: respecting confidentiality, respecting others by agreeing to disagree, using “I” perspective for sharing opinion, respect for everyone in the group, respectful touch (as certain games and exercises involved physical touch), and free to step out of the game/exercise in case someone is not comfortable. The list of agreements was accepted by all participants. Discussion and debrief on the online activity were done. Subsequently, the participants were made to participate in some carefully selected and sequenced games[21],[22] and exercises, like “Name playback”, “Cover the space”, “Colombian hypnosis”, “Colombian hypnosis with forum”, “The circle of knots”, “Cat and mouse”, “The blind car”, “The glass cobra”, “Image theater”. These games were devised by Augusto Boal.[21],[22] Each exercise was followed by discussion and debrief.

Final part of the workshop was a **Forum theater, in which the participants enacted five stories in five small groups of five to six members each, with the help of a play. Each play depicted an unfinished story of clear oppression. Buildup of the stories began during the workshop, where the facilitator asked the participants to enlist [Figure 1] any “social issue,” “personal struggle” or any “unresolved dilemma” or “unfinished story” in a word or a phrase on the board and create short plays around those stories in small groups. Each group chose one story out of all the stories of different members in a particular group.
Figure 1: List of issues written by the participants

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The five stories which were played were as follows:

  1. Motivation and career choice: This story was of a medical student who suffers from burn out in the 1st year after she was forced to choose medicine as a career choice, whereas she wished to study literature
  2. *Rudaali: This story depicted the social oppression experienced by the professional mourners
  3. The tunnel of darkness: The story reflected the discrimination between a teenager boy and a girl by the father and the family
  4. Doctor and the society: This story depicts the physical assaults experienced by the doctors
  5. Sookhe Patte (dry leaves): This story depicted an elderly mother who is abandoned by the family and is neglected by the society. “Dry leaves” was used as a metaphor for elderly.


All the stories were played in front of the audience (spectators), which comprised faculty members, residents, nursing staff, and students. Then, they were asked whether they were able to relate to the stories and would like to examine any particular story (issue) deeper. In order to select one story out of five, spectators were asked to vote for each story by show of hands. “Sookhe patte” got the maximum number of votes, hence was selected for the Forum Theater and was replayed. The audience were apprised by the **Joker that during the Forum Theater, any spectator could intervene by raising a hand and saying 'stop” aloud at a point where he/she strongly felt that he/she could change the outcome of the story. He/she could replace the person who is experiencing oppression (protagonist) and suggest the possible outcome by acting it out, thus becoming a “Spect-actor.” The first intervention was played by the Head of institute, in which he replaced the oppressed female. The contest began between the oppressor and the oppressed. After this point, the story moved in an unscripted way, because no one knew beforehand, what intervention would be played and what would be the outcome. Many interventions were made by various faculty members and the students, trying to break the cycle of oppression and bring a different outcome to the story, but the oppressor kept growing stronger. The forum theater came to the end when interventions stopped coming. It lasted for more than two and half hours and was concluded by the remarks of the head of institute.

Evaluation of the program

Program was evaluated using Kirkpatrick's model[23] of program evaluation by,

  1. Immediate feedback from the students about the program (reaction) using a questionnaire, [Appendix 1] containing ten closed ended items with five-point Likert scale from strongly disagree to strongly agree and three open-ended questions
  2. Reflections of the students on their experience (learning) using Driscoll[24] framework of reflection. The students were asked to submit their reflections in a week time.


Data analysis

SPSS 16 (USA) statistical software was used for data analysis. Frequency analysis of the feedback questionnaire responses was performed and agreement to each item was calculated by adding the frequencies of “strongly agree” and “agree” responses, disagreement to each item was calculated by adding the frequencies of “disagree” and “strongly disagree” responses. Reflections were subject to qualitative data analysis.


  Results Top


A total of 30 students participated in the workshop. The online activity triggered a rich discussion and evoked a lot of emotions. All the students filled up the feedback questionnaire; the response rate was 100%. Response rate of the reflections was 93.33%, as two students did not submit their reflections.

Perceptions of students

Perceptions of students to the closed-ended items of the feedback questionnaire are depicted in [Table 1]. One hundred percent of the students marked either agree or strongly agree on the Likert scale 1–5, to the items 1, 2, 3, 8, 9, and 10, whereas in items 4, 5, 6, and 7, the percentage of students who marked agree or strongly agree was 86, 93.33, 90, and 93.33 respectively, and the remaining percentage of students marked neutral option in these four items. None of the students marked disagree or strongly disagree to any of the items.
Table 1: Perceptions of the students on their experience of the workshop

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[Table 2] and [Table 3] depict the responses to open-ended items of the feedback questionnaire depicting games which were found most meaningful and which they enjoyed the most, respectively. Forum theater was found to be most meaningful and also most enjoyable followed by blind games such as Glass Cobra. Many students suggested to organize more such workshops in near future in the last section, which asked to write any limitations/remarks/suggestions.
Table 2: Games found most meaningful by number of students

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Table 3: Games enjoyed most by the students

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Reflections of students

The key words identified during WhatsApp discussion were; duty, ethics and professionalism, empathy and motivation.

Key themes identified from the reflections on the experience of physical workshop were fun and enjoyment, empathy, listening skills and communication, mutual trust and respect, doctor patient relationship, overcoming fear of judgment, improvisation, and appreciating diversity of thoughts. Representative reflections of the students on WhatsApp online activity and physical workshop are shown in [Table 4] and [Table 5], respectively.
Table 4: Representative samples of students' reflections on WhatsApp activity

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Table 5: Representative samples of the students' reflections on their experience of physical workshop

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  Discussion Top


The present study explored and documented the experience of students of participating in a TO workshop. In their feedback, all the participants have expressed that the workshop was an active learning exercise, it gave them opportunity for adequate interaction, it was an effective utilization of time, it provided them a meaningful experience, these indicate that the workshop was able to engage them meaningfully for experiential learning. 86.66% of students have agreed that they were able to voice their opinion without inhibitions, which reflects that the workshop provided them a safe space where they could be themselves without the fear of being judged; however, sometimes, there are some participants who are shy and take more time to open up; that may be the reason that 13.34% of students have marked neutral option to this item. Many TO games are played in silence and with eyes closed, which heightens the sense of touch and proprioception of the participants; it is also evident in their feedback in which 100% of the participants have agreed to this point. During the discussion and debrief sessions, all the participants and the facilitators sat on the floor in a circle and everyone was encouraged to share their feelings and views. The atmosphere during the discussion and debrief was such that any given time, only one person was speaking and others were listening, which enabled the listeners become receptive to others ideas, without any hierarchical obstacles, as evident in their feedback, where 93.33% of students have agreed that they became more open and receptive to others opinion. 100% of the students agreed that they would like to attend more such workshops in future.

The participants' responses in the WhatsApp activity reflect that most of them were able to appreciate the value of empathy and human connection in health care. They also expressed that they “feel blessed” pursuing medicine as a career. It seems that they were able to identify their “life-calling”, after having watched and reflected on the video. Danielle Ofri[25] compares medical humanities to the photographic negative of clinical practice, which enlightens the dark places of clinical practice, and in this process, we can explore what it means to be in medicine? We feel this is an important point, that, as teachers, if we are able to engage our students in activities, which can help them reflect on questions such as what is my motivation behind choosing medicine? why am I in medicine? and we can stimulate their intrinsic motivation for medicine for the reason that motivation influences learning and academic success.[26]

The participants' responses on the physical workshop reflect that they enjoyed the workshop and had fun while learning; it gave them a break from the mechanized daily time table of their studies. Similar results have been reported by other studies. A study by Ravi Shankar[22] reported the students having fun while learning in a TO workshop. Gupta et al.[27] also reported that TO offers a promising and enjoyable option to learn MH and suggests that in order to be effective, learning should be perceived as fun. According to Danielle Ofri,[25] joy and fun is not a part of pursuit of medicine, if humanities bring joy to our students battling with the overloaded curriculum that alone is a reason for celebration.

Many of our participants expressed that they felt more empathetic toward the patients and underprivileged. Empathy toward a disadvantaged group will help the students recognize the value of each individual and will effectuate into commitment to social justice.[28] Hence, if we can expose our students to situations which help them appreciate diversity and develop empathy, it can have profound positive outcomes in health-care delivery. Empathy, which is at the core of patient centered, humanistic approaches to medicine,[28] is regarded as an essential component of effective and quality health care[29] and has been suggested as an essential component of ABCDE paradigm for medical humanities to teach professionalism and humanism. Studies have reported that playing games and exercises in TO, the participants develop new insights and feelings, which indirectly improves empathy and communication.[4],[27]

Some of the participants have appreciated the impact of silence during the workshop. In TO, many games are played in silence, which forces to the participants to reflect deeply on their experiences. The participants communicate through their bodies and there is a lot of non-verbal communication taking place. The lesson is that we as doctors should not focus only on what the patient is telling us, and we should be able to “hear” through the body language of the patient.

The participants have also expressed that they listened more during the workshop, which is an important attribute of a humane doctor. Close listening is suggested as an essential strategy for practicing empathy, in addition to close noticing and close reading, which can be incorporated in teaching of health humanities.[29]

According to Alan Bleakley,[30] when a doctor listens closely to the patient and encourages questioning from the patient, the process of medicine becomes democratic and that helps in increasing trust between doctor and the patient. He, thus, proposes that the medical students should be educated with pedagogies that can inculcate democratic habits and development of interpersonal trust.

Many participants have reflected that having played the games, they developed “mutual trust” with their class mates and dwelt on the role of trust in doctor–patient relationship. Trust is the cornerstone of doctor patient relationship, so the students learned an important lesson.[31]

Many participants expressed that they developed better understanding of self, their bodies, abilities, and emotions and also identified their weakness and strengths. We believe that understanding of self is essential for self-care, which in turn is very important for maintaining a balance personal and professional aspects of life. Humanities offer personally enriching and restorative qualities, and thus, exposure to humanities can be used as a personal resource for physicians to remain balanced, sensitive, and understanding of the human condition.[32]

During the interventions in forum theater, the participants had to improvise and respond quickly. Similarly, when the students acquire the role of professionals, they have to deal with array of roles and tasks requiring them to adapt and respond quickly. This is an important skill for the doctors, which is needed throughout their professional journey. In TO context, we call it the ”rehearsal for reality.”[13]

In addition, most of them have expressed that they felt more confident as a result of the workshop. They developed respect for diversity of opinions, felt comfortable to express themselves in a “safe” space. They felt the positive energy and vibes in the environment. As a whole, in the garb of games and activities, the students learned many lessons, relevant to their personal and professional lives, which was evident during the discussion, debrief sessions, and from their feedback and reflections.

Authors reflections

The institute was only 2 years old at the time of workshop and the participants belong to the first batch of the institute. We feel both of these factors will be helpful in establishing the humanities group in the college. In the workshop, we witnessed that the students were a coherent group from the word go. We watched them engaging in the games and reflecting on their feelings. We saw their inner child manifest. The atmosphere during the Forum Theater was full of energy and lots of emotions. After the workshop, many cried, they did not want to leave the workshop hall and expressed that they cannot wait to have another TO workshop in near future. We feel that the students should be exposed to more such workshops for the safe space TO provides for potential personal and professional transformation.

Challenges and limitations

Facilitation of a TO workshop needs a trained facilitator, who has a crucial role in terms of building camaraderie in the group, choice of games and exercises, probing with the questions, guiding the reflections, and capturing the essence in the debrief sessions, which is crucial to help the students establish the connection between the games and the covert meaning. We were able to meet this challenge as the second author has received “6 days facilitators training from the Centre for Community Dialogue and Change, Bengaluru, India.[33] Second, in our experience, immediate impact on the participants is tremendous; however, it cannot be said with certainty that their experience of TO will have long term impact (Kirkpatrick's level 3 and 4 of impact evaluation,[23] on their attitudes and behavior, for that they need to be followed up in future.

The way forward

We took a small step with a TO workshop and now we are in the process of following our participants up, as it has completed 2 years, since they participated in the workshop. We intend to report our findings in the near future. Alongside, it is proposed that the participants can be exposed to TO exercises longitudinally, across different professional years of medicine, where the TO can be woven around specific themes of health care: ethics in research, disability studies, vulnerability, paternalism, and stigmatization. TO has been suggested as a teaching learning strategy for disability competencies in the foundation course by the Medical Council of India.[34] Various Attitude, Ethics and Communication competencies[35] given by the Medical Council of India for Indian Medical Graduate can also be approached using TO.


  Conclusion Top


The study documents the experience of exposing the students to medical humanities using an interactive tool “Theatre of the Oppressed.” The feedback of students reflects that the workshop was successful in bringing deep insights on the role of human values in medicine and they want to participate in more of TO workshops in future.

Footnotes

Forum theater

Forum theater is a game in which a problem is shown in an unresolved form, in which the audience members are not silent spectators, rather, they can participate in the theater and become “spect actors,” and attempt to change the outcome of the play. The forum is a form of contest between spect-actors trying to bring the play to a different end (in which the cycle of oppression is broken) and the actors try to bring it to its original outcome (in which the oppressed is beaten and the oppressors are triumphant). Usually, multiple interventions are enacted in the course of a single forum – the result is a pooling of knowledge, tactics, and experience, and at the same time what Boal calls a 'rehearsal for reality'. The whole process is presided over by a facilitator, which is called as “Joker” in TO parlance, whose role is to ensure smooth running of the play.

Rudaali: According to a custom, in certain areas of Rajasthan, women are hired as professional mourners after the death of a relative. These women are referred to as a “rudaali” (roo-dah-lee), literally translated as female weeper.

Acknowledgment

The current work was undertaken as a part of partial fulfillment of the Foundation for Advancement of International Medical Education and Research (FAIMER) Fellowship of the first author at PSG-FAIMER Reginal Institute, Coimbatore, India. We wish to acknowledge the guidance and mentoring of faculty members at PSG-FAIMER Reginal Institute, Coimbatore, especially Dr. Thomas Chacko and Dr. Shital Bhandary for their guidance. We also wish to thank our colleagues and Dr. Mukesh Yadav, Principal, N.C. Medical College and Hospital, Panipat, Haryana, for their support. We wish to thank the participants of the study for their participation and sharing their insights. We wish to thank Dr. Radha Ramaswamy from Centre for Community Dialogue and Change, Bengaluru, Dr. Satendra Singh, UCMS, New Delhi, Dr. Upreet Dhaliwal and Dr. Navjeevan Singh, Ex. UCMS, New Delhi, for their mentoring and support, Dr. Punita Salwan who was kind enough to review the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Appendix 1 Top


Feedback Questionnaire

The purpose of this questionnaire is to capture your feedback on the games and exercises which you played during the “Theatre Workshop for Medical Humanities” using “Theatre of the Oppressed'. Your response is important to us as it will not only help us evaluate the workshop and also develop insight about the meaning this workshop carries for you. Your identity will not be revealed in any way. Please provide your feedback by checking the appropriate box/option in items from 1-10 and answering to questions 11-13.

1-strongly agree (SA) 2-agree (A) 3-neutral (N) 4-disagree (D) 5-strongly disagree (SD)



11. Name one game which you found most meaningful

12. Name one game which you enjoyed the mosts

13.Any limitations/remarks/suggestions



 
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    Figures

  [Figure 1]
 
 
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  In this article
Abstract
Introduction and...
Materials and Me...
Results
Discussion
Conclusion
Appendix 1
References
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