Cinemeducation in medicine: a mixed methods study on students’ motivations and benefits

Cinemeducation courses are used to supplement more standard teaching formats at medical schools and tend to emphasise biopsychosocial aspects of health. The purpose of this paper is to explore why medical students attend the cinemeducation course M23 Cinema (M23C) at LMU Munich and whether a film screening with a subsequent expert and peer discussion benefits their studies and their future careers as medical doctors. An exploratory sequential mixed methods study design was used. Qualitative research, i.e. three focus groups, four expert interviews, one group interview and one narrative interview, was conducted to inform a subsequent quantitative survey. Qualitative data was analysed using qualitative content analysis and quantitative data was analysed descriptively. The findings were integrated using the “following a thread” protocol. In total, 28 people were interviewed and 503 participants responded to the survey distributed at seven M23C screenings. Participants perceive the M23C as informal teaching where they learn about perspectives on certain health topics through the combination of film and discussion while spending time with peers. The reasons for and reported benefits of participation varied with educational background, participation frequency and gender. On average, participants gave 5.7 reasons for attending the M23C. The main reasons for participating were the film, the topic and the ability to discuss these afterwards as well as to spend an evening with peers. Attending the M23C was reported to support the students’ memory with regards to certain topics addressed in the M23C when the issues resurface at a later stage, such as during university courses, in the hospital, or in their private life. The M23C is characterised by its unique combination of film and discussion that encourages participants to reflect upon their opinions, perspectives and experiences. Participating in the M23C amplified the understanding of biopsychosocial aspects of health and illness in students. Thus, cinemeducative approaches such as the M23C may contribute to enabling health professionals to develop and apply humane, empathetic and relational skills.

topics which -from the students' point of view -are not sufficiently covered in the curriculum and which would benefit from being discussed from multiple perspectives (e.g. intersexuality, transgender, abortion, surrogacy, euthanasia, Pompe disease, fast food, stigma about psychiatry, amputation). There is no restriction on the types of film (e.g. feature films, documentaries or short films). For the discussion, experts and, if possible, those affected by the topic (e.g. patients, relatives) are invited. The event is moderated by a medical student from the organising committee with questions raised mainly by the audience.
What distinguishes M23C from other cinemeducation courses is (1) the structure of M23C with the division into film screening and audience discussion, (2) that it is a voluntary evening event and (3) that in M23C the learning objectives as well as the questions to the experts and stakeholders are not predefined. The learning objectives are decided upon by the learners themselves and can be addressed by raising questions in the discussion.
Despite the fact that the M23C was established more than 15 years ago and is widely attended by between ten and 300 students per event, it is still not clear what motivates students and others to participate in these events and how the M23C enables learning.
The first objective of this study was therefore to assess the reasons that students attend the M23C on a voluntary basis. In particular, we investigated whether these reasons vary between different groups of participants. The second objective was to assess how students benefit from attending the M23C. We explored whether and how these benefits played out in their ongoing education. Until the study was conducted, there was only speculation about the reasons for participating in M23C and what the benefits might be. By knowing the reasons for and benefits of attending the M23C, we wanted to find out to what extent psychosocial aspects matter in M23C. As for the current generation of medical students, working and learning with film can encourage interest, enthusiasm and creativity [17], we wanted to provide arguments why cinemeducation courses should play a broader role in medical curricula.

Setting
This study was conducted at the medical faculty of the LMU Munich in Germany. The qualitative component of the study took place from October 2016 until February 2017. The quantitative component took place in the summer term 2017 and winter term 2017/2018.

Literature search
We conducted non-systematic literature searches in MEDLINE, PUBMED, PsycINFO, Psyndex and ERIC with the key words "cinema", "medical cinema", "film and medicine" and "cinemeducation", followed by additional searches of the reference lists of relevant articles. We used this literature to (i) inform the design of this study and, importantly, to (ii) design the guides for qualitative interviews and focus group discussions as well as the questionnaire.

Mixed methods study
We first wanted to explore the topics within the complex M23C course before deciding what variables needed to be measured. Therefore, we used a mixed methods approach [30,31] with an exploratory sequential design [32], where the qualitative component of the study preceded the quantitative component of the study and was used to inform quantitative data collection. The qualitative component entailed three focus group discussions (FGDs), four expert interviews, one group interview and one narrative interview. The quantitative component entailed a survey.

Qualitative sampling and recruitment
For the qualitative component, we employed purposive sampling [33]. The main inclusion criterion for focus groups was that participants had taken part in at least two cinema evenings. Inclusion criteria for expert interviews were that participants had taken part in one M23C evening in the last 12 months and that we could interview an affected person and an expert from the same event. Participants were approached via e-mail, a faculty newsletter and the M23C social media page.

Qualitative data collection
The data collection was undertaken by two researchers (MR, LMP). All interviews were conducted in German.
In order to provide all participants and organisers with adequate time and space to express their thoughts on the M23C, we chose four different qualitative methods: a narrative interview, FGDs, group interviews and expert interviews.
To explore the experiences, perspectives and motivations around the M23C and how and why it was established we chose the method of the narrative interview for the founder of the M23C. By providing a minimum of structure we aimed to stimulate the participant to reconstruct the initiation and continuation of the M23C.
In order to be able to discuss a range of perspectives on the M23C, we decided to have three internally homogeneous FGDs with different groups of participants (i.e. medical students, other health professionals, organising committee) who presumably had had different experiences with the M23C.
A qualitative group interview took place with two members of the founding organising committee members. We chose the method of a group interview because the number of former participants was not sufficient for an FGD.
We integrated the perspectives and experiences of the panel discussion participants by conducting four expert interviews with an expert or a patient to ensure that they could talk openly about all other experts or patients.
All interviews and FGDs were conducted using semistructured guides. For the narrative interview we developed an interview guide with i) a narrative stimulus, ii) narrative follow-up questions and iii) closing questions. All other guides contained five sections: i) reasons for attending the M23C, ii) experiences with the M23C, iii) what students learn and how they benefit, iv) how students learn and v) final questions to end the interview. The guide for the M23C committee contained an additional section on vi) organising the M23C.
All guides were pilot-tested before conducting the first interview and FGD. We conducted the nine FGDs and interviews face-to-face in seminar rooms at the university or the hospital to ensure a private atmosphere. Apart from the two researchers and participants, no one else was present. All interviews were audio recorded. MR and LMP took field notes after all interviews and focus groups.

Qualitative data analysis
All nine audio files were transcribed by MR using f5 transkript [34] and analysed using structured content analysis as described by Schreier [35] using MAXQDA 2020 [36]. Schreier provides a thorough guide throughout the process of qualitative content analysis whereas other authors provide little or no guidance [35]. The coding frame was inductively developed, with coding themes derived from the data [37]. Patterns in the data were recognised by initially sorting data more-than-once-occurring sequences of explanations and by searching for extreme or counterintuitive examples. Starting from a rather descriptive analysis, we started to identify, specific and consolidate emerging patterns within the data. In an iterative process, patterns were consolidated, specified and integrated where it made sense [38]. MR and LMP independently coded one FGD transcript, discussed emergent themes and agreed on an initial coding frame. Thereafter, this coding frame was applied to all transcripts by MR. In the analysis, the different qualitative data were coded using the same frame, while at the interpretation level we paid particular attention to the different perspectives of the participants. The research team met regularly during the study to discuss the analysis. After data analysis was finalised, the category system as well as exemplary quotes were translated into English by MR.

Quantitative sampling and recruitment
We used a convenience sample of M23C participants during seven medical M23C screenings (see Table 1). There was no additional recruitment for the survey beyond the usual promotional efforts of the M23C (i.e., faculty newsletter, M23C social media, posters, flyers). The survey was distributed in the lecture hall, where the M23C evenings took place, before the film started.

Quantitative data collection
Informed by the findings of the qualitative research, we developed a multiple-choice survey with 16 items on reasons for attending the M23C and three items on benefits of attending the M23C. Through qualitative content analysis we derived at a coding frame. The subcategories of the category reflecting on the reasons of attending as well as the benefits of attending were then transformed into quantitative survey items. An example of how this transformation was done can be found in Table 2. One question about dating was added post hoc, informed by discussions in the research team.
For the benefits questions we used a five-point Likert scale, with 1 meaning "disagree" and 5 "agree". Sociodemographic characteristics addressed included gender, age, course of studies, university, education level and participation frequency. Zensus direkt [39] was used to construct the survey.

Quantitative data analysis
We performed a descriptive analysis (i.e. mean value, standard deviation) and constructed bar and Likert plots in R [40].

Integration
For the integration of the qualitative and quantitative findings we used the software MAXQDA 2020 and applied the "following a thread" protocol [41][42][43][44]. First, we sorted the data by creating a unified list of themes and constructing a convergence coding matrix. Second, we analysed the data in a joint display table by agreement, partial agreement or neutral and disagreement [45].  Third, in a completeness assessment we compared the qualitative and quantitative results and shared the integrated results with the research team for feedback and comment.

Ethical approval
Ethical approval for the study was obtained from the Ethics Committee of the Medical Faculty of LMU Munich (No. 537-16). All potentially eligible participants were informed about the research in oral and written form. Furthermore, participants in the qualitative component of the study received and had to sign an informed consent form stating that all data would be treated anonymously. An exception was the narrative interview with MS, who agreed that his data could be published nonanonymously. Participants in the quantitative component of the study were informed about the survey in oral and written form and signed an informed consent form. No fees were paid for participation in this study although participants in the qualitative component of the study were taken out for an inexpensive dinner.

Characteristics of participants in the qualitative study component
In total, 28 persons were interviewed. Table 3 provides an overview of their characteristics.

Reasons for attending M23C
Reasons for participating in the M23C varied in the qualitative and quantitative component. Figure 1 presents the reasons for attending M23C obtained through the survey, listed in order of importance. More than half of the 480 participants gave one or several of the following five reasons, i.e. that they had an interest in the film (355 or 74.0%), in the topic (325 or 67.7%), in the discussion (311 or 64.8%), that they wanted to spend an evening together with friends (304 or 63.3%) and/or to broaden their horizon (265 or 55.2%). On average, a participant gave 5.7 reasons (SD: 2.96) for attending the M23C. The three reasons that were of least importance to participants were "get to know myself better" (27 or 5.6%), "want to meet other medical students" (26 or 5.4%) and "want to network" (16 or 3.3%).
In general, reasons for attending the M23C were similar among males and females, Interestingly, more male participants reported an interest in spending an evening with friends and to use the M23C as a means of looking for potential partners.
In the following, we describe a selection of reported reasons for attending M23C, as well as one surprising  (Table 4) demonstrates the integration of the qualitative and quantitative component. Agreement, partial agreement and disagreement with the item in the qualitative data as well as lack of data for the different items are contrasted with the overall and stratified agreement in the quantitative component.

Film as a reason
The quality of the film seemed to be of importance, as described by this student:  Students also expect to see films they would otherwise not watch by themselves, which this student elaborates on:

And then I just said "Well, then you'll go when you
And maybe these are also films, I think, that I wouldn't watch in such a private setting, but which I still find totally interesting. And then discussing them with experts afterwards might give me the incentive to say "Cool, I'm actually interested in that. Then I'll just watch the film. -B5, other health professional students, focus group Interestingly, one of the organising committee members disagrees with the film itself always being a major reason: As shown in Fig. 2, 76.8% medical students and 76.9% other health students "have an interest in the film", compared to 56.1% non-health students. Some participants in the qualitative study elaborated on this in more detail.

Topic of the evening as a reason
The M23C seems to offer a safe space for difficult topics: One of the members of the organising committee argued that the choice of topic was her first priority for organising an event: I always thought about a topic that I would find interesting for me personally and looked for it accordingly. -B2, organising committee, focus group One of the invited affected persons who participated in the discussion supported this previously addressed high interest in the respective topic addressed at the respective evening:

… to feel that there is so much interest in the topic. -Affected person, expert interview
Of the first-time participants, 58.2% (103 out of 177) attended the M23C due to an "interest in the topic", compared to a range of 63.3 to 84.6% of participants who had attended the M23C before (cf. Fig. 3).

Discussion as a reason
Some of the first-time participants did not seem to know about the discussion and considered it as a reason to attend several times: At the very beginning I simply found the film exciting. I didn't know about the discussion [...] at all.       Of the first-time participants 49.7% (88 out of 177) attended the M23C due to an "interest in the discussion", and the percentage was even higher in those participants who repeatedly attended the M23C (cf. Fig. 3).

Evening with friends as a reason
There seems to be a group of participants who mainly want to enjoy an evening with friends and see the M23C as an event: Of the medical students 67.6% (227 out of 336), compared to 52.6% (41 out of 78) of other health professional students and 54.5% (36 out of 66) of non-health professional students attend the M23 because they "want to spend an evening together with friends" (cf. Fig. 2).

Broadening one's own horizon as a reason
The M23C seems to stimulate students to take on other perspectives:  Fig. 3).

Balance to curricular studies as a reason
Both the organising committee and the participants see the M23C as a balance to their studies: Of the medical students 38.1% (128 out of 336), compared to 26.9% (21 out of 78) of other health professional students and 9.1% (6 out of 66) of non-health professional students attended the M23C due to its inherently different character when compared to other subjects in the curriculum (cf. Fig. 2).

Dating as a reason
None of the participants in the qualitative study mentioned dating as a reason to attend the M23C.
Of the female participants, 9.8% (36 out of 366) are looking for a partner at the M23C, compared to 19.6% (22 out of 112) of male participants and 0.0% (0 out of 2) of participants of other gender.

Perceived benefits from participating in M23C
In the following, we describe insights from the qualitative component of the study as well as the most commonly reported benefits for attending M23C (Fig. 4). Participants reported several benefits from participating in the M23C during other courses in their curriculum, clinical internships or in everyday life. In addition uncertain benefits were reported.

Perceived benefits for university course
A medical student remembers exam situations in which they were confronted with content from the M23C: I actually must say that it has happened to me a few times during exams, that I read something there and something actually rang in the back of my head. And where I thought I had heard that before [in M23C]. -B3, medical student, focus group More than half of the participants who attended the M23C several times remembered an M23C evening during another university course (cf. Fig. 4, mean: 3.29, median: 4, variance: 1.9, SD: 1.38, on a Likert scale from 1 meaning "disagree" to 5 "agree").

Perceived benefits for clinical internships
Participating in the M23C might help a student to remember an illness when they see a patient during a rotation:  One medical student shared that he assumes that patients of the soon-to-be doctors might benefit from the broader view, the focus on psychosocial aspects and interdisciplinary approach fostered by M23C:

Perceived benefit in everyday life
A former medical student reported that he was able to tell interesting stories by participating in personal conversations at parties:

Main findings
To the best of our knowledge, our study represents the first mixed-method study of a cinemeducation course in Germany. It integrates in-depth qualitative insights on why students participate in the M23C and how they benefit from it and largely representative quantitative insights on the extent to which these reasons and benefits play a role for participants. In terms of reasons for attending, we found that the majority of participants attends the M23C due to an interest in the film, the topic and the discussion as well as to spend an evening with peers or to broaden their horizon. Some reasons vary depending on the educational background (medical vs. other health vs. nonhealth students), participation frequency and, to a lesser extent, gender. In addition, we were able to show that the perceived importance of the discussion increases when the M23C is attended multiple times. With repeated participation, the desire to broaden one's horizons seems to increase in importance. With respect to likely benefits, we found that the M23C helps to become aware of different perspectives of a disease and to remember a cinema evening or an illness later on, for example, in the clinic during an internship or as a doctor.
At the initiation of the study we presumed that the unique method of the cinemeducation course M23C is the combination of a film with an audience discussion. We hypothesised that a large share of the participants attended because of the possibility to watch a film for free. We were surprised to see that this motivation shifted in participants who had participated several times and who perceived the discussion and the topic as integral. This finding confirms previous research that reported that films can initiate significant group discussions [46,47].
The M23C pursues an open discussion where the audience -the students -play a critical role in raising questions. This is different from most other cinemeducative approaches: Baños et al. describe that their discussion focuses on questions prepared by the teacher [48]. The open approach of the M23C, that the moderator sparks a discussion among the participants, that the students themselves pose questions that interest them and that the invited guests mainly speak on questions addressed directly to them and do not prepare a presentation, seems to be an essential success factor positively perceived by the participants in this study.
Due to the fact that the search for experts in the organising committee takes up a large part of the time, we assumed that the invited experts were an important reason for participation -similar to the film, discussion and topic -and were surprised that this was rarely explicitly mentioned. However, participants described that the different invited guests had different perspectives on the topic and that they had benefited from the diversity of perspectives in forming their own opinions.
Medical students, despite increasing emphasis on the biopsychosocial model described by Engel in 1977, still seem to notice a lack of "human touch" in their curricular studies. This gap can be filled by voluntary cinemeducation courses like the M23C [49]. Our study showed that the majority of participants use the M23C to widen their horizon which is consistent with other studies [50]. We assume that this broadening of their horizon will enable medical students to recognise different human perspectives on health and illness.
Compared to non-health and other students, medical students seem to attend the M23C more as a balance to their curricular studies and in order to spend an evening together with friends. This could indicate that medical students use the M23C as compensation, but still want to learn something. It could also suggest that medical students have a greater need for compensation to their studies, or that there are currently not enough compensatory events with a psychosocial background in medical studies compared to other studies and health professional trainings. The results, particularly the qualitative components, may imply that it remains difficult for medical students to perceive the need for psychosocial aspects of health and illness as a priority learning experience and that there should be a shift from purely biomedical content to biopsychosocial approaches in medical school courses to foster a holistic overview of health topics. The students' quotes seem to imply that they undervalue psychosocial elements in their curricula but that when they are exposed to it, e.g. in M23C, they find that they value it highly.
Students reported benefits from participating in the M23C. In general, they linked knowledge acquired in M23C with memories of the film and the discussion, which is consistent with Shankar's [1] experience. Participation in the M23C could help prospective physicians to consider psychosocial aspects such as support groups and relatives for their patients. In addition, the medium of film with a subsequent peer discussion seems to help participants to remember content from the M23C later on in both professional and private contexts.
To date, it has not been researched how many cinemeducation courses are offered globally. Judging from the literature, a handful of medical cinemas exist in Germany, some of them located at medical faculties and clinics or medical societies with varying target groups. In addition, there are isolated film festivals worldwide with a focus on global health, public health, psychiatry and stigma -often organised outside of the university context. In university courses, whole films or excerpts of films are increasingly used for teaching purposes, although many curriculum designers do not seem to be aware of the research field of cinemeducation [17,19,29,51]. The proportion of non-health students and the open approach, suggest that the cinemeducation methodology as used in M23C can be transferred to other disciplines.

Strengths and limitations
Due to the fact that we chose a mixed-methods study design and involved most of the organisers of the M23C (idea provider, former and current organising committee) as well as different groups of participants, experts and affected persons, we were able to obtain a comprehensive overview of the M23C. The multiple data sources enabled us to answer our questions in a more nuanced way. For example, we were able to show not only various reasons for participating in the M23C, but also the percentages in which these are important in different groups of participants. Initially, it was planned to conduct one further focus group with medical students. We, however, decided to refrain from further data collection after one focus group with medical students due to data saturation. The design of FGD might have prevented some students from sharing further reasons from participating due to peer pressure; however, we are confident that the risk of social desirability was relatively low. Due to our exploratory sequential design, where the qualitative study component preceded the quantitative study component, we were not aware of the large presence of non-health professional students and did not arrange for further data collection with this subgroup of participants. This lack of representation of non-medical and non-health views in our qualitative data may have led to some reasons for participation or some benefits not being adequately reflected in our survey tool. In light of the qualitative results we might have included "interest in psychosocial aspects of medicine" as a reason in the survey which should be taken in consideration for future research. Integrating a clustering of the qualitative codes in our study design could have resulted in a more in-depth analysis.
By generating the questionnaire and the reasons from the qualitative results and a literature search, we believe that we were able to integrate the most important reasons for participation. In addition, we distributed the questionnaire on seven cinema evenings and can thus ensure that any systematic differences between evenings would not have biased the results.
The data collection was conducted by two researchers (MR, LMP). The participants of some qualitative components may have refrained from mentioning negative aspects of M23C because some of them were acquainted with MR. In order to minimise this risk, we deliberately pointed out at the beginning of the interviews and FGD that positive and negative contents about M23C are of interest and encouraged participants to openly share their perceptions. However, we cannot rule out potential effects of two different interviewers/moderators on the perspectives shared by the participants. Due to the anonymous nature of the survey, it is moreover likely that the 503 surveys were not filled out by 503 different individuals but that some of the participants attending more than one event filled in the questionnaire multiple times.
In order to present our findings to a broad international audience, we had to translate exemplary citations into English. This might have resulted in some loss of meaning. Our study provided rich qualitative and quantitative data. Integration represents a strength of our study in that we were able to use the qualitative quotes to better frame, understand and interpret the quantitative results.

Conclusions
This study provides an overview of the M23C at the LMU Munich, exploring the different reasons for participants to attend and how it benefits them in their future careers in health care. The M23C is rooted in the combination of film and the subsequent peer and expert discussion that encourages participants to reflect upon their opinions and experiences. Participants seem to value this combination and to benefit by gaining a better understanding of the biopsychosocial aspects of health and illnesses. Furthermore, the film and the discussion also seem to help the participants to remember the contents of the cinema evening at later points in their studies, in a clinical setting or in everyday life.
The study also provides useful insights for planning future cinemeducation courses. It suggests that cinemeducation organisers should above all attach great importance to the selection of films and topics and less to the invited experts. Cinemeducation courses like the M23C could contribute to teaching health professionals a more humane and empathetic way of medicine -something which is still rarely taught in medical school.