Cardiology and Films: An Important Teaching Tool

Mailing Address: Ana Luisa Rocha Mallet Rua Almirante Alexandrino, 1808/SS-302. Postal Code: 20241-263, Santa Teresa, RJ Brazil. E-mail: alr.mallet@gmail.com Cardiology and Films: An Important Teaching Tool Ana Luisa Rocha Mallet,1,2 Fatima Geovanini,2 Luciana Andrade,2 David Kestenberg2 Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ);1 Rio de Janeiro, RJ Brazil Universidade Estácio de Sá,2 Rio de Janeiro, RJ Brazil

The use of films and literary texts as didactic material in medical school has increased based on the perception that it might benefit the discussion of certain technical aspects of clinical conditions and enable students to experience the illness process.
An article on literature and cardiology 1 has shown that the description of the death process in Tolstoy's novel "The death of Ivan Ilyich" could be more powerful to provide medical students and physicians with the perception of the finitude process than reading theoretical texts about the end of life. Similarly, Marguerite Yourcenar's "Memoirs of Hadrian" could help to understand the suffering of a patient with heart failure.
Similarly to literature, films have been used for medical education to discuss questions related mainly to ethics and medical practice. Some films, such as "Patch Adams", "Cry Danger", "The Sea Inside", "Black Swan", "As Good as it Gets", "Wit", are classically presented to medical students for medical education.
If on the one hand, by telling a story and showing an image, films can reduce our ability to imagine how the story's characters and places would be, on the other, they provide us with a different aesthetic experience, usually shorter than book reading, by offering images and sounds that affect our sensitivity in a different way than book reading does. Both literature and films allow us access to a level of internalization difficult to achieve when reading a medical book or text about a certain disease. Medical books provide the description of cells, organs and diseases, how to establish a diagnosis, in addition to the drugs and other treatments to be used, while literature and films provide us with the experience of patients with their illnesses.
Regarding cardiology, the year 2016 was particularly interesting, because two awarded films, "Manchester by the Sea" and "I, Daniel Blake", approached under different aspects one of the most prevalent heart conditions worldwide: heart failure.
Kenneth Lonergan's "Manchester by the Sea" was awarded with the 2017 Oscar for best actor in a leading role (Casey Affleck) and best original screenplay. Its central plot is the return of a man to his hometown after the death of his brother to take care of his 16-year-old nephew, re-opening an unspeakable tragedy. The film scene that interests us, due to its potential to foster a cardiology class discussion, lasts less than three minutes and approaches the disclosure of his brother's heart failure diagnosis to the patient and his family (wife, brother and father) by a female doctor during one of his hospitalizations. The doctor talks with the patient about his diagnosis and prognosis, explaining that the data presented were statistics and not definitive numbers about a particular patient. The scene raises ethical and technical questions, such as possible heart failure etiologies, its treatment, its mechanisms of death, its prognosis. In addition, that scene provides us with the different ways to react to such talk, always difficult, especially the patient's and his wife's reactions.
Talks involving the disclosure of the diagnosis and prognosis of life-threatening diseases, also known as bad news, are one of the most difficult attributions of a doctor. Bad news in the healthcare field are any information that will drastically affect the future perspective of patients and families. Difficulties in communicating bad news usually postpone discussions with the patients and families about terminal diseases, Int J Cardiovasc Sci. 2018;31(4)451-453 Viewpoint proximity of death and indication for exclusive palliative care. [2][3][4] But we might have to face even tougher situations when managing patients with heart failure, such as answering the following questions: "How many years do I still have?", "Will I live to attend my child's graduation?", "Will I live to see my grandchildren grow up?", and other questions that might cross their mind. Perhaps one of the defenses we put up is to restrict all room for that sort of questioning. In addition to not being the proper solution, this attitude somehow postpones coping with those issues, which ends up avoiding that discussion, because, not rarely, the outcome soon becomes clear to both patients and families. However, that attitude hinders the communication with patients and families, delaying their understanding of the situation.
In addition, the discussion about that scene can go beyond medicine as we realize that the diagnosis is established by a female doctor of Asian origin. This can lead us to debate our reality in the Brazilian medicine, in whose graduation programs female students predominate. How will this affect medical practice? Will this change the doctor-patient relationship? Moreover, the Asian origin of the doctor can open the discussion about "the other", "the foreigner" in a country that seems to move away from its cosmopolitan tradition. Perhaps we could draw a parallel to the issue that "the other", through the quota system, affirmative actions, ProUni and FIES, has become an increasing presence at medical schools in Brazil, one of the most elitist courses in the country.
The other film from 2016, Ken Loach's "I, Daniel Blake", was awarded with the Palm d'Or in the Cannes Film Festival and also approaches the heart failure issue, but from a social perspective. In that film, set in England, Daniel Blake, interpreted by Dave Johns, after having a heart attack, is advised by his doctor not to return to his work at a carpentry, and, thus, must fight the bureaucratic forces of the system to receive Employment and Support Allowance. He faces the bureaucratic system, the coldness of the institutions, which supposedly exist to make the patients' lives easier, the difficulties enlarged by his digital illiteracy, and a whole process that reminds us of the Franz Kafka's novel "The Trial", which tells about the distressing, meaningless and cruel bureaucratic trial to which citizens are submitted.
Watching this film can bring to the classroom discussions about situations rarely approached in lectures on myocardial infarction and heart failure, but which are extremely frequent when managing patients with such conditions. Who has not been asked: "Doctor, when can I go back to work?", "Doctor, am I entitled to retirement benefits?", "How do I receive my support allowance?", "Doctor, they have cut my benefits. What should I do?". These situations are so frequent for those following patients up after myocardial infarction and with heart failure that we have to know something about the legislation to instruct our patients in a responsible way regarding their rights, providing them with reports to allow them to have their rights ensured. Usually such reports need to be systematically renewed, which not rarely makes the patient feel shy, fearing to be bothering the doctor.
An additional theme for discussion in that film is the question of "the other". In one of his several visits to the government offices, Daniel Blake befriends a white woman who had just moved to the city and also seeks for social support. She has two children, one of them is a black girl, who also suffers with the social security insensitivity. Although our patients might face much bigger difficulties than English citizens do, this film shows that bureaucracy and insensitivity are not exclusive characteristics of our society.

Conclusion
The use of films or film scenes is an important tool to discuss heart conditions, not only regarding the disease's technical aspects, but also the social, ethical and existential aspects involved in the diagnosis of a severe heart disease. To quote Arthur Kleinman, the laureate films "Manchester by the Sea" and "I, Daniel Blake" are examples that can help us practice medicine in a more sensitive and reflexive, alert and morally responsible way in face of the emotional and experiential challenges presented by the profession. 5

Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.