Equus – August 2019

26 EqUUS 498

Horses are helping to train

the next generation of medi-

cal doctors—but not in the

ways you might think. Instead

of serving as models for com-

parative physiology or sub-

jects for the practice surger-

ies, they are being used to

teach medical students how

to cope with ambiguity.

Since 2014, students at

the Warren Alpert Medical

School of Brown University in

Rhode Island have been given

the option of participating in

a three-and-a-half hour work-

shop that uses horses to

illustrate the real-world

uncertainties that can make

diagnosis difficult.

“Tolerance of ambiguity

is important in clinical prac-

tice because medical edu-

cation often trains students

to think in black-and-white

with definitive answers on

tests and other schoolwork,”

says Daniel S. Jamorabo,

MD, a gastroenterologist who

helped develop the program.

“Yet trainees have to be able

to understand the nuances of

a patient’s symptoms, labs,

imaging, etc., to build a differ-

ential diagnosis.”

Medical schools have

long sought better ways to

prepare students for these

uncertainties. A chance meet-

ing between Kevin Liou, MD,

and Connie Crawford, a pro-

fessor at Brown University’s

theater department, led to an

inspired solution. “We met

at a lecture on improvisation

in the medical field,” says

Crawford, an avid equestrian

who often uses horses when

teaching her classes on act-

ing. “I told him of the work I

do with horses and our ad-

venture began.”

In the workshops, medi-

cal students travel to a local

boarding farm and are intro-

duced to horses by Crawford

and trainer Alyshia Gaw.

“Horses are foreign to most

of the students, thereby offer-

ing greater areas of ambiguity

and concern,” says Crawford.

“They are large and easier

to read than smaller animals

and they are more coopera-

tive than other animals.”

Under Crawford’s and

Gaw’s guidance, the medi-

cal students participate in

two group activities. In the

first, they observe and inter-

act with the horses to make

a “diagnosis” that captures

the horse’s personality. In

the second activity, they try

to persuade the horse to

take three steps forward and

backward and to lower his

head. Although the program

uses school horses who are

accustomed to handling, the

students find the tasks chal-

lenging, says Crawford. “We

examine the process as it

is happening. Students are

given many opportunities to

discuss and then practice

ways of communicating and

coping with any frustrations

that arise.

“I believe that horses of-

fer an excellent analogy for

human patients,” continues

Crawford. “The horse models

a patient who does not speak

our language, is from a differ-

ent culture and is in a stress-

ful situation. When a medi-

cal student unfamiliar with

horses interacts in a foreign

setting with foreign beings,

their own self-preservation

heightens. Two beings with

strong self-preservation offer

wonderful complications of

communication. Working with

students to be mindful and

compassionately aware while

dealing with new situations

that could be dangerous de-

velops their confidence.”

To test the efficacy of the

program, the school organ-

ized a session in which the

students complet-

ed Budner’s

Tolerance of

Ambiguity

Scale before

and after the

training. This

scale is a validated method of

assessing change in ambigu-

ity tolerance among medical

trainees by measuring their

reactions to various state-

ments. The data showed that

all the participants had a

lower post-workshop score,

indicating a greater toler-

ance of ambiguity, but this

difference was statistically

significant only among first-

year students. This, say the

educators, was likely due to

the larger sample of first-year

students but may also reflect

greater flexibility during ear-

lier years of medical training.

Although it may not al-

ways be feasible, Crawford

believes other medical stu-

dents could benefit from sim-

ilar programs. “Personally, I

believe that horse work is ex-

tremely valuable,” she says.

“I would like to see more

in-depth practice offered to

medical students who want

to work directly with patients.

The skills honed are pro-

foundly valuable to improving

patient outcome.”

MEDICAL STUDENTS LEARN HORSE SENSE

Reference: “Foreign bodies: Is it feasible to develop tolerance for ambiguity

among medical students through equine-facilitated learning?” Medical

Teacher, March 2019

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