Getting It Right: Fidelity in the Use of Visual Thinking Strategies in Medical Education

Visual Thinking Strategies (VTS) is a structured, evidence-based pedagogical method that has been increasingly embraced in medical education to foster essential clinical competencies such as observation, interpretation, communication and empathy. Originally developed for use in K-12 classrooms, VTS involves a standardised facilitation method centred on three carefully sequenced questions posed in response to a visual artwork. Although deceptively simple in format, effective facilitation of VTS requires extensive training and adherence to specific practices that activate collaborative and critical thinking processes. As interest in arts-based pedagogies grows in medical education, VTS stands out as a method with defined guidelines and demonstrable educational outcomes. However, this paper argues that the expanding adoption of VTS be accompanied by a commitment to fidelity-in how the method is implemented, studied and described in the academic literature. While an increasing number of medical educators are enthusiastically incorporating VTS into their curricula, the literature belies a concerning trend of deviations from the method's core components. These include altered wording of the three core questions, inconsistent naming of the method, facilitation by untrained individuals and inadequate or inaccurate methodological descriptions. Such deviations, even when subtle, can compromise the internal validity of research findings and risk misrepresenting the nature and effectiveness of the intervention. This lack of fidelity could threaten the integrity of educational outcomes and the credibility of arts-based approaches in the broader field of medical education. Compounding the issue, peer reviewers and journal editors may lack sufficient familiarity with VTS to identify these inaccuracies, enabling flawed implementations to persist in the literature. We contend that ensuring fidelity to the original VTS methodology is a shared responsibility across researchers, educators, institutions and scholarly publications. Adherence to the method maintains its pedagogical and scholarly value. To that end, we offer practical recommendations, such as formal VTS facilitator training (with greater accessibility to educators in low-resource settings), accurate reporting standards, peer reviewer education and the cultivation of a community of certified practitioners. As VTS continues to gain traction, we recommend that educators aim for fidelity in its use and study, ensuring that its full potential to enrich clinical education is realised and preserved for future generations of learners.