Old Works of Art Are Helping Med Students Learn How to Diagnose
It's all in the details.
Yale Center for British Art
Artists have long been fascinated by illness, rendering everything from syphilis to arthritis to tuberculosis in careful brush strokes. The diseases depicted, frozen on the canvas, have in turn created a type of diagnostic mystery for modern day physicians. As an intellectual exercise that doesn't require medical malpractice insurance, for years doctors have been publishing their theories and arguing with each other over the diagnoses of people long dead.
The discoloration and breast malformation depicted in Rembrandt's "Bathsheba at Her Bath," for instance, has been explained away with a variety of possible causes. Papers have argued that everything from breast cancer to tuberculous mastitis to an abscess are responsible for the swelling and blue mark around one breast of the famous bather. Corot's lively "Gypsy Girl with a Mandolin" probably didn't play for long after she was painted. Her puffy hands are indicative of inflammatory arthritis, doctors concluded. A science themed painting from 1768, "An Experiment on a Bird in the Air Pump," yielded a diagnosis of a rare skin disease on one of the experiment's onlookers that was not formally described until a century after the work was painted. The fate of the poor bird remains lost to time.
What started out as a fun hobby for practicing physicians has morphed over the past two decades into a burgeoning field in medical education. In an age when most young doctors barely look up from their laptops and depend on multiple expensive test results for diagnostic clues, medical educators have had to get creative to reteach the art of looking, so they turned to looking at art. It started sixteen years ago with Linda Friedlaender, the senior curator of education at the Yale Center for British Art and Irwin Braverman, a dermatologist at the medical school at Yale.
Together they created a program to teach first year medical students how to notice details by studying paintings in the University's art museum as part of their medical training. Today in addition to teaching Yale's medical students, Friedlaender works with the nursing and physician assistant programs at Yale as well as a neighboring medical school. Ever rivals, Harvard soon started their own program. Harvard recruited art educator Alexa Miller, who runs a consulting business to teach medical practitioners how to observe better using art, called Arts Practica, to help develop it.
These days programs using art to teach students and practicing doctors how to be better diagnosticians exist in 70 medical and nursing schools in the US. Friedlaender has gotten inquiries and visits from educators interested in starting their own programs from Israel, Egypt, Taiwan, China, Japan, France, and England. Both the Harvard and Yale programs have published studies demonstrating how something as simple as visiting a museum, carefully observing paintings, and discussing them can lead to better diagnostic and descriptive skills down the road.
In a typical class, Friedlaender will assign students to look at a painting for ten minutes before joining a group discussion focused on describing what they saw in as much detail as possible. If, for example, the painting depicts a woman holding a flower stem, she will ask students with which fingers the woman holds the flower stem, and how she is holding it—gently or clutching it. She will keep asking more and more detailed questions about every aspect of the painting before moving on to the subjective, asking students to explain what the painting depicts.
Any conclusion about what is happening in a painting is fair game, Friedlaender says, as long as students can point back to some aspect of the painting to prove their point. Medical students will often say that as soon as they figured out what they thought was the right answer, they stopped looking at the painting for additional clues. Stomping out that type of thinking, which allows a doctor to close off all other possibilities and stop looking as soon as one conclusion presents itself, is part of what Friedlaender and Miller seek to teach.
Learning to look is only part of the skills that art teaches, explains Miller. In her work with mid-career medical practitioners, she finds art helps break the strict hierarchy in medicine. While a nurse may hesitate to contradict a doctor at the hospital, when it comes to a class on looking at art, knowledge levels may differ, but they don't striate strictly by degree, she explains. Many times in her art classes, those people who have less familiarity with the artwork also bring the most interesting observations because they are looking at the work without any preconceived notions. Miller ties those lessons back to medical cases, demonstrating that sometimes the person who is not, strictly speaking, the "expert" in the room can see something no one else does, and needs to speak up about it.
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Another skill both Miller and Friedlaender emphasize is comfort around uncertainty, a common predicament in medicine. In looking at a painting, students often don't agree on the right conclusion around the narrative depicted. Friedlaender reassures students that it's okay to not be sure about the conclusion, and that more than one narrative might fit, similar to how a patient may present with multiple conditions at the same time, which might cloud the diagnosis. Making space to acknowledge uncertainty and talking about how to respond to it is an important part of the lesson that Miller seeks to impart. Learning to get comfortable around uncertainty in something neutral, like art, makes it easier when it presents itself in something important, like making a correct diagnosis.
Dealing with the reality that doctors are human is another lesson art offers. Miller will sometimes pick artwork that is inherently unpleasant or repulsive, a canvas that people have a visceral response to and want to avoid. The reality is that sometimes doctors will have a strong response to a patient, disliking the person on contact, just like anyone else. That dislike can factor into how well a physician will diagnose the patient. Spending time with a work they don't like and talking about the experience of observing carefully something that is inherently unpleasant can help doctors deal with their feelings when it comes to a real patient. Friedlaender sees art as another tool for medical students to discuss inherent biases and recognize them in themselves before they face a patient. If a doctor comes across as judgmental when speaking with a patient, "forget about learning more about that patient," Friedlaender says.
Both art educators hope that programs like the ones they run will continue to gain traction in medical schools and continuing education programs, leading to doctors who notice the little details, learn how to describe them, and stop to really look carefully at all of their patients. For Miller in particular, eliminating errors in medicine is a passion since her birth by cesarean section, from which she tells me her mother suffered because of medical error. She hopes by learning to deal with uncertainty, not ruling out other possibilities too early, and carefully backing every diagnosis with an observation, that medical errors—both of observation and of thinking—will be greatly reduced.
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