February 05, 2013 

A growing number of medical schools are incorporating the arts into their curricula to improve students’ diagnostic skills. Schools such as Yale University and Harvard University are partnering with museums, where a painting is the patient, the gallery is the hospital room, and the students are practicing diagnosticians.
Photo: Henry Wallis’ 19th century painting “The Death of Chatterton” is used in exercises as part of a diagnostics class at Yale University School of Medicine.

A slender young man in a loose, open shirt is sprawled on a bed, his right arm draped limply over the side of the bed and his knuckles brushing the floor. The room in which he lies is dim, lit only by muted sunlight entering through a small window, but you can make out scattered paper and an empty vial on the floor. Looking more closely, you notice his body’s contortion and the uneven placement of weight on his hip. Further examination reveals scratches on his chest and an ashen tint to his face.

Is he asleep? Is he drunk? Is he dead?

Determining the diagnosis is up to the first-year students from Yale University School of Medicine, who are examining “The Death of Chatterton,” Henry Wallis’ 19th century painting of English poet Thomas Chatterton, shown dead after he poisoned himself with arsenic in 1770.

The exercise has been a required part of the curriculum at Yale School of Medicine for 10 years and is illustrative of a broad movement in medical education to incorporate the humanities — literature, social sciences, the arts — into schooling as a means of nurturing skills of observation, analysis, empathy and insight into the human condition.

These programs also address the problems that arise in physical diagnosis — dealing with competing diagnoses, conclusions based on insufficient information and ambiguities in data.

And in the age of frequent reliance on MRIs and CT scans, the programs substantiate the value of the physical examination.

The Physician as Observer

This innovative use of art as in instruction is the brainchild of Irwin M. Braverman, M.D., professor emeritus of dermatology at Yale University School of Medicine. Dr. Braverman says there are more than 25 medical schools that have followed suit. For some students, it’s required. At other schools, it’s an elective. Regardless, it gives medical students the chance to hone their skills at something that may have taken their predecessors a decade to master, Dr. Braverman says.

“Observational skills are notoriously hard to teach and learn,” Dr. Braverman says. “Most medical students learn by rote, but you can’t teach good skills of observation by lecture alone. Doctors learn how to do it on their own through hard-learned experience. It takes a number of years. This workshop is trying to jumpstart that process to make observers of students when they’re first starting out.”

Following the establishment of the program, Yale conducted a two-year study of the approach, which demonstrated its efficacy. The findings were published in the Journal of the American Medical Association.

“Louis Pasteur said ‘Chance favors the prepared mind.’ By teaching students to think critically, you can have physicians with prepared minds who see when something doesn’t happen like it should. That’s how advances are made. If it weren’t for that fact, we’d still be practicing like they did in the time of Hippocrates.”

— Irwin M. Braverman, M.D., professor emeritus of dermatology, Yale University School of Medicine

Likewise, Harvard Medical School was at the forefront of teaching observational skills, launching its elective course, “Training the Eye: Improving the Art of Physical Diagnosis,” in 2005. Analyzing art and clinical images before and after 12 sessions in the art museum, students made 38% more clinical observations after completing the course of study, according to a study conducted by the school.

“There’s a very visible improvement,” says Alexa Miller, co-creator of Harvard’s course, a principal arts learning consultant and an adjunct faculty member at Brandeis University. “Students begin listening to one another and build on each other’s ideas more. In the earlier sessions, everybody’s presenting their own ideas, but as time goes on they interact more. The general comfort level is greater, and they describe more freely what they see.”

Removed from the intense pressure to perform in the clinical setting, Miller says, students feel they have permission to think more imaginatively in the museum.

The Museum as Classroom

Dr. Braverman takes his students to the Yale Center of British Art, where the collection includes a wealth of Victorian and pre-Victorian art. All of the paintings are narrative, he says; all of them tell a story.

“The paintings are very much like patients because they have a lot of signs and a lot of contradictions,” Dr. Braverman says. “The students have to recognize and find the contradictory information. The paintings are surrogate patients in every way possible.”

Yale separates classes into groups of four to work with a museum docent. Dr. Braverman trains the docents in the medical relevance of each painting, schooling them in a series of questions to pose to the students. With Dr. Braverman’s coaching, the docents grow to understand the concept of differential diagnosis.

Similarly, Miller gathers her students at the Museum of Fine Arts and the Isabella Stewart Gardner Museum, both in Boston. Students generally look at two or three works of art for 15 to 20 minutes each.

Miller selects paintings that are provocative of deep discussion, those that have ambiguity, contradiction, and both recognizable and unfamiliar elements of the world.

“We’ll look very closely at the works of art using a method called Visual Thinking Strategies, a research-based facilitation method,” Miller says. “The staple of that method is asking three questions: ‘What’s happening here?,’ What do you see that makes you say that?,’ and ’What more can we find?’”

Interpretations must be backed up with evidence. Observations must be separated from inference.

Sessions are followed up with clinical experiences. In Harvard’s course, students participate in clinical rounds. In Yale’s workshop, students analyze a complicated image of herpes zoster.

“The usual comment at the end is the students say, ‘I look at things differently now,’ and that is a very significant statement,” Dr. Braverman says. “We’re getting the students to use that vital connection between their eyes and their brains. Now all they have to do is keep practicing.”


No comments

Be the first one to leave a comment.

Post a Comment