Irwin M. Braverman, M.D.
Cell 2 Soul. 2006 Winter; 2(4):a11
Based on presentation at Cell 2 Soul Conference
November 12, 2006
Pattern recognition is essential for diagnosis in all branches of medicine and is vitally important in dermatology, radiology, pathology and ophthalmology.
Accurate differential diagnosis relies on an astute clinician who is able to discern the fine details in a pattern. This ability is a skill that needs to be continually practiced and honed for ultimate effectiveness. For example, a diagnostician must be able to recognize subtle differences between lesions that resemble one another, but which are actually signs of different disorders, such as the telangiectases of scleroderma and those of hereditary hemorrhagic telangiectasia (1).
Observation is necessary in variety of disciplines
Visual training is a necessary process in honing one's skills of observation, as noted by experts in a number of disciplines. Sherlock Holmes, in Study in Scarlet, addresses this need: "Like all other arts, the Science of Deduction and Analysis is one which can only be acquired by long and patient study, nor is life long enough to allow any mortal to attain the highest possible perfection in it. Before turning to those moral and mental aspects of the matter which present the greatest difficulties, let the enquirer begin by mastering more elementary problems. Let him, on meeting a fellow-mortal, learn at a glance to distinguish the history of the man, and the trade or profession to which he belongs. Puerile as such an exercise may seem, it sharpens the faculties of observation, and teaches one where to look and what to look for. By a man's finger nails, by his coat-sleeve, by his boot, by his trouser knees, by the callosities of his forefinger and thumb, by his expression, by his shirt cuffs — by each of these things a man's calling is plainly revealed. That all united should fail to enlighten the competent enquirer in any case is almost inconceivable."
Sir Ernst Gombrich, author of the celebrated standard fine arts textbook, The Story of Art, proposes that "We notice only when we look for something, and we look when our attention is aroused by some disequilibrium, a difference between our expectation and the incoming message."
William Osler admonished physicians to "Learn to see, learn to hear, learn to feel. Learn to smell, and know that by practice alone can one become expert."
In 1981, Richard M. Caplan, MD, raised the subject of using observation and analysis of fine art to heighten awareness in the art of medical diagnosis. In an article titled, Can Art be CME? in the Journal of the
Iowa Medical Society, he posited the following: "Being attentive to appearance, words and manner is a crucial first step in the doctor-patient relationship and a great aid to diagnosis. We teach it (or think we do) at a student's earliest contact with patients, but alas we soon forget about it. It requires reinforcement since most of us grow callous or indifferent. To gaze closely in the museum allows for an awakening of the spirit of attending which may have grown dull through the patterns of routine. One needs a refresher course for the skill of clinical observation."
Can medical students increase observation skills?
To test this principle, I helped initiate a program at Yale University designed to determine the effectiveness of pattern recognition training. First year medical students were divided into two groups: those receiving training intervention and those receiving no training. The intervention group was taken to the museum to study a variety of fine art paintings. Specific visual training questions and exercises were presented to increase powers of observation and analysis.
The students in both groups were shown photographs of patients with medical disorders prior to the fine art training as well as after the training, and their pre- and posts-responses were analyzed. The students in the intervention group improved their mean test score by 9%, while the mean score of the control group showed no improvement. In addition, significantly more students in the intervention group improved their test scores than in the control group.
How does one become a better diagnostician?
Our continued "art walks" through the museum jump start the cerebral expression of discovering the meaning of what one has never seen before. Observing paintings helps medical students and residents to Look! As a result, they become better diagnosticians. So how do we approach the task?
Assume that every feature in a painting has been placed there by the artist for a reason, whether part of the scenery or details on human figures. Every feature is artificial; nothing is there naturally. The task is to identify every detail (e.g, the curl in the hair, the blemish on the ear, the 3 wrinkles on the forehead) and try to understand why it is there and what it means. It may not always be possible to determine the meaning of every feature; however, a good observer should be able to identify every feature present.
We begin by scanning the entire painting. It is important to first grasp a basic idea of what the style and subject matter are; e.g, a landscape showing a village with many people going about their chores, a full length portrait of a farmer holding his tools, a portrait of a young child, etc.
Next, we develop a systematic method of examining the painting so we are sure to cover every inch of the canvas. We might proceed from the foreground and move to the midground and then the background. Or we might split the canvas into sections, such as perusing each of four quarters. We look for every detail possible to help determine clues such as: what season is it, what time of day, what is the geographic location of the scene, what activities are taking place, why are people depicted as they are? Answers to these questions pull focus to the myriad details represented.
Another approach might be to formulate a quick interpretation of what the artist is trying to convey on a first quick pass. Then, seek out details that either support or negate the initial conclusion. Do all the observed features lean in one direction or another, or do some go one way and others go in a different direction? Are there any internal contradictions in the painting?
Whether carefully observing paintings, butterflies, flowers or leaves, we have found that training medical students to look more carefully at details in art and objects crosses over into the practice of medicine. By training the wonderful connection between the eye and the brain, we rise above succumbing to a reliance on the crutches of imaging and testing.
It may not be that physicians don't always know enough, rather that they do not see enough.
References.
- Braverman IM. Skin Signs of Systemic Disease, 3rd Ed. WB Saunders, Philadelphia, 1998
- Adrian-Harris D: Aspects of visual perception in radiography. Radiography XLV: 237- 243, 1979
- Caplan, Can Art be CME?, J Iowa Med Soc, Oct 1981
- Dolev JC, Friedlaender L, Braverman IM: Use of fine art to enhance visual observational skills. JAMA 286:1020-1021, 2001
- http://info.med.yale.edu/dermatology/dept/braverman.html
Editor's Note: For a stunning example of the reaction of a student who participated in an Art Walk led by Irwin Braverman at the Williams College Art Museum following the Cell 2 Soul Conference, please read
A Student's "Art Walk" Notes, by Hannah Foote, in this issue.