The White Coats are Coming!: A Museum Visit Helps Improve Diagnostic Skills of Medical Students

For over a decade, the Yale Center for British Art has welcomed first-year students from the Yale School of Medicine to look at paintings in the largest collection of British art outside of the UK. Before the students’ eyes adjust to the natural light of Louis I. Kahn’s Entrance Court, they are divided into groups and asked to leave behind their white coats. A specially trained docent or education staff member facilitates the museum experience by taking four students into the galleries and placing each student in front of a distinct work of art. The student is asked to closely look at the artwork for fifteen minutes without consulting the label text or Googling information. The student may take notes or sketch the artwork and is reminded that all observations must be grounded in objective fact. No interpretations, no theories, no conclusions—only visual fact.

This time of independent, sustained looking isn’t simply an exercise but a crucial skill that is constantly challenged in an era of 140 character tweets and six-second Vine videos. StatisticBrain.com collated data that shows a goldfish has a longer attention span than the average person today—albeit by one second – if attention span is “the amount of concentrated time on a task without becoming distracted.” In 2000, when Linda Friedlaender at the Center and Irwin Braverman at the Yale School of Medicine began bringing medical students to look at paintings, the average attention span was 40% longer. With diminishing attention spans on the whole, inattention blindness (in other words, not seeing something because it’s not what is expected or looked for) is a common danger for physicians in the age of high-tech diagnostic imaging, laboratory testing, and larger patient loads.

In this context, Friedlaender and Braverman designed a study to document the benefits of a museum intervention for first-year volunteer Yale med students. Before and after the museum visit, participants were given three minutes to write a comprehensive description of a patient photograph. The descriptions were blindly marked with a point given for every detail that the student noted. The scores were then analyzed, and the results demonstrated a significant improvement in detecting important details in the museum intervention group. Accordingly, “Enhancing Observational Skills” is now a requirement for medical and nursing students at Yale. Business schools as well as biology departments have adopted this program and over 20 medical schools including Harvard, Quinnipiac, and Stanford have similar programs. More information on the study can be found in Use of Fine Art to Enhance Visual Diagnostic Skills in JAMA, Journal of the American Medical Association, 10/2001; 286(9) 1020-1.

YCBA_Med_2

Now, back to the students. After sitting alone with their painting for a long fifteen minutes, they share their observations.
Student: “In this painting there is an old woman in the corner and…”
Facilitator: “Stop. How do you know it is an old woman?”
Student: “She looks old.”
Facilitator: “What makes her look old?”
Student: “She has gray hair and wrinkles in her face.”
Facilitator: “Okay. Good. How do you know it is a woman?”

The first student usually has the most difficulty in visually itemizing everything in the artwork and subsequent students quickly pick up the process. The inventory is based on visual fact, yet students often surprise facilitators with their methods for organizing information in order to construct meaning. Some begin in the top left corner as if reading a text, while others start with the detail that first caught their eye. If the student recently studied radiology, she may break the painting into quadrants as if reading x-rays.

YCBA_Med_3

Often students leave out a detail that they believe to be too obvious to mention. However, it is important to direct attention to “elephant-in-the-room” details because what someone views as obvious may not be noticed by another. The acknowledgement of all details without dismissal or value judgment is paramount to the physician-in-training. When one aims to equally consider all information, his focus is no longer only on what is out of place but on everything from commonplace to unusual. Sherlock Holmes tells Watson, “I have trained myself to notice what I see." (Insert Benedict Cumberbatch’s snarky tone.) This noticing of what one expects to see, as well as what one doesn’t expect to see, is important to clinical practice and a key goal of “Enhancing Observational Skills.”

The analytical part of the exercise begins after the visual inventory. Culling all observations, students begin to develop a narrative. If an interpretation veers off course, another student will re-direct the group using the visual evidence or the facilitator may intercede. This activity informs differential diagnosis, a diagnostic method used to determine and identify a possible disease or disorder. Differential diagnosis collects and eliminates information in order to accurately diagnose a patient. (Think Dr. House and his team discussing symptoms and probable causes.) After the initial “differential diagnosis” of a painting, it is reexamined for missed visual details (similar to learning results of additional laboratory tests). By using representational paintings, the subject matter is more removed for students than a human patient and the problem of premature conclusions based on only partial data is made clear.

In 1853, cardiologist Sir Dominic Corrigan stated, “The trouble with many doctors is not that they do not know enough but that they do not see enough.” By inviting medical students to look closely at and interpret a narrative artwork with well-defined yet contradictory details, the Education Department at the Yale Center for British Art is contributing to a generation of physicians that can truly slow down, observe the entire patient, and consider the data that both supports and challenges an initial diagnosis.