Where: University of Pennsylvania, Philadelphia.
The issue: Improving clinical observational skills among medical students.
Jaclyn Gurwin, MD, a postgrad year 4 resident at the Scheie Eye Institute of the University of Pennsylvania, grew up painting, drawing, and sculpting. As a premed student who minored in the fine arts, she brought the observational skills she'd learned with her into residency. She quickly discovered, however, that not all of her peers had the same skill set.
“When you're examining a patient, the first thing you have to do is observe,” she said. “When you walk into a room, you must think to yourself, what is the patient's body position? Is their skin pale? Is it flush? Do they look like they are in pain?”
Clinically, trainees also have to describe what they see, to either an attending or as part of the medical record. When a patient presents for an eye exam, a trainee may need to describe a spot on the retina, for example.
“If I am documenting a description of a choroidal nevus, I might say, for instance, that the patient has a 2-disc-diameter nevus, about 3 disc diameters from the optic nerve along the superior arcade. It looks flat without subretinal fluid, and there is no overlying orange pigment.” she said. “All of these descriptive terms are essential for determining the difference between a regular freckle in the back of the eye as compared to something much more serious such as a melanoma.”
With her background, Dr. Gurwin thought that there were essential fine arts skills that medical students could directly apply to clinical practice to become comfortable with observation, seeing things from multiple perspectives, description, evidence-based observation, and communication.
Dr. Gurwin hypothesized that formal training in the visual arts, which had helped her hone her observational skills, might help other medical students the same way. She worked with seven doctors and art educators to pilot a study and ultimately implement it as an elective in the curriculum at The Perelman School of Medicine at the University of Pennsylvania.
How it works
Dr. Gurwin and several instructors developed an art observation course, “Artful Thinking,” in which Philadelphia Museum of Art educators instructed first-year medical students on systematically observing works of art. In six 1.5-hour sessions over three months, students were taught how to describe colors, line, movements, and perspective.
Classes also focused on encouragement of empathy, creative questioning, reasoning, and consideration of multiple perspectives. Eighteen first-year medical students were randomly assigned to the art class, and 18 were randomly assigned to a control group in which they continued the regular medical school curriculum. The first painting students in the training group looked at was “The Gross Clinic,” by Thomas Eakins.
One of the goals of the class was to improve the way future physicians describe medical conditions, Dr. Gurwin said. For example, in a patient with diabetes, the retina may exhibit very specific diabetic changes. A resident may have to describe the changes, such as three small round intraretinal red dots (dot blot hemorrhages) in inferotemporal periphery, Dr. Gurwin said. “Just in that sentence you're describing the quantity, the size, the shape, the depth, the color and the distribution, which are the same exact terms that are learned in the fine arts training,” she explained.
In a baseline pretest, the entire cohort was asked to assess art images, retinal photos, and images of external eye diseases and describe in writing what they saw. After the art class was completed, all 36 students were asked to do the same assessment again. Written descriptions were scored by reviewers who were blinded to study group assignment and whether the test was a pre or posttest.
After the course was completed, the reviewers noted a mean change in observational skill score of 19.1 points among students who took the art class compared with the control group, who had a mean change of −13.5 points (P=0.001). For clinical images (retinal and external eye photograph scores combined), the mean change in score was 12.8 points in the training group and −5.9 points in the control group (P<.001). When each type of image was considered separately, the mean change in score was 6.1 points and 6.7 points in the training group and −2.8 points and −3.1 points in the control group for retinal and external images, respectively (P=0.001 for both comparisons).
The results of Dr. Gurwin and colleagues' study were reported in the January 2018 Ophthalmology. She and her coauthors noted that it is difficult to make accurate observations when presented with complex clinical information but concluded that art observation training “provides a structured approach by which medical students, who have little relevant medical context early in their training, can find their way through such visually challenging clinical situations.”
And in addition to the clinical improvement they gained, students enjoyed the course, Dr. Gurwin said. “We did a post-study questionnaire and they had rave reviews,” she said. “One of the things that they liked the most was that they were taken out of their comfort zone, taken out of the medical school classroom where no one was expected to know anything. They could branch out and make observations without being worried that they were wrong or being scrutinized.”
Dr. Gurwin hopes to continue to study the connection between art and medicine in the event that the course is offered to residents, fellows, and attendings. She and her instructors are still working to expand this type of class to other trainees in medicine. They are also seeking to apply the course to other specialties besides ophthalmology, especially specialties that rely on observational skills, including dermatology, radiology, internal medicine, and psychiatry.
“For the time being we are continuing the course for medical students as an elective, but in the future we hope to create smaller courses within residency and fellowship programs,” she said.