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How looking at paintings became a required course in medical school

Yale Medicine Magazine, 2014 - Spring


A group of seasoned doctors stood before a chaotic scene. “What do you objectively see?” asked Irwin M. Braverman, M.D. ’55, professor emeritus of dermatology.

“Two men, sitting at opposite ends of the table appear to be smoking,” said Mary V. DiGangi, M.D. ’64. In the scene before her, another man lies sprawled across the floor, and yet another is poised to set his jacket sleeve on fire with a candlestick. Luckily, this is no hospital, but rather the Yale Center for British Art, and the scene before the doctors had been set in oil paints more than two centuries ago.

The veteran physicians‒a group of Yale alums back on campus for reunion‒have just taken a crash-course version of an observational skills training workshop that was developed by Braverman for first-year medical students. The workshop is an exercise in visual training that gives students an opportunity to look at something totally foreign to them early in their medical careers ‒in this case, an 18th century British painting‒and extract the relevant information. “In essence, this is a physical examination of a patient,” said Braverman. The exhibit hall is the examination room, and the painting becomes the patient.

“It’s a far cry from what we had,” said Braverman, recalling his own medical education. “We were taught to look for patterns that were already known to exist.” These kinds of shadows on an X-ray mean this kind of problem. But what happens when a doctor encounters a situation they weren’t exposed to in medical school? They have no pattern to fall back on. According to Braverman, it takes about 10 years to develop the skills to solve medical puzzles, and he wanted to give his students a head start.

The idea to use works of art to practice observation skills first occurred to Braverman at grand rounds in 1998, when he noticed the dermatology residents weren’t describing what they saw on patients as thoroughly as they should. “It occurred to me that if I were to ask them to describe some object that they were totally unfamiliar with‒like a painting‒they wouldn’t know what was important or unimportant. They would describe everything in that object,” said Braverman. He worked with Linda Friedlaender, curator of education at the center, to develop the program for medical students.

In the workshop, students are given 15 minutes to observe an assigned painting individually and gather as much detail as possible. As a group, they discuss what may be taking place in each painting based on their observations. Braverman explains that 18th- and 19th-century British paintings are perfect for this exercise because many tell a story about a real historical event, but like a patient with unexplained symptoms, they often contain ambiguous or contradictory information. “Students always realize that on first view they think something’s happened and 10 or 15 minutes later they think it’s quite different,” says Mona Pierpaoli, a museum guide who has taught the course alongside Braverman for the past 10 years. In the end, the story is less important than the gathering of details, and according to a study published in JAMA: the Journal of the American Medical Associationin 2001, the workshop improves students abilities to pick up on important details by almost 10 percent.

For the alumni group, many of whom had returned to New Haven at the end of May for the 50th anniversary of their own medical school graduation, the course was a reminder of the human tendency to jump to conclusions. “That’s what you do naturally with the world around you,” said DiGangi. “[The course] taught one to not just automatically interpret but to really observe. It was very enjoyable.”

Today’s medical students agree. In fact, the course, which is mandatory, has been so successful at Yale that since 1998, when it was offered for the first time, more than 26 medical schools from all over the world have established similar programs.

Braverman is trying to impress upon the students that physical diagnosis requires more than a glance. According to Braverman, doctors today spend only a short amount of time actually looking at their patients, relying instead on tests and numbers. The more time a doctor spends with a patient, the more likely they are to notice something that tests would miss. “I tell the students, if someone hadn’t been making independent observations in every generation, we would be practicing medicine like Hippocrates,” he said.

This year, for the first time, Braverman replaced the standard post-workshop evaluation with a specific question: what have you learned about yourself as an observer? Nearly every student who responded said that, though they had considered themselves to be adequate observers before the workshop, afterwards they realized they were looking at things superficially. The course had helped them learn to look at the world, and their patients, more in depth. “After 16 years, they finally validated what we were doing,” said Braverman.

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