By Ava Kikut
Scheie Vision Annual Report 2017
It may seem unfitting, a class on art observation in medical school. Thus, when a team of Penn medical students and physicians designed the curriculum for a pilot course in 2014, they conducted a study to measure its effects (if any). The results, recently published in Ophthalmology, demonstrated that art observation training has a quantifiable impact on clinical observation performance.
The idea began when Jaclyn Gurwin, MD, and Stephanie Davidson, MD, then Penn medical students, learned of a course at another institution that weaved art training into clinical observation lessons. They wondered what would happen if medical students took a course solely focused on art without a correlate class in medical observation. "We felt that training medical students in art observation alone would translate into medical observational skills," explained Dr. Gurwin. Dr. Gurwin, now a resident at the Scheie Eye Institute, studied communications and fine arts as an undergraduate at the University of Pennsylvania. She has always been interested in the intersection of art and science. "Having studied fine arts myself and having witnessed its impact on my medical training, I knew art observation training would be a beneficial practice in medical school," Dr. Gurwin said.
Drs. Davidson and Gurwin connected with Scheie resident, Karen Revere, MD, now an Assistant Professor of Ophthalmology at Penn; Horace DeLisser, MD, Associate Dean of Diversity and Inclusion; and Gil Binenbaum, MD, MSCE, Shafritz Chair of Ophthalmology Research. Dr. Binenbaum noted a specific need to teach observation skills in ophthalmology, as well as in radiology and dermatology — specialties that rely heavily on observation for diagnosis and treatment.
One of the team's objectives was to encourage students to notice and articulate the details of an image before attempting to draw conclusions. "Being able to observe and verbalize the clinical examination is crucial to developing a differential diagnosis. At the start of medical school, students don't yet have the experience to know what part of a clinical exam they should be mentioning, so it's helpful to develop a technique for systematically observing and describing," Dr. Gurwin said. "These skills are taught very well in the visual arts." To design a curriculum that would help students break down and discuss images, the study team collaborated with art experts Suzannah Niepold, MAT, Rebecca Mitchell, MA, and Barbara Bassett, MSEd, at the Philadelphia Museum of Art.
The pilot course extended over a three-month period, and consisted of six 90-minute sessions at the art museum. During these visits, art professionals showed students artwork and led exercises to facilitate thoughtful discussions. Following the "Artful Thinking" approach, each session was dedicated to one of the following themes: Observing & Describing; Questioning & Investigating; Reasoning; Comparing & Connecting; Exploring Viewpoints; and Perspective Taking. During the Observing & Describing session, for example, students were asked to stare at a piece of art for 30 seconds, list 10 words or phrases that came to mind, and then repeat. In a Questioning & Investigating session, students would answer prompts such as: "What do you think about the artwork? What questions or puzzles do you have? What does the artwork or topic make you want to explore?" For the Reasoning session, students were encouraged to make claims, support their claims, and then ask questions related to their claims. All of the classes involved collaboration between students as they engaged with the artwork.
To measure the effects of the art training, students were assessed before and after taking the course. A diagnostic test of observational skills asked for descriptions in paragraph form of three kinds of images: art, retinal photographs, and pictures of faces with ocular or periocular diseases. At the end of the three months, the students took a post-test with similar questions. Art experts graded descriptions of art based on how well students demonstrated flexibility, empathy, and the capacity to interpret, associate, and observe. Ophthalmologists assessed descriptions of medical images based on inclusion of specific details, which were part of a priori rubric, such as mentioning swollen eyelid or darkening of lower lid skin for a photo of limbal vernal conjunctivitis.
In addition to testing for changes in observation and description abilities, the study aimed to measure how the course affected interpersonal skills, particularly empathy. The group hypothesized that art observation training would help with reading emotional cues. "I believe that the first step in being able to empathize is being able to observe someone," said Dr. Gurwin. Along with observation tests, students took an online emotional recognition assessment called "Reading the Mind in the Eyes".
The study enrolled 36 medical students with no formal art training. After the initial assessments, the cohort was divided evenly and randomly into an art-training group (which would take the course) and a control group. All students were compensated with a year of free admission to the art museum.
The initial and follow-up description assessments demonstrated that art training had a significant impact on observational skills. For clinical image observation, the mean score of students in the art-training group went from 35.1 to 47.0 (out of 48 points). The mean for students in the control group decreased from 36.4 to 30.4. The leaders of the study stated that the decline in control group scores suggests medical school courses "may actually inhibit the development of good observational skills early on" (Gurwin et al., 2017). Dr. Gurwin added, "In medical school, instead of learning techniques for observation, there's more focus on learning memorized signs."
In contrast to the dramatic improvements in observation testing, empathy did not seem to change after the course. The study group noted this could be because the initial emotional reading test scores were already quite high or because the test used was not an accurate measure of empathy. Dr. Gurwin plans to try alternative empathy testing measures in future studies.
Despite the quantitative data on changes in empathy, many of the students did feel the course increased their appreciation for considering alternative points of view. Rachel Johnson, who was a member of the art-training group as a first-year medical student, remarked: "The class opened my eyes to some of the parallels between art and medicine: the importance of observation in any clinical encounter, the power of story, the skill required to see things from multiple perspectives and question previously held assumptions." Rachel's experience in the art observation course inspired her to become the course coordinator for the fourth-year elective, "Art, Observation, and Mental Illness."
Christy Hong, another student in the art-training group said, "My biggest takeaway was the importance of appreciating perspectives of other people." Christy is in the MD/MBA program at Penn, and continues to apply the lessons she learned in the art-observation pilot course to her work in both clinical and business settings. "Through discussions around various artworks, I realized my peers and I picked up different stories even though we were looking at the same painting. That taught me that my observation alone is not enough, especially in patient care. By relying solely on my initial read of the patient, I may miss out on some key aspects that would influence management decisions. I now seek the opinions of my colleagues on the floor if possible, which enables us to triage the patient more appropriately as a team." As with analyzing a piece of art, exchanging perspectives and observations with others can strengthen the overall understanding of a clinical case.
The proven benefits of formal art training for clinicians are becoming more widely recognized. When the investigators of Penn's art observation training study presented their results at the Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus in April 2017, a number of physicians approached them with questions for how to bring similar curricula into their own programs. "It's definitely becoming more accepted, and I think it's extremely promising for the future of medical education," said Dr. Gurwin. Dr. Gurwin hopes to conduct a follow-up study on the long-term effects of art observation training on students' medical school experiences and clinical careers. While observation is especially important in ophthalmology, Dr. Gurwin is certain there is something to be gained from formal observation training for future clinicians in all specialties. "The results of our study should be a reminder to the medical community that we should not be hesitant to look to other fields, especially the liberal arts, for assistance in training quality physicians," she said.