PAINTINGS AND PATIENTSenhancing observational skills

Irwin M. Braverman MDProfessor of Dermatology

Yale Medical School

Medical Education

ROTE MEMORIZATION OF FACTS AND PATTERNS

ANALYTICAL OBSERVATIONAL SKILLS NOT TAUGHT

PRINCIPLES AND PROBLEMS OF OBSERVATIONAL SKILLS

• ACTIVE VISUAL SEARCH

• OBJECTIVE OBSERVATION

• HIGH THRESHOLD

• INTELLECTUAL BUT NOT PRACTICAL UNDERSTANDING OF HOW TO SEE

GOMBRICH

“ WE NOTICE ONLY WHEN WE LOOK

FOR SOMETHING AND WE LOOK

WHEN OUR ATTENTION IS AROUSED

BY SOME DYSEQUILIBRIUM, A

DIFFERENCE BETWEEN THE

EXPECTATION AND THE INCOMING

MESSAGE”

PAPPWORTH – A PRIMER OF MEDICINE

“INSPECTION SHOULD ALWAYS BE AN

ACTIVE SEARCH FOR EVIDENCE AND

NEVER JUST A HURRIED GLANCE OR

BLANK STARE.”

“ LOOK DEEPER. OBSERVATION,HARRY. WE

CAN MAKE A CONSCIOUS CHOICE TO SEE,

NOT JUST TO LOOK AT. PASSIVE VERSUS

ACTIVE VIEWING. OBSERVATION AND

LOGICAL DEDUCTION, THE TWO TOOLS THAT

EVERYONE HAS AND NO ONE USES.”

THE ART THIEF by NOAH CHARNEY ATRIA BOOKS, 2007 p. 174

CZESLAW MILOSZ 1911-2004

“DESCRIPTION DEMANDS INTENSE

OBSERVATION, SO INTENSE THAT

THE VEIL OF EVERYDAY HABIT

FALLS AWAY AND WHAT WE PAID NO

ATTENTION TO, BECAUSE IT

STRUCK AS SO ORDINARY, IS

REVEALED AS MIRACULOUS.”

NY TIMES BOOK REVIEW SEPT 12, 2004

Sir Dominic Corrigan, cardiologist 1853

“THE TROUBLE WITH MANY DOCTORS

IS NOT THAT THEY DO NOT KNOW

ENOUGH BUT THAT THEY DO NOT

SEE ENOUGH.”

Sir William Osler

“LEARN TO SEE, LEARN TO HEAR,

LEARN TO FEEL, LEARN TO SMELL,

AND TO KNOW THAT BY PRACTICE

ALONE YOU CAN BECOME EXPERT.”

Leonardo Da Vinci

SAPERE VEDERE

LEARN TO SEE THINGS

Sherlock HolmesSir Arthur Conan Doyle

“…ON MEETING A FELLOW-MORTAL, LEARN AT A GLANCE…THE

HISTORY OF THE MAN AND THE TRADE OR PROFESSION TO

WHICH HE BELONGS…IT SHARPENS THE FACULTIES OF

OBSERVATION…BY A MAN’S FINGERNAILS…COAT-SLEEVE…

BOOTS…CALLOSITIES OF FOREFINGER AND THUMB…

EXPRESSION…A MAN’S CALLING IS PLAINLY REVEALED.”

A STUDY IN SCARLET. CH 2

Pappworth − A Primer of Medicine

“DISTINCTION SHOULD BE MADE

BETWEEN WHAT WE REALLY SEE AND

WHAT WE INTELLECTUALLY INFER.”

ASTRONOMICAL OBSERVATIONS

“SEEING IS IN SOME RESPECTS AN ART THAT MUST

BE LEARNED.” Sir William Herschell (1738-1822)

“BESIDES LEARNING TO SEE, THERE IS ANOTHER

ART TO BE LEARNED − NOT TO SEE WHAT IS NOT.”

Maria Mitchell (1818-1889)

Adult Stem Cell Reports Overplayed. Vastag B. JAMA 286:293,2001

EXPERTS: “…IF YOU READ THE LITERATURE, IT

SAYS THESE ADULT STEM CELLS CAN DO

EVERYTHING…LOOK AT THE LITERATURE…MORE

CRITICALLY…MANY OF US DOUBT MAJOR

CONCLUSIONS…I DON’T THINK THERE’S FRAUD OR

ANYTHING MALICIOUS THAT ANYONE HAS REALLY

DONE…BUT WHEN YOU WANT TO SEE

SOMETHING, YOU CAN SEE IT.”

ADRIAN-HARRIS D:

ASPECTS OF VISUAL PERCEPTION IN RADIOGRAPHY.

RADIOLOGY 45:237-243, 1979

NUSSLEIN-VOLHARD C.

KRÜPPEL, A GENE WHOSE ACTIVITY IS REQUIRED EARLY IN THE ZYGOTIC

GENOME FOR NORMAL EMBRYONIC SEGMENTATION

DEVELOPMENTAL BIOLOGY 104;172-186, 1984

WHY CAN’T WE USE PATIENTS TO TEACH OBSERVATIONAL SKILLS?

HIGH THRESHOLD FOR SEEING DETAILS IN FAMILIAR OBJECTS (SKIN AND PEOPLE); NEED TO LOWER OUR THRESHOLD

BRAIN CENSORS MOST NORMAL ATTRIBUTES; ONLY GROSS CHANGES ARE INITIALLY APPRECIATED.

POINTING OUT DETAILS LEADS TO MEMORIZATION NOT ANALYTICAL DEVELOPMENT.

INTELLECTUAL UNDERSTANDING OF CONCEPT “LOOK FOR THE DETAILS.”

PRACTICAL APPLICATION IS DIFFICULT.

LOOKING FOR DETAILS IS AN EXPERIENTIAL PROCESS THAT CAN BE PROVIDED BY EXAMINING FINE ART.

IN A FOREIGN OBJECT (PAINTING) ALL THE VISUAL FEATURES HAVE IDENTICAL PRIORITIES FOR THE VIEWER.

ALMOST EVERY DETAIL WILL BE DESCRIBED.

CENSORING BY THE BRAIN DOES NOT AUTOMATICALLY OCCUR.

THIS LOW THRESHOLD IS TRANSFERABLE TO THE PHYSICAL EXAMINATION.

Our narrative Victorian paintings behave as a surrogate for a patient because they have a large number of well defined details ( signs and symptoms) that often are internally contradictory (allowing for a differential diagnosis as well as raising the issue of how to deal with data that do not support your initial conclusions). This is a way to introduce first year medical students to these concepts in clinical medicine by using concrete examples rather than a theoretical discussion. Once a differential diagnosis (all possible explanations about the meaning and intent of the painting) is constructed, the painting can be reexamined for other visual clues (additional lab tests) to narrow the differential down further.

It highlights the problem of premature conclusions based on incomplete data.

It highlights the problem of what to do with data that do not fit your initial conclusions (discard or begin again).

It highlights the problem of looking for data that only supports your initial conclusions.

CUMULATIVE MEANS

1998-2000 PRE POST SIG

YCBA=81 50% ± 0.1 57% ± 0.1 P= 0.0001

CNTRL=65 47% ± 0.1 46% ± 0.1 P=0.2

MAJOR FACTOR UNDERMINING CAREFUL OBSERVATION OF PATIENTS

TOO MUCH RELIANCE ON IMAGING

TECHNIQUES AND LABORATORY

TESTS FOR MAKING DIAGNOSES

MEDICAL EDUCATION

MEDICAL SCHOOL

HS TRAINING

PRACTICE <5 YR

PRACTICE >5 YR

ROTE MEMORIZATION

ROTE APPLICATION

ROTE APPLICATION

DEDUCE,INTEGRATE

& INNOVATENobel Laureate Herbert Simon’s law: It takes ten years to master any skill.

MEDICAL EDUCATION

MEDICAL SCHOOL

PRACTICE > 5 YRS

ROTE MEMORIZATION

DEDUCE,INTEGRATE

& INNOVATE

Nobel Laureate Herbert Simon’s law: It takes ten years to master any skill.

J

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GOALS

LOWER OBSERVATIONAL THRESHOLD

ANALYTIC OBSERVATION AND NOT JUST ROTE

PATTERN RECOGNITION

RECOGNIZE EXISTING PATTERNS OF DISEASES AND DISCOVER MANIFESTATIONS OF NEW DISORDERS

PROGRAM ADOPTION IN WHOLE OR IN PART

BROWN USC KECK SCHOOL OF MED DUKE NEW YORK MEDICAL COLLEGEUNIV. COLORADO JEFFERSON MED SCHOOL

CORNELL COLUMBIA P&S MEDICAL CTRUNIV CALIF IRVINE TOURO MEDICAL SCHOOL (NYC)UNIV ROCHESTER under development:UNIV TEXAS AT HOUSTON MT. HOLYOKE (undergraduate)MT. SINAI UNIV. NEBRASKA MEDICAL CTR . NYUSTANFORDUCSF

FINIS