- Email: [email protected]
To see or not to see: How visual training can improve observational skills
Clinics in Dermatology (2011) 29, 343–346
DERMATOLOGIC DISQUISITIONS AND OTHER ESSAYS Edited by Philip R. Cohen, MD
To see or not to see: How visual training can improve observational skills Irwin M. Braverman, MD ⁎ Emeritus Professor of Dermatology, Yale School of Medicine, New Haven, CT 06520, USA
Introduction Observational skills have always been the physician’s most important weapon in the diagnosis, care, and treatment of the patient. In the early 20th century, the physician was equipped primarily with a keen sense of observation and a compassionate heart; effective medications, and diagnostic laboratory tests; reliable imaging techniques were still to come. During house calls, the physician used his observational skills to evaluate both the surroundings and family members with respect to their limitations and benefits in regard to the patient. The observational skills of vision, hearing, touch, smell, and taste were well developed in most doctors. These skills were honed to razor-sharpness in the “diagnostician,” a term of honor applied to any physician, specialist, or nonspecialist, who was able to decipher complex clinical problems. With the development of computed tomography (CT) and magnetic resonance imaging (MRI), as well as more sensitive and reliable laboratory tests in the late 1970s, the learned observational skills of physicians began to decline from disuse as reliance on these modalities for establishing diagnoses increased. Clinical medical decision making became unduly influenced by the tyranny of the tests, even though for many medical conditions—endocrine, infectious, malignant, and rheumatic, among others—the use of the eye and ear was sufficient to make the correct diagnosis or arrive ⁎ Corresponding author. Yale Medical School, 333 Cedar St., New Haven, CT 06520, USA. Tel.: +1 203 785 4092; fax: +203 785 7637. E-mail address: [email protected]. 0738-081X/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.clindermatol.2010.08.001
at a limited group of diagnoses more rapidly and at much less cost.
Historical development of the Yale observational skills program In November 1997, under this umbrella of circumstances, I came to consider how visual observational skills might be better taught, as well as enhanced, in residents and medical students. I conceived of using a visually foreign object as a tool to teach how to detect fine details in an object under scrutiny. This idea arose after a teaching session in which dermatology residents had considerable difficulty in identifying subtle features in skin lesions of patients presented at Grand Rounds. It seemed that using an unfamiliar object about which the student had no biases and no significant prior knowledge would result in the object being very carefully inspected and every feature reported. The unfamiliar object that came to mind was a painting. We are so accustomed to looking at one another that we unconsciously filter out normal features and only concentrate on the abnormal. After a session at the Yale Center for British Art (YCBA), in which each dermatology resident was asked to study a narrative representational painting and describe what he saw, subsequent descriptions of patients by the resident staff at Grand Rounds improved dramatically. Two groups of first-year students at Yale School of Medicine (YSM) participated in this exercise at the YCBA, shortly thereafter. At the conclusion of their gallery experience, both groups of students meticulously and
344 accurately described the skin lesions in a projected image of a patient with herpes zoster in a way that had never been done previously in my teaching experience. These events were directly responsible for the designing of a formal study to test whether fine art can be used to teach observational skills. In mid-1998, Dr Jacqueline Dolev (YSM 2001) chose this topic for her required YMS thesis. Volunteer first-year YSM students were randomly assigned to an intervention or a control group. Pretests and posttests consisting of photographs of patients with specific medical disorders were used to test the efficacy of the intervention strategy using statistical criteria. Examples of the paintings that were used in her study, the pretests and posttests, and statistics can be found at info.med.yale.edu/dermatology/education. The study, published in 2001,1 demonstrated that visual examination and objective description of a representational narrative painting conferred skills that were transferable to the examination of photographs of patients with medical disorders. The mean scores of the intervention group improved 9% when the pretest scores were compared with posttest scores, whereas the control group means scores remained unchanged. As a result, this program has been a required component of the YSM curriculum since 2002 and has been adopted in whole or in part by 20 other medical schools. For her thesis requirement, Dr Erin Mahony (YSM 2005) designed a self-study workbook containing four paintings from the YCBA as a follow-up to the Dolev study. The same pretests and posttests and statistical criteria were used, and the mean scores of the students in the self-study group showed a statistical improvement of 5% after completing the workbook in approximately 1 hour.
Visual training exercises In 1964, Ulric Neisser,3 Professor of Psychology at Emory and Cornell universities, investigated human cognitive function by having participants look at strings of 250 consonants in which a target (a single vowel or 1 to 10 other consonants) were placed at different but predetermined positions. The participants timed themselves on how long it took to find the vowel. A simple calculation gave the number of seconds it took for an individual to find the target no matter where its position was in the string. In experiments in which the participant had to find targets consisting of a single character or as many as 10 characters, the time to find the target(s) remained the same, a process he coined “parallel processing” long before there were computers. The exact mechanism(s) are not understood, but they are operative in the case of experienced clinicians who are able to obtain a medical history from a patient while simultaneously evaluating a patient’s body language, affect, and nuances of content. Adrian-Harris, a student at the university in Wales, repeated this experiment in 1979 as a requirement in a
I.M. Braverman psychology course.2 The subject was his wife, who found the targets nine times faster than the participants in Neisser’s studies. Adrian-Harris realized that his wife, who was a radiologist, was accustomed to searching for subtle details in x-ray images. He then designed an experiment in which a group of experienced radiologists were randomly assigned to one of two groups. One group scrutinized 10 strings of 250 characters in which there was a single vowel, 5 days a week for 3 weeks. After 3 weeks of rest, they resumed their study for an additional 5 days. The other group continued with their usual activities and did not engage in these visual exercises. At times 0, 3 weeks, and 7 weeks, both groups were shown identical sets of x-ray images. They were asked to indicate whether the x-ray images were normal, probably normal, or abnormal. The radiologists who studied the strings of letters improved the accuracy of their readings from 49% to 76%, whereas the control group showed no improvement (51% to 49%). Although Neisser’s experiments were originally meant to study cognitive thinking, they also served as an instrument of visual training. The ability to find a single vowel was transferred to the skill of finding details in x-ray images for more accurate diagnoses. Why can’t patients themselves (traditional bedside teaching) be used to teach observational skills? Classical bedside teaching usually is a twofold process. In the first part, the teacher frequently uses the Socratic method of questions and answers to foster the development of analytic reasoning skills in students from the information gathered by their history taking, physical examination skills, and previously acquired medical knowledge. In the second part, the teacher presents a personal assessment of the clinical problem and emphasizes the key features of the disease(s) under discussion as they relate to the history, physical findings, including observational components related to any of the five senses, and laboratory tests. (In the current parlance of medical education, this process is referred to as “clinical diagnostic reasoning,” and a variety of educational strategies have been proposed for teachers to promote its attainment). The end result of a “bedside” teaching or “clinical diagnostic reasoning” session, unfortunately, is the construction of a pattern that is memorized. When the student next encounters this pattern and recognizes and remembers it, he has a diagnosis or set of diagnoses from which he can proceed in the care and treatment of the patient. As teachers, we have assumed that all students, medical or otherwise, who do not observe details and patterns as well as we believe they should are “poor students,” rather than realizing that we have not taught them how to observe. Although each of us has innate talents of observation and logic, in some they have not been fully developed or their existence even recognized. So, how does a student deal with patterns that have not been previously taught? We have not taught him to be observationally analytic; we have taught him only to recognize existing patterns. The student solves the immediate
To see or not to see problem by his asking teachers and more experienced peers for help. So, how do diagnosticians develop their skills? Physicians entering clinical practice become responsible for making decisions in the absence of a more experienced peer or colleague looking over their shoulder. Clinical experience combines with previously acquired formal education—by mechanisms not understood—to produce an efficient, successful, and unique skill of visual analysis in most physicians, but unfortunately, not in all. Doctors begin to hear and see things they have not encountered before that spontaneously aggregate into unique patterns (clues, “pearls”) that allow them to make diagnoses correctly and more rapidly. Osler’s aphorism: “learn to see, learn to hear, learn to smell, and to know that by practice alone you can become expert” becomes realized at that point. This is experiential learning. It takes about 5 years in the case of dermatologists, whom I have personally observed since completion of their residency training, to evolve into superb diagnosticians. Studies of chess grandmasters indicate that their skills come not from some secret analytic process but from intense study over the course of 10 years. Nobel Laureate Herbert A. Simon4 concluded from his lifelong studies in psychology, management, computer science, and economics that it takes 10 years in general for anyone to master their field of interest. The goal of enhancing observational skills is not simply the recognition of patterns to make accurate diagnoses but is also the recognition of novel details so that new clinical patterns can be developed for the advancement of medicine in both the research and clinical arenas. One of the goals in teaching observational skills is for the student to routinely and without prompting always look at the normal and not just at the grossly abnormal features of a patient. We want the threshold of observation to be at its minimum. The moment the teacher points out a subtle detail, however, it becomes memorized as part of a pattern, even though the purpose of pointing out the subtle detail is to illustrate what it means to lower one’s visual threshold. The current medical educational system, requiring memorization with feedback of what the teacher says, makes it virtually impossible for an individual to develop visual analytic skills on his own. This is the essence of our project: we are jump-starting the experiential process so that the students can begin to develop and enjoy their own mechanisms of visual analysis in the first year of medical school and not 10 to 15 years later. We are attempting to lower their threshold of observation to its minimum so that normal features and subtle details are appreciated and not just the grossly abnormal. We want to start them on the path to gather and reassemble their observational data in a coherent and logical way in order to solve the problem at hand. That is the skill of the diagnostician and our favorite Sherlockian detectives—a skill that cannot be taught formally by lecture, but only by experiential learning.
345
Yale course on observational skills The mechanics of the Yale course are as follows. Students are divided into groups of four with a supervising teacher. Each student is assigned a painting to study for approximately 12 to 15 minutes with a caution not to read the label. The student is told that every object and feature in the painting, both obvious and subtle, has been placed there artificially by the artist for a reason, and it is the student’s task to identify all of them, even though their function and significance may not be immediately apparent. The student then is asked to describe the painting, while standing in front of it, to the other students in the group in such a way that anyone who is listening, but not viewing the painting, will acquire a mental image of it. The student is not allowed to make interpretations or draw conclusions in the initial phase of the description; for example, if the student should inadvertently state, “the central figure looks happy,” the student will be asked to describe the features of the facial expression that led to the interpretation of “happy.” Open-ended questions, as necessary, are asked by the teacher during the student’s description to provide assistance with the visual analysis. After the objective description of the entire painting has been completed, the student is allowed to interpret and speculate. Aspects of the painting that illustrate the medical principles of differential diagnosis, handling contradictory data, and thoroughness of examination are emphasized at appropriate points during the student’s presentation. After the student’s discussion is completed, the group is asked whether any additional information can be gleaned from the painting and if they agree with the analysis. To conclude the discussion, the teacher informs the group about the meaning and purpose of the painting.
Paintings as patient surrogates Many representational Victorian and pre-Victorian paintings at the YCBA tell stories with ambiguity and internal contradictions, thus serving as excellent surrogates for patients. Modern paintings, whether abstract, impressionistic, or representational to the point of simulating photographs lack the features found in the YCBA collections. The staged photographs of Jeff Wall and Gregory Crewdson, however, display the same ambiguities and contradictions found in the YCBA paintings and could serve the same purposes as the paintings used in our course. As the students describe what they see in the paintings without any initial interpretations, they are learning to collect information in an objective manner. Due to the ambiguity, several interpretations become possible. To decide which ones are more probable, the student is encouraged to return to the painting to search for additional clues to assist in this deliberation. This process simulates the construction of a differential diagnosis in the clinical care of a patient. The
346 internal contradictions in the paintings introduce the fledgling doctors-to-be to the problem of contradictory laboratory data in a patient in whom a specific diagnosis is being considered. Do you just use the data that support the favored diagnosis and discard the nonsupporting data, or do you start over and consider whether the patient may have more than one disorder? Invariably, in each student group, an active interchange develops among the four students as the discussion of the painting proceeds, with the result that students learn to accept and consider alternate interpretations and to work as a team.
References 1. Dolev JC, Friedlaender LK, Braverman IM. Use of fine art to enhance visual diagnostic skills. JAMA 2001;286:1920-1. 2. Adrian-Harris D. Aspects of visual perception in radiography. Radiography 1979;45:237-43. 3. Neisser U. Visual search. Scientific American 1964;210:94-102. 4. Chase WG, Simon HA. Perception in chess. Cognitive Psychology 1973;4:55-81.
I.M. Braverman Irwin M. Braverman, MD, was born in Boston, Massachusetts, where he attended the Boston Latin School and Harvard College, from which he graduated with an AB in 1951. After receiving his MD degree from Yale School of Medicine in 1955, he spent 2 years as a captain in the Army Medical Corps, 2 years training in internal medicine, and 3 years in dermatology at Yale New Haven Medical Center before being appointed to the faculty at Yale in 1962. He became a full professor of dermatology in 1973 and professor emeritus of dermatology in July 2010. He continues to see patients and teach. His research has covered three major areas: (1) the microanatomy, three-dimensional organization, and flow characteristics of the dermal microcirculation and its vascular malformations as elucidated by electron microscopy, computer reconstruction in three dimensions, and laser Doppler flow measurements; (2) immune complex vasculitis and the cutaneous lesions of psoriasis and cutaneous T cell lymphoma, both in therapeutic responses and in relapse phases, studied with the same techniques; and (3) the dermal components of normal skin, as it aged both chronologically and in response to damage by sunlight, investigated with similar modalities. His most recent investigative interest is the use of fine art to teach and enhance observational skills in physicians. He is the author of Skin Signs of Systemic Disease (WB Saunders), which has gone through three editions from 1968 to 1998.
Please submit contributions to this section to Philip R. Cohen, MD. E-mail address: [email protected].
DERMATOLOGIC DISQUISITIONS AND OTHER ESSAYS Edited by Philip R. Cohen, MD
To see or not to see: How visual training can improve observational skills Irwin M. Braverman, MD ⁎ Emeritus Professor of Dermatology, Yale School of Medicine, New Haven, CT 06520, USA
Introduction Observational skills have always been the physician’s most important weapon in the diagnosis, care, and treatment of the patient. In the early 20th century, the physician was equipped primarily with a keen sense of observation and a compassionate heart; effective medications, and diagnostic laboratory tests; reliable imaging techniques were still to come. During house calls, the physician used his observational skills to evaluate both the surroundings and family members with respect to their limitations and benefits in regard to the patient. The observational skills of vision, hearing, touch, smell, and taste were well developed in most doctors. These skills were honed to razor-sharpness in the “diagnostician,” a term of honor applied to any physician, specialist, or nonspecialist, who was able to decipher complex clinical problems. With the development of computed tomography (CT) and magnetic resonance imaging (MRI), as well as more sensitive and reliable laboratory tests in the late 1970s, the learned observational skills of physicians began to decline from disuse as reliance on these modalities for establishing diagnoses increased. Clinical medical decision making became unduly influenced by the tyranny of the tests, even though for many medical conditions—endocrine, infectious, malignant, and rheumatic, among others—the use of the eye and ear was sufficient to make the correct diagnosis or arrive ⁎ Corresponding author. Yale Medical School, 333 Cedar St., New Haven, CT 06520, USA. Tel.: +1 203 785 4092; fax: +203 785 7637. E-mail address: [email protected]. 0738-081X/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.clindermatol.2010.08.001
at a limited group of diagnoses more rapidly and at much less cost.
Historical development of the Yale observational skills program In November 1997, under this umbrella of circumstances, I came to consider how visual observational skills might be better taught, as well as enhanced, in residents and medical students. I conceived of using a visually foreign object as a tool to teach how to detect fine details in an object under scrutiny. This idea arose after a teaching session in which dermatology residents had considerable difficulty in identifying subtle features in skin lesions of patients presented at Grand Rounds. It seemed that using an unfamiliar object about which the student had no biases and no significant prior knowledge would result in the object being very carefully inspected and every feature reported. The unfamiliar object that came to mind was a painting. We are so accustomed to looking at one another that we unconsciously filter out normal features and only concentrate on the abnormal. After a session at the Yale Center for British Art (YCBA), in which each dermatology resident was asked to study a narrative representational painting and describe what he saw, subsequent descriptions of patients by the resident staff at Grand Rounds improved dramatically. Two groups of first-year students at Yale School of Medicine (YSM) participated in this exercise at the YCBA, shortly thereafter. At the conclusion of their gallery experience, both groups of students meticulously and
344 accurately described the skin lesions in a projected image of a patient with herpes zoster in a way that had never been done previously in my teaching experience. These events were directly responsible for the designing of a formal study to test whether fine art can be used to teach observational skills. In mid-1998, Dr Jacqueline Dolev (YSM 2001) chose this topic for her required YMS thesis. Volunteer first-year YSM students were randomly assigned to an intervention or a control group. Pretests and posttests consisting of photographs of patients with specific medical disorders were used to test the efficacy of the intervention strategy using statistical criteria. Examples of the paintings that were used in her study, the pretests and posttests, and statistics can be found at info.med.yale.edu/dermatology/education. The study, published in 2001,1 demonstrated that visual examination and objective description of a representational narrative painting conferred skills that were transferable to the examination of photographs of patients with medical disorders. The mean scores of the intervention group improved 9% when the pretest scores were compared with posttest scores, whereas the control group means scores remained unchanged. As a result, this program has been a required component of the YSM curriculum since 2002 and has been adopted in whole or in part by 20 other medical schools. For her thesis requirement, Dr Erin Mahony (YSM 2005) designed a self-study workbook containing four paintings from the YCBA as a follow-up to the Dolev study. The same pretests and posttests and statistical criteria were used, and the mean scores of the students in the self-study group showed a statistical improvement of 5% after completing the workbook in approximately 1 hour.
Visual training exercises In 1964, Ulric Neisser,3 Professor of Psychology at Emory and Cornell universities, investigated human cognitive function by having participants look at strings of 250 consonants in which a target (a single vowel or 1 to 10 other consonants) were placed at different but predetermined positions. The participants timed themselves on how long it took to find the vowel. A simple calculation gave the number of seconds it took for an individual to find the target no matter where its position was in the string. In experiments in which the participant had to find targets consisting of a single character or as many as 10 characters, the time to find the target(s) remained the same, a process he coined “parallel processing” long before there were computers. The exact mechanism(s) are not understood, but they are operative in the case of experienced clinicians who are able to obtain a medical history from a patient while simultaneously evaluating a patient’s body language, affect, and nuances of content. Adrian-Harris, a student at the university in Wales, repeated this experiment in 1979 as a requirement in a
I.M. Braverman psychology course.2 The subject was his wife, who found the targets nine times faster than the participants in Neisser’s studies. Adrian-Harris realized that his wife, who was a radiologist, was accustomed to searching for subtle details in x-ray images. He then designed an experiment in which a group of experienced radiologists were randomly assigned to one of two groups. One group scrutinized 10 strings of 250 characters in which there was a single vowel, 5 days a week for 3 weeks. After 3 weeks of rest, they resumed their study for an additional 5 days. The other group continued with their usual activities and did not engage in these visual exercises. At times 0, 3 weeks, and 7 weeks, both groups were shown identical sets of x-ray images. They were asked to indicate whether the x-ray images were normal, probably normal, or abnormal. The radiologists who studied the strings of letters improved the accuracy of their readings from 49% to 76%, whereas the control group showed no improvement (51% to 49%). Although Neisser’s experiments were originally meant to study cognitive thinking, they also served as an instrument of visual training. The ability to find a single vowel was transferred to the skill of finding details in x-ray images for more accurate diagnoses. Why can’t patients themselves (traditional bedside teaching) be used to teach observational skills? Classical bedside teaching usually is a twofold process. In the first part, the teacher frequently uses the Socratic method of questions and answers to foster the development of analytic reasoning skills in students from the information gathered by their history taking, physical examination skills, and previously acquired medical knowledge. In the second part, the teacher presents a personal assessment of the clinical problem and emphasizes the key features of the disease(s) under discussion as they relate to the history, physical findings, including observational components related to any of the five senses, and laboratory tests. (In the current parlance of medical education, this process is referred to as “clinical diagnostic reasoning,” and a variety of educational strategies have been proposed for teachers to promote its attainment). The end result of a “bedside” teaching or “clinical diagnostic reasoning” session, unfortunately, is the construction of a pattern that is memorized. When the student next encounters this pattern and recognizes and remembers it, he has a diagnosis or set of diagnoses from which he can proceed in the care and treatment of the patient. As teachers, we have assumed that all students, medical or otherwise, who do not observe details and patterns as well as we believe they should are “poor students,” rather than realizing that we have not taught them how to observe. Although each of us has innate talents of observation and logic, in some they have not been fully developed or their existence even recognized. So, how does a student deal with patterns that have not been previously taught? We have not taught him to be observationally analytic; we have taught him only to recognize existing patterns. The student solves the immediate
To see or not to see problem by his asking teachers and more experienced peers for help. So, how do diagnosticians develop their skills? Physicians entering clinical practice become responsible for making decisions in the absence of a more experienced peer or colleague looking over their shoulder. Clinical experience combines with previously acquired formal education—by mechanisms not understood—to produce an efficient, successful, and unique skill of visual analysis in most physicians, but unfortunately, not in all. Doctors begin to hear and see things they have not encountered before that spontaneously aggregate into unique patterns (clues, “pearls”) that allow them to make diagnoses correctly and more rapidly. Osler’s aphorism: “learn to see, learn to hear, learn to smell, and to know that by practice alone you can become expert” becomes realized at that point. This is experiential learning. It takes about 5 years in the case of dermatologists, whom I have personally observed since completion of their residency training, to evolve into superb diagnosticians. Studies of chess grandmasters indicate that their skills come not from some secret analytic process but from intense study over the course of 10 years. Nobel Laureate Herbert A. Simon4 concluded from his lifelong studies in psychology, management, computer science, and economics that it takes 10 years in general for anyone to master their field of interest. The goal of enhancing observational skills is not simply the recognition of patterns to make accurate diagnoses but is also the recognition of novel details so that new clinical patterns can be developed for the advancement of medicine in both the research and clinical arenas. One of the goals in teaching observational skills is for the student to routinely and without prompting always look at the normal and not just at the grossly abnormal features of a patient. We want the threshold of observation to be at its minimum. The moment the teacher points out a subtle detail, however, it becomes memorized as part of a pattern, even though the purpose of pointing out the subtle detail is to illustrate what it means to lower one’s visual threshold. The current medical educational system, requiring memorization with feedback of what the teacher says, makes it virtually impossible for an individual to develop visual analytic skills on his own. This is the essence of our project: we are jump-starting the experiential process so that the students can begin to develop and enjoy their own mechanisms of visual analysis in the first year of medical school and not 10 to 15 years later. We are attempting to lower their threshold of observation to its minimum so that normal features and subtle details are appreciated and not just the grossly abnormal. We want to start them on the path to gather and reassemble their observational data in a coherent and logical way in order to solve the problem at hand. That is the skill of the diagnostician and our favorite Sherlockian detectives—a skill that cannot be taught formally by lecture, but only by experiential learning.
345
Yale course on observational skills The mechanics of the Yale course are as follows. Students are divided into groups of four with a supervising teacher. Each student is assigned a painting to study for approximately 12 to 15 minutes with a caution not to read the label. The student is told that every object and feature in the painting, both obvious and subtle, has been placed there artificially by the artist for a reason, and it is the student’s task to identify all of them, even though their function and significance may not be immediately apparent. The student then is asked to describe the painting, while standing in front of it, to the other students in the group in such a way that anyone who is listening, but not viewing the painting, will acquire a mental image of it. The student is not allowed to make interpretations or draw conclusions in the initial phase of the description; for example, if the student should inadvertently state, “the central figure looks happy,” the student will be asked to describe the features of the facial expression that led to the interpretation of “happy.” Open-ended questions, as necessary, are asked by the teacher during the student’s description to provide assistance with the visual analysis. After the objective description of the entire painting has been completed, the student is allowed to interpret and speculate. Aspects of the painting that illustrate the medical principles of differential diagnosis, handling contradictory data, and thoroughness of examination are emphasized at appropriate points during the student’s presentation. After the student’s discussion is completed, the group is asked whether any additional information can be gleaned from the painting and if they agree with the analysis. To conclude the discussion, the teacher informs the group about the meaning and purpose of the painting.
Paintings as patient surrogates Many representational Victorian and pre-Victorian paintings at the YCBA tell stories with ambiguity and internal contradictions, thus serving as excellent surrogates for patients. Modern paintings, whether abstract, impressionistic, or representational to the point of simulating photographs lack the features found in the YCBA collections. The staged photographs of Jeff Wall and Gregory Crewdson, however, display the same ambiguities and contradictions found in the YCBA paintings and could serve the same purposes as the paintings used in our course. As the students describe what they see in the paintings without any initial interpretations, they are learning to collect information in an objective manner. Due to the ambiguity, several interpretations become possible. To decide which ones are more probable, the student is encouraged to return to the painting to search for additional clues to assist in this deliberation. This process simulates the construction of a differential diagnosis in the clinical care of a patient. The
346 internal contradictions in the paintings introduce the fledgling doctors-to-be to the problem of contradictory laboratory data in a patient in whom a specific diagnosis is being considered. Do you just use the data that support the favored diagnosis and discard the nonsupporting data, or do you start over and consider whether the patient may have more than one disorder? Invariably, in each student group, an active interchange develops among the four students as the discussion of the painting proceeds, with the result that students learn to accept and consider alternate interpretations and to work as a team.
References 1. Dolev JC, Friedlaender LK, Braverman IM. Use of fine art to enhance visual diagnostic skills. JAMA 2001;286:1920-1. 2. Adrian-Harris D. Aspects of visual perception in radiography. Radiography 1979;45:237-43. 3. Neisser U. Visual search. Scientific American 1964;210:94-102. 4. Chase WG, Simon HA. Perception in chess. Cognitive Psychology 1973;4:55-81.
I.M. Braverman Irwin M. Braverman, MD, was born in Boston, Massachusetts, where he attended the Boston Latin School and Harvard College, from which he graduated with an AB in 1951. After receiving his MD degree from Yale School of Medicine in 1955, he spent 2 years as a captain in the Army Medical Corps, 2 years training in internal medicine, and 3 years in dermatology at Yale New Haven Medical Center before being appointed to the faculty at Yale in 1962. He became a full professor of dermatology in 1973 and professor emeritus of dermatology in July 2010. He continues to see patients and teach. His research has covered three major areas: (1) the microanatomy, three-dimensional organization, and flow characteristics of the dermal microcirculation and its vascular malformations as elucidated by electron microscopy, computer reconstruction in three dimensions, and laser Doppler flow measurements; (2) immune complex vasculitis and the cutaneous lesions of psoriasis and cutaneous T cell lymphoma, both in therapeutic responses and in relapse phases, studied with the same techniques; and (3) the dermal components of normal skin, as it aged both chronologically and in response to damage by sunlight, investigated with similar modalities. His most recent investigative interest is the use of fine art to teach and enhance observational skills in physicians. He is the author of Skin Signs of Systemic Disease (WB Saunders), which has gone through three editions from 1968 to 1998.
Please submit contributions to this section to Philip R. Cohen, MD. E-mail address: [email protected].