paintings and patients enhancing observational skills
TRANSCRIPT
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.”
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.”
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.
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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