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Monet? Gauguin? Using art to make better doctors

New courses improve powers of observation

Email|Print|Single Page| Text size + By Liz Kowalczyk
Globe Staff / July 20, 2008

Dr. Joel Katz's class of Harvard Medical School students meets on Friday afternoons at the Museum of Fine Arts, where they discuss the Seated Bodhisattva, a towering figure carved in ancient China, Joseph Mallord William Turner's Slave Ship, and other artworks Katz believes will make them better doctors.

On one Friday this spring, 24 of the country's most promising future physicians circled the limestone Bodhisattva as art instructor Alexa Miller posed a question: "What's happening here?" The students initially observed that the figure was made of stone and appeared peaceful. But she pushed them further. "What do you see that makes you say that?" she asked.

After an hour at the museum, the class walked back to Harvard Medical School to apply what they had learned about examining art to diagnosing breathing problems, skin rashes, and neurological disorders, and to reading lung X-rays.

Katz's class is one of a growing number of art courses offered to medical students nationwide and aimed at improving their observation and diagnostic skills at a time when doctors are increasingly relying on CT scans, Maris, biopsies, and other technology to do their work, even though it is far more expensive - and sometimes unnecessary to pinpoint illnesses.

Nana Aqua Judah, who graduated from Harvard in June and is now an obstetrics and gynecology resident in Toronto, said the art class taught her to look more carefully at patients for clues. For example, if a young mother looks run down, it might indicate she's too stressed to take a medication that requires five doses a day, leading Judah to prescribe a once- or twice-a-day drug. Besides, said Judah, who was taking six or seven classes at the time, "to me it seemed like a relief. We were going to an art gallery for a class."

At tradition-minded Harvard, many faculty were skeptical about the idea of using art to make better doctors when Katz proposed the class five years ago, especially since the first- and second-year students who enroll are already overwhelmed with work. But Katz's belief that physicians can improve their diagnostic skills by observing art was bolstered this month when he and his colleagues published a study in the Journal of General Internal Medicine showing that after completing the class, students' ability to make accurate observations increased 38 percent. When shown artwork and photos of patients, students were more likely to notice features such as a patient's eyes being asymmetrical or a tiny, healed sore on an index finger. Observations by a control group of students who did not take the class did not change.

"We're trying to train students to not make assumptions about what they're going to see, but to do deep looking. Our hope is that they will be able to do this when they look at patients," said Katz, an internist at Brigham and Women's Hospital and a former graphic designer. He said several studies show that doctors' physical exam skills, which include observation and taking a medical history, as well as the hands-on examination, are declining.

The most difficult part of the class for the high-achieving Harvard students, Miller said, seems to be letting go of their urge to find the one right answer. The Bodhisattva, for example, can spark a wide range of emotions, as the statue is towering and imposing when seen from the front but then "almost disappears into space" when looked at from the side, Miller said. As she pushes students to look harder at the sculpture, using a technique called visual thinking strategies, students' observations become more complex, and they notice that the Bodhisattva is powerful, but also small and poignant.

While diagnosing a medical condition involves reaching the right answer, often, to get there, doctors have to open their minds to myriad possibilities.

"When we get fixated on getting the right answer, we miss the diagnosis because it blocks the ability to think flexibly," Miller said. "We want them to puzzle through things."

Educators at other medical schools that offer art classes have similar goals. Weill Medical College of Cornell University has offered a noncredit art course in collaboration with the Frick Collection in New York City for eight years, while Yale Medical School runs an art observation course for medical students that is now a required class.

Students in the Harvard class study a wide range of original art, including oil paintings by Paul Gauguin, Claude Monet, and John Singer Sargent, and sculptures from Iran and India. Students have the option of drawing a nude model as well. Instructors draw exact parallels between some artworks and diagnosing illness; students, for example, study texture and pattern in Jackson Pollack's abstract Number 10, and then return to the medical school to study how patterns in patients' rashes can indicate specific conditions. But the course primarily trains students to look at what they're seeing more carefully.

Dr. Robert Brown, a pulmonologist at Massachusetts General Hospital and a course instructor, gets undressed above the waist to give his lecture on breathing muscles. Three patients enter the classroom, including a quadriplegic man who also is shirtless, a woman with muscular dystrophy, and a woman with a deformed spine. Afterward, students list what they saw. Brown wants them to notice that his upper rib cage moves outward while the paralyzed patient's upper rib cage moves inward. Paralysis of the diaphragm is a diagnosis doctors often miss, he said, but inward movement of the belly while breathing is one sign.

If they look carefully "during the physical exam they can begin to put the pieces together," he said.

While research into doctors' physical exam skills is sparse, there is a consensus in medicine that those skills are waning. Some doctors believe medical schools are giving short shrift to the physical exam, but others believe these skills atrophy once doctors graduate and start practicing their specialty.

"When I've been to Africa and the Amazon and there are no CT scans and X-rays and it's just you and a flashlight and a stethoscope and something to look into the patients' ears, you have nothing to fall back on other than your clinical skills," said Dr. Ronald Silvestri, a pulmonologist at Beth Israel Deaconess Medical Center who runs Harvard's doctor-patient course, which teaches the physical exam.

In the United States, he said, doctors turn more quickly to these widely available tests and tend to be very rushed when seeing patients. "If you have a 10-minute visit, how good an observer can you be?" While Silvestri believes the quality of care doesn't suffer from the widespread use of diagnostic tests, he thinks the overall healthcare system does.

"It's one reason that American medical care is so expensive," he said.

But whether art classes will have a lasting impact remains an open question.

Students in the course run by Katz and Brigham neurologist Dr. Shahram Khoshbin were evaluated immediately after they took the course, not as practicing doctors, when they will face the threat of malpractice lawsuits for wrong diagnosis.

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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