Class Helping Future Doctors Learn the Art of Observation

Kevin Koo and other medical students filed into the Yale Center for British Art recently to spend the afternoon looking at paintings.

While future physicians with heavy course loads at the Yale School of Medicine usually don’t have the time to ponder art, these students were visiting the museum for a required class — one that could someday save a patient’s life.

All first-year students at the School of Medicine are required to take the innovative class, which was developed by Yale medical school faculty member Dr. Irwin Braverman and Linda Friedlaender, curator of education at the Yale Center for British Art, which houses the world’s largest collection of British art outside the United Kingdom.

The visual tutorial, now marking its 10th anniversary, draws together disciplines that are usually worlds apart — art and medicine — in order to hone the observational skills of future physicians.

Braverman and other experts believe that, in an age when physicians rely heavily on high-tech imaging and tests, the art of detailed, careful observation is getting short shrift. But detecting small details can make all the difference in coming up with accurate diagnoses, believes the Yale faculty member.

Braverman began trying to find a way to increase observational skills of medical school students at around the same time that Friedlaender became frustrated with the continued misdiagnosis of a close friend. They happened to meet at a gathering and began laying the groundwork for the class, which makes the most of the museum’s collection by asking medical students to “diagnose” individuals portrayed in its artworks.

The course has proven so successful that more than 20 other medical schools have imitated the program.

“We know that this works,” said Braverman, professor of dermatology. In fact, Braverman and colleagues published a study in the Journal of the American Medical Association based on the experiences of the first groups of students who received the training. The results showed a nearly 10% improvement in students’ ability to detect important details.

Koo, a student from New Hampshire, says he found the class eye-opening — literally. He says it trained him to look at things he was seeing more carefully, without initially making assumptions and interpreting what he saw.

On a recent afternoon at Yale, the students noted what they saw in detailed Victorian paintings in the museum and then applied their enhanced observational skills to photographs of patients with skin and other ailments they could encounter as doctors.

For the class, sheets of paper had been placed over the titles of the paintings and the accompanying texts so the students had to start their observations from scratch — the way Braverman wants his students eventually to look at their patients. The students discovered that the images often were not what they appeared to be.

“This painting is of a young man reclining on a bed in a dark room in the morning,” Koo said as he began to tell professor Braverman what he saw. The student managed to pick out several clues — smoke rising from a just-extinguished candle, for example, morning light streaming into the attic room, and writings torn to shreds.

As fellow students chimed in with their observations, and Braverman drew out detail upon detail, Koo began to see things more precisely, until the young man’s contorted position on the bed, his pallid face and an empty vial on the floor made it clear to him that the painting depicted a suicide. “I believe that he’s dead,” Koo finally said of the subject of the painting.

He was right. “The Death of Chatterton,” an 1856 work by Henry Wallis, depicts Thomas Chatterton, who poisoned himself in despair in 1770 after his forgeries of 15th-century poems were unmasked.

“It made me notice things that my eyes had just not seen,” Koo said of the class. “In going through it in my own mind and with my peers I was able to develop a fuller story, and that enabled me to put the pieces to­gether in a way that was closer to the reality.”

The group of students that curator Friedlaender tutored in the museum carefully noted the details in a 1770s painting called “The Gore Family,” by Johann Joseph ­Zoffany.

Sounok Sen, a student originally from Maryland, deftly described the details he picked out in the painting. “That was fantastic,” Friedlaender told him.

The painting depicts an engagement party. But the nature of the event — and which of the several individuals in the work were the man and woman about to be married — didn’t become apparent to the students until Friedlaender drew out their detailed observations.

A student from Nigeria, Oluwatosin Onibokun, wasn’t sure at the outset of the class that her observational skills could improve by looking at the paintings. By the end, after she had painstakingly considered details in the photographs of patients that Braverman passed around a table for examination, she had no doubt of the museum tutorial’s ­benefit.

“I paid more attention to colors, shapes and sizes of skin blotches, lesions and other conditions,” she said. Her observational skills had already improved. “It was great,” she said of the class.

Lane English, a museum docent, spoke to the medical students, offering her own very personal support for what Braverman and Friedlaender are doing to train doctors. Several years ago English suffered what appeared to be a blockage — the result of a stroke — behind her left eye that caused temporary blindness. Her sight partially returned, but she was directed to Yale-New Haven Hospital for examination, and doctors initially could not figure out what was wrong. Braverman invited English to tell her story to his students at the end of the museum class.

“All of a sudden,” she told the students, “one of them said, ‘Oh my God, look at her lip.’” That physician noticed a spot that was a telltale sign of a hereditary condition known as HHT, which causes blood vessel malformations in the lungs that rob the body of oxygen. HHT can be fatal if not detected and treated. Tests confirmed the suspected diagnosis, and Dr. Robert I. White, an expert in the detection and treatment of HHT, was able to correct the condition without surgery by an image-guided procedure to close off abnormal blood vessels, noted English.

The students were transfixed as English described her ordeal. As Braverman and Friedlaender had hoped, English became the embodiment of how keen observational skills can impact the lives of patients, their families and the doctors who diagnose them.

Because of English’s eye problem, the doctors initially were thinking of stroke, Braverman told the students. The correct diagnosis of HHT came about because someone was looking at English with much more attention to small detail.

“That probably saved my life,” English said.

— By Daniel P. Jones and Karen Peart