The art of looking at patients

Clinical diagnosis involves history-taking, examination and investigation. Examination is subdivided into inspection, palpation and auscultation.  Medical students and doctors spend many hours learning how to palpate and auscultate. 

It is often assumed that inspection is innate, something that everyone will do equally well without much effort or instruction. When a medical tutor asks a student ‘what do you see?’, he expects that the student sees exactly what he himself sees — the physical signs of disease. The medical student tries to give the ‘right’ answer. If tutor and student concur, it is usually taken as evidence of successful observation. As doctors, we learn to look quickly; to make ‘spot’ diagnoses; to recognise patterns; to ‘see’ as many patients as we can, as quickly as we can; make a diagnosis, a management plan and attend to the paperwork.  This is considered good medicine: Efficient, effective and productive.

William Osler, the Canadian physician responsible for moving physicians-in-training out of the lecture theatre and to the patient’s bedside, wrote that “the whole art of medicine is in observation”.

Prior to the development of the advanced imaging technology available today, human observation of patients often made the difference between good and great medicine.  But is this still true for today’s patients and doctors? In our fast-paced world, is there any value in slowing down and practicing the art of looking at patients?  If so, is there an effective way of achieving this?

‘Training the Eye: Improving the Art of Physical Diagnosis’ is a museum-based course for medical students at Harvard Medical School. It is a trans-professional initiative involving art educators, curators and clinicians. Students are encouraged to look at art, interpret it and discuss it, in a facilitated group setting. The objective is to enhance observation skills, increase awareness of one’s emotional response to art, use this awareness to enhance meaning-making, consider the evidence for this meaning and respectfully engage in dialogue with others. Students learn to be comfortable with uncertainty and become familiar with their individual thought patterns when trying to make sense of art. They learn that there is no ‘right’ answer. Following the museum sessions, students are given the opportunity to employ the same skills with patients. The students have subsequently been found to have increased diagnostic accuracy and enhanced clinical reasoning compared to students who did not participate in the course.

Apparently, our responses to art reflect our responses to people. Simple scenes are interpreted quickly without much attention to detail or attempts at analysis. Just as in medicine, a dermatomal rash is quickly diagnosed as shingles.  A more complex or abstract piece of art requires closer observation.  Sometimes, after a longer period of looking, the discovery of a specific detail may completely alter the big picture, causing us to change our mind about the artist’s meaning or a comment from a fellow observer may lead to a new interpretation.

Not long ago, a young man presented to me with stridor. On examination, he had a goitre. A respiratory examination did not reveal any further abnormality. I referred him for surgical assessment. While waiting for this assessment, the man developed shortness of breath and was diagnosed with metastatic lung disease. My spot diagnosis was wrong. 

Closer observation may have uncovered the true cause of the stridor earlier. There may have been a detail that was missed that would have altered my diagnosis and management. It would not have made any difference to the outcome in this case, but the lesson I learned was to look a bit longer and bit deeper. To remain open to the possibility that what at first glance appears obvious can be significantly altered with the addition of less obvious details. Humans are much more complicated than art. Time spent in observation and reflection is time well-spent.

Observation is a skill that can be learned and enhanced at any stage of our career.  With the rise of medical technology and specialised medicine, we may forget that our observations are powerful influencers of our decision-making. Art observation may not seem like a useful skill for doctors, but looking at art has a lot in common with looking at patients. It involves paying attention to what is present, forming an impression and communicating it. 

However, there is one major difference. Observing art is not as overwhelming as observing humans. Art does not verbalise joy or distress. Art allows us to sit in silence, engage, or turn away as we see fit, without fear of being judged or misinterpreted. Art observation can renew our interest and enthusiasm for patient observation, increase diagnostic accuracy, decrease referral rates and investigations. Observation skills can still be the difference between good and great medicine. 

For a useful toolkit to enhance your art observation skills, visit www.artspractica.com  and don’t forget to claim your study leave for your summer visits to the galleries.