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The Art of Observation Impact of a Family Medicine and Art Museum

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					                                                                                                         Vol. 38, No. 6       393

Medical Student Education



      The Art of Observation: Impact of a Family Medicine
       and Art Museum Partnership on Student Education
                               Nancy C. Elder, MD, MSPH; Barbara Tobias, MD;
                              Amber Lucero-Criswell, MA; Linda Goldenhar, PhD

Background and Objectives: Compared to verbal communication, teaching the skill of observation
is often shortchanged in medical education. Through a family medicine-art museum collaboration,
we developed an elective course for second-year medical students titled the “Art of Observation”
(AOO). To evaluate the course’s effect on clinical skills, we performed a qualitative evaluation of
former students during their clinical rotations. Methods: In the spring of 2005, all students who had
completed the AOO course in 2003 or 2004 were invited to take part in an online evaluation consisting
of eight journaling survey questions. Students were instructed to answer the survey questions with
specific examples. Question areas included the most memorable experience, the course’s influence
on the doctor-patient relationship, usefulness during clinical years of medical school, and skills
unique to AOO. The anonymous data were analyzed qualitatively, coding the responses to categories
derived from the data, leading to the formation of themes. Results: Of the 19 students eligible, 17
participated. We found three important themes: (1) the AOO positively influenced clinical skills, (2)
both art museum exercises and a clinical preceptorship were necessary to achieve those skills, and
(3) the AOO led to a sense of personal development as a physician. In addition, students told us that
the training in observation and description skills they learned were unique to the AOO. Conclusions:
This collaboration between a department of family medicine and an art museum produced a course
that facilitated observational skills used in successful doctor-patient relationships.

(Fam Med 2006;38(6):393-8.)


“There is no more difficult art to acquire than the art                        In recent years, medical schools around the country
of observation, and for some men it is quite as difficult                   have begun adding observation skills training to their
to record an observation in brief and plain language.”                     curriculum. Several schools are now offering courses
William Osler, Aphorisms From Bedside Teachings                            using the visual arts to facilitate students learning
and Writings.                                                              the skill of observation. These courses have differing
   The doctor-patient relationship is a cornerstone of                     goals and, as such, have been structured differently.
a positive therapeutic outcome for patients.1 This rela-                   Goals for medical school courses using artwork include
tionship is based on understanding and communication                       improving descriptive dermatology skills,5 improving
between the patient and physician. Communication                           observation and interpretation skills,6-10 cultivating
is a complex process, which depends on both verbal                         multicultural sensitivity,11 and providing a space for
and nonverbal skills. In medical education, the verbal                     reflection, contemplation, and insight.12 Some involve
communication skills of question asking, listening, and                    looking at slides of artwork in a classroom,10 while
talking are emphasized more, and often separated from,                     others go to art museums,5,8 and yet others incorporate
the nonverbal skill of observation.2,3 Even within the                     drawing.9 The courses last from a few hours to a full
patient-centered model of care, talking and listening                      semester.
activities are stressed.4                                                     In 2001, the Department of Family Medicine at
                                                                           the University of Cincinnati, in conjunction with the
                                                                           Cincinnati Art Museum, began an elective course for
                                                                           second-year medical students, titled the “Art of Obser-
                                                                           vation” (AOO). The primary goal of the course is to
From the Department of Family Medicine (Drs Elder and Tobias) and Office
of the Dean (Dr Goldenhar), University of Cincinnati; and Cincinnati Art   improve communication and observational skills used
Museum, Cincinnati, Ohio (Ms Lucero-Criswell).                             in the patient-doctor relationship by guided instruction
394     June 2006                                                                                                Family Medicine

in observation, description, interpretation, and reflec-
tion of the visual arts. However, as a course that teaches                                   Table 1
clinical skills in a preclinical year, the standard end-of-
course evaluation was unable to gauge the effectiveness                 Art of Observation Course Description
of the course in meeting its objectives. Therefore, we
performed an evaluation of previous AOO students at           Course objectives:
the end of their third or fourth year of medical school.        • Apply observational skills learned in the visual arts sessions to the
                                                                  clinical setting.
We used qualitative methods since they offer a rich             • Contrast the terms description and interpretation as they apply to
understanding of the effect of educational components             the visual arts and the clinical encounter.
on student outcomes.13-15 This paper’s purpose was to           • Identify one’s own biases and perceptions as integral elements of
                                                                  interpretation through examination of the cultural, ethnic, age, and
describe the objectives and methods of our AOO course             gender context of subjects depicted in photographs and portraiture.
and the results of a qualitative online journaling survey       • Understand how the physician’s interpretation of the patient’s mood,
on the course’s influence on the doctor-patient relation-          affect, position, and body language impacts the clinical encounter.
                                                                • Using the visual arts as a model, describe how the components of
ship. It also describes the skills and insights from the          observation and interpretation form the basis for response and
course that students found useful in subsequent clinical          reflection in the clinical setting.
rotations in medical school.                                  Course meetings:
                                                                • Six 2-hour sessions at the Cincinnati Art Museum.
Methods                                                         • Two 1-hour discussion sessions at the University of Cincinnati.
Course Description                                              • Seven to nine 4-hour clinical sessions observing the family
                                                                  physician faculty in their practices.
  The AOO is an 8-month elective for second-year
medical students. Class size is limited to 12 students        Course curriculum:
per year, and 8–12 students take the course each year.          • Months 1–3: Description
                                                                  • Art Museum: exercises focusing on observing and describing
The details of the course are shown in Table 1.                      paintings, sculptures, or other artwork using both representa-
                                                                     tional and abstract work.
Participants                                                      • Clinical preceptorship: students write descriptions of the patients
                                                                     and the doctor-patient encounter and sketch a picture of one
   All students who completed the course in 2003 or                  patient each session.
2004 were contacted in late spring of 2005 to take part           • Discussion session: informal discussion of their clinical
in an online structured journaling survey to qualita-                observation notebooks, which have been reviewed by the course
                                                                     faculty.
tively evaluate the AOO course. These students were
chosen because they had completed 9 or more months              • Months 4–6: Interpretation
of clinical rotations in medical school after the AOO             • Art Museum: exercises focusing on observing and interpreting
                                                                    paintings and photographs, stressing descriptive justification for
course and thus could address the role, if any, of the              interpretation; photographs are chosen to address racial, age,
course on their clinical education. Our institutional re-           gender, and socioeconomic differences among people.
view board reviewed and approved this study. Students             • Clinical preceptorship: students write descriptions and
                                                                    interpretations of the patients and the doctor-patient encounter.
who completed the evaluation received a gift card to              • Discussion session: informal discussion of their clinical
a bookstore.                                                        observation notebooks, which have been reviewed by the course
                                                                    faculty.
Data Collection                                                 • Months 7–9: Response
   Drawing on the course objectives and the medi-                 • Art Museum: exercises focusing on observing and responding
cal literature on the effectiveness of medical school               to paintings, photographs, and sculpture, stressing the emotional
                                                                    and psychological state of the subjects in the art, the artist, and
courses using the visual arts,5,8-12 the course directors           the observer of the art.
(two family physicians, one museum curator), together             • Clinical preceptorship: students write descriptions and
with a medical education evaluator, developed a series              interpretations of the patients and the doctor-patient encounter
                                                                    and comment on their emotional responses to the patient and the
of eight journaling survey questions that were posed to             encounter.
the students on a secure Web page via the College of
Medicine’s dean’s office. Results from this Web page             • Final wrap-up session: review the course experience and watch the
                                                                  video “Wit,” a patient’s experience with cancer and the health care
went only to the medical education evaluator, who                 system.
de-identified the responses before collating them and
sending them to the course directors. Students were
instructed to answer the survey questions with specific        Data Analysis
examples and stories in a journaling mode. Question              The three course directors served as data analysts,
areas about the course included the most memorable            with one family physician serving as primary analyst.
experience, influence on and understanding biases in           The student responses were read independently by the
the doctor-patient relationship, influence on second year      analysts, who then met to discuss initial issues, ideas,
of medical school, usefulness during clinical years of        and themes. From this discussion, using NVivo 2.0
medical school, skills or insights unique to AOO, and         software, the primary analyst sorted the interview data
influence on experiencing art-related activities.              into coding categories derived from the data, explicitly
Medical Student Education                                                                      Vol. 38, No. 6          395

checking them against other categories and the origi-          Watching my mentor’s interactions with patients helped
nal data and then searched for patterns and themes.            me to realize the different levels of the patient-doctor
During coding, categories were added or modified as             relationship and greater appreciate different types of
needed as we drew on the original transcripts for mean-        communication . . . physical, vocal.
ingful segments of text.16 All the analysts then read
and discussed the coding categories and the original            Ten students discussed how they developed skills
data and developed themes related to the acquisition         through the exercises at the Art Museum. One student,
of clinical skills from the course.                          for example, felt that her descriptive abilities improved
                                                             from those exercises:
Results
   Of the 19 students who had taken the course during          One way this course was extremely helpful was in
their second year of medical school, 17 completed the          learning the process of studying paintings, photos, etc.
online journaling survey. The 17 respondents included          So many times during the clinical years you are asked
11 women and six men. One woman and one man did                to describe something without interpreting it.
not participate. There were nine current fourth-year
students and eight current third-year students partici-      Self-reflection and Personal Development
pating.                                                         Students commented that the course allowed them
                                                             to reflect on their role as a physician and the challenges
Main Themes                                                  they face as they assume this role. Seven students com-
  We found three important themes in our students’           mented on personal growth; one student, for example,
evaluations relating to learning skills for the doctor-      commented on understanding an emotional response
patient relationship: (1) how the AOO influenced clini-       she had to a patient:
cal education, (2) which part of the course was felt to
be most responsible for the influence, and (3) how the          There was one patient I went to see with one of the
AOO impacted self-reflection and personal develop-              preceptors. During the time period we were allowed
ment as a physician. In addition, we noted (4) how the         to reflect, I realized she made me feel uncomfortable
course affected the second year of medical education           because she seemed like one of the “cool kids” from
and (5) what educational benefits of the AOO course             high school. I thought it was important to learn to
the students believed were unique to the AOO and not           acknowledge the effect your patients have on you and
covered elsewhere in the medical school curriculum.            why they have that effect.

Influence on Clinical Education                                  Eight students commented on an awareness of chal-
   Table 2 describes the main influence the AOO course        lenges in being a doctor, such as the challenge of sepa-
had on students’ clinical education. Only two students       rating response, interpretation, and description.
did not feel there was much effect—one student re-
flected that there was no influence on the doctor-patient        To reflect on a painting and then describe the painting
relationship and the other no influence on clinical skills.     to the rest of the group based solely on the observa-
The other students felt they gained understanding of           tions we made—it was difficult not to project our own
important concepts such as physician biases and the            thoughts as to the meaning of the painting and focus
doctor-patient relationship, as well as specific clinical       solely on the physical being. I think that it is in our na-
skills. These skills included observation, nonverbal           ture as physicians to latch on to one cardinal symptom
and verbal communication, and description skills, as           a patient gives us and then jump to a diagnosis (a.k.a.,
well as an ability to see the patient as a whole person.       label a patient), often times before we have fully and
While most of these skills were specifically addressed          artfully observed all aspects of the patient.
in the curriculum, some, such as verbal communica-
tion, were not.                                              Effect on Preclinical Education
                                                                The AOO course had little perceived educational
Importance of Course Components                              benefit during the actual year it was taken. Two students
   Students shared with us that both the clinical precep-    felt that they didn’t “think it had much influence at all
torship with the family physician faculty as well as the     during the second year of school.” However, a number
art museum experience played a role in the skills they       of students felt the course helped them by assisting them
gained. Eight students mentioned specific examples of         in setting life and school priorities (10 students) and
how the role modeling observed during preceptorship          served as a needed change of pace from academic life
affected their education. For example:                       (eight students). Frequently mentioned was the mental
                                                             health break the students got from the course.
396       June 2006                                                                                                                 Family Medicine


                                                                    Table 2

                              Impact of Art of Observation Course on Clinical Education

                                                                                                                               Number of Students
 Type of Impact        Category of Impact                                                                                      Mentioning
 Awareness and         Awareness of physician biases                                                                           12
 Understanding
  Sample quote:        I still remember my encounter with the first patient I saw on the first day . . . she had an unusual way of dressing, styling
                       her hair, and wearing her makeup, in addition to many piercings on her face. The more I tried not to stereotype her and
                       look beyond the physical appearance, the more I realized that observing the physical appearance is a crucial part of what
                       a doctor does. I began to realize the important difference between observing as a professional doctor in order to help the
                       patient versus making judgments based on one’s appearance and allowing that to affect interactions with and treatment of
                       the patient.
 Awareness and         Understanding the doctor-patient relationship                                                           6
 Understanding
  Sample quote:        I strongly believe that the Art of Observation gave me a different insight into the patient-doctor relationship. It has made
                       me look deeper into the patient and [his/her] illness, which is a skill I will definitely carry through my career.
 Clinical Skills       Observation skills                                                                                      9
  Sample quote:        A patient I have now has dysphonia/dysphagia/expressive aphasia and paraplegia. She sometimes attempts “yes” or
                       “no” but mostly regards and acknowledges me through eye contact and expression. I may not have picked up on her
                       communication or ability to do so if I had not been challenged to pay attention to these subtleties in the elective. I was
                       better able to facilitate the doctor-patient relationship, having been perceptive enough to relate to the patient.
 Clinical Skills       Nonverbal communication skills                                                                          7
  Sample quote:        I found it particularly helpful in our third-year psych clerkship, where part of your exam and diagnosis depend on your
                       observations and impressions, and they don’t have time to teach it during the clerkship. I found myself remembering our
                       discussion about noticing details of clothing and face. Even on other services, it ALWAYS helps to really stop and look at
                       your patient and their room, everything they are doing, reading, inhaling, infusing, etc. It helps both with treatment and
                       with establishing rapport.
 Clinical Skills       Verbal communication                                                                                    5
  Sample quote:        I think that really listening to patients and their families is important for the doctor-patient relationship and that if they
                       don’t think the doctor is truly concerned about them, they will not be as open with the doctor.
 Clinical Skills       Ability to see patient as a whole                                                                       4
  Sample quote:        The AOO taught me to look at the whole patient and to not make assumptions based on what I see at first glance. I am
                       now conscious of taking a step back looking at all the details and information and assessing the whole patient without any
                       preconceived biases.
 Clinical Skills       Descriptive abilities                                                                                   3
  Sample quote:        One way this course was extremely helpful was in learning the process of studying paintings, photos, etc. So many times
                       during the clinical years, you are asked to describe something without interpreting it. For example, it is important to be able
                       to describe a person’s overall appearance without saying “They looked like a COPDer.” This is not an easy thing and takes
                       a skilled observer. It also helped enormously with radiology. One of the main goals of radiology is to be able to initially
                       describe what you see without interpreting it.




  Quite simply, it reminded me that I need to get out                           at the museum just reminded me that it was not only
  of the hospital and do something besides health and                           “OK” to think outside of the box but that it is vitally
  science whenever possible, which was wonderful for                            important.
  my mental health. I was a much better student during
  my second year.                                                            Unique Qualities of Course
                                                                                While several courses in medical school aim to
  For others, the course and its time for self-reflection                     teach students skills in the doctor-patient relationship,
helped some students set personal priorities.                                our student participants felt that there were definite
                                                                             skills they learned only in the AOO course. In addi-
  I don’t mean this in the superficial sense of it just                       tion to the obvious exposure to art and art museums
  being nice to take a study break, but it really went to                    mentioned by eight students, students also felt that the
  a deeper level of allowing us the time and space to                        skills they gained in description (three students) and
  explore the human side of ourselves. . . . I guess being                   understanding of the doctor-patient relationship (four
Medical Student Education                                                                    Vol. 38, No. 6         397

students) were unique to the AOO course. For example,            Our student evaluation also confirmed for us the im-
one student felt that:                                        portance of combining a clinical preceptorship with the
                                                              art museum exercises. As students took their museum
  No other course takes the time to really focus so much      exercises in description, interpretation, and response
  on seeing your patients and interpreting what that          directly to a clinical encounter, they could immediately
  means to them and you. It is something from which           practice these skills in a medical setting, and the stu-
  every person would benefit, especially physicians.           dents could also bring their clinical experiences back
                                                              to their observation of artwork (Figure 1).
  In addition, seven students noted the importance of            The use of arts in education has been described as
personal growth offered in this course. One student           “anecdotal and unsystematic,” and the need for a con-
noted that:                                                   ceptual framework has been stressed.12 While ours is
                                                              just an individual course, and not a school-wide cur-
  In medical school there is little time allowed for ob-      riculum, our synergistic model (Figure 1 and Table 1)
  servation and self-reflection in any sort of structured      provides a framework of integration of the arts with
  format. The Art of Observation did that for us.             clinical skills. Descriptions of other courses using
                                                              the visual arts often use those components in isola-
Discussion                                                    tion.5,6,8,21 We designed this course to build on a base of
   The humanities in medical education have blos-             observation and description, which must be mastered
somed in the last 2 decades, as physicians and those          to accurately interpret and to communicate responses
involved in medical student education have discovered         and reflections.5,8,10 Integrating clinical experiences
the benefits of using literature and, more recently, the       with the visual arts is a key to the assimilation of all
visual arts in training health care providers.17-19 Only by   these skills.
performing an evaluation of our course after students            Responding to art, and reflection on that response,
had significant clinical experience in their third and         has been a part of art appreciation for a long time.
fourth year of medical school, and by using a qualitative     Our students commented on the importance of having
method, could we adequately assess the effects of our         time and structure for this activity relating to both art
course and determine which components of our course           and clinical observations; for many, the AOO, “went
were necessary to achieve our goals. We believe our           to a deeper level of allowing us the time and space
experience in collaboration between a department of           to explore the human side of ourselves.” We began
family medicine and an art museum has produced an             these reflection exercises with artwork, where all
elective course for second-year medical students that         could safely observe, discuss, and reflect on the same
has achieved its clinical objectives (Table 1), while also    piece. That made it easier to move it into the clinical
offering students a time for self-reflection, personal         setting, where initially the students observed doctor-
growth, and an enhanced appreciation of art.                  patient interactions with their preceptors. Then, as we
   Our qualitative evaluation revealed three important        learned in these interviews, they later responded to
findings. First, description and interpretation are not        and reflected on patients and relationships during their
systematically taught elsewhere in our curriculum.            clinical rotations. This self-awareness, sensitivity, and
Second, improving observation skills within the doc-          self-reflection are skills that lead to improved doctor-
tor-patient relationship require both a visual arts and       patient communication.4 We are encouraged that our
an integrated clinical component. Third, time and             student participants continued to find these activities
guidance for personal reflection and growth are seen           useful to them clinically.
by medical students as vital to their education.                 There are limitations to our study, however. First,
   Many of our student participants noted that important      the AOO is an elective, and students with an interest
components of communication were covered only in              in such topics are most likely to enjoy and learn from
the AOO course. The need for improved communica-              such activities. Second, more women than men took
tion education in medical school has been highlighted         the elective, and the possibility of gender bias exists.
in recent years,2,20 specifically noting that “Students        However, our qualitative evaluation asked for stories
develop communication skills by observing others              and specific experiences that allow us to understand
and then practicing these skills.”2 However, actually         what specific skill set these students gleaned from the
teaching students how to observe is not mentioned.            course and what components of the course were im-
Our course fills that gap for many students who take it.       portant for learning those skills. These evaluation data
While clinical clerkships are a typical place to observe      are important, even when coming from a self-selected
and practice communication skills, communications             group of students.
training across multiple courses and years is more likely        A third limitation is that our “interview” with the
to be effective.2,20 The capacity for self-reflection, as      students was online, not allowing any clarifying ques-
provided in our AOO course, also increases the likeli-        tions or prompts. This was done to improve the response
hood of effective communication.2,4                           from the students, who often needed to do the survey
398       June 2006                                                                                                              Family Medicine

during their “free time” on weekends and evenings.
We achieved a 90% response rate with this method.                                                              Figure 1
Fourth, we also were not able to confirm our analysis
with our participants, since half of them had graduated                                       Interactions of Components of
by the time the analysis was complete. While this would                                       the Art of Observation Course
have strengthened the analysis, we believe having mul-
tiple analysts, including a medical education evaluator,
                                                                                 Clinical Preceptorship                             Art Museum
did add to the credibility of the analysis.
                                                                                        Patients                               Paintings, portraiture




                                                                                                                ↑ ↑
Conclusions                                                                         Doctor and staff                               Photographs
                                                                                Doctor-patient relationship                          Sculpture
   While the medical and lay literature contains many                                                                                Artifacts
reports of the use of visual arts in medical education,




                                                                                            ↑
almost all are descriptions of their course, with no                                                           Exercises
                                                                                                                                        ↑
evaluative component.5-11,21,22 A call for “incorporat-
                                                                                                      Art museum exercises
ing outcome assessments as a component of arts-re-                                                  Written clinical observations
lated programs for medical students” has been made.12                                                 Sketching and drawing
Medical education has also been challenged to improve                                                    Group discussions
the communication skills necessary for improving
                                                                                                                  ↑
the doctor-patient relationship.2,20 We believe that our
evaluation data show that the AOO course, designed
and implemented to improve the observation, descrip-                                                            Reflection
tion, interpretation, and response skills of medical                                                            Response
                                                                                                              Interpretation
students, meets many of these challenges. This course                                                          Description
is an example of how medicine continues to be informed                                                         Observation
by the arts.
                                                                                                                  Skills
Corresponding Author: Address correspondence to Dr Elder, University of
Cincinnati, Department of Family Medicine, PO Box 670582, Cincinnati,
OH 45267-0582. 513-558-1436. Fax: 513-558-3266. eldernc@fammed.
uc.edu.



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