Rheumatology Students Learning How To Look for Symptoms

Dr. Helfgott, MD

There is a photo of a young woman that I like to show medical students when I lecture on the topic of the treatment of autoimmune diseases. It shows a “before-and-after” headshot of a twenty-something patient: the “before” shot was taken about a year prior to the onset of her illness. It depicts a pretty young woman with shoulder-length auburn hair and sparkling green eyes. The “after” shot was taken at a time when we were struggling to control her raging lupus nephritis. I ask the students to describe what they see: her cheeks are bloated and covered with a deep red butterfly rash, there is some patchy acne over her chin, and her previously thick mane of hair has thinned considerably. Her eyes have lost their sparkle. The smile has disappeared. Most of the students quickly surmise that what they are seeing are the ravages of long-term corticosteroid use in a woman whom they guess may have lupus.

We move on to the second case. This one is a bit trickier—it is the photograph of a lovely middle-aged patient of mine, Mary C., who has had rheumatoid arthritis for more than twenty years. She passed away a few years ago, but while she was alive, Mary loved attending these sessions in person so that she could show off her charming face. She had a most unusual complexion for a woman of Irish ancestry; it featured a bluish gray tinge. She would regale the students with her colorful account of how her appearance once led an experienced infusion center nurse to mistakenly call a “code blue” because she thought that Mary was experiencing severe respiratory difficulties and turning blue in the face. In fact, her slate gray appearance was merely depicting the telltale sign of chrysiasis, something we rarely get to see these days following the demise of gold salt therapy. The students generally miss this visual finding, although last year, one sharp student recounted how she had seen a similar facial discoloration in a patient treated with amiodarone. These teaching sessions made me wonder about all those times in our daily practice when we fail to see what should be obvious, missing the diagnosis that is literally under our nose.

One of the more egregious examples of this phenomenon occurred many years ago when I was a second-year medical student. I elected to spend three months on a neurological service to see whether I was destined to become a neurologist. (I guess not!) One of our patients was the head neurosurgical scrub nurse who was admitted for evaluation of a variety of neuroendocrine anomalies. Three years earlier, she had undergone bilateral carpal tunnel surgery for release of both of her entrapped median nerves. The following year she was diagnosed with type I diabetes, and more recently she began to notice that she could no longer fit her previously slender fingers into the same-sized surgical gloves that she wore her entire career. Even a lowly second-year medical student could realize that she was displaying all of the features of a textbook case of acromegaly. The bizarre part of the story was that the preeminent neurosurgeon whose specialty was the resection of pituitary tumors was the same surgeon who had worked with her for the past ten years and had performed her carpal tunnel surgeries. Despite seeing patients with acromegaly who were referred to him from all over the world, he missed this diagnosis in a person who worked alongside him nearly every day for the past decade!

The Art of Diagnosis

It goes without saying that teaching the techniques of the skillful physical examination has lost some of its luster in medical school and residency training curricula. There are a number of reasons why the emphasis has shifted away from careful clinical evaluation to expediting patients’ problems with the help of lab tests and imaging studies ordered following a cursory physical examination. First, there is the time squeeze—clinicians are expected to see a rising number of patients at an ever-quickening pace. Second, there is the medico-legal-financial need to spend so much of the precious face-to-face encounter documenting the findings of this foreshortened exam. Third, there is the allure of expensive imaging and laboratory technologies that promise an expedited, focused work-up of the patient. Of course, labs and imaging studies are an essential part of the medical evaluation, but too many clinicians seem to wholly rely on these tests rather than spending a few extra minutes focusing on careful clinical observation. Fourth, there is a shortage of effective clinicians who have both the time and commitment to teach trainees the dying art of the physical exam. There are some notable exceptions, such as Abraham Verghese MD, senior associate chair for the theory and practice of medicine at Stanford University in Palo Alto, Calif., who is on a mission to revive the lost art of the physical exam that requires some old-fashioned touching, looking, and listening. With each passing year, fewer medical schools and residency programs are either willing or able to allocate the requisite funds to compensate clinicians for their teaching time and effort.

However, several medical schools and internal medicine programs are bucking that trend by offering trainees some novel teaching formats. Some have built simulation centers that can help teach critical procedures. For example, this technology can be useful in teaching medical residents how to perform arthrocentesis procedures. Most medical schools incorporate the objective structured clinical exam (OSCE) into their clinical examination curricula. The OSCE relies on using standardized patients and actors to simulate the patient clinician encounter. This exercise is good up to a point; simulation is great, but there is a tendency for participants to see it as being a practice drill and most prefer seeing real patients instead. What is really needed is a way to teach the art of “learning to look,” a term coined by Charles Bardes MD, professor of clinical medicine at Weill-Cornell Medical College in New York. Dr. Bardes and others have developed educational collaborations with local art museums for the purpose of developing student skills in clinical observation, description, and interpretation. As he noted: “Courses in physical diagnosis teach the students to recognize normal and abnormal findings, especially the cardinal signs and symptoms of disease, but do not emphasize the actual skill of careful looking in itself. Looking is often assumed. In the visual arts, on the other hand, the act of looking carefully is made explicit. In art education, major emphasis is placed on meticulous observation and description of visual information.”¹ Can art appreciation enhance our skills as medical detectives?

Visual Thinking Strategies

A recent study done at Harvard Medical School in Boston set out to answer this question by creating a course for first- and second-year medical and dental students consisting of eight paired sessions of art-observation exercises (20 hours) coupled with didactic lectures that integrated fine-arts concepts with physical diagnosis topics.²

The frequency of accurate observations on a one-hour visual-skills examination was used to evaluate pre- and postcourse descriptions of patient photographs and art imagery. Students were given eight minutes to report their free-text observations and interpretations of five slides depicting three patients with a variety of clinical disorders and two artworks in different genres, none of which were shown or discussed during the course. The clinical images included physical findings associated with upper-extremity deep-vein thrombosis, stroke, and (yes) relapsing polychondritis.

Class participants increased their total mean number of observations by nearly 40% compared to control students who had not participated, and they showed an increased sophistication in their descriptions of artistic and clinical imagery. There appeared to be a ‘dose response’ to learning since those who attended eight or more sessions scored significantly better than participants who attended seven or fewer sessions. It appears that this type of intervention promotes strategies for students to confront and decipher visual information. They achieve this by exercising visual problem solving in art and medical imagery using the repeated practice of observing and describing. By exploring a wide range of artistic concepts, art genres, and medical conditions, course faculty were able to challenge students to see beyond specific content areas.

These instructors and many others around the country employed a method known as visual thinking strategies (VTS) that linked visual art concepts with physical diagnosis. VTS is a method that was developed by Abigail Housen, DEd, a cognitive psychologist, and Philip Yenawine, an art educator. Originally, this technique was created as a tool to foster aesthetic development and to assist empathic understanding of others’ experience of the visual world through visual art. VTS has gained popularity as a way of using art to assist students in developing critical thinking, communication, and observation skills.

An interesting article about VTS published in Smithsonian magazine describes how the process has been used to improve the visual skills of police detectives so that they can increase their observations at crime scenes.³ In fact, these skills were credited in helping members of an undercover task force assigned to break up the mob control of garbage collection in Connecticut. According to Bill Reiner, the FBI special agent who headed the task force, these visual exercises helped one key undercover agent sharpen his observations of office layouts, storage lockers, desks, and file cabinets containing incriminating evidence. Reiner praises the effectiveness of VTS: “Don’t just look at the picture and see a picture. See what’s happening.” The information that this particular agent provided led to detailed search warrants and ultimately resulted in 34 convictions and government seizure and sale of 26 trash-hauling companies worth $60 million to $100 million. Here are your taxpayer dollars hard at work!

How can we apply VTS to our everyday practice of medicine? First, clinicians need to adopt a bit of the art critic’s mindset. We should learn how to read and interpret patients’ gestures and expressions. Was there eye contact when speaking with the patient? Was her smile crooked, or that eye a bit droopy, telltale signs of a facial palsy? (See Bell’s palsy: The answer to the riddle of Leonardo da Vinci’s Mona Lisa.⁵) First impressions may not always hold true; a second look might have you seeing things differently (See Rene Magritte, The Voice of Space4). Don’t get caught just looking at the obvious, to where the eye is initially drawn. As VTS teaches, try to see what is going on “in the shadows.” (See The Railroad Bridge at Argenteuil by Claude Monet.) Learn to sort out the relevant from the less-significant observations. (See Vase of Flowers with Pocket Watch, by Willem van Aelst.) Some of the imagery of medicine can be grotesque; the initial reflex of the viewer might be to look away. A careful observation of some of the finer details of the image may stimulate a more thoughtful response. (See The Ugly Duchess by Quentin Massys.)

The idea of using art appreciation as a way to educate doctors has growing support.

The 2010 Carnegie Foundation report, “Educating Physicians: A Call for Reform of Medical School and Residency,” discusses the importance of humanities and social science education in the formation of the physician. Among the report’s recommendations are innovative programs that use art museums as teaching laboratories. But there may also be some selfish reasons for all of us to consider incorporating museum visits into our lives. A fourteen-year Swedish study looked at possible determinants of survival in a random cohort of over 10,000 individuals between the ages of 25 to 74. The authors observed a higher mortality risk for those people who rarely visited the cinema, concerts, museums, or art exhibitions compared with those visiting them most often. The significant relative risks for surviving the duration of the study ranged between 1.14 (95% CI, 1.01–1.31) for those who attended art exhibitions, and 1.42 (CI, 1.25–1.60) for those attending museums, when adjusted for the nine other variables. Visits to the cinema and concerts also resulted in significant relative risk values that were intermediate to these two results. However, the authors could not discern any beneficial effect of attending the theatre, church service, or sports event as a spectator or any effect of reading or making music by the participants.

Spend an afternoon at an art museum, for the good of your body, your soul, and your patients.

Dr. Helfgott is physician editor of The Rheumatologist and associate professor of medicine in the division of rheumatology, immunology, and allergy at Harvard Medical School in Boston.

References

1. Bardes CL, Gillers D, Herman AE. Learning to look: Developing clinical observational skills at an art museum. Med Educ. 2001; 35:1157-1161.
2. Klugman CM, Peel J, Beckmann-Mendez D. Art rounds: Teaching interprofessional students visual thinking strategies at one school. Acad Med. 2011:86;1266-1271.
3. Hirschfeld N. Teaching cops to see. Smithsonian. October 2009. Available at www.smithsonianmag.com/arts-culture/Teaching-Cops-to-See.html#ixzz1ylZXxjyx. Accessed July 12, 2012.
4. Shapiro J, Rucker L, Beck J. Training the clinical eye and mind: Using the arts to develop medical students’ observational and pattern recognition skills. Med Educ. 2006; 40:263-268.
5. Maloney WJ. Bell’s palsy: The answer to the riddle of Leonardo da Vinci’s ‘Mona Lisa’. J Dent Res. 2011; 90:580-582.