COMMENTARY

How to Be a Better Ophthalmologist? Go to the Art Museum

An Eye for the Eye

William C. Ou; Charles C. Wykoff, MD, PhD

Disclosures

April 27, 2018

A Feast for the Eye

The retina is special in that it is one of the few places in the body where, in most cases, both anatomy and pathology can be directly visualized with light and basic optics, without the need for more advanced imaging modalities. Funduscopic examination is an extremely powerful tool for the diagnosis of various vascular, degenerative, neurologic, or even malignant diseases that may appear in the retina, either as a primary process or as a secondary manifestation of systemic disease. Beyond this staple, a variety of ancillary tests exist (ie, fundus photography, angiography, and optical coherence tomography) that are used in the clinic and generate qualitative image data that must subsequently be interpreted or quantitated by the physician (or possibly in the near future, by a computer algorithm).[1]

Therefore, perhaps more so than in many other medical specialties, retina specialists must have excellent observational skills. This is particularly true in light of the lack of universally accepted standards for the clinical staging of diseases, like age-related macular degeneration, and the burden of management decisions that is placed on each clinician's individual judgment.[2]

Medical education is constantly evolving. In pursuit of well-rounded education, one trend that has rapidly gained traction over the past two decades has been the increasing incorporation of the arts and humanities into medical school curriculums to foster the development of competencies such as critical thinking, communication, and observation. Of 145 schools surveyed in the 2016-2017 Association of American Medical Colleges (AAMC) Curriculum and Inventory Reports, 125 (86%) reported that humanities education was a required part of the curriculum.[3]

Art Observation in Medical Schools

For many medical schools, art observation has emerged as a popular way to teach observational skills. One of the pioneering attempts at this approach was implemented at Yale in 1998, in partnership with the Yale Center for British Art (YCBA).[4] In this program, medical students were assigned a painting at the YCBA to study and describe in detail to their classmates under the supervision of a curator. Students who participated in this program demonstrated greater improvements than control groups in their performance on subsequent descriptive assessments. In the nearly two decades that have followed, many other medical schools have implemented similar programs, and the results have generally been positive by both qualitative and quantitative standards.[5,6,7,8]

Arts-Based Observation Training in Ophthalmology

This interest in the arts has also infiltrated the Perelman School of Medicine at the University of Pennsylvania, where Gurwin and colleagues[9] have recognized the potential utility of arts-based observation training in ophthalmology specifically.

Researchers recruited 36 first-year Perelman medical student volunteers and randomly assigned them 1:1 to receive either formal art observation training at the Philadelphia Museum of Art or a free membership to the museum. The art observation training consisted of six 1.5-hour sessions taught by professional art educators. The sessions were custom-designed, based on the "Artful Thinking" approach, a program developed by Harvard Project Zero as a model for incorporating art into classrooms.

The main outcome measure analyzed in this study was the degree of improvement in students' ophthalmologic observational and descriptive skills following intervention. For assessment of this outcome, students were asked to analyze and write free-text descriptions for three types of images: art, retinal photographs, and clinical photographs of faces demonstrating ophthalmologic disease. The art images were graded by Philadelphia Museum of Art educators using a predefined rubric, but without a maximum score. The retinal and clinical photographs were graded on a 24-point scale by two ophthalmologists and a fourth-year medical student using a predefined rubric, with points being awarded for specifically defined observations (eg, "spots are circular/oval"). Retinal pathologies presented to students included retinal hemorrhages with macular hemorrhagic cyst, ocular histoplasmosis, chorioretinitis, and Stargardt disease.

Students assigned to art observation training demonstrated significantly higher improvements in overall score from pre-test to post-test compared with the control group (mean change of +19.1 points vs -13.5 points, P = .001). A subgroup analysis of the retinal images alone revealed a similar effect (mean change of +6.1 points vs -2.8 points, P = .001). The authors concluded that the art observation training significantly improves students' observational abilities.

Strengths of this study include randomization, controlled design, and use of a predefined, quantitative grading system.

Several limitations are worth mentioning, however. Because all of the participating students were volunteers, there exists the possibility of selection bias—as the authors themselves note, motivated students who take on "extra work" on top of an already rigorous medical school curriculum might be more compelled to respond to training. Therefore, it is unclear whether similar results would be obtained should the program be instituted as a mandatory part of the curriculum. Additionally, the degree to which the testing methodologies utilized (ie, describing photographs) correlate with real-world clinical observational skills or diagnostic proficiency remains to be determined.

Nevertheless, the positive results of this study indicate that additional investigation into the utility of art-based interventions in the training of ophthalmologists and retina specialists could be of great value. Indeed, usefulness of the arts may not be limited to students. One study in the United Kingdom[10] found evidence that art observation training can improve observational skills even in practicing physicians and nurses.

Gaining a New Point of View

Nor are the potential benefits limited to observational skills.

In post-study surveys, the Perelman students expressed that the training contributed meaningfully to their clinical education (eg, by improving their ability to interact with standardized patients and to be more open-minded in group settings).[9]

In an accompanying editorial,[11] journalists David Epstein and Malcolm Gladwell take these ideas even further, alluding to the centuries-old ideal of the "Renaissance Man" and pointing out that many of the greatest minds in science held interests outside their respective fields. Throughout history, many well-known physicians, including the likes of William Osler ("the Father of Modern Medicine"), have been bibliophiles, writers, or musicians.[12] Perhaps, with efforts like those of Gurwin and colleagues, both trainees and practicing physicians of today might be encouraged to follow in their footsteps.

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