A curious thing happens to medical students shortly after they enter clinical training. As explained in an evocative essay in the New York Times, the students begin to stop trusting their own ability to examine a patient. They instead start to lean on the machines that create medical imagery—MRIs, CT scans, ultrasounds—to do the work of “seeing” for them. These and other diagnostic tools are so good at what they do that young doctors may not feel pressured to develop their own powers of observation.
That’s a shame, say the previous generations of doctors that act as their mentors, because it means the young docs can miss less-obvious clues in a patient, or the patient’s environment, that could point to obscure or even common health conditions, or teach them something useful about a patient’s lifestyle or mental state.
To encourage students to build a habit of thorough visual inspections, Yale professor and dermatologist Irwin Braverman, and Linda Friedlaender, curator of education at the Yale Center for British Art (YCBA), co-pioneered a novel program in 1999 that introduced medical students to Victorian and Pre-Victorian art. Variations of the program caught on across the country and are now in place at more than 70 institutions.
At Yale, Friedlaender explains, students are divided in groups of four and assigned to a moderator. Each one takes a turn with a selected painting, sitting in front of it for 12-15 minutes, perhaps with a notepad or sketchbook, to jot down their impressions. They are then asked to describe the painting to their peers in as much detail as possible. (All the paintings are representational.)
In the first half of the subsequent discussion, the students are required to supply only an objective description of the painting; they are not allowed to interpret, draw conclusions or offer an opinion. Making judgements is usually their first instinct, however. “A student will say ‘This painting is of a sad woman,’ and we’ll say, ‘That’s an opinion. Tell us more about what you see in her,'” says Friedlaender. They’re taught to note things like a furrowed brow or a lowered chin, hand gestures, posture, and clothing, and all the objects and environmental details, even those in the edges of a painting.
Then comes the second half of the discussion: “Once we are satisfied that they’ve given a complete visual inventory of the painting, they are allowed to draw conclusions about the narrative,”
Friedlaender says. That’s when another student might jump in with a different interpretation. “We talk about how we’re looking at the same object, i.e., the same patient, and people are coming up with different conclusions,” says Friedlaender. The same thing can happen with a patient who presents with symptoms that don’t neatly point at an obvious diagnosis. It may look like pneumonia, for instance, but it might be something completely different—or maybe the patient has pneumonia and another illness....MUCH MORESomehow the article omits mention of the real-life inspiration for Sherlock Holmes and his powers of deduction, Dr. Joseph Bell whom Arthur Conan Doyle first met in 1877 while a medical student at the University of Edinburgh.
An anecdote in "Teller of Tales: The Life of Arthur Conan Doyle" (p. 27-28) via Neatorama:
In the book Teller of Tales: The Life of Arthur Conan Doyle, author Daniel Stashower illustrated Bell's observation skills: Bell was able to tell that a man was an alcoholic by observing that he habitually carried a flask in the inside breast pocket of his coat, and that another man was a cobbler by seeing that the inside of the knee of the man's trousers was worn (that's where the man had rested the lapstone - a tool used by cobblers to condition leather). Bell was able to discern different accents to deduce a man's origin. He was also able to tell the difference between hand calluses of a carpenter from a mason, and the difference in the walking gait of a solider and a sailor.
Conan Doyle recounted this celebrated example of Bell's abilities when a patient whom Bell had never seen or talked to before came forward:
"Well, my man," Bell said, after a quick glance at the patient, "you've served in the army."
"Aye, sir," the patient replied.
"Not long discharged?"
"A Highland regiment?"
"A non-com officer?"
"Stationed at Barbados?"
Bell turned to his bewildered students. "You see, gentlemen," he explained, "the man was a respectful man but did not remove his hat. They do not in the army, but he would have learned civilians ways had he been long discharged. He has an air of authority and he is obviously Scottish. As to Barbados, his complaint is elephantiasis, which is West Indian and not British, and the Scottish regiments are at present in that particular island."
Doyle went on to be Bell's clerk and got to observe the techniques of early forensic medicine first hand.