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To the Editor: Observational skills that define the astute clinician are usually only acquired after years of clinical experience. Recognizing both the subtle and obvious visual details is a critical aspect of visual diagnosis or "seeing." Nonetheless, the formal teaching of observational skills is rarely included in the medical curriculum.We studied whether the experiential process of seeing such visual details can be enhanced in medical students through systematic visual training using representational paintings.
During the first month of the doctor-patient encounter course in the first year of medical school, students were encouraged to participate in the Yale Center for British Art (YCBA) project, which uses a student-centered approach to teaching.1 In academic year 1998-1999, 90 medical students who expressed an interest were randomized to a control group (n = 30), an intervention group (YCBA group, n = 30), or a lecture group (n = 30). In 1999-2000, 86 students were randomly assigned to either the control group (n = 35) or the YCBA group (n = 51). A lecture group was not used in 1999-2000 after preliminary data revealed no change in the students' observational performance (paired t test, P = .93). By the end of their academic year all students, regardless of group assignment for the purpose of this study, attended the YCBA for visual training as part of the general curriculum.
The control group attended clinical tutorial sessions in which a physician preceptor taught history taking and physical examination skills. The lecture group attended an anatomy lecture that featured abdominal radiographic images related to that week's dissection. The intervention group attended the YCBA program in which each student studied a preselected painting for 10 minutes before describing it in detail to their group of 4 students. Descriptions were based solely on visual evidence. For example, in describing a portrait of a woman's face, a student could not simply state that the woman looked depressed. The appearance of the eyes, mouth, and other facial features that led to the interpretation had to be specified. The discussions were moderated by the curator of education who used open-ended questions to encourage students to describe systematically the entire painting. Direct questioning was used if a specific visual point had not been addressed.
Sets of photographs (A and B) of persons with medical disorders were administered as a pretest prior to the groups' sessions and as a posttest after they were completed. Students randomly received either set A as the pretest and set B as the posttest or vice versa. Students were given 3 minutes to write descriptions of what they observed in each photograph. They were specifically asked not to provide a diagnosis or indicate any pathophysiologic process. Students' descriptions were graded blindly using a key that assigned 1 point for each of the 9 or 10 visual diagnostic features present in each photograph. Statistical analysis was performed using the SPSS program, version 10.0 (SPSS Inc, Chicago, Ill), and Microsoft Excel (Microsoft Corp, Redmond, Wash) with analysis of variance or 2-tailed t tests.
The groups did not have significantly differing pretest scores in 1998-1999 (P = .21) or in 1999-2000 (P = .56). Posttest scores differed significantly between groups in both 1998-1999 (2-way repeated-measures analysis of variance, F2,87 = 6.4, P = .003) and in 1999-2000 (F1,84 = 11.68, P = .001). The 1998-1999 YCBA group had significantly higher mean (SD) posttest percentage improvement scores (56% [14%]) than both the control (44% [14%]; P = .001) and the lecture group (46% [12%]; P = .009) as did the 1999-2000 YCBA group (57% [11%]) compared with the control group (47% [9%]) in 1999-2000 (P = .001). Students in the YCBA group achieved higher posttest scores in each of the photographs used in the posttest examination.
Students who received lower scores on their photograph descriptions generally concentrated on global visual attributes only, described details haphazardly, or made observational mistakes. Approximately 6% of all students were poor at describing what they observed (accuracy score <30%).
The use of representational paintings capitalizes on students' lack of familiarity with the artworks. The viewers search for and select all of the details in the paintings because they do not have a bias as to which visual attribute is more important than another. This lowered threshold of observation has direct application to the examination of the patient.
Although our program has concentrated on teaching and improving the observational skills of first-year medical students, it could serve as the basis for a continuing curriculum and may be applicable to all physicians.
Examples of the paintings used at the YCBA, photographs used in the pretest and posttest, grading keys, and mean raw scores results for each group can be seen on our Web site (http://info.med.yale.edu/dermatology/html/faculty/indexpage.html).
Acknowlegment: We thank Marvin Chun, PhD, for his advice and support in the early phases of this project and Zeev Kain, MD, and Matthew Cooperberg, MD, MPH, for their support and guidance with overall statistical methods and analysis.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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