Vincent Cracolici
Chicago, Illinois, United States

Art and medicine: Skills for creative problem solving

Despite similar training, all physicians are not equally skilled in recognizing and solving clinical problems. Those who have been remarkably innovative in their specialty often share similar characteristics with one another. Though gifted in the technical aspects of their fields, many of these prolific, highly influential physicians possess various degrees of training and practice as artists.¹ Interestingly, recent data suggests medical students’ observation skills improve substantially when experience in the visual arts is included in the curriculum.^2,3 These skills include tolerance of ambiguity, enhanced recognition of subtle and complex patterns, and improved so-called “deep seeing” or humanizing patients beyond collections of symptoms and fostering skepticism of initial presumptions.^2,3 Visual literacy, especially in a clinical context, is essential for modern physicians and medical students: all fields of medicine rely heavily (or, in some instances, nearly exclusively) on recognizing visual cues to function. The life and work of Lord Howard Florey, an Australian pathologist, Nobel Laureate, and visual artist, illustrate how the creative process and visual arts help to shape the abilities of medical students and physicians.

Art and science embodied

Lord Howard Florey was remarkably influential during his career as a highly decorated Nobel Laureate. He is renowned primarily for transforming penicillin from a laboratory anomaly to an effective therapeutic agent and subsequently revolutionizing the treatment of infection. As such, he has been the subject of many profiles and biographies. However, these often fail to mention that Florey was not only a physician-scientist, but also spent much of his leisure time practicing in the visual arts, most notably photography and cinematography, and also, in his later years, painting with oils (Figure 1).⁴

Florey’s rise to prominence has been recounted many times.^4,5,6 He is often portrayed as the quiet hero of the penicillin discovery team in the late 1930s and early 1940s. For this achievement, Florey was recognized along with Sir Alexander Fleming and Sir Ernst Chain with the Nobel Prize in Physiology or Medicine in 1945.^4,5,6 His primary contributions to the group focused on the clinical and practical applications of penicillin: performing early animal experiments to determine safety and dosing, overseeing the first human clinical trials, and navigating the necessary avenues to ensure mass-scale pharmaceutical grade production for use in patients.⁶ Given the significance of Florey’s achievements, he was yielded much acclaim. He was knighted in 1944, and in 1960 was the first Australian to be elected President of the Royal Society of London.⁶ In 1965, he was made baron of Adelaide and Marston.⁷

Unfortunately, little has been said about Florey’s artistic life. Biographers frequently expound on his purportedly frank demeanor and withdrawn personality, yet mention of his artistic skills or the relationship between his art and his professional work remains largely relegated to footnotes or overlooked entirely.

According to his son, Dr. Charles Florey, Howard Florey was an avid photographer throughout his adult life, beginning no later than 1922 at age 24, and continuing well into the 1960s.⁷ He had a deep-seated passion for photography and throughout his career took thousands of photographs.⁷ Beginning in the 1920s, he made numerous 16 mm films during his travels. He filmed his laboratory in action, as well as the “clinical effectiveness of penicillin on healing wounds in soldiers fighting in North Africa” during World War II.⁷ Later, perhaps in the early 1950s, Florey began oil painting landscapes and portraits⁷ and was known to keep an easel with canvases in his professional office.⁴ Painting became a more dedicated hobby after his retirement, and according to his son, was explored in order to “contemplate a scene rather than just take a photograph.”⁸ Florey found methods to combine his modes of expression: he painted the images of photographs he had taken to “see an image in two-dimensions” by projecting his photographs directly onto canvas and painting over them.^7,8 His technique was said to “be quite competent,” noteworthy as he had no formal training.⁸

Florey also illustrated the figures in some of his scientific publications, appearing to take special care to emphasize the most pertinent features.⁴ This feat, now largely a remnant of the past, is suggestive of another critical skill: the ability to accurately convey visual information without the aid of a photograph.⁹ Florey was able to find a balance between true objectivity of an image as recreation of the natural world, and a subjective judgement of the image as an educational device.⁹ Florey’s various pieces currently reside with different family members, perhaps indicative of the personal nature of his art.⁷

Many aspects of the penicillin story have elevated it to the forefront of 20th century medical history: Fleming’s serendipitous discovery of the mold’s antibiotic properties, the volatile relationship between the scientists, and Florey’s decision not to patent the process of manufacturing mass penicillin quantities have all created a colorful legacy.^5,10 Missing are the details of the influence of artistic thinking and creative problem solving that permeated the discovery process, particularly by Florey. Notably, all three penicillin Nobel Laureates had dedicated artistic pursuits: Fleming was also a painter whose hobby of making microbial paintings contributed to his discovery of penicillin,¹¹ and Chain many times considered leaving the sciences for a career as a professional pianist.¹⁰

The role of visual arts in medical training

Becoming a visually literate physician is a daunting task. Considering the electronic medical record and the patient, the influx of sensory information in the clinical arena is overwhelming to beginners, and little guidance is provided to learn how to evaluate these data. Visual literacy, that is the skill of critically appraising the visual world, is a tool for both budding and seasoned physicians to observe more than what is apparent and begin to make clinical discoveries.

Those pursuing the arts may be practicing these skills independently and informally. Like Florey, there is no need to be an expert or professional artist in order to benefit from the use of art in medical education and practice. Florey’s work, as expected of any artist, varied in style and quality over time, and few, if any, were ever sold or are in collections.⁷ Art transcends the rigid hierarchy of medical training and practice, and the benefits seen in various studies focus on students that are art novices rather than established physician-artists.¹² Cognitive skills, like developing appropriate questions to stimulate broad clinical thinking, understanding the importance of so-called “negative findings,” and challenging habitual thinking patterns are essential for physicians and may all be enhanced with training in the arts and creativity.¹³

Before understanding what to look for, medical students must learn how and where to look,¹⁴ though, unfortunately, trends in modern medical education do not encourage frequent critical appraisal of images and have placed students into a realm of passivity. Digital slideshows have replaced the black-board style of teaching, requiring students to do little more than “watch” text on a slide be read during lectures.¹⁶ As such, these trends foster dependence on technology, have non-existent nonlinear use, and hinder meaningful engagement with the teacher.¹⁶ The role of traditional and effective tools like simple sketching are at risk of being lost in the transition to modern digital education systems, along with the structural learning that accompanies them.¹⁷ Florey demonstrated a method of deeply engaging with images when drawing his own scientific publication figures, and was perhaps more elegantly able to report a teachable concept through this process. Though this may have been borne out of necessity at the time, the method is a clear example of how students and physicians can use images for education and communication.

Though they are increasingly tech-savvy, many students report dismay and disengagement with digital slideshow based content delivery, and increased ease of developing concepts, sustaining interest, and improving understanding when more visually-centered teaching methods are used.¹⁸ In the new era of medical education, creative problem solving tools: the ability to re-conceptualize ideas, recognize patterns, appreciate subtleties, enhance empathy, and to learn how to look, may be the key to opposing the growing trend toward passivity.¹⁴

Creativity, originality, and problem-solving skills are essential components at the heart of innovation.¹³ These traits transcend the technical boundaries of any particular field, and promote the ability to approach situations with renewed insight, deeper contextual appreciation, and unique perspective.¹⁹ The arts can be a physician’s tool to avoid becoming solely a technical thinker and retain a true sense of dynamism throughout their career. Looking to notable physician-artists such as Florey for inspiration can help modern physicians and students to become leaders in the field and compassionate, thoughtful practitioners.

References

1. Root-Bernstein R.The Art of Innovation: Polymaths and Universality of the Creative Process. International Handbook on Innovation. 2003; 267-78.
2. Perry M, Maffuli N, Willson S, Morrissey D. The effectiveness of arts-based interventions in medical education: a literature review. Med Ed Review. 2011; 45: 141-8.
3. Naghshineh S, Hafler JP, Miller AR, Blacno MA, Lipsitz SR, Dubroff RP, Khoshbin S, Katz JT. Formal Art Observation training improves Medical Students’ visual diagnostic skills. J Gen Int Med. 2008; 23(7): 991-7.
4. Root-Bernstein R. Howard Florey: Photographer, Cinematographer and Sunday Painter. Leonardo. 2009; 42(3): 265.
5. Bickel L. Rise Up to Life: A Biography of Howard Florey who gave Penicillin to the World. London: Angus and Robertson; 1972.
6. Ligon BL. Sir Howard Walter Florey- The Force Behind the Development of Penicillin. Semin in Pediatr Infect Dis. 2004; 15(2): 109-14.
7. Professor Charles du Ve Florey direct correspondence via e-mail with Vincent Cracolici MD, February-June 2015.
8. Florey C. Professor Charles du Ve Florey in interview with Dr. Max Blythe, Edinburgh, 17 February 1998. (The Royal College of Physicians and Oxford Brookes University Medical Sciences Video Archive MSVA 179, 1998) pp. 10–15.
9. Galison P. Judgement Against Objectivity. In: Galison P, Jones CA, ed. Picturing Science, Producing Art.New York (NY): Routledge, 1998. 327-59.
10. Williams T. Howard Florey: Penicillin and After. Oxford: Oxford University Press; 1984.
11. Root-Bernstein R. Discovering. Cambridge: Harvard University Press; 1989.
12. Klugman CM, Peel J, Beckmann-Mendez D.  Art Rounds: Teaching Interprofessional Students Visual Thinking Strategies at One School. Acad Med. 2011; 86: 1266-71.
13. Ness RB. Teaching Creativity and Creative Thinking in Medicine and the Health Sciences. Acad Med. 2011; 86:1201-3.
14. Boisaubin EV, Winkler MG. Seeing Patients and Life Contexts: The Visual Arts in Medical Education. Am J Med Sci. 2000; 319(5): 292-6.
15. Bardes CL, GillersD, Herman AE. Learning to Look: Developing Clinical Observational Skills at an Art Museum. MedEduc. 2001; 35: 1157-61.
16. Jones AM. The Use and Abuse of Powerpoint in Teaching and Learning in the Life Sciences: A Personal Overview. BEE-j. 2003; 2: 1-13.
17. Haddawy P, Dailey MN, Kaewruen P, Sarakhette N, Hai LH. Anatomical sketch understanding: Recognizing explicit and implicit structure. Artif Intell Med. 2007; 39: 165-77.
18. Singh S, Singh S, Gautam S. Teaching Styles and Approaches: Medical Student’s Perceptions of Animation-based Lectures as a Pedagogical Innovation. Pak J Physiol. 2009; 5(1): 16-9.
19. Baum N. Thinking like Leonardo da Vinci and its Implications for the Modern J Med Prac Manage. 2013; 29(2): 137-9.

Special thanks to Dr. Robert Root-Bernstein, Professor, Department of Physiology, Michigan State University, and Dr. Charles Florey, Professor Emeritus, University of Dundee, Scotland