Daniel V. Schidlow
Florence Gelo
Philadelphia, Pennsylvania, United States

“Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone you can become expert.”
—Sir William Osler (1849–1919)

A group of third-year medical students enters the office, anxious to move on to the patient wards for the promised clinical rounds. They crave hands-on clinical experience and bedside teaching. Before starting rounds, however, they must engage in two exercises. First, they must listen to a portion of the opera I Lombardi di la prima crociata (The Lombards on the first crusade, by Giuseppe Verdi; libretto by Temistocle Solera). Set in Milan in the eleventh century (and first performed there in the late nineteenth) and in Jerusalem, it is a love story whose plot unfolds a holy war and the battle of two brothers for the love of a woman.

In Act Three (scene three) Oronte, the Saracen warrior and lover of the Christian Giselda, lies in a cave, dying from battle wounds: “Giselda, io manco . . .” (I am dying). A barely audible lament. “Or tu m’ascolta, o Dio de’ padri miei . . . Tu crudel!” (Listen, you cruel God of my ancestors!) cries out Giselda, her delivery rhythmically accented. A hermit appears, in bass baritone sternly admonishing Giselda for her utterances, condemning the illicit love. “Chi accusa Iddio? Questo amor delitto egli è!” (Who accuses God? This love is forbidden!). He later baptizes Oronte:“L’acque sante del Giordano sian lavacro a te di vita!” (The holy waters of the Jordan will give you life). Oronte’s conversion will allow a later reunion of the lovers in heaven. The music swells majestically. What follows is one of the most beautiful pieces in the Verdian repertoire, the trio “Qual voluttà trascorrere” (A wondrous pleasure I feel), as a sublime feeling of peace, serenity, and beauty overcomes Oronte.

As the music fades, we ask the students first to identify the types of voices they heard (tenor, soprano, bass) and then to explain the state of mind of the characters, what they may be singing about and who these personages may be. Although most do not understand the language, after some hesitation students easily recognize the rage, despair, love, and fear in the voices of the tenor and soprano, and identify the hermit as a voice of authority (and, later, comfort). Given no other background information on the storyline of I Lombardi, students are asked to deduce a plausible plot and explain the action. They must, in essence, “hear beyond the words” to identify the characters’ intentions and emotions.

We switch now from the aural to the visual, and ask the students, sensitized emotionally, to look at a reproduction of Diego Velázquez’s Las Meninas (The Maids of Honour, painted in1656). Perhaps the most important of Velázquez’s paintings, this complex tableau, today hanging in the Prado, depicts members of the royal family of Spain in the seventeenth century, surrounded by an assemblage of attendants, courtesans, and court buffoons. The piece challenges viewers to immerse themselves in a true life moment in a distant world, containing a multiplicity of enigmatic characters and points of view. Students are asked not only to discover what is being depicted but also to reflect on whom the painter may be addressing. As Joel Snyder, professor of art history at the University of Chicago, notes, Las Meninas seems “frustrating . . . the sense it gives of being transparent and yet closed to us”¹—a descriptor that might be employed by physicians treating patients. Velázquez himself figures prominently, paintbrush and palette in hand at his easel, facing the observer and behind the central figures (the Infanta Margarita—daughter of the king and queen, Felipe IV and María de Austria—and her maids). Two dwarfs are in the foreground, an older woman with the classic features of achondroplasia and a child whose physiognomy differs but whom historians have identified as the woman’s son and also a dwarf.

As Henrik Hagtvedt of Boston College notes, “visual art is a complex stimulus.”² As the students describe what they see, personality types, cognitive processes, and spirit of inquiry come into play. Some students focus on the girl at the center who stands in the light; others immediately remark on the variations from normality (the dwarfs). The dozing mastiff in front captures the imagination of quite a few.

Students must then describe each of the characters and their possible roles in the action, and integrate what they see into a coherent story. Most students fail initially to realize that the painter has portrayed himself facing the viewer, thus suggesting that he is not painting the subjects who feature most prominently, but rather the royal couple, visible only in a small mirror in the back. Whose viewpoint, then, is most important? To complete the exercise students must capture the multiple visual and emotional elements of the picture, then engage in integrative reasoning to discover the painting’s “story.” The process, some may now realize, is akin to a diagnostic assessment.

While some medical educators do not believe that art-based approaches to learning would pass the evidence-based test of efficacy, students who participated in the arts-based third year program [described above] reported that they enjoyed the experience and became better observers, listeners and collaborators in testing hypotheses.

Physician educator Sheila Naghshineh and colleagues have proposed that structured observation of artworks may represent a method of “enhancing medical students’ diagnostic acumen by expanding their visual skills through the close observation and guided discussion of visual art.”³  Yenawine (1997) defines “visual literacy” as the “ability to find meaning in imagery.”⁴ This skill may also help teach medical students “the ability to reason regarding physiology and pathophysiology from careful and unbiased observation,” according to Naghshineh.

Diagnostic assessment is a holistic process that involves examining and talking to a patient, talking with his or her family members, and listening to them describe issues that may be related to the patient’s condition (perhaps including peculiarities of the patient at home, known only to the family). As an examination proceeds (with the patient or family’s permission), we teach students how to ask, how to thank, and how to interact, encouraging patients and families to ask questions, request explanations, and provide their own perceptions. The ability to “read” a painting is similar; a skill parallel to “reading” and “interpreting” a patient. The exercise of anxiously standing in front of a painting also becomes a training opportunity for medical students to address the anxiety they will feel in patient encounters.

Medical care has been transformed by our current rapid access to knowledge databases, remote monitoring technologies, and noninvasive diagnostic techniques. In the process, many have observed that we may have sacrificed some of the basic interactive elements in the doctor/patient relationship. Referring for sophisticated imaging, and clicking on databases available at our fingertips via mobile devices, we are in danger of omitting systematic and logical categorization and relevant weighing of the evidence of our senses. Listening to music and looking at art in a structured manner teaches “slow looking”—perhaps a trend to be encouraged, like that of “slow food”?—and the careful weighing of information from multiple sources, that is indispensable in patient- and family-centered care.

Medical education should begin with learning to see and hear. Opera and painting are just two examples of art experiences that could be combined to sensitize medical students to emotional content and help them develop as perceptive and responsive practitioners of health care. The Brazilian family medicine doctors⁵ assert that opera is a “total experience of immediacy.” Opera characters, they note, are “pure and clean,” “shaped to exhibit archetypal temperaments . . . so [that] passions . . . show up sharply and are well defined.”

Visual arts, as well, have the power to foster connections between “book learning” and clinical experience. Joanne Shapiro and colleagues at the University of California, Irvine, School of Medicine, have found that clinical observation skills can be developed using art-based training that enhances awareness of emotional responses in self and others, “cultivation of empathy, identification of story and narrative, and awareness of multiple perspectives.”⁶

Khaled Karkabi and colleagues at Technion-Israel Institute of Technology in Haifa, Division of Family Medicine, have highlighted the ability of art to “deepen compassion for suffering.”⁷ Paintings “are metaphors for human feelings . . . they are nonliteral symbols of the inner life,”⁸ says Hermine Feinstein, author of Reading Images: Meaning & Metaphor. Paintings trigger emotions and insights, “generating associations and tapping new, different, or deeper levels of meaning.” Used in medical education, such experiences can help students learn to recognize their own responses, awaken to their own inner lives, as a first step to recognizing the emotions of their patients in order to establish rapport, prior to diagnosis and treatment. We can foresee such techniques used in a formal manner to sensitize medical students to issues of gender, race, culture, and professionalism, as well as to the needs of diverse patient populations.

Learning about emotions through opera and fine art painting is a departure from the historical, idealized posture of detachment characteristic of modern medicine. Like the aria and the painting, human affliction has a central theme and complex visual and aural detail that can be apprehended using the same skills one draws on to appreciate the artistic treasures of the ages. The preclinical “music and arts” exercise described here accomplishes its goal if it enables students to learn to experience patient encounters as integrated sensory experiences, uniting emotional response to factual thought.

The effect of such sensitization—whether or not the process will ultimately contribute to making these students into better physicians—is as difficult to confirm as proving that high passing board scores are predictors of long-term professional success. The “mere” exposure to visual and aural art forms at an early stage of a physician’s formative years should, at a minimum, make them more receptive human beings. In itself, such is a laudable accomplishment.

References

1. Snyder J. “Las Meninas” and the Mirror of the Prince. Critical inquiry 1985: 539-572.
2. Hagtvedt H, Hagtvedt R, Patrick VM. The perception and evaluation of visual art. Empirical Studies of the Arts 2008; 26(2):197-218.
3. Naghshineh S, Hafler JP, Miller AR, Blanco MA, Lipsitz SR, Dubroff  RP, Katz JT. Formal art observation training improves medical students’ visual diagnostic skills. Journal of General Internal Medicine 2008; 23(7): 991-997.
4. Yenawine Phillip. “Thoughts on visual literacy” New York: Visual Understanding in Education; 1997.
5. Blasco PG, Moreto G, Levites MR. Teaching humanities through opera: leading medical students to reflective attitudes. Family Medicine 2005; 37(1):18-20.
6. Shapiro J, Rucker L, Beck J. Training the clinical eye and mind: using the arts to develop medical students’ observational and pattern recognition skills. Medical Education 2006: 40.3: 263-268.
7. Karkabi K, Cohen CO. Deepening compassion through the mirror of painting. Medical Education 2006; 40:462.
8. Feinstein H. Reading Images: Meaning and Metaphor. National Art Education Association 1996; 45-55.