Art and medicine: visual literacy and things faithfully (though unwittingly) recorded in art and spotted later by medically trained people

"In the fields of observation chance favors only the prepared mind" - Louis Pasteur, apparently

tl;dr

• Observing and learning about art might help to teach medical students to 'see' more in their observations of patients
• Drawing is a useful tool for surgeons enabling them to quickly explain concepts to patients or peers, as a useful way to filter out unnecessary info (that would be visible, not always helpfully, in photos) and as a way to show changes over time on a single page (eg before and after surgery)
• Artists faithfully recording how people look might include medical features that will need to wait for people with the relevant medical knowledge to make sense of. Another example is given from botany where a variation in flowers was painted about a century before it was observed and explained by Charles Darwin (though it was already known to florists too).
  

You might also enjoy @candyanatomy on Instagram - physiology 'drawings' made from sweets.

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Artists and doctors both observe, but where humans are the observed subject then knowledge about the meaning of what is being observed may be very different between those two groups. I've been delighted and fascinated to have this facet of art and medicine expanded for me by a series of articles - at the end of this post there's a sort of 'annotated reading list'. There are always interesting things happening where two domains of knowledge intersect (Edit: see later post on Combining Careers: the interdisciplinary game / activity).

Probably my first introduction to medical students learning about (unintentional) depictions of medical conditions in art was Robin McKie's article, "The fine art of medical diagnosis", in The Observer in 2011. Prof Michael Baum had been getting his medical students to become familiar with various works of art as part of their training and the article includes some observations on famous paintings.

In A Satyr Mourning over a Nymph a satyr crouches over the dead body of a woman (Procris) who, in the story, has been killed by a spear thrown (accidentally during a hunt) by her husband Cephalus. However aspects of the female model's appearance don't match what would be expected from a living model, and what's on the painting seems to be much darker.

The artist, Piero de Cosimo, may have visited a mortuary to paint a female subject. The body of the woman in the painting shows signs that she probably died (in real life) trying to fight a knife-wielding attacker. Her left hand is folded into a particular position, known as the waiter's tip, and indicates a spinal cord injury at the top of the neck. The artist is very unlikely to have known any of this but it seems that the 'model' was a woman who'd died under violent circumstances before the artist used her for the painting.

"Seen through Baum's eyes, the entire National Gallery looks more like a doctor's waiting room: Monet's paintings, which grew darker and darker until his cataracts were operated on and his works brightened again." - of course we can also tell something about the artist, not just the art he or she has produced. See also Famous paintings can reveal visual disorders (2015)

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Inspiration for this post
When I read the article above it inspired me to collect articles and papers that touch on the same topic - medical students learning how to observe patients by learning how to observe art. I was prompted to write this post after reading two unrelated tweets earlier this week. The first was a thread about the botanical accuracy of plants drawn in art from the 1700s, the second on an observation made about Michelangelo's David.

Botanical art spots something, later explained by Darwin
"Quite amazing that this detail of the structural polymorphism in Primulas / auriculas flowers is depicted in the painting" from Graham Coop's tweet shows that the artist has observed and reproduced two flower variants with different middles ('styles') - one's a 'pin-eyed' form, one's 'thrum-eyed' as they were known to florists but later Darwin called them long- and short-styled respectively (see page from Alfred Wallace's 1889 book). 

Graham's thread led me to "On the origins of observations of heterostyly in Primula" article in New Phytologist.

"One day, while appreciating a print of Primula vulgaris from William Curtis’ Flora Londinensis, I was struck by the fact that I was looking at images of dimorphic Primula flowers captured in a late‐1700s copper‐plate engraving that predated Darwin's observations by over 70 yr. This realization triggered a journey into archives of botanical texts, herbals and florilegia from the 16^th to 19^th Centuries, and correspondence archives, in search of earlier documents that could have influenced Darwin and the origins of an idea."

I also enjoyed Atlas Obscura's article about archaeobotanist Isabella Dalla Ragione in Atlas Obscura who is 'searching art for lost fruit' to grow and sell. She's of the opinion that Albrecht Dürer's 'Madonna and child with the pear' painting actually features an apple.

 
Visual literacy in medicine
A tweet from Trisha Greenhalgh alerted me to a paper on "the David sign" which is a new observation about Michelangelo's David statue. The short paper discusses the distension of his jugular vein and how this can relate to heart failure, or to a state of excitement in an otherwise healthy person.

Different 'pre-knowledge' can help experts notice things that are already in a painting, 'hiding in plain sight', that others without that knowledge might miss. Can 'visual literacy' improve medical students' and doctors skills? Possibly yes, though the academic studies investigting it are fairly small. I suppose that doctors with particular knowledge may see something in a painting, but medical students trained to see / notice something about a painting may better primed to spot something in a patient. And of course just being good at observing things doesn't necessarily mean you'll be good at solving other problems.

In "Formal art observation training improves medical students’ visual diagnostic skills" (2008) the authors gave a group of pre-clinical medical students lessons in art observation and linked this to clinical observation; they included a control group who didn't do the course. They then showed the students some artwork that hadn't been on the course, and some images of patients displaying clinical features and asked them to make some observations about them. Those who'd undergone the training made 'more' observations than the control group, they also referenced more fine arts terms in their clinical observations (referencing colour, shadow, light, symmetry and balance).

In "More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy" (2017) researchers used 'Visual Thinking Strategies (VTS)', a "...pedagogic (teaching) approach involving discussions of art works and deciphering the different possible meanings entailed in them" to foster tolerance for ambiguity ("in the sense of accepting multiple interpretations.") among medical students. Seemed to work, though a small study, and it also seemed to help with empathy. 

"The art of medicine: arts-based training in observation and mindfulness for fostering the empathic response in medical residents" (2017) explored empathy in more depth with visual literacy training and the ever-ambiguous mindfulness training though I think the study was too small to draw many conclusions (apparently empathy tends to drop among medical students after a few years of study, despite a fairly high-empathy start).

Presumably it is deemed to have some value (intuitively it seems that it would but that's rarely a good basis for determining whether to do something, particularly if it takes time away from other clinical studies) as there seems to have been a bit of a flurry for medical schools to run parallel art appreciation classes. "Why Med schools are requiring art classes" (2017) reports on Penn State Medical College's seminar "Impressionism and the Art of Communication" which aims to help students communicate better with patients "by developing insights on subjects like mental illness and cognitive bias".

It seems to be part of a trend, with professors arguing "that engaging in the arts during medical school, ... is valuable in developing essential skills that doctors need, like critical thinking and observational and communication skills, as well as bias awareness and empathy." The 'Why Med schools...' article references a course created by Robert Rock (see reading list below) and his view that museums and art galleries can be more neutral territories for medical students to feel they can ask questions without the rather hierarchical experience on wards (also they're not dealing with life and death situations).

My favourite example of getting trainee doctors to try and make sense of something with incomplete information is where they're paired up with another student who has a postcard of a famous painting. They must describe the contents of the postcard to the other student who has to try and paint a copy of the painting by asking the postcard-holder questions about it in order to build up a picture.

"... paying attention to self-awareness is a form of self-care ..."

"Looking at Art could help Med students become better doctors" (2018) looks at Anna Willieme's six-week course "Observation and Uncertainty in Art and Medicine" which includes having students draw a copy of a piece of art for two minutes at a notebook then move to the next students' notebook and continue what they'd been drawing of the same piece. In this way the students are exposed to how other students are seeing the same thing, and what they've focused on first. This was part of a study and again, small numbers of participants involved, but it certainly indicated that this sort of training could help people see things from different points of view. Plenty of the students also found the course pleasant and relaxing, which if nothing else, is probably fairly helpful during medical school.

"Is drawing a valuable skill for surgeons? I asked 100..." (2019) talks about the use of drawings during ordinary medical practice, where surgeons annotate patient notes as part of the handover, or want to illustrate something quickly and simply. Surgeons use drawings to explain things to patients or colleagues, also as a record of what's been planned for an operation or what's been done (can be useful in a legal setting), it's also used to clarify written or spoken information.

"The 21st century has brought photography and medical imaging technology to medicine, which are routinely used to create detailed pictures. Despite availability of these modalities, the author noted many surgeons would draw routinely in practice" - photography captures everything whereas a drawing can highlight only the salient points so may actually be more useful - "Schematic diagrams were praised for lack of detail, which made them easier to assimilate." (emphasis added). 

Filtering can simplify things allowing "the non-expert (such as a patient or trainee), to have an ‘experts view’, where only the relevant structures are apparent." Also, a photograph is just a snapshot in time but a drawing can also be used to show features that aren't currently visible (hidden behind an organ for example), or highlighting changing features before and after an intervention.

Here's the annotated reading list, well done if you got this far :-)

I look forward also to hearing about other example of "things spotted later in pieces of art" such as the fact that a depiction of a cockatoo in a 13th century manuscript tells us a little more about trade routes of the time.

Reading list
"Formal art observation training improves Medical students’ Visual Diagnostic Skills", several authors, Journal of General Internal Medicine, July 2008 (23:7)p 991-997 - summary only available without subscription - "One method of enhancing inspection skills is teaching “visual literacy,” the ability to reason physiology and pathophysiology from careful and unbiased observation."

"An allegory with Venus and Cupid: A story of syphilis" by Christopher Cook in the Journal of the Royal Society of Medicine, 13 October 2010
- suggests that the painting, typically considered as a bit of erotica, is actually a warning against syphilis. It's quite likely that it was intended as such at the time but that this aspect is less obvious to modern audiences. Mentioned in McKie's Observer article.

"The fine art of medical diagnosis" by Robin McKie in The Observer, 11 September 2011

"Can studying art help medical students become better doctors?" by Robert Glatter in Forbes, 20 October 2013
- "...an observation-type program, originally created at Harvard Medical School, and specially designed to enhance visual literacy has now been replicated at many other schools, helping to improve students’ visual-spatial skills, with improved performance noted during their clerkship rotations."

"Famous paintings can reveal visual disorders", Scientific American, 1 March 2015

"On the origins of observations of heterostyly in Primula" by Philip M. Gilmartin in New Phytologist, 10 August 2015

"Reunion 2016: A look at paintings raises awareness in the doctor-patient encounter" by Tiffany Penn, article on Yale Medical school's website, 24 June 2016
- "In medicine, he [Robert Rock, undergrad med student] said, it’s important to understand the power dynamic between patients and providers. “When the stakes are so high, expressing biases—whether unconsciously or consciously—can undermine and really sabotage the therapeutic relationship before it starts and influence the delivery of care,” he said. “It’s heavy stuff. We are going to use the art and the space to discuss a slippery, very difficult topic. We are going to study the expression of bias in Western culture, using works of art to critically assess the skewed lens through which we perceive the world.”"

"The use of Visual Arts as a window to diagnosing medical pathologies" by Katrina Bramstedt in AMA J Ethics, 1 August 2016, 18(8): 843-54. (full)

"More than visual literacy: art and the enhancement of tolerance for ambiguity and empathy" by Miriam Bentwich and Peter Gilbey in BMC Medical Education, 2017; 17: 200

"Why Med schools are requiring art classes" by Casey Lesser, Artsy, 21 August 2017

"The art of medicine: arts-based training in observation and mindfulness for fostering the empathic response in medical residents" by various authors, in Medical Humanities, 2017 Sep;43(3): 192-198

"Looking at Art could help med students become better doctors" by Casey Lesser, Artsy, 27 November 2018 

"A lesson on looking" TED Talk by Amy Herman visual educator, October 2018, on art, memory, teaching and looking for what isn't there.

"Is drawing a valuable skill for surgeons? I asked 100..." by Ciléin Kearns on the Artibiotics blog on 19 February 2019 (a version of a paper published by Taylor & Francis in The Journal of Visual Communication in Medicine on 18/2/19, available online: https://doi.org/10.1080/17453054.2018.1558996)

"The David Sign" by Daniel Gelfman in JAMA Cardiology, 26 December 2019 

Graham Coop's tweet and thread on differences in types of auriculas, observed by artists, posted 31 December 2019.

Trisha Greenhalgh's tweet on the David sign, posted 1 January 2020

What role could art play in improving visual literacy in dermatology? BMJ (February 2021)

Audio list
"Knife imitates art - how surgeons use creativity" by Peter Curran, BBC Radio 4, 13 June 2019

Misc, on medical illustration
Art and anatomy: the fabric of the human body, a six-week art history and theory course from 2019 (now finished) at the RA.

"Medical Illustration: Art in Medical Education" by Rachel Hajar in Heart Views, 2011, Apr-Jun; 12(2): 83-91
- on the history of medical illustration

Other articles I didn't make room for in this
"Art courses could help medical students become better clinical observers" Science Daily, 6 September 2017

"A Medical Lesson in Observation and Diagnosis through Art" by Audrey Lee, NICHD, 12 October 2017

"Under the skin: Anatomy, art and identity" - course at Aberdeen Uni

"Doctors Diagnose Diseases of Subjects in Two Famous Paintings" by Jason Daily, Smithsonian, 26 May 2016

Jo's notes for later updates
Something I read (I failed to make proper notes on it!) discussed medical students being shown paintings with the central portion hidden and asked to focus on what they could observe in the periphery.