AAMC Reporter: October 2006

Time For a Field Trip

Medical School-Museum Partnerships Foster Innovation

Carnegie Museum curator K. Christopher Beard

Throughout his 40-year career, Yale University School of Medicine Dermatology Professor Irwin Braverman, M.D., had been urging residents to pay attention to the subtler points of the rashes they were observing in patients.

"Not just the gross changes but the fine details sometimes really provide the clues as to what's going on," he said.

But after years of doing this, he concluded residents were memorizing what they had observed, not learning how to visually analyze something they had never seen before.

So one day in 1998, after a disappointing set of rounds with residents, Braverman had a mild epiphany.

"I thought, what if I showed them something with which they had no prejudices or biases?" he said. "I bet they'd tell me about everything that's there, because they don't know what's supposed to be important and unimportant. So what could I show them? It immediately popped into my head: a painting."

After that, Braverman and his residents were soon viewing and describing narrative paintings at the nearby Yale Center for British Art.

"Over the next few weeks, I noticed that they were actually doing a better job of describing what they observed on rounds," he said.

Partnerships with museums may seem like an unusual fit for medical schools. But from Cincinnati to North Carolina, an increasing number of medical schools are sponsoring curricular ventures with museums ranging from Manhattan's Frick Collection and Metropolitan Museum of Art to the Cincinnati Art Museum. Courses vary in length, scope, and focus. Some are elective, and some are required. But if their growing popularity is any indication, museums and medical schools are an attractive fit.

The department of family medicine at the University of Cincinnati School of Medicine now offers an eight-month-long second-year elective called "The Art of Observation" in partnership with the Cincinnati Art Museum. Harvard Medical School features "Training the Eye: Improving the Art of Physical Diagnosis," a 10-session elective course for first- and second-year medical students taught by the curator of education at Wellesley College's Davis Museum and Cultural Center. Duke University School of Medicine holds an "Art of Physical Diagnosis" class for first-year students that brings them to Duke University Museum of Art for a day of observation.

Other medical schools are broadening the scope of the school-museum partnership by incorporating exhibits into courses on medical history and even ethics. By proving its initial success was no fluke, follow-up research on the Yale experiment essentially opened the floodgates for medical school-museum cross-pollination. When Braverman repeated the project with first- and second-year medical students, he asked them to describe slides of rashes both before and after visiting the museum.

Hilary Oman, a first-year University of Pittsburgh School of Medicine student observing the lower jaw of a modern gorilla

"They described this particular slide of shingles so accurately, in a way no other student had ever done before," he recalled. Excited, he presented the idea to Yale's dean of students, and the school later began offering the session as an elective. It is now a required one-afternoon session, called "Enhancing Observational Skills," and is offered during first-year students' preclinical clerkships and directed by Professor of Medicine Margaret J. Bia, M.D.

A more structured evaluation of the new course, conducted by a medical student for her Yale thesis, revealed that students who spent time describing paintings improved their scores on an observational test by an average of about 9 percent, while control groups, who spent the same time either taking clinical histories or in an anatomy lecture, didn't see scores change at all. And so, this spur-of-the-moment visit to an art museum has proven so successful that two dozen other medical schools have adapted it to fit their own curricula.

Perhaps most enthusiastic about working museums into the curriculum is the Joan and Sanford I. Weill Medical College of Cornell University, which offers not one but two such programs, one with the Metropolitan Museum of Art and one with the Frick Collection.

Lyuba Konopasek, M.D., an assistant professor of pediatrics at Cornell, teaches a four-session elective clinical observation course in partnership with the Frick Collection. The course, which usually mixes first-, second-, and fourth-year students, is offered twice a year, and always has more applicants than it can take for its 12 to 15 slots. Students split into groups of four or five, observe a painting, and discuss it actively for about 10 minutes. After that, the group "rounds" on all the paintings, and each group stands next to its painting and presents its findings. The first session of the course is focused on single portraits; the second, on the relationship between people, and the third on images of illness and aging. The fourth session is a tour and a debrief.

"We don't give away what the paintings are and the stories of them during the actual sessions," Konopasek said. "We want to encourage students' intellectual curiosity without going for a 'right' answer. We want them to talk about what they see in very descriptive terms and interpret what they see. Doing that really allows us to explore a lot of pieces, like cultural self-awareness. These are people from the 19th century and earlier, so what does a ring on a finger mean, for example? It may be something very different from what it means now. It encourages curiosity, looking at the whole image, and thinking about what are the next questions to ask."

These observations sometimes bring out issues that would be almost impossible to get at in a standard clerkship. In one class, two students were discussing Jacques Louis David's 1810 portrait "Comtesse Daru."

"They were having a very hard time describing her. What finally came to light is that they just didn't like her; they didn't like the way she looked," Konopasek said. "That was a great launching point for a discussion of what happens when you have a patient like that. When you first see a patient, what assumptions do you make and what emotions does it trigger? That's very difficult to get at clinically, certainly taboo to talk about in the setting of an observed patient encounter, but we can talk about it in the safety of a museum setting."

Not all museum-medical school partnerships focus on "the art of observation," however. A new elective course on the natural history of medicine, offered for the first time this year by the University of Pittsburgh School of Medicine in cooperation with the Carnegie Museum of Natural History, appears to be the first of its kind involving a medical school and a natural history museum.

The course covers the evolutionary origins of human disease, including the history of disease-causing pathogens, a topic that should help students better understand relevant contemporary public health concerns, such as avian flu, and think about treatment and prevention approaches that modern society may have overlooked. It is taught by four museum curators who have been given faculty appointments at the school of medicine, where they are teaching workshops, seminars, and courses as well as mentoring medical students choosing to conduct scholarly research projects at the museum.

"It examines how our common evolutionary history has bequeathed us with an anatomical baggage that has important consequences for health care today. Or to put it differently, four legs, two legs bad," said John Mahoney, assistant dean for medical education at Pittsburgh. "Standing on two legs gives you back pain. We weren't supposed to do that. When you think about how posture and gravity work and why we evolved to be the way we are, it offers terrific insights into why health and illness are as they are. This isn't all about bones and mummies. I truly believe that understanding the past has terrific potential for opening our eyes as to what is over the next horizon and giving us insights as to how we prepare to deal with it."

Also at Cornell, a two-week clerkship for third-year students on ethics and palliative care, uses the famed Egyptian galleries of the Metropolitan Museum of Art as a springboard for discussing issues of death and dying. The one-afternoon session is "a cross-cultural experience of death and dying across continents and millennia," said Joseph J. Fins, M.D., chief of the school's division of medical ethics. "We're using objects related to the ancient rituals and the belief systems of a different culture that dealt with the one common constant across time: that we're all going to die."

Students observe objects like funeral boats and tombs, and must quickly absorb the scene before them, identify its elements in detail, and integrate them into a coherent whole. "For example, students identify the different activities being performed by small wooden figures on the funeral boat — the captain presenting himself for instruction to the statue of the deceased, the priest reading the texts," Fins said. "We're going back 3,000 years to a totally distinct culture, and yet we share this common thread of concern about mortality, what it does to the family, and the place of religion in death and dying. Although they had completely different rituals, there is a common dimension: the inevitability of human frailty. As they're learning to become doctors, this is an important lesson."

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