246 April 2009 Family Medicine

Literature and the Arts in Medical Education

Johanna Shapiro, PhD
Feature Editor

Dean Gianakos, MD
Associate Editor

Editor’s Note: In this column, teachers who are currently using literary and artistic materials as part of 
their curricula will briefly summarize specific works, delineate their purposes and goals in using these 
media, describe their audience and teaching strategies, discuss their methods of evaluation, and speculate 
about the impact of these teaching tools on learners (and teachers). 

Submissions should be three to five double-spaced pages with a minimum of references. Send your 
submissions to me at University of California, Irvine, Department of Family Medicine, 101 City Drive 
South, Building 200, Room 512, Route 81, Orange, CA 92868-3298. 949-824-3748. Fax: 714-456-7984. 
jfshapir@uci.edu.

(Fam Med 2009;41(4):246-8.)

Each year, about 70% of the first-
year medical students at one of 
our institutions acknowledge their 
involvement in various aspects of 
the arts prior to medical school. 
Some have exchanged professional 
careers in the arts for a stethoscope 
and the world of science, a world 
that is very different from the world 
of art. Or is it?

In a physical diagnosis course, a 
medical student stood at the front 
of the lecture hall before 140 of 
his peers and spoke briefly about 

how he used his artistic skills to 
transform the head-and-neck im-
age of one of his older friends into 
the 30-by-20-inch oil painting on 
the canvas displayed on an easel 
before the class. After finishing 
his introductory comments, the 
medical student stood quietly while 
a physician, who knew nothing 
about the person depicted except 
for the brush strokes on the can-
vas, described the individual’s 
chronic heart and lung problems, 
his dysthymia and loneliness, and 
his tenuous financial situation from 
pursuing his lifelong love of music. 
The medical student, formerly a 
professional artist in New York 
City for 5 years, was familiar with 
the health and personal history of 
his friend and could not help but 
express his astonishment at the 
accuracy of the clinician’s report. 
How can this be? How can a physi-
cian know so much about someone 

without conducting an interview or 
doing a physical exam?

The student and his classmates 
were about to find out. Over the fol-
lowing week, the students went on 
their own time to the university art 
museum to complete a homework 
assignment modeled on the lecture 
hall presentation. In the museum’s 
education classroom, seven por-
trait paintings of varying sizes and 
styles were displayed on a wall next 
to a space suitable for viewing by 
small groups of students. Some of 
the paintings were realistic, almost 
photographic in their detail. Others 
were more abstract. 

Each student took 1 to 2 hours 
to take notes and discuss one of 
the portraits with their classmates 
and with the museum’s education 
curator who was also available for 
consultation. Following a struc-
tured format, the students did a 
write-up describing their selected 

Is It Impressionism or Is It Medicine?
Richard W. Pretorius, MD, MPH; Ginny O’Brien Lohr, MFA, MA, RN; 

Niv Mor, MFA; Karen H. Zinnerstrom, PhD; Ana T. Blohm, MD

From the Department of Family Medicine (Dr 
Pretorius), University at Buffalo Anderson Gal-
lery (Ms O’Brien Lohr), School of Medicine 
and Biomedical Sciences (Mr Mor), and Office 
of Medical Education (Dr Zinnerstrom), SUNY 
at Buffalo; and Department of Medicine, Mount 
Sinai School of Medicine (Dr Blohm).



247Vol. 41, No. 4Literature and the Arts in Medical Education

individual’s physical health (com-
menting on three separate organ 
systems of their choosing), the 
individual’s mental health (com-
menting on level of consciousness, 
affect, and judgment), and the 
individual’s social characteristics 
(commenting on age, gender, edu-
cation, occupation, ethnic group, 
economic status/yearly income, 
family, house, health beliefs). For 
each of these descriptors (15 in all), 
the students were expected to make 
three objective observations to sup-
port each subjective hypothesis, 
similar to the conscious (and some-
times unconscious) process that the 
experienced clinician instinctively 
uses at the bedside. 

The student, for instance, may 
make the following three objective 
observations about the individual’s 
respirator y system—breathing 
comfortably through the nose, no 
increase in size of accessory re-
spiratory muscles, pink skin—and 
come to the subjective hypothesis 
that the individual’s respiratory 
system is healthy and free of dis-
ease. Similarly, the student might 
note the following three objective 
observations about the individual’s 
affect—wonder, astonish ment, 
high degree of attentiveness—and 
make the subjective hypothesis 
that the individual does not suffer 
from a mood disorder. In regard 
to age, the students might record 
that the individual has early bald-
ing at the temples, adult adipose 
distribution, and a maturing face 
without wrinkles and conclude that 
the individual is most likely in his 
early 30s.

All of these observations and hy-
potheses are subject to independent 
verification, of course. But that is 
precisely the point, isn’t it? How 
else is medicine practiced other 
than through the careful collection 
of data, the thoughtful interpreta-
tion of the data, the recognition of 
the relationship between seemly 
disparate bits of data, and the draw-
ing of conclusions that are based on 

the quality of the data and the rigor 
of the analysis? 

After completing the homework 
assignment, the students’ write-ups 
were graded by their small-group 
leader. Since there were no previ-
ously established diagnoses avail-
able to use as gold standards, the 
grading was based on the quality 
of the observations, the rigor of the 
clinical reasoning, and the likeli-
hood of the subsequent hypotheses. 
In addition to its emphasis on 
careful observation, many faculty 
involved in teaching the physical 
diagnosis course liked this par-
ticular exercise because it enabled 
students to focus systematically 
on each of the intermediate steps 
comprising the clinical analysis 
rather than jumping to unsupported 
conclusions by taking cognitive 
shortcuts.

Although this homework exercise 
occurred only once in the semester, 
given the usual limitations on cur-
ricular time, the students later had 
the option of earning bonus points 
on a 15-minute written analysis 
of an unknown portrait at a clini-
cal skills station on their midterm 
examination. While this testing sta-
tion was optional, 100% of students 
participated since, it appeared, the 
opportunity to obtain extra points 
without the risk of penalty could 
not be bypassed. Despite a rigorous 
grading protocol, based on the logic 
that bonus test points should be 
honestly earned, students received 
a mean of 83% of the possible 
points. This seemed to indicate 
that students could successfully 
apply their nascent observational 
skills using a structured approach. 
Further, it is possible that improve-
ment in student performance in a 
subsequent clinically based course, 
with a decrease in student failure 
on an end-of-course exam to 2% 
from 13% the previous year, related 
in part to the clinical skills that 
were augmented through the art 
exercise.

So what are the benefits of such 
an exercise? (1) Students lear n 
that talking and touching patients 
during the interview and physical 
exam, while important, can be 
supplemented through the simple 
act of looking. (2) The quantity 
and quality of data that is available 
through observation typically far 
exceed the students’ expectations. 
(3) Scientific analysis is not lim-
ited to scientists, nor is integrative 
thinking limited to artists. (4) Preci-
sion in clinical conclusions can oc-
cur with realistic paintings as well 
as through the less-concrete data 
found in more-abstract drawings. 
(5) A systematic approach to using 
a single clinical skill such as obser-
vation can be highly productive. (6) 
Medical skills are not restricted to 
the bedside but can be used equally 
in other settings, including a uni-
versity art museum.

Future developments include 
consideration of var iations on 
the principles taught through this 
exercise. One of the authors, for 
instance, is a skilled photographer 
who also happens to take medical 
students and residents on sched-
uled home visits as part of her 
clinical responsibilities. She has 
taken a number of high-quality 
photographs of the interiors of her 
patients’ homes, many without the 
patient in the scene. One approach 
may be to show a photograph to the 
learner as an unknown, to ask the 
learner to describe the health of the 
patient based on the appearance of 
the patient’s home, to review the pa-
tient’s actual medical history after 
the learner has developed appropri-
ate hypotheses, and then—and only 
then—to meet the patient.

The evolving role of art in medi-
cal education can no longer be 
considered as merely supplemental. 
Rather, the integration of the two 
worlds is creating a new synergy. 
The whole is not just greater than 
the sum of the parts; the whole 
informs our understanding of the 
parts. While many physicians are 



248 April 2009 Family Medicine

also artists,1, 2 and art has been used 
as a means to a scientific end (eg, to 
teach anatomy),3 only more recently 
have visual thinking strategies been 
recognized as a legitimate cognitive 
tool.4-6

Corresponding Author: Address correspondence 
to Dr Pretorius, SUNY at Buffalo, Department of 
Family Medicine, SUNY Clinical Center, Room 
125, 452 Grider Street, Buffalo, NY 14215-3021. 
716-898-3565. Fax: 716-831-8649. pretor@
buffalo.edu.

References

1. Byth S. “The doctor is an artist.” Med J Aust 
2004;181(11-12):626-7.

2. Vogel S. The role of humanities and arts in 
medical education with special reference to 
neurosurgery. The importance of visual arts 
in the life of a neurosurgeon. Acta Neuro-
chirurgica 1993;124(2-4):168-71.

3. Challacombe E. The art of anatomy. Minn 
Med 2006;89(7):40-3.

4. Boisaubin EV, Winkler MG. Seeing pa-
tients and life contexts: the visual arts 
in medical education. Am J Med Sci 
2000;319(5):292-6.

5. Dolev JC, Friedlaender LK, Braverman IM. 
Use of fine art to enhance visual diagnostic 
skills. JAMA 2001;286(9):1020-1.

6. Reilly JM, Ring J, Duke L. Visual thinking 
strategies: a new role for art in medical 
education. Fam Med 2005;37(4):250-2.