A total of 44 out of 47 students who took the class completed the written course evaluation. Eighteen students participated in focus group interviews, which ranged from 30 to 70 minutes in duration. Four major themes were identified from the focus groups and course evaluations: enhancement of observational skills, awareness of the subjectivity and uncertainty of perception, exploration of multiple points of view, and recognition of the course as a place for restoration and connection to classmates.
Observation skill enhancement
Students frequently remarked on how the course strengthened their observation skills. One student mentioned that the course encouraged “stopping, slowing down, [and] being intentional about seeing, [while] everything in med school is at such a fast pace.” Another student noted that the course strengthened being able to “better perceive easily missed details and better able to describe elements that at first seem indescribable.” One student commented that the course promoted heightened curiosity and more nuanced observation and description. “It might be enough for me to say that ‘the chair is red’ six weeks ago, but now I might look at the chair and say, well, ‘What kind of red is it?’”
Additionally, several students expressed how observation outside of class was affected. One said, “I began to notice subtle details in everyday experiences and began to take more time to consider their meaning and purpose.” Another student commented, “I have noticed being more aware of my surroundings…. I just notice what’s in the park more than I used to when I just walked by.” Several students expressed a desire to leverage these skills of observation in future clinical work, including one who said, “I have definitely learned to be more observant and attentive and will try to cultivate that skill further in my career as a physician.”
Subjectivity and uncertainty of perception
Students often shared how emotions, biases, and context all affected what was perceived through acts of observation. One stated, “I began to realize how I can directly impact what I am perceiving, whether it be by my own thoughts or emotional state.” Another found that working with art presented opportunities to ponder questions such as, “Why am I disgusted by that sculpture? Or why does it frighten me?”
Students also focused on how recognition of the subjectivity of perception required them to grapple with the discomfort of uncertainty. For one student, subjectivity and uncertainty of perception in art served as “a reminder that … we can’t escape that with the ‘objectivity’ of medicine.” Another student connected the notion of uncertainty with adjusting to medical training in general.
Med school is a long journey through accepting uncertainty.… I think this whole year for me has been a long process of being comfortable with being uncomfortable. I can’t know everything…. I can’t do everything I need to do. I don’t have the time. And accepting that, moving on and not letting it cause so much anxiety. This class added to that.
Exploration of multiple points of view
Students acknowledged that engagement with art in groups resulted in appreciating the value of multiple points of view. Such insights included recognizing that different people notice varying details and have diverse interpretations and emotional responses, even when looking at the same art object. As one student remarked, “I never noticed the map in the Vermeer painting until [another student] pointed it out.” Another student offered: “An expression on someone’s face that I interpreted as sad, somebody else interpreted as frustrated.… It made me realize how singular my own perspective is and how important it is to really consider multiple interpretations.” Students also noted how others’ observations impacted their own. One student noted, “It was very informative hearing other people’s take on the same image, and that often made me change the way that I thought about it.” Another student noted the benefit of having multiple points of view: “I … really enjoyed the Rodin piece because it was so involved. It took a lot of ‘lifting’ so to speak from the group as a whole.”
Sanctuary for restoration and connection
One student felt the course “was like a sanctuary away from campus.” In fact, some of the lengthiest and most frequent comments involved descriptions of the restorative aspects of the course. A student noted, “I realized just how exhausted I was and how much I really, really needed this.” The same student went on to say that it “was healing in many ways just to get out of that narrative of being a med student.… It reminded me that I need to take large chunks of time on a regular basis for self-care and it’s okay to do that. It’s healthy to do that. It will make me a better doctor to do that.” The theme of self-care also included comments regarding benefits and support of having deeper connections with classmates. Students experienced strengthened bonds with classmates by learning things about them that might not have come up in typical curricular experiences. As one student put it, “I really enjoyed seeing my peers in this new way.”
Visual observation is a foundational means of knowing one’s world, yet educators cannot assume that students and clinicians know how to skillfully observe. Although it is also the bedrock of medical practice, few, if any, opportunities occur in the traditional medical educational curriculum where skills of observation are explicitly taught.
Students frequently noted enhanced observational skills as a consequence of taking this course. Several described careful observation not as an ever-present, automatic capacity but, rather, as a “tool” to be used purposefully, in the way a stethoscope must be placed on the patient’s body in a particular fashion to appreciate heart sounds. The use of the metaphor suggests that the observer’s skill can be trained and honed. It also suggests that the observer should have an awareness of when careful observation is needed and then have the desire to use it. Discoveries students made in the course about artwork or one’s environment through careful observation may possibly serve as evidence of the benefits of employing such practices. Indeed, several students commented specifically on how skilled observation might enhance their future clinical practices.
The OUAM course was designed specifically to help students grapple with uncertainty of one’s observations and engage in reflection around this issue. Students noted that the course led them to consider how their emotions, personal histories, and situational contexts affected perception. They also recognized the benefits that accompanied the limits of one’s perception. For instance, persons observing the same object may perceive the object differently, and attending to those multiple points of view may lead to a deeper understanding of that object. The application of this insight to the benefits of team-based clinical care are readily apparent. Such comments from students represent considerations about the object (nature of the exterior that is being seen), as well as the subject (nature of the person doing the seeing), and the relationship between the two. This type of negotiation of interior with exterior parallels the important recognition of the self in relation to the other that is deeply characteristic of clinical practice.
Any thoughtful exploration of the subjectivity of perception and the relationality of self with the outside world requires reflection, a foundational habit of the skillful practitioner.22 We observed robust improvements in the GRAS inventory, which measured ability to reflect. This survey includes items such as “I can see an experience from different standpoints,” “I can empathize with someone else’s situation,” and “I reject different ways of thinking” (reverse coded). Though they did not achieve statistical significance, we saw improvements in the scales for tolerance for ambiguity (TFA) and awareness of biases (BIQ). One can postulate that enhancing reflective practice is a necessary step toward becoming aware of one’s emotional responses to uncertainty and becoming aware of one’s inherent biases in thinking. Our hope is that the skillful practitioner would then take stock of those insights to make appropriate clinical decisions. The phenomena of subjectivity of perception, tolerance of uncertainty, and cognitive biases play out at the intimate, personal, and singular level, but when considered collectively, these concepts have relevance to the broad public health concerns of diagnostic error, overtesting, and cost of health care.
A key theme that emerged was that the course was a restorative experience, with one student describing it as a “sanctuary.” Indeed, comments related to this theme were emotional, eloquent, and compelling. The experience of the course as a safe and restorative place is particularly important for exploring uncertainty and bias because these topics may prove to be uncomfortable and even unsettling to learners. Uncertainty, a central feature in clinical practice, is at odds with an educational environment that is populated by multiple-choice questions and the false notion that there is a “right” answer to most clinical situations. Recognizing that one’s perception, and even scientific knowledge generation as a whole, is bounded by a zone of uncertainty can be a troubling notion; this may be particularly disturbing while providing clinical care when the stakes are the highest. Importantly, in courses like OUAM, these lessons are learned through a direct experience and experimentation, and not through theory and detached learning. This embodied learning attends to the emotional dimensions of the topics explored and provides rich opportunity for reflection and discussion; a nonjudgmental and supportive environment will best allow such insights to occur.23
The word sanctuary also points to the course’s role in self-care and connection with classmates. Students noted that they learned things about classmates they might not have discovered through the normal course of medical training in classrooms and hospitals; these types of experiences facilitate a more nuanced understanding of one’s classmates and colleagues and strengthens relationships and community. These attributes of the course, in addition to the practices of reflection mentioned above, have been identified as features that promote resilience.24–26 Given the concerning rates of burnout in medical education, facilitating habits of self-care and providing opportunities for connection with classmates seems a necessary element of a healthy and flourishing training environment.
This program evaluation has limitations. The students from Weill Cornell enrolled in the course electively, and although the course satisfied a curricular requirement for the Columbia students, they still had some choice in selecting our particular art-based course. Thus, participant selection for this study may be biased toward students who have a prior affinity for art and those who may be more receptive to museum-based education. In addition, the total number of participants is relatively small and thus affects generalizability. The lack of a comparison group limits causal inference. Though this study was conducted with students from two different medical schools, both schools are based in New York City with easy access to museums; however, schools in many other settings typically can find access to art in smaller galleries and even within hospital settings. A skilled artist and facilitator led our course, representing a local resource that might not be present in some institutions. Other schools might rely on local experts with whom to partner or seek avenues to train those interested in leading such sessions.
The findings in this evaluation indicate that art-based education holds promise to explore important competencies critical to medical practice such as observation, reflection, self-care, and tolerating uncertainty. Facilitating such curricula, however, requires schools to dedicate curricular time and devote other necessary resources. More research is needed to assess feasibility at different institutions. Finally, students noted how the lessons regarding close observation impacted their habits outside of the course. Further research examining impact of art education on clinical practice is needed.
The authors thank Dr. Herbert Chase and Dr. Pablo Tinio for their early consultations on this study and thank Deborah Lutz for teaching some of the sessions in the course.
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