ABSTRACT

Background

The use of fine art in medical education has a long history. Numerous studies have investigated the potential benefits of incorporating art in medical education; however, there are gaps in knowledge regarding the efficacy, methodology, and clinical significance of these studies.

Objective

This scoping review of the literature aims to describe the available literature on the incorporation of art education in medical school and residency.

Methods

PubMed, Google Scholar, and MedEDPortal were queried from their inception dates through December 2019. English-language studies providing a detailed methodology and detailed analysis were included. A total of 37 studies were identified. Upon further screening of the studies' methodologies and results, 16 studies describing art education implemented with medical students and 12 studies describing art education implemented with residents were included for final review.

Results

Various methods of art education exist, including Visual Thinking Strategies (VTS), rigorous curricula, and unstructured roundtable discussions with art curators or artistically minded clinicians. Studies range in duration, art media, and type of analysis.

Conclusions

There has been an increasing effort to incorporate fine art education into medical training, primarily to enhance visual perception skills and empathy. Although there is limited research on its efficacy, and wide variations in study methodologies exist, results consistently indicate that participants find the incorporation of art into curricula beneficial. Further research analyzing which methodologies are most likely to yield statistically and clinically significant improvements in visual perception and empathy may lead to increased utilization of this teaching method.

Introduction

Physicians utilize pattern recognition and visual acuity skills to recognize physical examination findings and associate them with diagnoses. Examining and studying fine art could theoretically supplement a resident's training in this task. In the modern era of medical training, art has not been a curricular focus, despite having a role in the early days of medical training.1  Recently, however, there has been an effort to incorporate the use of fine art into medical training. Proponents purport that learning how to analyze fine art may improve not only clinicians' intellectual curiosity and critical thinking, but also their diagnostic skills and ability to empathize with patients.2 

Observational skills may be especially useful in visually oriented specialties. Dermatologists must be skilled in pattern recognition in order to distinguish and diagnose cutaneous diseases, some with subtle differences in examination findings. Similar skills are required for radiologists in their examination of a variety of imaging modalities. With increasing use of telemedicine, it is important for physicians to be able to appreciate clinical situations in the absence of a full physical examination.

While there are numerous studies investigating art in medical education, there remain gaps in knowledge regarding the efficacy, methodology, and clinical significance of these courses. We discuss the results of a scoping review of the literature on the use of art education in medical training, highlighting the results of a few representative studies.

Methods

PubMed, Google Scholar, and MedEdPortal were queried from their inception dates through December 2019 using variable combinations of the keywords: art, art education, medical education, residency, and medical residency. Only articles published in English were included. Titles were then filtered for relevance, as the broad search terms yielded results that were not related to the research topic (figure). Studies were excluded if they were reviews, lacked a postintervention assessment, the methodology was not described well enough to appropriately replicate, or the article was inaccessible via the institutional library. For example, some articles were excluded as the type of art intervention was not specified. This process was primarily performed by 1 author (Y.D.), with oversight by the other 2 authors (E.C.M. and E.A.R.).

figure

Flowchart of Identified Studies

figure

Flowchart of Identified Studies

Results

A total of 37 curricular interventions that discussed the implementation of art in medical education were identified for full-text screening. Upon further review, 28 articles330  were selected for inclusion owing to their detailed methodologies and analyses, including 16 describing art education with medical students (table 1)311,1319  and 12 involving residents (table 2).12,2030  Some interventions relied on professional art curators to teach fine art to participants, while others used artistically minded clinicians. The duration of the projects ranged from 1 to 17 sessions. The media of art also greatly varied.3,4  While most programs utilized art as a vehicle to increase observational skills, other interventions used art to directly depict medical conditions.31,32  The data were separated into 2 categories: interventions implemented among medical students and interventions implemented among residents. Details on research design, endpoints, and results are outlined in tables 1 and 2.

table 1

Studies of Medical Students

Studies of Medical Students
Studies of Medical Students
table 2

Studies of Residents in Training

Studies of Residents in Training
Studies of Residents in Training

Visual Art Implementation in Medical School

A variety of fine art curricula have been integrated into medical school education (table 1). Four of the 12 student-based interventions utilized control groups.6,8,16,18  Three of these 4 achieved a statistically significant increase in observational skills.6,8,16  Thirteen37,911,1315,17,19  of the 16 were led by art educators and were primarily qualitative in nature, while 9 incorporated a quantitative component.58,11,13,1618  Two interventions (one quantitative and one qualitative) showed a dose-dependent response between the number of art sessions participants attended and the level of improvement in observational skills.5,6 

In 2001, Bardes et al published the first study examining the use of fine arts in medical education.7  Their qualitative study demonstrated that students who participated in an art intervention improved their objective observational skills as well as their subjective ability to interpret facial expressions of patients.7  Subsequently, Dolev et al provided quantitative evidence of the benefits of fine art education in medical students.8  In this study, students described a photograph of a person with a medical disease both before and after an arts curriculum intervention, and responses were graded on a predefined objective scale. After the intervention, students made more detailed observations and less observational mistakes.8 

Elder et al described an integrated program in which medical students attended a real patient-physician encounter, and then sketched a picture of the encounter.9  Bentwich and Gilbey investigated other effects of art education, such as increased empathy, tolerance of ambiguity, and teamwork.10  Their findings showed an increased tolerance for ambiguity among participants. They also found that the inherent ambiguity of fine art and the resultant “acceptance of multiple meanings” understood by students was the strongest factor correlated with the intervention, even more so than increased visual skills.10  Additional projects also demonstrated the benefits of fine arts interventions improving mindfulness, identification of patient story, and emotional awareness among participants.4,7,11  Across most interventions, medical student participants voiced satisfaction with the art programming.

Visual Art Implementation in Residency

There have been few studies evaluating the efficacy of fine arts education specifically in residency (table 2). Three of the interventions used control groups, and one of those achieved a statistically significant increase in observational skills.3234  Nine of the 12 contained a quantitative component, and 9 were led by professional art educators.

Some medical educators utilized Visual Thinking Strategies (VTS), a teaching paradigm to improve the visual literacy of both experienced and inexperienced art observers.35,36  VTS-trained educators encouraged participants to think in a structured format when viewing images by asking simple questions, such as “What is going on in this picture?” “What do you see that makes you say that?” and “What more can we find?”37  Curricula implemented at Harvard University utilized VTS-trained instructors from the Museum of Fine Arts, Boston, to teach dermatology residents, who attended 4 sessions each training year.12,38,39  The goal was to improve residents' observational skills and program camaraderie, and to gain more insight into their own observational biases. In a pilot study of this program by Huang et al, a test was administered prior to and after the intervention.12  The test asked participants to list as many observations about certain images as they could recall, and the responses were objectively graded to determine if there was a statistically significant change between pre- and post-intervention observations.12  The results did demonstrate a dose-dependent improvement in pretest and posttest scores, as residents who attended less than 3 sessions did not show a statistically significant improvement in the number of details they recalled, while those who attended 3 or 4 did (P < .034).12 

Discussion

As described in the literature, various methods of utilizing fine art to advance medical student and resident education appear to be effective. Incorporating art into medical education appears to improve visual perception skills, empathy, and personal reflection among students. Such an intervention could improve diagnostic accuracy, ethical competency, identity formation, and psychological functioning in students and physicians.40,41  Despite the variation in these interventions, satisfaction-level outcomes have been generally positive: students have noted wide appreciation for fine art courses and advocated for their continued use.

This scoping review was limited by the keywords and databases used, exclusion of non-English studies, accessibility of the journal articles, and overall quality of the studies available. Many studies had small sample sizes, lacked control groups, and did not incorporate quantitative data. A more comprehensive systematic review was not pursued given the variable study populations and the highly heterogenous study designs, methodologies, and reported outcome measures, making inter-study comparisons and conclusions difficult to draw.

With increased use of technology and imaging in medicine, there is a growing need for physicians to observe minute differences in examination findings. Additionally, in aesthetic fields like dermatology, ophthalmology, and plastic surgery, many physicians perform cosmetic procedures that require a keen eye for observing fine details. Beyond enhancing visual perception, available research demonstrates that art education improves empathy among participants and may be a way for budding physicians to better connect with patients. Despite the growing available literature, there remain several unanswered questions regarding the benefit of art education interventions in medical training. Further research analyzing which methodologies are most likely to yield statistically and clinically significant improvements in visual perception and empathy may lead to increased utilization of this teaching method. Specifically, identifying the optimum point of intervention during medical education, as well as conducting follow-up studies to elucidate whether positive effects are lasting, would be beneficial.

In reviewing the current literature, best practices on how to incorporate fine arts in medical education appear to emerge. An ideal curriculum should encompass 4 domains: pattern recognition, deep seeing, facial expression, and pertinent negatives. These domains could be modified or adapted to suit curricula in visually intensive fields (eg, dermatology, radiology, endoscopic gastroenterology).

Pattern recognition is an experience-based process of perceptual learning whereby trainees recognize physical examination findings and associate them with diagnoses. Traditionally this is developed through studying countless clinical images and managing thousands of patients. Fine art curricula incorporating pattern recognition skills could help enhance diagnostic acumen and efficiency. Deep seeing involves the ability to perceive textures and colors that may not be immediately distinguishable. This can translate clinically to observing details beyond the most prominent colors and textures. Moreover, with the increasing use of telemedicine, it is important for residents to be able to “see” the textures in the absence of a full physical examination. Interpretation of facial expressions of a painting's subject(s) often helps identify the artist's intent or message. In medicine, similarly, accurate interpretation of facial expressions is likely to enhance empathy and quality of care. Finally, pertinent negatives are a critical aspect to forming a diagnosis as what is not found on physical examination can affect the differential diagnosis of the patient. When studying fine art, students are often encouraged to observe what the artist intentionally did not depict.

The framework of VTS seems to be effective, and the evidence suggests that instructors comprise both clinicians and art curators. Future efforts would benefit from a standardized curriculum and assessment guidelines.

Conclusions

An increasing effort to incorporate fine art education into medical training has yielded early data that suggest the possibility of enhanced visual perception skills and empathy. Although substantial limitations characterize the data and further work is needed, studies consistently indicated that participants found the incorporation of an art curriculum to be beneficial to medical education.

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Author notes

Funding: The authors report no external funding source for this study.

Competing Interests

Conflict of interest: The authors declare they have no competing interests.