Journal of General Internal Medicine

, Volume 23, Issue 7, pp 991–997 | Cite as

Formal Art Observation Training Improves Medical Students’ Visual Diagnostic Skills

  • Sheila Naghshineh
  • Janet P. Hafler
  • Alexa R. Miller
  • Maria A. Blanco
  • Stuart R. Lipsitz
  • Rachel P. Dubroff
  • Shahram Khoshbin
  • Joel T. KatzEmail author
Original Article



Despite evidence of inadequate physical examination skills among medical students, teaching these skills has declined. One method of enhancing inspection skills is teaching “visual literacy,” the ability to reason physiology and pathophysiology from careful and unbiased observation.


To improve students’ visual acumen through structured observation of artworks, understanding of fine arts concepts and applying these skills to patient care.


Prospective, partially randomized pre- vs. post-course evaluation using mixed-methods data analysis.


Twenty-four pre-clinical student participants were compared to 34 classmates at a similar stage of training.


Training the Eye: Improving the Art of Physical Diagnosis consists of eight paired sessions of art observation exercises with didactics that integrate fine arts concepts with physical diagnosis topics and an elective life drawing session.


The frequency of accurate observations on a 1-h visual skills examination was used to evaluate pre- vs. post-course descriptions of patient photographs and art imagery. Content analysis was used to identify thematic categories. All assessments were blinded to study group and pre- vs. post-course evaluation.


Following the course, class participants increased their total mean number of observations compared to controls (5.41 ± 0.63 vs. 0.36 ± 0.53, p < 0.0001) and had increased sophistication in their descriptions of artistic and clinical imagery. A ‘dose-response’ was found for those who attended eight or more sessions, compared to participants who attended seven or fewer sessions (6.31 + 0.81 and 2.76 + 1.2, respectively, p = 0.03).


This interdisciplinary course improved participants’ capacity to make accurate observations of art and physical findings.


medical education curriculum physical diagnosis physical examination fine art 



Grant support was provided by The Creative Center, New York, NY. We appreciate the administrative assistance provided by Linda Grover and Robert E. Heroux. We are grateful to Judith Hill for her contribution to the assessment process. Judy Pembroke, Wai-Kit Lo, M.D., course faculty members, MFA collaborators, including Barbara Martin, and participants in the 2003–2004 TE pilot, provided important creative contributions to the course design. Assessment tools were developed with the input of Philip Yenawine, Abigail Housen, and Patricia Foley of Visual Understanding in Education. The funding organization had no role in the (1) design or conduct of the study, (2) collection, analysis, or interpretation of the data, or (3) preparation, review, or approval of the manuscript.

Name and date of any conferences

Some of this material was presented at the October 2006 Medical Education Day poster session, Harvard Medical School, Boston, MA.

Conflict of interest

None disclosed.

Supplementary material


  1. 1.
    Mandel JH, Rich EC, Luxenberg MG, Spilane MT, Kern DC, Parrino TA. Preparation for practice in internal medicine—A study of ten years of residency graduates. Arch Intern Med. 1998;148:853–6.CrossRefGoogle Scholar
  2. 2.
    Anderson RC, Fagan MJ, Sebastian J. Teaching students the art and science of physical diagnosis. Am J Med. 2001;110:419–23.CrossRefPubMedGoogle Scholar
  3. 3.
    Garden G. Physical examination in psychiatric practice. Adv Psychiatr Treat. 2005;11:142–9.CrossRefGoogle Scholar
  4. 4.
    Goldstein LB, Simel DL. Is this patient having a stroke. JAMA. 2005;293:2391–402.CrossRefPubMedGoogle Scholar
  5. 5.
    Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees: A comparison of diagnostic proficiency. JAMA. 1997;278:717–22.CrossRefPubMedGoogle Scholar
  6. 6.
    Dunnington GL, Reisner L, Witzke D, Fulginiti J. Teaching and evaluation of physical examination skills on the surgical clerkship. Teach Learn Med. 1992;4:110–4.CrossRefGoogle Scholar
  7. 7.
    Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA. 1995;274:1380–2.CrossRefPubMedGoogle Scholar
  8. 8.
    Mangione S, Burdick WP, Peitzman SJ. Physical diagnosis skills of physicians in training: a focused assessment. Acad Emerg Med. 1995;2:622–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Fagan MJ, Griffith RA, Obbard L, O’Connor CJ. Improving the physical diagnosis skills of third-year medical students. JAMA. 2003;18:652–5.Google Scholar
  10. 10.
    Yenawine P. Thoughts on visual literacy. In: Flood J, Heath SB, Lapp D, eds. Handbook of research on teaching literacy through the communicative visual arts. New York, NY: MacMillan Library Reference; 1997:845–60.Google Scholar
  11. 11.
    Housen A. Aesthetic thought, critical thinking and transfer. Arts and Learning Research Journal. 2002;18:99–132.Google Scholar
  12. 12.
    Dolev JC, Friedlaender LK, Braverman IM. Use of fine art to enhance visual diagnostic skills. JAMA. 2001;286:1020–1.CrossRefPubMedGoogle Scholar
  13. 13.
    Elder NC, Tobias B, Lucero-Criswell A, Goldenhar L. The art of observation: Impact of a family medicine and art museum partnership on student education. Fam Med. 2006;38:393–8.PubMedGoogle Scholar
  14. 14.
    Shapiro J, Rucker L, Beck J. Training the clinical eye and mind: Using the arts to develop medical students’ observational and pattern recognition skills. Med Educ. 2006;40:263–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Mangione S, Peitzman SJ, Gracely E, Neiman LZ. Creation and assessment of structured review course in physical diagnosis for medical residents. J Gen Intern Med. 1994;9:213–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Tashakkori A, Teddlie C. Handbook of Mixed-Method in Social and Behavioral Research. Thousand Oaks, CA: Sage Publications; 2003:241–71.Google Scholar
  17. 17.
    Schubert WH. Curriculum: Perspective, Paradigm and Possibility. New York, NY: MacMillan; 1980:25–53.Google Scholar
  18. 18.
    Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. 2Thousand Oaks, CA: Sage Publications; 1994:50–89.Google Scholar
  19. 19.
    Lipsitz SR, Molenberghs G, Fitzmaurice G, Ibrahim J. GEE with Gaussian estimation of the correlations when data are incomplete. Biometrics. 2000;56(2):528–36.CrossRefPubMedGoogle Scholar
  20. 20.
    Bardes CL, Gillers D, Herman AE. Learning to look: Developing clinical observation skills at an art museum. Med Educ. 2001;35:1157–61.CrossRefPubMedGoogle Scholar
  21. 21.
    Reilly JM, Ring J, Duke L. Visual Thinking Strategies: A new role for art in medical education. Fam Med. 2005;37:250–2.PubMedGoogle Scholar
  22. 22.
    Housen A. Validating a measure of aesthetic development for museums and schools. ILVS Review: A Journal of Visitor Behavior. 1992;2:213–37.Google Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Sheila Naghshineh
    • 1
    • 2
  • Janet P. Hafler
    • 3
  • Alexa R. Miller
    • 4
  • Maria A. Blanco
    • 5
  • Stuart R. Lipsitz
    • 1
    • 8
  • Rachel P. Dubroff
    • 6
  • Shahram Khoshbin
    • 1
    • 7
  • Joel T. Katz
    • 1
    • 8
    Email author
  1. 1.Harvard Medical School, Medicine Education OfficeBrigham and Women’s HospitalBostonUSA
  2. 2.University of CaliforniaLos AngelesUSA
  3. 3.Tufts University School of MedicineBostonUSA
  4. 4.Davis Museum and Cultural CenterWellesley CollegeWellesleyUSA
  5. 5.Harvard Graduate School of EducationCambridgeUSA
  6. 6.Department of MedicineColumbia University Medical Center, New York-Presbyterian, HospitalNew YorkUSA
  7. 7.Department of NeurologyBrigham and Women’s HospitalBostonUSA
  8. 8.Department of MedicineBrigham and Women’s HospitalBostonUSA

Personalised recommendations