Every year, dermatology students and residents across the US visit local art museums. They have one main assignment: Look, describe, and discuss.

A painting by Edvard Munch, the Norwegian artist who is most famous for “The Scream,” might be on the agenda at Harvard University’s Busch-Reisinger Museum. It shows a man and woman from the back, seemingly gazing at a body of water from a shore. They seem to be estranged — but maybe not. Which observations about the painting are facts and which are interpretations?

In Connecticut, the Yale Museum of British Art’s vivid pre-Raphaelite painting of a pale young man sprawled lifelessly across a bed spawns differential diagnosis-style explanations about what’s going on. Which theories make the most sense given the evidence?

The goal of the discussions about the artworks is to encourage critical thinking, Elizabeth A. Buzney, MD, assistant professor of dermatology, Harvard Medical School, and outpatient clinical director in the Department of Dermatology, Brigham and Women’s Hospital, both in Boston, said in an interview.

“It’s visual skills, which is what we do” as dermatologists, she said, describing “a rash that is not immediately obvious, that has a lot of different morphologies or components to it visually” as an example. “How do you synthesize all of that? How do you take it all in, communicate it? If you’re not sure what something is, how do you manage that ambiguity and eventually reach a conclusion?”

Brainchild of a Dermatologist and a Curator

Trips to museums weren’t always part of the dermatology curriculum or, as at Yale School of Medicine, New Haven, Connecticut, a requirement for all first-year medical students. But they’ve become commonplace in medical schools over the past three decades, expanding well beyond dermatology, and there’s even research to support this approach for honing clinical vision.

The roots of these workshops lie in a conversation about 30 years ago between Irwin Braverman, MD, now professor emeritus of dermatology at Yale, and an art curator friend. During the chat, Braverman told Medscape Medical News, he said he was concerned about how medical students lacked keen observation skills.

“So we got to talking, trying to come up with a way to improve these looking skills,” recalled the friend, Linda Friedlaender, senior educator for engagement at the Yale Center for British Art, in New Haven, in an interview. What if students went to the museum, looked at artwork they hadn’t seen before, and learned how to hone their observation skills?

Friedlaender and Braverman went on to develop an art-based workshop for medical students and studied its impact. In JAMA, in 2001, they reported that those who took part in the program scored higher at analyzing images of medical disorders than nonparticipants. Other research published since that time has also supported museum-based medical instruction too.

As a result, Yale Medical School created the Enhancing Observational Skills program and made it mandatory for all first-year students. Similar programs have spread to a dozens of medical schools worldwide, including the University of Virginia, University of Pennsylvania, Stanford University, and Canada’s Queen’s University.

Look First, Interpret Later

One key aspect of the Yale workshop is that guides don’t allow students to draw conclusions, at least at first. Friedlaender is quite strict about this.

Students are given a few minutes to sketch an artwork, she explained, and then “I ask them to describe everything they saw without giving any conclusions, speculations, opinions, or interpretations about what they were looking at. If they do, they are stopped and told ‘You just drew a conclusion, and we don’t want to know what the conclusion is.’ That seems to be one of the more difficult things for the students to do.”

The idea is to highlight the difference between facts and suppositions. Only later does Friedlaender allow students to theorize about what’s going on in the artwork.

Regarding the pre-Raphaelite painting of a pale young man sprawled on a bed, for example, she asks: What do the clues in the image reveal? The painting’s label is obscured so participants don’t get any hints from its title or description.

Uncovering a Young Man’s Story

Students may come up with a handful of theories about the man in the painting. For example: He’s drunk and passed out. No, he’s awake. Well, maybe he’s been murdered or killed himself. “So now we have different differential diagnoses. You have to go back now, and by process of elimination, come up with the one that seems to be the most appropriate and correct,” Friedlaender said.

Ultimately, the students may eliminate some possibilities but not others, prompting a discussion about the inform

ation they need to be certain their theory — their diagnosis — is correct, she said.

(This painting, “Death of Chatterton” by Henry Wallis, depicts the suicide of a 17-year-old British poet Thomas Chatterton, who poisoned himself with arsenic and became a hero of 19th-century Romanticism.)

How is the workshop specifically helpful to future dermatologists? The 2001 study in JAMA revealed improvement in their descriptive language, Friedlaender said, such as when they described the margins, height, texture, and coloring of rashes in clinical photos. Compared with nonparticipants, “after spending 3 hours in the gallery doing this exercise, they’re getting much more detailed in what they are talking about, giving us a whole lot more information.”

At Harvard, a Focus on ‘Slow Looking’

At Harvard Medical School, dermatology professor Buzney designed the Visual Arts in Dermatology: Training the Eye program about 12 years ago with colleague Jennifer Huang, MD, a pediatric dermatologist and dermatology section chief at Boston Children’s Hospital after residents called for more training in visual observation.

One goal is to discourage snap decisions. “Getting people to slow down and really look at something is different from what we’re used to,” Buzney said. “But it becomes very important in the clinic, to be able to focus, take a moment, really think about what you’re seeing when you’re evaluating the skin, a rash, or a lesion.”

The workshop, held every 2 years, relies on “visual thinking strategies” (VTS) developed by Philip Yenawine, a former director of education at the Museum of Modern Art in New York City. Research has supported the use of Yenawine’s strategies in medical training, suggesting “they can serve as a vehicle to develop crucial clinical competencies.”

VTS involves “three basic questions that are asked over and over again to get people to focus on what they’re seeing and do something called ‘slow looking,’” Buzney said.

The three questions are:

• What’s going on in this picture?
• What do you see that makes you say that?
• What more can we find?

The strategy “gives you an anchor when you encounter something you might not be able to make sense of immediately,” Buzney said.

In one exercise, a resident sits in a chair and describes a work of art to another resident who’s facing the other way. The second resident’s job is to sketch the artwork based only on their partner’s words.

“You realize the difficulties in turning what you see into words and how carefully they have to be chosen when you’re trying to get someone to draw a 3D [three-dimensional] image of a small sculpture,” Buzney said.

Understanding the Clinical Impact

Dermatologist Anusha Mohan Kumar, MD, MSc, of Beth Israel Deaconess Medical Center, Boston, and Harvard Medical School, who helped update a museum-based workshop during her last year of residency at Harvard, highlighted its discussions of Edvard Munch’s painting “Two Human Beings (The Lonely Ones).” It shows a couple who appear to be standing at a shore.

Participants focus on “high-power,” granular details such as brushstrokes and “low-power,” general details such as the image’s background and framing, Kumar told Medscape Medical News.

This strategy “correlates with being able to integrate detailed features of a rash, such as the presence of vesicles, with a broader perspective on arrangement and distribution, such as distribution in a dermatome, [which suggests] a diagnosis of herpes zoster/shingles,” she explained.

The artwork exercise, Kumar said, also offers a lesson in “separating objective descriptors from those that assume interpretation, such as describing a rash as red and scaly vs eczematous.”

The lessons of the museum visits can stick around throughout the career.

Buzney said that she still draws upon slow-looking techniques in the clinic. “In those moments when I may be uncertain exactly what I’m seeing on first glance, it reminds me to slow down and remind myself that the process of looking in a slow, focused way will help me reach a conclusion.”

The dermatologists and curators interviewed for this article reported having no disclosures.