Teaching the Art and Science of Medical Decision Making Using Art, Literature and Clinical Vignettes Bill Lydiatt, MD Kirk Vaughn-Robinson, Sculptor.
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Teaching the Art and Science of Medical Decision Making Using Art, Literature and Clinical Vignettes Bill Lydiatt, MD Kirk Vaughn-Robinson, Sculptor OUTLINE Evolution of Medicine Teaching Difficult Topics Rational for Visual Art, Literature, Poetry Teaching Observational Skills Sculpting with Kirk Question time External Disease Concept Evil spirits -Religious and superstition based An imbalance in humors Observation based Historical Evolution of Medicine Disease of parts Diseased organ -anatomy based-16th and 17th Century Diseased cell -microscopically based-19th Century Fifth as genetic or epigenetic abnormalities or insults –lab and technology test-based20th Century Technology became the hero Disease Oriented Medicine Led to disease oriented treatment approaches Success was defined as diagnosing and curing a specific abnormal cell or organ Very effective approach to many types of illnesses, particularly acute infectious diseases Knowledge Based Practioners became king Knowledge General knowledge in science deals with populations and statistics 75% chance of successful treatment of disease works great for population health Knowledge or more accurately information is now readily available but… The patient is either a 0 or 100 Specific knowledge of the patient is more of an art BUT it is a person that has the diseased cell or organ “they hate cancer more than they like people” Science and Humanistic Concepts 21st Century Alleviation of suffering When to treat and when not to How to balance risks and benefits of treatments and clinical testing Suffering May come from physical aliments psychic aliments disease and its treatment Hard for individual to predict what will be the major cause of their suffering Harder still for caregivers to predict and anticipate Suffering occurs most often when the aliment threatens the future or their perception of the future for that individual Suffering involves an assault on personhood Some aspect of personhood is at risk Future or current loss of an aspect of the self Only the person can define whether and how much they are suffering Therefore alleviation of suffering is value laden, complex and nuanced Health Care Values Science Medicine Value free Value laden Based on careful observation Based on observation Generalized knowledge Specific knowledge about the about diseases Technology aids Looking for facts patient’s disease and the context of that disease Technology distances Looking for relief of suffering Providers of the Future Knowledge is important Psychology is important Observational skills are important Values are important So How Do We Teach This? Knowledge needs context Knowledge needs nuance Knowledge needs perspective Saving Faces Ian Hutchison, Maxillofacial Surgeon in London Saving Faces toured Europe and North America Mark became an artist in residence at UNMC and now earned a PhD Graphic Image Ahead! Extended Maxillectomy Virginia Aita, PhD Initiated the Saving Faces Exhibition in Omaha Secured Funding to provide Mark Gilbert with a residency Headed the advisory board Directed qualitative research efforts Lessons Learned from Saving Faces and Portraits of Care Art and medicine are linked intellectually and emotionally Viewers react to the art in a variety of ways Shared viewing and reflecting elicits compassion, leads to appreciation of paradoxical nature of vulnerability, strength, dignity Mark taught the importance of observation to the high school alliance class High School Alliance Facts 196 students graduated from 22 high schools in 11 school districts 35.1% Free and Reduced Lunch 96% of graduates are attending college and 78% are in STEM related fields Anna on MG During the activity, I would say I felt a plethora of emotions. Mr. Gilbert mentioned feeling vulnerable while working on his drawings, and I could definitely relate in that sense. I think I felt vulnerable because the drawing's ultimate appearance was out of my control, especially when I was instructed not to lift the charcoal from the page. … I also experienced feelings of excitement because of my lack of control and the surprises in the drawings that surfaced. Other Avenues? Pictorial Art Surgical Training Literature Poetry Teaching observational skills Sculpture Ellie’s Choice “Jungle Fish” by Stuart Moskowitz Ellie on Visual Art Project I feel hopeful because it is placed in a place where health professionals such as doctors and nurses are doing their best to make sad, sick kids well again. Even though there is quite a bit of sadness on this floor there is also a large amount of hope and trust, which is shown by this artwork. Mark Gilbert’s Rendition of Mandibular Resection Literature Death of Ivan Illyich Leo Tolstoy Complications Atul Gawande Ward #6 Ted Kooser Winner of more than 24 prizes for poetry and writing 11 full length poetry collections 2 nonfiction works Pulitzer Prize for Delights and Shadows 13th Poet Laureate of the United States Melissa on TK One of the most interesting things I learned was that he said that once we read the poems and we interpret them a certain way that poem is no longer his it is ours. Hearing that surprised me because I thought he would tell us exactly what he meant in each poem. Observational Skills Study Overview Bill Lydiatt, M.D. Virginia Aita, Ph.D. William Roccafort, M.D. Mark Gilbert Ted Kooser Special Agents Dan Clegg and Jonathan Robitaille Teaching: Providing Future Providers Resident Education Surgical Techs Training Nursing Medical Students Dental Residents Why Is Observation Important? Physical diagnosis is dependent upon it Not limited to one sense for example head and neck cancer may cause abnormalities in: How the head is held - vision Odor of the breath - smell Pattern of articulation - hearing Consistency of a mass – touch OK, usually not taste since the days when urine was tested for diabetes Often patients will not volunteer information and the ability to see visual clues can lead to an opening in the conversation Arthur Conan Doyle, M.D. Watson “When I hear you give your reasons, the thing always appears to me to be so ridiculously simple that I could easily do it myself, though at each successive instance of your reasoning I am baffled until you explain your process. And yet I believe that my eyes are as good as yours..” Holmes “You see, but you do not observe. The distinction is clear. For example, you have frequently seen the steps which lead up from the hall to this room…” A Scandal in Bohemia, The Adventures of Sherlock Holmes Can Observational Skills Be Taught? Experiential evidence suggests that senior clinicians may be better observers Balance between looking to confirm what is expected and what is actually there Dolev, et al reported using art as a means of improving observational skills in first year students JAMA 2001, 186: 1020-1. How Many Horses Do You See? Teaching Observational Skills Gallery discussions of Mr. Gilbert’s ability to observe Speculated student’s might benefit from his techniques Knew Mr. Kooser was a keen observer and also a Professor of English Developed a pilot series of seminars in consultation with Mr. Kooser and Mr. Gilbert Methods 3 seminars with lecture and participation plus keep a journal of observations and thoughts on how observation is used in practice Session 1 Introduction to drawing and observation by Mark Gilbert Defuse fear of being a poor artist Teach a few techniques Session 2 Introduction to observation by Ted Kooser Describe a pepper Spoke of his experiences reading medical reports Session 3 Drawing a patient simulator First Drawing Left handed and standing up Not looking at paper Final drawing Journal entry Results- Subjects 10 M3 students 10 Otolaryngology-Head and Neck Surgery residents Results Evaluations Generally felt helpful and enjoyed the class Participants most surprised that observation not as keen as they thought-best demonstrated by inability to draw from looking Journals Kept the concept of observation at the forefront of the students’ mind How Many Faces Can You See? Kirk Vaughn-Robinson THANK YOU