Jeffrey campbel 8A Hanard ede Seta, ston, seach Corresponding ‘nutri Campbel e& (Gefey.compbetihs harvard es), Section Editor Roraane Youre. ‘Associate Eto, jamacor Opinion Art and the Uncertainty of Medicine ‘Our patient was a pale, lithe woman in her mid-20s, cdearly dancer. Her left arm projected in a contorted spiral, the muscles taut beneath her semitransparent skin. She held her clawed hand perfectly stil. A group ‘of medical students and instructors congregated in an arc around her and began to construct a differential diagnosis, recalling the pathways of nerves, vessels, and muscles, and speculating about her history. Our patient remained frozen, forcing us to use ust our eyes tocareflly extract clues. In fact, when we turned to her record, we found that she fad been here for100 years. Born in 1882, she was fixed in oil on canvas, embalmed by the painter John Singer Sargent (1856-1925). Our group was diagnosing” the central figure of Sargent’ ET Jaleo, the centerpiece of Boston’ Isabella Stewart Gardner ‘Museum (Figure). As part ofa course designed to teach ‘medical students clinical observation skills through close scrutiny of art,’ our band of first-year students crisscrossed Gardner's diverse collection. stopping in front of preces as varie as ancient Egyptian sculptures, Gothic porticos, and Sargent's masterwork. At each, the group's task was to observe and describe bath the details and the greater effects ofthe work, anticipating. practicing, and honing the complex skills needed to reach a diagnosis in animate patients. While the danc les pale and twisted arms played centrally into how we. interpreted the figure, we did not aim fora specific clagnosis. Rather, at this formative stage of our medical training, we targeted the process of converting our ‘observations into interpretations, Previous research onthe intersection of medicine and the visual arts has focused on how observing art helps students and physicians look closely and astutely atpatients This rationale helps explain why these pro: grams have become increasingly popular in medical education. But there is more to be gained from the study of art than a sharpened medical gaze. In her essay “The Value of Medical Uncertainty?” Wellbery illustrates how the process of working through the ambiguity ofa painting or a poem allows for “lfc: tion of values” allowing the careful reader or observer to discover fundamental meaning by grappling with uncertainty She suggests that by encouraging sel teflection, art may make physicians more comfortable vith uncertainty Although uncertainty remains a cen- tral feature of medical practice, medical education typ ‘ally als to teach students to grapple effectively with it. While Welbery discusses the relationship between the arts and uncertainty generally, here | describe how art can serve a practical pedagogical role in training, ‘medical students to thrive in an environment fraught with uncertainty Uncertainty takes many forms in medicine, froma physicians dilemmas in diagnosis toa patient's ques tions about prognosis is uncertainty something that physicians should become “comfortable with? One might argue that comfort with uncertainty implies a sense of complacency. However, | suggest that devel- ping tolerance and heathy respect for uncertainty. aswell as recognition ofthe prominent role it paysin a patients experience ofilress, isa fundamental compo: nent in our abit to provide effective and empathetic cae Oft* pointed out that physicians are often deeply intolerant of uncertainty, to the point that they can focus on a shred of dataso intensely that they forget the human beng sitingin font of them. The ive for ‘certainty stems in part from our traning as medial sts ‘ents Repeatedly students ean to condense complex diagnoses and treatment pans ito exact, mnemon- cally orgoized facts. We lean tables of diagnoses, bubble precse answers on examinations even parse intricate soclhstries into incall relevant” hem: sentences, all withthe aim of distiling the experience illness into a string of reportable data. Immersedin an atmosphere that places a premium on specific knowledge, students face the ever-present thought that "Tere are so many things that I should know but dont” To compound this, we become imbued witha fear that our patients will ot respect usif we donot havea definite answer Lingard and colleagues” um up a common response t this ileama: "Where unavoid- abl, (medical students] understand thatthe best way tohandle uncertainty isto dsguse, deny, o° delet? Infact. students and seasoned physicians alike exper ence such emotions as guilt and denial in response to dlagnesticuncertainty>* Perhaps one reason for thsi that teaching med cal students facts is latively easy but teaching them how to tlerate uncertainty isnot. How would one go about leaming tobe less uncomfortable with uncer tainty? One place to stati in an environment away from the hierarchical hospital The art museum comes tomind Inher classic essay on medical uncertainty, Fox? identified limitsofinvidualkrowledgeasaceresource of uncrtaintyin ciagnosis. Within the walisof te hs: pital where factual knowledgelsabadge of honor (and a criterion used to grade students, aversion to uncer tainty rowsreadily.Exceptingthe few arthistoriansand aficionados whchavemade theleaptomedcne the art museum evelsthe plying ld Witadesciptiveplec: ard conveniently absent, our cass approached Eco wih noexpectationsofpre established knowledge. We were al, by definition, uncertain ofthe painting’ sub ject, ofits accepted meaning, and of its creation and provenance. Because we all quickly reached the limits of ou invcual knowledge, and because those limits rested in approximately the same place foreach of us JAMA Decerber10,2014 Volume 312, Number 22Opinion A Pieceaf Figure. Jo Singer Sargent (856195), leo, 682, American, Ol on canvas. 232.4 3556 cm Courtesy ofthe eel Stewart Gardner Museum (tps ma bidgeranertcomler-USleacllocaton/3970 sels stewart grdher mezcum boston mo), Boston, ssachets The rdgeman At bay we could acknowledge our uncertainty without the stigma of not knowing the ans ven more fundamental, art iself-and discussion of art defies certainty. Whenintrpretingan: theres no way tobe wrong because, equally there iso way tobe right In font of piece of a each elgnosi valid, Where one student saw the dancer's ‘igiimbs assnapshotsofsoontobe released tension wthina fd dance another saw theselibsas impossibly twisted, a pacody of themechanicsofhumanmovement Although my pers ew from thesamedetails-the twisted shoulders, the cawedfingers-these detailsrenderedoppesnginterpretations.Thechancetoadmitthat we dd not know the trv meaning of Elo, and were not even seekinga"trve" meaning allowed usto focus onthe proces ofc: quiring impressions and generating hypotheses. (n the wards, the proces of cagnos sim involves inter pretation of data. Bu unfortunate s we lam tobe physicians. we often lose sight ofthe process by which an observation becomes a conclusion Driven bya fear of ambiguity, students often rely on patter recognition and the pathognomonic sign bluring the boundary between whats evidence and whats inter pretation. As we observed Jaleo, unencumbered by the need to stata decisive answer each detailpresente tse asa component of many valid conclusions Ths was not easy or necessary sats ing. After return tothe tasted arm furore times, on each aceasion formulating new hypotheses about the painting's mes <26e, began to mss the eureka moment and the escition that JAMA December10,2014 lume 32, number 22 comes with a definitive answer. But while | honed this process based rather than answer based method of converting observa tions into interpretations, | was in effect practicing an ideal version ofbuldinga differential diagnosis After deliberating over the painting's details, our next cha lenge was to describe the image and convey our analyses to our peers. One beautiful and arduous aspect of describing arts that spoken or written language cannot encapsulate an image, much less its meaning, Writing about Velzzquez’ Las Meninas, Foucaut® proposed that “the relation of language to painting is an infinite relation” and onl by avoiding a language of certainty will a painting “releases iluminations” Inthe medical classroom and on the wards, rich depictions ‘often yield to the discrete, eponymous snippets that convey exact diagnoses or differentials. Phrases lke “palpable purpura” attain significance beyond pure description. By permitting us to rapidly ‘convey a diagnosis, this shorthand eliminates ambiguity. But s stu dents’ medical vocabulary becomes populated with these defini- tive signifier, and when we spin a patient’ story to convey a pre- determined diagnosis, something is ost. Not only do we risk prematurely anchoring ona dagnoss, we aso subliminaly lam to eschew language that leaves room for uncertainty ‘The urge to signify diagnoses with our descriptions can result in dangerous consequences when a finding itself is unclear, or when we must convey unsure observations to others. As other ‘writers have suggested, the conditional language we use to render paintings (but which we might be loath to depict, say, a patient's rash allows for the development of multiple, disparate, and equally valid interpretations.® While we described El Jaleo, ‘our class hunted for precise characterizations, but without the 4im or even the possibilty of implying irefutable conclusions with our words. The exercise allowed us to practice descriptive language while tolerating the uncertainty that our words neces: sally contain. ‘A patient | recently saw in the hospital arrived with a diffuse cdesquamating, erythematous rash with a positive Nikolsky sign, allin the setting of a recent methicllin-resistant Staphylococcus ‘aureus infection. The dermatologist’ description and assessment convincingly argued for a diagnosis of Staph scalded skin syn. drome. My resident and I were about to sign an order for vanco- ‘mycin when we stepped back to review what we did not know about the patient's case: Why was his kidney function worsening? Why had prior vancomycin therapy failed to cure his infection? Were we convinced that he had a positive Nikolsky sign? ‘Acknowledging our own uncertainty ed us to another diagnosis— \vancomycin-induced linear iga dermatosis, which was confirmed bya biopsy the next day In this case, we used the tools that the Confetofimterest isdosures: The autor hs cormpleted ad submited the CMUE Form forthe Disclosure of Potent Confts ol iterest and none were reprtd ‘Addons Contbutons: The athe woud keto thank el Katz MO, Amy Ship. MO, and lea Milerferther mers ae gunce 1. Nagin Hafler Pil AR etl Formal art obsenatin vanng improves medal sues visual dagosticsils J Gen tar Med 200823 (sais 2. Perry My MafullN, Wilson, Morisey D.The tfc as based intervention nme eduction erature reve Med Edu. 2075 neta. for doctors) 12003:563)603 66 Jamacom 3. Welber C.The value of medical uncertain? Loneet 2010;375(8727:15861657, 4. fr. Uncertainty shar for doctors. NewYork Ties lune, 2013. tpifwebiogs 2 iytinescom/2013/06/06huncertanty share ‘5. UngardL Garwood, Schye CF, Satord MM ‘Acetainartof uncertainty case presentation and the development of poesonalldety, oc Sc Med APleceof My Mind. Opiion art museum effectively provides: we recognized the ints of our knowledge (asking why parts ofthe story cid not ft), we assessed how our observations became interpretations (thinking caefuly about an unconvincing Nkoshy sign, and we recognized our bias ested by exact language (by reevaluating the dermatologis's convincing assessment). Uncertainty permeates the practice of medicine, but medical traning urges students to tink in terms of verified fact an cer: tain conclusions. The art museum provides a fertile ground to cu tivate students tolerance of uncertainty andto practice skilsofob- servation and description in an arena where “not knowing” is inevitable. n the museum, the limits of our knowledge are almost instantly reached, our subject matter defies definitive interpreta- tion andthe anguage we se to describe our subjects vorced from implicit meaning To work wth team, develop broad and encom: passing cfferetials, eschew cogitve base, recognize our wn liitations, and, believe fundamentally empathize with our pa tients, physicians must eam to tolerate uncertainty and work ef fectvely within its bounds. fteratript the at museum, we are ‘more prepared to approach the pale Spanish dancer who walks through our clnic door. 7. FoeRC. Tring for uncertain in Merton RK, aad Kanal ce. The tert Physio, Cambie, Ma Harvard ives Press 1957207 1. Foucault. The Oder of Tings: Archeology ofthe Human Scences. ew York, NY Random House, 199489 9. Miler A. Grohe, Kreshins, Katz. From the salresto the ine: appving a museum sors Topitiet care Med Huan 2013:34(4)-435-438, 16. CivstalisNA.Onthesocoiogalansiety of ys. In: Messorer CM, Sua J, ‘Geisman Aes. Socety and Medina: sayin Honor of nee. Fr. New Srunsck Ni: Mansaeton Publeners 2003.05 144 JAMA Decemberi0,2016 Volume3I2.Number22 2539Copyright of JAMA: Joumal of the American Medical Association is the property of American Medical Association and its content may not be copied or emailed to multiple sites, or posted to a listserv without the copyright holder's express written permission. However, usets may print, download, or email articles for individual use.