Restoring right-brain activities to medical school

Medical education is in a crisis. According to a study in the Annals of Internal Medicine, half of 4,287 students surveyed at seven medical schools experienced burnout and 10 percent expressed suicidal ideation. And doctors aren't much better off; a second study in JAMA Internal Medicine of 7,288 physicians showed that almost half had experienced some symptom of burnout.

The public image of doctors hasn't fared well, either. While the popular notion of doctors was once the wise and avuncular Marcus Welby, M.D., more recent portrayals tend toward Dr. Gregory House, a brilliant but annoying know-it-all with a decided God complex.

Salvatore Mangione, an associate professor at Thomas Jefferson University, thinks he knows why. In talks and papers, he has investigated how medical education veered off course and how it can be reinvigorated.

"For lack of a better term, we've left out humanities," he says. "We've ignored art, poetry, and drama, all of which offer a different way of thinking, seeing, feeling, and engaging with the world."

"Doctors," he says, "have lost their souls."

Medical school, Mangione says, encourages the development of left-brain activities, favoring the verbal over the visual, the scientific over the artistic, and ignores growing evidence that people who think in pictures may have greater powers of intuition and creativity. One answer, said Mangione, is to reintroduce spatial and visual thinking into the med school curriculum, and to encourage the admission of students with more flexibility and empathy.

"Many physical findings were first described by artists," he says, citing Michelangelo and Leonardo da Vinci as prime examples. He quotes the art historian Kenneth Clark, who pointed out that "people think Leonardo drew so well because he knew so much, but it was more likely he knew so much because he drew so well."

Mangione's own medical training bears this out. As a student in Rome, he came to the United States to do rounds, and was impressed by an attending physician in Camden who drew the changes in acute pancreatitis. The information stayed with him far longer than that delivered verbally.

"The whole of medicine is observation," says Mangione, 60, who lives in Wynnewood. "If you have to draw something, you see it differently. The thing I know for sure is that if I haven't drawn something, I haven't really seen it."

To test his thesis, this semester Mangione recruited 40 first-year Jefferson medical students for a basic drawing class at the Fleisher Art Memorial in South Philadelphia. The class had a number of objectives: to improve students' powers of observation, which has been shown to enhance their ability to diagnose patients; to fuel their sense of ambiguity and empathy; and to prevent burnout.

There were 10 three-hour sessions. Before and after the class, medical students were evaluated for signs of burnout, levels of empathy, tolerance for ambiguity, and visual literacy, alongside a control group who did not attend the classes. The data will be compiled into a paper to evaluate the program.

"We've heard [anecdotally from students] that the class was almost like Zen therapy," says Mangione. "The students felt that this helped them see things differently and to feel differently."

One model for the endeavor was a Harvard University class called "Training the Eye," in which medical students tour a museum and freely answer questions about paintings on display. The goal of that course was to encourage their observation and diagnostic skills. And the results were impressive: A 2008 study showed that Harvard students who took the class improved the accuracy of their clinical observations by 38 percent compared with a control group.

Jefferson isn't alone in this region. This fall, Cooper Medical School of Rowan University will be offering a course in observational drawing, and Drexel University College of Medicine will embark on an observational arts and medicine program with the Pennsylvania Academy of the Fine Arts. Temple University has paired with the Barnes Foundation to have medical students study paintings, and the University of Pennsylvania is in talks with local museums to develop a visual arts pilot for this fall.

In many ways, Mangione points out, the neglect of the "right brain" endeavors in medical education can be traced to the Flexner Report, published in 1910 to reform medical school curriculums. Mangione notes that before that time, the predominant model was Franco-English: a medical education spun off from the humanities. Flexner advocated a more Germanic approach, which favored science above humanities, as exemplified by the introduction of a white coat and the lab, both German practices.

"The pendulum may have swept too much toward science," says Mangione. "Now we need a better balance that includes wisdom, intuition, visual and spatial thinking, and creativity."

Introducing students to these concepts at the start of their careers is also key; they are less receptive later on. "By the time they make it to the third and fourth year, something has broken," he says.

"Lots of data show that empathy and tolerance for ambiguity tend to drop during medical school," he adds.

This isn't idle thinking; it's going to refocus the direction of Jefferson's medical school. This fall, a drawing program in anatomy will be introduced for all 260 first-year students, as well as an advanced class in sketching.

"In the future, these art exercises should become as integral a part of the curriculum as biochemistry and cardiology," says Stephen Klasko, the president of Thomas Jefferson University.

For Sarah Jones, 30, a first-year student who never drew before, the course was a revelation.

"Looking is different from really seeing. It's a wonderful phrase that I've taken away from this class. I hope it will be something I can use in my practice. Not to see patients for what I think they are based on assumptions that I had before they came in to the room."

Michael Natter, 28, who majored in neuroscience and art before he arrived at Jefferson, also found the class eye-opening. "Everyone in medical school loves the material, but the information is being fed to us by a fire hose. As an artist, I like the chance to marinate."

"The other thing is that when you draw, you are seeing something and interpreting it as you see it," says Natter. "That's a huge point to make. Diagnosing can get onto a certain path. Looking at things in a new way gives you the flexibility to change directions by thinking outside the box."

"As a society we value sciences and think that the arts are fluff," says Julia Clift, the drawing teacher for the course. "But when you learn drawing, you learn a lot of skills - intense focus and concentration, patience, deductive reasoning. Gesture drawings hinge on the ability to be extremely present, aware, and to make good decisions in a rapidly changing, fast-paced environment."

The class is already paying dividends. While working in a student-run clinic at Jefferson, Jones found herself noticing details she might have otherwise missed: one patient's slightly swollen tongue, the tautness of another man's face that turned out to reveal some recent personal traumas.

"When I went to class, it was like opening up a door to another part of my brain, a better connection to my emotions," Jones says. "Class could be an emotionally charged experience. I think I'm a pretty balanced person, but medical school can push you straight ahead, while drawing can connect you to yourself."


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