Appreciating visual arts may not foster medical diagnosis skills

Koji Matsumoto

doi:10.12688/f1000research.129219.1

Home Browse Appreciating visual arts may not foster medical diagnosis skills

ALL Metrics

Views

Downloads

Get PDF

Get XML

Export

▬

✚

Research Article

Appreciating visual arts may not foster medical diagnosis skills

[version 1; peer review: 2 approved with reservations]

Koji Matsumoto

PUBLISHED 19 Jan 2023

Author details Author details

Faculty of Economics, Nagoya Gakuin University, 1-25, Atsuta-nishi-machi, Atsuta-ku, Nagoya, Aichi, 456-8612, Japan

Koji Matsumoto
Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Japan Institutional Gateway gateway.

Abstract

Background: This article examined intervention studies that used appreciation of visual arts to foster observation skills and discussed their effectiveness in making accurate diagnoses in terms of expertization.
Methods: In order to collect journal articles and academic books (written in English) on empirical intervention studies that examined the use of visual arts for cultivating observation skills in health professionals’ education and training, the author first targeted articles that had been included in previous systematic reviews. In addition, they conducted a manual search. From this body of literature, the author selected studies that objectively measured observation skills only through the appreciation of visual art. They collected and read around 300 articles and selected 12 studies after applying the inclusion and exclusion criteria.
Results: This article revealed no concrete evidence on whether appreciating visual art contributes toward an accurate diagnosis. Extant studies determined that such appreciation facilitates the observation of more visual features and a detailed view over time. However, they did not confirm the positive effects of appreciating visual arts on an accurate diagnosis. This article also confirmed that such appreciation does not reduce misdiagnoses or develop tolerance toward ambiguity that prevents premature closure. Moreover, the transfer of observation skills from one context to another is unlikely to be as successful as the intervention studies had intended.
Conclusions: For fostering diagnostic skills, providing students with many instances of medical cases and appropriate knowledge to evoke implicit learning for extracting subtle differences in the cases, should be prioritized over visual art appreciation. On the other hand, such appreciation may foster verbalization skills and understanding or extraction of the patient’s background and context. These competencies may cultivate teamwork and perspective-taking, indirectly leading to an accurate diagnosis.

Keywords

visual arts appreciation, diagnostic skills, observation skills, expertization, perceptual learning, mental images, pattern recognition, intuition

Corresponding author: Koji Matsumoto

Competing interests: No competing interests were disclosed.

Grant information: This study was supported by JSPS KAKENHI Grant Number JP20H01685.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2023 Matsumoto K. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Matsumoto K. Appreciating visual arts may not foster medical diagnosis skills [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:79 (https://doi.org/10.12688/f1000research.129219.1) First published: 19 Jan 2023, 12:79 (https://doi.org/10.12688/f1000research.129219.1) Latest published: 19 Mar 2025, 12:79 (https://doi.org/10.12688/f1000research.129219.2)

Introduction

Observation is crucial in various areas or specialties of medicine¹^–⁴ and it is necessary for medical advancement.⁵ Though medical education has not included the cultivation of observation skills until recently,²^,⁶ intervention studies on such training have been growing rapidly, sometimes in collaboration with art museums.⁷ These intervention studies usually use visual arts, such as painting, based on the assumption that there are similarities between observing visual arts and making observations in medical examination or potential applications of appreciating visual arts in making medical observations.⁶^,⁸^–¹¹ For example, Jacques et al.¹²^{, p.9} asserted that “the arts foster many of the same skills required of physicians, including risk-taking, problem-solving, careful and attentive looking, interpretation and analysis, developing empathy for others, and seeing an issue from multiple perspectives.”

Gelgoot et al.¹³ and Elhammoumi and Kellam¹⁴ reviewed several studies on developing observation skills in medical or nursing education; however, they only listed the main findings without discussing them. Additionally, Perry et al.,¹⁵ Mukunda et al.,¹⁶ and Alkhaifi et al.¹⁷ concluded that such studies offer reasonable evidence in favor of using visual arts to improve observation skills. Dalia et al.¹⁸ reviewed the incorporation of visual arts in medical school and residency and identified the following four elements that should be included in the curriculum: pattern recognition, deep seeing, facial expression, and pertinent negatives. Though Turton et al.¹⁹ reviewed the intervention studies that used various forms of art for training in palliative care, their conclusions cannot be validated because they did not report all the literature that was used. Ike and Howell’s²⁰ review is the only known study on intervention studies that used visual arts to develop observation skills among medical professionals. However, they only discussed the validity of the psychometric scales or quantitative observation metrics used in these studies.

Thus, although one of the primary goals of developing observational skills through visual arts appreciation should be to develop diagnostic skills, it remains unclear whether appreciating visual arts is effective for improving the accuracy of diagnoses. The present article provides an overview of intervention studies that used the appreciation of visual arts for fostering observation skills and discusses their effectiveness in making accurate diagnoses in terms of the expertization of medical professions. Medical experts can diagnose more accurately through the expertization.²¹^–²³ Hence, an analysis of expertization studies should provide rich insights.

The following sections of my paper are structured as follows. The Methods section explains the process of selecting the target articles. The Results section provides an overview of the intervention studies that considered the appreciation of visual arts for fostering observation skills. The Discussions section presents the findings of the target articles in terms of the expertization of medical professions. Finally we present the study’s main conclusions, limitations, and implications for future research and practice.

Methods

Search strategy and selection criteria

This study referred to the search results of the aforementioned review studies¹³^–²⁰ to search journal articles and academic books (written in English) on empirical intervention studies that used visual arts for cultivating observation skills in health professionals’ education and training. Manual searches for additional articles were also conducted because the search results were inconsistent; moreover, it was difficult to collect information from databases by using typical search words such as “visual arts,” “observation skills,” and “medical education.”

Detailed inclusion and exclusion criteria to assess the results of the interventions in which only appreciating visual arts affected observation skills were set, comprising those that used only visual arts to foster observation skills. Therefore, studies that included other activities were excluded, except for pre- and post-tests, such as drawing or creating visual arts and observing medical images. Additionally, studies on “graphic medicine”²⁴ were also excluded, because these studies used comics that included written dialogues.

Moreover, studies that objectively measured observation skills were included, such as using psychometric scales, quantitative metrics, or grading participants’ statements by predetermined criteria. Thus, studies that subjectively measured observation skills, irrespective of the method used (e.g., participants’ subjective evaluation of their skills were excluded, their free comments on the interventions, and scales of their impressions of the interventions). For example, studies that extracted key concepts from the participants’ comments, such as thematic analysis²⁵ were excluded because they are not suitable for determining the learning effects for the entire concerned population since the concepts are identified from the comments of only a few participants.

Data collection

The full texts of the related articles identified by the search results of the aforementioned review studies¹³^–²⁰ were collected. Through manual search, the titles of articles that seemed to use visual arts appreciation in health professionals’ education were selected by checking reference lists and the articles listed in PubMed’s sidebar or Google’s search result of related articles. Then, their abstracts were reviewed via websites, such as PubMed and Google. If the abstract met the inclusion criteria, the full-text article was collected. Additionally, if the abstract could not be obtained or was insufficient to determine whether the article met the inclusion criteria, the full-text article was collected. Therefore, if it could be clearly determined from the abstracts that the inclusion criteria were not met, full-text articles were not collected. This process was repeated until no more related articles could be found. I conducted this search from January to June 2022.

Data analysis

After a review of the full texts that were collected, studies that met the inclusion criteria were selected. An exhaustive summary of each study was collated. The summary described the features, research design, and key results of the study (see Table 1).

Table 1. The features, research design, and key results of the selected intervention studies.

Reference No.	Authors	Participants (N is the number of samples analyzed)	Time/Duration/Frequency	Types of visual arts used	Number of visual arts used	Main activities/Protocol of the intervention	Including pair/group discussion	At an art museum	Instruction to look at the whole image in detail	Instruction to separate interpretation from description	Teaching about visual elements	Other distinctive instructions	Control experiment	Pre- or/and post-test	Timing of the pre-/post-test	Measurement of observation skills	Scoring criteria	The measurements rating the number of features/words answered/used	The measurements assessing accurate diagnoses	Key results
26	Agarwal et al. (2020)	1st year students in a medical school (N=101)	3h×2 sessions over 2 weeks	All narrative art with no abstract objects	6	VTS	✓	✓	✓				Yes: recruited separately (intervention or doing nothing)	Yes (different but similar-in-theme images in each test)	Pre: prior to the sessions, post: the day after the last session	Electrocardiograms and chest radiographs to describe observations of differences between normal and abnormal, and a patient image to describe any observations	Frequency of clinical observations, diagnostic comments, general patient observations, and “self-deprecating” remarks/Time spent	✓ (clinical observations, diagnostic comments, general patient observations)		Some post-test scores (clinical observations and general patient observations) of the intervention group increased. Intervention group spent a statistically significantly greater time than the control group.
27	Dolev et al. (2001)^a	1st grade students in a medical school (N=90, but it is unclear whether the data were obtained from all)	Not reported	Representational paintings that the students were not familiar with	Not reported	Individual and group descriptions of visual evidence in paintings	✓		✓	✓			Yes: randomized voluntary applications (intervention/clinical tutorial sessions of history taking and physical examination skills/anatomy lecture that featured abdominal radiographic images)	Yes (different photos in each test)	Not reported	Patient photos were presented to write descriptions of what they observed, not a diagnosis or any pathophysiologic process (the number of artwork and images used was not reported)	A key that assigned 1 point for each of the nine or 10 visual diagnostic features present in each photograph	✓		The intervention group’s post-test score improved by 56% than the pre-test and it was 10-12% higher than the other groups.
28	Garino (2008)	Physician associate students of a school in 2008 and 2009 (N=29, 36, respectively), before dermatology and physical exam training	2 h×1 session (a mandated element of the curriculum)	Not reported	Average of 4 works for each student	Participants were asked to describe the paintings individually and in groups	✓	✓		✓			No	Yes (different photos in each test)	Not reported	Three medical photos depicting physical abnormality were shown and participants were asked to describe what they observed, ranged from patient portraits to studies of an isolated anatomical structure	A key that assigned 1 point for correctly identified item out of all 10 items in each photo. Items ranged from the very general to the very specific (lesion detail)	✓		Significantly improved in 2008 (14.07 to 15.69) but not in 2009 (14.00 to 14.63)
29	Goodman & Kelleher (2017)	1st year radiology residents in a school (N=15)	1 session (length of the session was not reported)	Paintings from the gallery’s collection	Not reported	Describing the painting, then interpreting it	Not reported	✓	✓	✓			No	Yes (different images in each test)	Pre: the first day of their residency (timing of the session was not reported), post: immediately after the session	Fifteen radiographs were shown to identify the location of abnormality, but the participants were asked to not present a diagnosis	Whether the abnormality was identified or not		✓	Improved (2.3 to 6.3)
30	Griffin et al. (2017)	Higher specialty trainees (specialist registrars) of dermatology (N=4, with 3 participants in the control group)	2 h×5 sessions with additional self and group reflection (duration of the sessions was not reported)	Abstract, landscape, still life, portraiture, and figurative artwork	Not reported	Analysis of selected artwork, group discussion, short lectures, and follow-up resources	✓	✓			✓	Encouraged to challenge their own perceptions, consider the artist’s viewpoint, and develop their own descriptive style	Yes: (probably) voluntary (intervention or control, but details of the control were not reported)	No (post-test only)	Not reported	Artwork and clinical images to identify key visual features and comment on texture, lines and contour, color (or shading), and contrast (the number of artwork and images used was not reported)	Frequency of correct answers pre-set by dermatologists (clinical images) and an arts educator (artwork)	✓ (probably)		No significant difference in clinical images (Controls: 12.67; Participants: 13.25) and artwork (Controls: 43.00, Participants 60.75)
31	Grossman et al. (2014)	Family nurse practitioner program students in a school (N=19, but it is unclear whether the data were obtained from all)	2 sessions held a month apart	Paintings with rich details and multiple possible interpretations. The students were unfamiliar with all the paintings	Not reported	Group activities to describe the paintings and discuss the interpretations based on the descriptions	✓	✓	✓	✓			No	Yes (different images of the same futures in each test)	Beginning and end of each session	Two photographs of dermatological lesions were shown and participants were asked to describe and interpret them	Lists of observations and interpretations	? (because the scoring procedure was not reported)		Post-test scores of both observation and interpretation for Session 1 were significantly higher than pre-test. Post-test scores for Session 2 were higher (but not significantly) than those of Session 1.
32	Gurwin et al. (2018)	1st year students in a medical school (N=36, but it is unclear whether the data were obtained from all)	1.5 h×6 sessions (1 session per week)	Not reported	Not reported	Artful Thinking approach	Not reported	✓	✓	✓	✓		Yes: randomized (intervention or control that did not receive any training but received free membership to the museum)	Yes (it is not known whether the same or different images were used in each test)	Pre: before randomization, post: end of the study period	Art images and two kinds of medical images were shown for observation (the number of images used was not reported)	Art image: frequency of using terms related to critical thinking skill. Medical images: frequency of observations and general quality of the description	✓ (medical images)		The intervention group in the post-test outperformed the control group and their pre-test scores for all the images.
33	Huang et al. (2016)	Dermatology house officers in a training program (N=27, but it is unclear whether the data were obtained from all)	Introductory 3 h + 1.5 h×3 sessions over 2 months	Not reported	Not reported	VTS + brief homework based on the session’s theme	✓	✓	✓		✓	Complementary themes, including the exploration of the assumptions and approaching ambiguity	No	Yes (different images in each test)	Not reported	Three clinical images and two art images were presented for observation	Frequency of unique, accurate observations per image	✓		Significantly increased (all images: 28.7 to 33.1)
34	Jasani & Saks (2013)	3rd year students (probably) in a medical school (N=70)	3 h×1 session	Both representational and non-representational art	8	4-step method customized VTS (observation, interpretation, reflection, communication)	✓		✓	✓			No	Yes (it is not known whether the same or different photos were used in each test)	Not reported	Two patient photos were shown and participants were asked to list unique observations regarding the first and write a free text description about the second	First: frequency of observations. Second: frequency of use of subjective terminology, scope of interpretations, speculative thinking, and use of visual analogies	✓ (first photo)		First: no significant difference. Second: decrease in subjective descriptions, increase in scope of interpretations and use of speculative thinking, and visual analogies
35	Klugman et al. (2011)	Students (1st to 3rd year) from a medical school and a nursing school (undergraduates and graduates) (N=23)	1.5 h×3 sessions (one session per week)	Paintings including less representational works	9	VTS	✓	✓	✓			In the 3rd week, participants were asked to focus on interpreting the emotional quality of works	No	Yes (randomly assigned to receive one of the two versions as the pre-test and the other as the post-test)	Pre: 2 weeks before the initial session, post: 1 week after the end of the program	Three images of artworks and three images of patients in dermatology were presented and participants were asked to write what they observed	Number of words used for the description/Frequency of single factual declaration	✓		Increased in both criteria of both images
36	Pellico et al. (2009)	An accelerated master’s program of nursing (N=66)	1.5h×1 session	Paintings including allegorical pieces	Not reported	Group activities to describe the painting and discuss the interpretations based on the descriptions	✓	✓	✓	✓			Yes: (probably) randomized (the control: teaching clinical learning strategies in the traditional classroom)	No (post-test only)	Not reported	Six patient photos were shown and participants were asked to write what they observed and their interpretations of the clinical issue represented in the photos	Written word count, frequency of plausible objective clinical findings, frequency of alternative diagnosis offered	✓		The intervention group mostly outperformed in every criteria
37	Poirier et al. (2020)	Students from an undergraduate honors level course on health, not all health care majors (N=17)	10 to 15 minutes were spent at the beginning of the class at least once per week	Various images of art mediums and styles	25	VTS			✓				No	Yes (same photos in both the tests)	Pre: beginning of the course, post: end of the course	Three paintings were shown and participants were asked to describe them using VTS questions	Frequency of descriptions of name or identifying something, frequency of descriptions of a single factual declaration	✓		No significant improvement (26.82 to 29.00/17.59 to 19.65)

a This review only covers the intervention that took place between 1998 and 1999.

On the basis of the summary, the features and tendencies were synthesized into the interventions’ goals and methods, research design, and findings of the studies. Then, the features and tendencies were examined in relation to the findings of the studies on expertization of medical diagnostic skills and visual perception, according to review articles on related themes as well as the articles discussed in those reviews. Through the examination, the aforementioned review studies¹³^–²⁰ and relevant articles that were collected but excluded in this study were also referenced.

Results

A total of around 300 articles were reviewed in detail. After applying the aforementioned inclusion and exclusion criteria, the literature search yielded 12 studies,²⁶^–³⁷ as listed in Table 1. Thereafter, 3 of these 12 studies²⁸^,³¹^,³⁷ were found by manual search and missed by search results of the aforementioned review studies.¹³^–²⁰ Five studies³⁸^–⁴² were excluded from the analysis because they included activities other than visual arts appreciation.

The intervention studies were conducted for under- or post-graduate students in various disciplines, such as radiology, dermatology, and nursing. They were implemented in a specific school, hospital, grade level, program, or class. Sample sizes in these studies were relatively small. The frequency of sessions in each study was diverse, ranging from a single session lasting only a few hours to multiple sessions over two months. The intervention studies were often implemented in art museums.

Most studies used paintings as visual art and asked the participants to describe and discuss the paintings’ details and their interpretations in pairs or groups. Some of the interventions utilized Visual Thinking Strategies (VTS), embodying the following three core questions: “What’s going on in this picture?,” “What makes you say that?” and “What else can we find?” These questions help participants to observe the entire painting carefully and make inferences based on the visual evidence.⁴³ Other interventions focused on separating the description of visual evidence from the interpretation or using the concepts of visual elements, such as color, light, and texture.

Most studies used control experiments or pre- and post-tests to examine participants’ descriptions of visual features in paintings or medical images. They revealed that the intervention enabled participants to describe what they saw in more detail and use more words. Some studies, however, did not show this effect, possibly due to few participants, disagreement between scorers, or a ceiling effect on the measurements. Concerning the qualitative aspects of participants’ descriptions, Jasani and Saks³⁴ observed an increase in descriptions through the use of visual analogies and scope of interpretations that involved the patient’s surroundings, perspective, or emotional state. They also observed an increase in the number of words used to express speculative thinking, which indicated the possibility of multiple interpretations. Furthermore, Agarwal et al.²⁶ reported that the intervention group spent a statistically significant and greater amount of time observing and describing than the control group.

Of these studies, only Goodman and Kelleher²⁹ directly measured diagnostic accuracy. They used the identification of abnormalities in the radiographs and reported that their intervention was successful. However, the correct identification rate was less than half, even though the abnormalities were conspicuous and of a low level of difficulty.

Discussions

Longer periods of careful and systematic observations

Most interventions instructed participants to carefully observe the entire target. As stated by Agarwal et al.,²⁶ taking time to observe is considered a sign of careful observation. However, observing for a longer period is not necessary for an accurate diagnosis. Experts take less time than novices to diagnose accurately. In contrast, they are more likely to misdiagnose if they take longer.⁴⁴^–⁴⁶

Moreover, systematic viewing intervention, such as detecting radiograph abnormalities by viewing the images in a given order, or full-coverage viewing intervention, such as mentally dividing each image into nine imaginary segments (3×3) and inspecting each segment separately, did not outperform non-systematic viewing intervention, wherein participants were urged to inspect whatever attracted their attention.⁴⁷ Systematic and full-coverage viewing took a longer (but not significant) time than non-systematic viewing. Van Geel et al.⁴⁸ also reported similar results.

Many studies⁴⁴^,⁴⁹^–⁵¹ and reviews⁵²^–⁵⁸ on medical image perception have shown that experts’ diagnosis is generally characterized by holistic and quick recognition. This is due to pattern recognition⁵⁹^–⁶¹ or intuition composed of scripts, schemas, or mental models/images/representations (hereinafter collectively referred to as mental images).⁶² Experts compare medical images or patients with mental images—which are associated with domain-specific knowledge—of normal and abnormal cases at a single glance.²³^,⁶³^–⁶⁵ A study using fMRI⁶⁶ revealed that when radiologists looked at radiographs, the brain regions related to visual attention and the encoding, storing, and retrieval of visual memory were activated.

Not just medical images, humans generally recognize things by associating them with mental images formed through our daily visual experiences.⁶⁷ For example, humans can recognize a scene’s gist and gaze into areas of interest through their knowledge of the world.⁶⁸^–⁷⁰ This top-down control of gaze by using mental images is common for humans and is not limited to those who diagnose medical images.

The experts’ intuition is cultivated through the accumulation of domain-specific knowledge and experiences. The number of mammograms observed is proportional to the accuracy of the diagnosis.⁷¹ Thus, it is not conducive if the intervention studies do not consider the participants’ pre-existing knowledge in measuring observation skills.

Cultivating tolerance for ambiguity

For encouraging persistent and detailed observation, some interventions³³^,³⁵^,⁷² (included in this article and others) are intended to cultivate tolerance for ambiguity. An increase in speculative thinking—which was observed by Jasani and Saks³⁴—implies such cultivation.

However, the intervention studies³⁵^,⁷² showed that using visual arts contributes very little or does not contribute toward building tolerance for ambiguity.

Discovering more visual features or signs

The intervention studies enabled the participants to describe the visual features in the paintings and medical images in greater detail. However, the observation and description of more visual features or signs in medical images or patient photographs do not lead to accurate diagnoses for novices and experts. Novices, such as medical school students, generate hypotheses based on constant information input and are unable to select appropriate hypotheses.⁷³ An experiment that presented electrocardiograms to non-medical laypersons revealed that participants usually misdiagnosed the problem because they were unable to overlook irrelevant features.⁷⁴

Not just in the context of medical images, experts generally diagnose and make decisions based on mental images.⁷⁵ They can extract more useful information about the given situation, immediately generate appropriate hypotheses, eliminate irrelevant hypotheses, and test the hypotheses.⁶²^,⁶³^,⁷⁶ Thus, expert general practitioners can make a correct diagnosis without discovering all the features of a disease.⁶⁰

Observing carefully for reducing misdiagnoses

Goodman and Kelleher²⁹ asserted that reducing misdiagnoses is one of the benefits of visual training, such as appreciating visual arts. Though they did provide an explicit reason for why visual training would reduce misdiagnoses, it can be asserted that misdiagnoses arise from careless observation, and appreciating visual arts can teach one to look carefully.

However, the causes are complex⁷⁷ and may not always be due to mere carelessness. In general, medical errors can be classified into search errors caused by not looking at the abnormality, recognition errors caused by not identifying an abnormality, and decision errors that occur in the process of clinical reasoning.⁷⁸

In the context of novices, Brunyé et al.’s⁷⁸ review showed that search errors generally occur when novices overlook definitive features with subtle visual features and look repeatedly at areas that are not relevant for a diagnosis. Misdiagnoses is also called when signs of extremely low prevalence are overlooked by novices (and experts). Novices are also likely to make recognition errors due to insufficient mental images and knowledge.⁴⁹^,⁶⁵ This implies that novices’ errors are caused by the lack of top-down control of gaze due to insufficient mental images.

On the other hand, experts can diagnose quickly and accurately by using mental images. Mental images are compromises between fitting the data and minimizing the complexity of the model,⁶⁷ which leads experts’ perceptions toward certain classes of stimuli in the domain.²³ Therefore, many expert radiologists overlook the gorilla inserted into chest CTs.⁷⁹ This demonstrates that experts’ errors, such as premature closure, may be a byproduct of expertization.²³^,⁸⁰

Furthermore, human and environmental factors that induce decision errors cannot be ignored.⁸¹ Therefore, cultivation of novices’ mental images, organizational/systematic support or use of cognitive tools/strategies⁸² may be more effective than appreciating visual arts to reduce medical errors.

Transfer of observation skills to identifying different objects

The intervention studies intended to transfer observation skills for the visual arts to apply to medical examination, based on the assumption that there are similarities between these fields. However, the transfer occurs only to a very limited extent. Experimental studies showed that in terms of radiology, expertise was positively transferred to the task of finding small low-contrast dots in phantom X-ray images⁸³ but not to the task of finding hidden targets in pictorial scenes.⁸⁴ The same can be said for visual recollection memory. Expert cytologists and radiologists were not better at recognizing scenes or isolated objects than non-medical participants.⁸⁵

The limitations of the transfer depend on the domain-specificity of mental images. Whether looking at medical images, patients, landscapes, or paintings, each requires unique domain-specific knowledge and experiences to form mental images.

Is there a more effective way?

I suspect that the effectiveness of Goodman and Kelleher’s²⁹ intervention is unsatisfactory. Their task was too easy, as making a diagnosis is more difficult than identifying abnormalities.⁸⁶ There may be more efficient or effective ways of fostering diagnosing skills than appreciating visual arts. For example, learning modules, based on theories of perceptual learning, such as Perceptual and Adaptive Learning Modules (PALM), have been developed to foster pattern recognition of medical images.⁶¹^,⁸⁷ All the relevant studies have reported excellent results of diagnostic accuracy for medical school students and/or residents²²^,⁸⁸^–⁹⁴ and non-medical participants,⁹⁵^–⁹⁸ however, it is possible such excellent results across the board could be due to publication bias (see also the review by Guégan et al.⁹⁹). Although it is difficult to directly compare the studies due to different testing methods, these modules seem superior to Goodman and Kelleher’s intervention.²⁹ It is also notable that the outcome measures used by these modules included fluency, or the speed of recognition. This is consistent with research findings on expertization.

Likewise, teaching a specific eye movement search pattern that corresponds with the characteristics of the area shown in the radiographs¹⁰⁰ or demonstrating an expert model that searches visually and interprets symptoms (eye-movement modeling examples)¹⁰¹ could also be effective.

Fostering verbalizing skills for diagnoses

It would be more accurate to say that the interventions that use the appreciation of visual arts foster verbalizing skills. It also may be useful to teach concepts of visual elements, such as color, light, and texture in order to foster such skills. Verbalizing accurately and lucidly is important for various reasons in medical practice.¹⁰²

Group discussions can also act as an opportunity to practice and reflect on one’s verbalization skills. This can contribute toward the development of communication skills that are required for teamwork. Klugman et al.³⁵ intended to develop communication skills and claimed that their intervention achieved the same objective. However, they did not present any empirical data to support their claim.

The use of visual arts may also be useful for group discussions across specialties. For example, Katz and Khoshbin¹⁰³ reported that their curriculum included visual arts to facilitate multidisciplinary team building. One possible reason for this was that the visual arts free the participants from the hierarchy of medical personnel and ensure their equal participation in discussions. It has been reported that even children who do not perform well academically or usually speak, actively participated in the VTS sessions.⁴³

Considering patients’ contexts and perspective-taking

Thus far, I have shown that appreciating visual arts may not have a direct effect on making an accurate diagnosis. Meanwhile, Jasani and Saks³⁴ observed an increase in descriptions of the scope of interpretation. Understanding the patient’s background and context—which are invisible—may be necessary for patient interviews. This corresponds with Shapiro et al.’s supposition¹⁰⁴ that teaching through cases would be effective in fostering pattern recognition, while teaching through paintings would promote interpretation skills based on a broader context, including a patient’s subjective perception and understanding of diseases.

Perspective-taking as cognitive empathy, such as knowing and postulating how another is thinking and feeling,¹⁰⁵ is also essential for patient interviews. Appreciating visual arts and group discussions about observations and interpretations of them may foster such perspective-taking. Although there are several reports on such practice,¹⁰⁶^–¹¹¹ none presented empirical evidence. On the other hand, Gurwin et al.³² used the Reading the Mind in the Eyes Test,¹¹² which assesses the ability to recognize emotions based upon photographs of actors’ eyes, and reported no significant difference, possibly due to the ceiling effect. It would be beneficial to consider using other measures, such as the Theory of Mind Test¹¹³ and Faces Test,¹¹⁴ as exemplified by Pino and Mazza.¹¹⁵

Understanding patients’ facial expressions is also likely to enhance perspective-taking for medical professions.¹⁸ It may be worthwhile to train such understanding because of the functional specialization for face perception in the brain.¹¹⁶ While several studies have reported on such practices,¹¹⁷^,¹¹⁸ they did not provide any supporting empirical evidence.

Conclusions

This article revealed that there is no concrete evidence on whether appreciating visual art contributes toward an accurate diagnosis. Although the appreciation of visual arts has helped facilitate the observation of more visual features and the ability to see more thoroughly by taking more time, findings of the expertization studies do not prove that these contribute toward the cultivation of skills required for making a diagnosis. Additionally, the claim that such appreciation can reduce misdiagnoses or cultivate tolerance for ambiguity that prevents premature closure has not been proven. Moreover, the transfer of observation skills to different objects is unlikely to be as successful as the intervention studies intend. Rather, it would be better to use learning modules based on perceptual learning using cases to foster pattern recognition. However, such appreciation (sometimes with group discussions) may foster verbalization skills and understanding of the patient’s background and context. This may indirectly contribute toward accurate diagnoses by facilitating teamwork or fostering perspective-taking. However, the effects of such appreciation remain ambiguous.

Alkhaifi et al.¹⁷ asserted that visual arts can be means to address important competencies that are difficult to teach using traditional methods; however, it is important to state that visual arts are not a panacea. The reasons why visual arts appreciation is unlikely to foster diagnostic skills can be summarized as follows. First, discovering more signs of a disease does not equate to diagnosis. Diagnosing medical images and actual patients involves determining whether the patients or medical images fit into a particular classification of diseases or not. Experts can make a correct diagnosis without discovering all the features of a disease because they focus only on useful features for such distinctions. Gibson’s theory of perceptual learning¹¹⁹ precisely explains expertization in such distinctions. Therefore, intervention studies have assumed that medical experts’ approaches to observation are similar to those adopted by artists; however, these approaches differ because no such distinctions are necessary for artists.

Second, such distinctions are intuitive and involve implicit perpetual learning.¹²⁰ It is possible even if the rationale is not verbalized, although more effective if it is verbalized.¹¹⁹ Experimental psychology has shown that simply looking at various paintings with the names of the artists at random can enable novices to differentiate between artists.¹²¹^–¹²³ Similar results were obtained in experiments that had novices diagnose psychopathological cases presented visually (through words) or aurally.¹²⁴ Additionally, novices have been shown to be able to detect melanoma by being shown benign and malignant cases side by side, but without being given instructions, such as the ABCD rule.¹²⁵ Further, instructing novices on such rules has little effect on diagnostic accuracy.¹²⁵^,¹²⁶ Protocols in which participants contrast similar cases—that learning modules such as PALM also adopt—use implicit learning to extract subtle differences in the cases. Therefore, it seems difficult to enhance such implicit learning through a closer look at a piece of visual art.

Third, mental images are domain-specific. Visual arts do not substitute domain-specific knowledge or one’ s experience with medical cases.

Limitations

This article has several limitations. First, I excluded articles published in languages other than English and those that subjectively measured observation skills. These studies may have included information that could have contributed to this article.

Second, I found only one study that directly examined the impact of appreciating visual arts on diagnostic skills. The conclusions of this article are tentative, while the findings of the expertization studies are sufficiently reliable.

Third, I was not able to fully interpret the results of Goodman and Kelleher,²⁹ specifically, the small transfer of visual arts appreciation to the identification of abnormalities in the radiograph. Although it may be due to adapting to the test format, it is not clear by what process the transfer occurred, if at all.

Implications for future research and practice

I offer the following suggestions for future research. First, while studies on expertization reveal qualitative differences between novices and experts, the process of expertization is not understood very well.⁷⁴^,¹²⁷ It is likely, albeit to a lesser extent, that listing more visual features and hypotheses is unnecessary for the process of expertization. Hence, it may be promising to investigate whether listing such features and hypotheses by appreciating visual arts is effective in scaffolding diagnosis skills. For example, such appreciation might accelerate learning through the learning module based on perceptual learning. Thus, longitudinal studies may be required¹³ because the effects of such appreciation may be delayed.

Second, to measure the effectiveness of appreciating visual arts, it is recommended to use the same tests that have been used to measure the effectiveness of learning modules on perceptual learning. Diagnostic accuracy and fluency should also be examined, as asserted by Kellman et al.²² Additionally, the influence of pre-existing knowledge should be considered.

Third, as mentioned by Perry et al.,¹⁵ the intervention methods must also be reported adequately. It is unlikely that merely looking at visual art develops the skills required for medical diagnoses. Rather, the design of the experience, such as selection of the paintings, instruction, and facilitation and activities within peers/groups is required because the outcome of the intervention should vary based on the type and number of paintings that have been viewed and on the activities or reflections mentioned as instructions.¹²⁸ It is also necessary to mention the responses that were evoked by the subjects (or paintings), prompts, and questions to identify whether the outcomes were intended or derived. Moreover, I found the following deficiencies in the studies used in this article: the number of missing samples from the participants; what did the control group do; details of the content and format of the lectures that the control participants were subjected to; maximum possible values of the scales or items for considering the ceiling effect; details of the scoring criteria; how many schools/organizations did the participants belong to; how many images were used for the test; and timing of the pre- and post-test. Thus, items listed in Table 1 should be reported in future studies.

Fourth, it is necessary to investigate whether the skills and knowledge that would be fostered by appreciating visual arts enhance diagnosis skills. This article found that appreciating visual arts may enhance verbalizing skills, teamwork skills, interpretive skills, and perspective-taking. Mukunda et al.’s¹⁶ review also found a paucity of rigorous studies on training modules that use arts to promote empathy, team building, communication skills, wellness/resilience, or cultural sensitivity.

Fifth, research is needed that directly compares the skills fostered by visual arts appreciation with other methods that attempt to foster the same skills, such as learning modules applied by perpetual learning and using other forms of arts. For example, we can use only visual arts and also performing arts for teamwork and communication skill development among health professionals.¹²⁹ Due to time constraints imposed by the many demands of medical education and training, it is necessary to identify a more efficient method among those available.

Finally, as Osman et al.¹³⁰ suggested, further research exploring the process of learning through visual arts appreciation is required, as extant literature only focuses on outcomes. Dominant research methods such as controlled studies and psychometric scales do not allow for such investigation¹²⁸^,¹³¹; thus, further research should include alternative methods and outcome measurements, such as qualitative methods.¹⁵^,¹³²

I also offer the following suggestions to practice fostering diagnostic skills. Given the time constraints, adopting visual art appreciation is not encouraged. Taylor⁶⁴ claimed that education in medical school should provide students with many instances of medical cases and appropriate knowledge to form adequate mental images. Such provision must be made in an appropriate manner, as in PALM, to evoke implicit learning in order to extract subtle differences in the cases. This should be prioritized over visual art appreciation.

Furthermore, since expert perception is a combination of observation and interpretation through intuition, separating observation and interpretation, as instructed in several intervention studies, seems to be unnatural and could be avoided. Jaarsma et al.¹³³ showed that in clinical reasoning, experts used less descriptive terms, like expressing colors and shapes, and used more comparative terms to interpret findings in terms of normal/abnormal or typical/atypical.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

Acknowledgments

The author would like to thank Editage (www.editage.jp) for English language editing.

References

1. Anderson N, Dietrich MR: Introduction: visual lessons and the life sciences.Anderson N, Dietrich MR, editors. The Educated Eye: Visual Culture and Pedagogy in the Life Sciences. Hanover (NH):Dartmouth College Press; 2012; pp. 1–13.
2. Braverman IM: To see or not to see: how visual training can improve observational skills. Clin. Dermatol. 2011; 29(3): 343–346. Publisher Full Text
3. Sandhu VK: Inspection—a fine art. JAMA Dermatol. 2018; 154(5): 630. PubMed Abstract | Publisher Full Text
4. Watson F, Rebair A: The art of noticing: essential to nursing practice. Br. J. Nurs. 2014; 23(10): 514–517. Publisher Full Text
5. Boisaubin EV, Winkler MG: Seeing patients and life contexts: the visual arts in medical education. Am. J. Med. Sci. 2000; 319(5): 292–296. PubMed Abstract Reference Source
6. Bardes CL, Gillers D, Herman AE: Learning to look: developing clinical observational skills at an art museum. Med. Educ. 2001; 35(12): 1157–1161. PubMed Abstract | Publisher Full Text
7. Pitman B: Art museum and medical school partnerships program descriptions. Richardson, TX:The Edith O’Donnell Institute of Art History, The University of Texas at Dallas;2020 [cited 2022 Oct 29].Reference Source
8. Pellegrino ED: Visual awareness: the visual arts and the clinician’s craft.Berg G, editor. The Visual Arts and Medical Education. Carbondale (IL):Southern Illinois University Press; 1983; pp. ix–xi.
9. Schaff PB, Isken S, Tager RM: From contemporary art to core clinical skills: observation, interpretation, and meaning-making in a complex environment. Acad. Med. 2011; 86(10): 1272–1276. Publisher Full Text
10. He B, Prasad S, Higashi RT, et al.: The art of observation: a qualitative analysis of medical students’ experiences. BMC Med. Educ. 2019; 19(1): 234. PubMed Abstract | Publisher Full Text | Free Full Text
11. Hoshiko BR: Nursing diagnosis at the art museum. Nurs. Outlook. 1985; 33(1): 32–36.
12. Jacques A, Trinkley R, Stone L, et al.: Art of Analysis: a cooperative program between a museum and medicine. J. Learn. Through Arts. 2012; 8(1). Reference Source
13. Gelgoot E, Caufield-Noll C, Chisolm M: Using the visual arts to teach clinical excellence. 1^st version. MedEdPublish. 2018; 7: 143. Publisher Full Text
14. Elhammoumi CV, Kellam B: Art images in holistic nursing education. Religions. 2017; 8(6): 1–8. Publisher Full Text
15. Perry M, Maffulli N, Willson S, et al.: The effectiveness of arts-based interventions in medical education: a literature review. Med. Educ. 2011; 45(2): 141–148. PubMed Abstract | Publisher Full Text
16. Mukunda N, Moghbeli N, Rizzo A, et al.: Visual art instruction in medical education: a narrative review. Med. Educ. Online. 2019; 24(1): 1558657. PubMed Abstract | Publisher Full Text | Free Full Text
17. Alkhaifi M, Clayton A, Kangasjarvi E, et al.: Visual art-based training in undergraduate medical education: A systematic review. Med. Teach. 2022; 44(5): 500–509. PubMed Abstract | Publisher Full Text
18. Dalia Y, Milam EC, Rieder EA: Art in medical education: a review. J. Grad. Med. Educ. 2020; 12(6): 686–695. Publisher Full Text
19. Turton BM, Williams S, Burton CR, et al.: Arts-based palliative care training, education and staff development: A scoping review. Palliat. Med. 2018; 32(2): 559–570. Publisher Full Text
20. Ike JD, Howell J: Quantitative metrics and psychometric scales in the visual art and medical education literature: a narrative review. Med. Educ. Online. 2022; 27(1): 2010299. PubMed Abstract | Publisher Full Text | Free Full Text
21. Coderre S, Mandin H, Harasym PH, et al.: Diagnostic reasoning strategies and diagnostic success. Med. Educ. 2003; 37(8): 695–703. PubMed Abstract | Publisher Full Text
22. Kellman PJ, Jacoby V, Massey C, et al.: Perceptual learning, adaptive learning, and gamification: educational technologies for pattern recognition, problem solving, and knowledge retention in medical learning.Witchel HJ, Lee MW, editors. Technologies in Biomedical and Life Sciences Education. Cham (DK):Springer; 2022; pp. 135–166. Publisher Full Text
23. Myles-Worsley M, Johnston WA, Simons MA: The influence of expertise on X-ray image processing. J. Exp. Psychol. Learn. Mem. Cogn. 1988; 14(3): 553–557. Publisher Full Text
24. Green MJ, Myers KR: Graphic medicine: use of comics in medical education and patient care. BMJ. 2010; 340: c863. PubMed Abstract | Publisher Full Text
25. Anglin C, Halpin-Healy C, Rosenfeld P: Reflecting art in nursing practice: developing visual arts programs to transform and strengthen practice. J. Nurs. Adm. 2020; 50(5): 274–280. Publisher Full Text
26. Agarwal GG, McNulty M, Santiago KM, et al.: Impact of Visual Thinking Strategies (VTS) on the analysis of clinical images: a pre-post study of VTS in first-year medical students. J. Med. Humanit. 2020; 41(4): 561–572. PubMed Abstract | Publisher Full Text
27. Dolev JC, Friedlaender LK, Braverman IM: Use of fine art to enhance visual diagnostic skills. JAMA. 2001; 286(9): 1020–1021. PubMed Abstract Reference Source
28. Garino A: Improving observation skill in physician assistant students. J. Physician Assist. Educ. 2008; 19(1): 47–52. Publisher Full Text
29. Goodman TR, Kelleher M: Improving novice radiology trainees’ perception using fine art. J. Am. Coll. Radiol. 2017; 14(10): 1337–1340. PubMed Abstract | Publisher Full Text
30. Griffin LL, Chiang NYZ, Tomlin H, et al.: A visual literacy course for dermatology trainees. Br. J. Dermatol. 2017; 177(1): 310–311. PubMed Abstract | Publisher Full Text
31. Grossman S, Deupi J, Leitao K: Seeing the forest and the trees: increasing nurse practitioner students’ observational and mindfulness skills. Creat. Nurs. 2014; 20(1): 67–72. PubMed Abstract | Publisher Full Text
32. Gurwin J, Revere KE, Niepold S, et al.: A Randomized controlled study of art observation training to improve medical student ophthalmology skills. Ophthalmology. 2018; 125(1): 8–14. PubMed Abstract | Publisher Full Text
33. Huang JT, Reynolds SD, DiGiovanni EB, et al.: Fine arts curriculum improves observational skills of dermatology trainees: a pilot study. Br. J. Dermatol. 2016; 175(4): 815–817. PubMed Abstract | Publisher Full Text
34. Jasani SK, Saks NS: Utilizing visual art to enhance the clinical observation skills of medical students. Med. Teach. 2013; 35(7): e1327–e1331. PubMed Abstract | Publisher Full Text
35. Klugman CM, Peel J, Beckmann-Mendez D: Art Rounds: teaching interprofessional students visual thinking strategies at one school. Acad. Med. 2011; 86(10): 1266–1271. PubMed Abstract | Publisher Full Text
36. Pellico LH, Friedlaender L, Fennie KP: Looking is not seeing: using art to improve observational skills. J. Nurs. Educ. 2009; 48(11): 648–653. Publisher Full Text
37. Poirier TI, Newman K, Ronald K: An exploratory study using Visual Thinking Strategies to improve undergraduate students’ observational skills. Am. J. Pharm. Educ. 2020; 84(4): 7600. PubMed Abstract | Publisher Full Text | Free Full Text
38. Ferrara V, De Santis S, Manicone F, et al.: The visual art as a learning tool in medical education. Senses Sci. 2020; 7(2): 1028–1040.
39. Honan L, Shealy S, Fennie K, et al.: Looking is not seeing and listening is not hearing: a replication study with accelerated BSN students. J. Prof. Nurs. 2016; 32(5S): S30–S36. PubMed Abstract | Publisher Full Text
40. Kirklin D, Duncan J, McBride S, et al.: A cluster design controlled trial of arts-based observational skills training in primary care. Med. Educ. 2007; 41(4): 395–401. PubMed Abstract | Publisher Full Text
41. Naghshineh S, Hafler JP, Miller AR, et al.: Formal art observation training improves medical students’ visual diagnostic skills. J. Gen. Intern. Med. 2008; 23(7): 991–997. PubMed Abstract | Publisher Full Text | Free Full Text
42. Nease BM, Haney TS: Evaluating an art-based intervention to improve practicing nurses’ observation, description, and problem identification skills. J. Nurses Prof. Dev. 2018; 34(1): 2–7. PubMed Abstract | Publisher Full Text
43. Yenawine P: Visual Thinking Strategies: Using Art to Deepen Learning across School Disciplines. Cambridge (MA):Harvard Education Press;2013.
44. Kundel HL, Nodine CF, Conant EF, et al.: Holistic component of image perception in mammogram interpretation: gaze-tracking study. Radiology. 2007; 242(2): 396–402. PubMed Abstract | Publisher Full Text
45. Nodine CF, Mello-Thoms C, Kundel HL, et al.: Time course of perception and decision making during mammographic interpretation. AJR Am. J. Roentgenol. 2002; 179(4): 917–923. PubMed Abstract | Publisher Full Text
46. Norman GR, Rosenthal D, Brooks LR, et al.: The development of expertise in dermatology. Arch. Dermatol. 1989; 125(8): 1063–1068. Publisher Full Text
47. Kok EM, Jarodzka H, de Bruin AB , et al.: Systematic viewing in radiology: seeing more, missing less? Adv. Health Sci. Educ. Theory Pract. 2016; 21(1): 189–205. PubMed Abstract | Publisher Full Text | Free Full Text
48. van Geel K , Kok EM, Dijkstra J, et al.: Teaching systematic viewing to final-year medical students improves systematicity but not coverage or detection of radiologic abnormalities. J. Am. Coll. Radiol. 2017; 14(2): 235–241. Publisher Full Text
49. Krupinski EA: Visual scanning patterns of radiologists searching mammograms. Acad. Radiol. 1996; 3(2): 137–144. PubMed Abstract | Publisher Full Text
50. Kundel HL, Nodine CF, Krupinski EA, et al.: Using gaze-tracking data and mixture distribution analysis to support a holistic model for the detection of cancers on mammograms. Acad. Radiol. 2008; 15(7): 881–886. PubMed Abstract | Publisher Full Text
51. O’Neill EC, Kong YX, Connell PP, et al.: Gaze behavior among experts and trainees during optic disc examination: does how we look affect what we see? Invest. Ophthalmol. Vis. Sci. 2011; 52(7): 3976–3983. PubMed Abstract | Publisher Full Text
52. Al-Moteri MO, Symmons M, Plummer V, et al.: Eye tracking to investigate cue processing in medical decision-making: a scoping review. Comput. Hum. Behav. 2017; 66: 52–66. Publisher Full Text
53. Evered A: What can cytologists learn from 25 years of investigations in visual search? Br. J. Biomed. Sci. 2005; 62(4): 182–192. PubMed Abstract | Publisher Full Text
54. Nodine C, Mello-Thoms C: Acquiring expertise in radiologic image interpretation.Samei E, Krupinski E, editors. The Handbook of Medical Image Perception and Techniques. Cambridge (UK):Cambridge University Press; 2018; pp. 167–187.
55. Norman GR, Coblentz CL, Brooks LR, et al.: Expertise in visual diagnosis: a review of the literature. Acad. Med. 1992; 67(10(suppl)): S78–S83. Publisher Full Text
56. Wu CC, Wolfe JM: Eye movements in medical image perception: a selective review of past, present and future. Vision (Basel). 2019; 3(2): 32. PubMed Abstract | Publisher Full Text | Free Full Text
57. van der Gijp A , Ravesloot CJ, Jarodzka H, et al.: How visual search relates to visual diagnostic performance: a narrative systematic review of eye-tracking research in radiology. Adv. Health Sci. Educ. Theory Pract. 2017; 22(3): 765–787. PubMed Abstract | Publisher Full Text | Free Full Text
58. Drew T, Evans K, Võ ML, et al.: Informatics in radiology: what can you see in a single glance and how might this guide visual search in medical images? Radiographics. 2013; 33(1): 263–274. PubMed Abstract | Publisher Full Text | Free Full Text
59. Gachon J, Beaulieu P, Sei JF, et al.: First prospective study of the recognition process of melanoma in dermatological practice. Arch. Dermatol. 2005; 141(4): 434–438. PubMed Abstract | Publisher Full Text
60. Groves M, O’Rourke P, Alexander H: The clinical reasoning characteristics of diagnostic experts. Med. Teach. 2003; 25(3): 308–313. PubMed Abstract | Publisher Full Text
61. Kellman PJ: Adaptive and perceptual learning technologies in medical education and training. Mil. Med. 2013; 178(10 suppl): 98–106. PubMed Abstract | Publisher Full Text
62. Ericsson KA: Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad. Med. 2015; 90(11): 1471–1486. PubMed Abstract | Publisher Full Text
63. Lesgold A, Rubinson H, Feltovich P, et al.: Expertise in a complex skill: diagnosing x-ray pictures.Chi MTH, Glaser R, Farr MJ, editors. The Nature of Expertise. Hillsdale (NJ):Lawrence Erlbaum Associates; 1988; p. 311–342.
64. Taylor PM: A review of research into the development of radiologic expertise: implications for computer-based training. Acad. Radiol. 2007; 14(10): 1252–1263. PubMed Abstract | Publisher Full Text
65. Waite S, Farooq Z, Grigorian A, et al.: A review of perceptual expertise in radiology-how it develops, how we can test it, and why humans still matter in the era of artificial intelligence. Acad. Radiol. 2020; 27(1): 26–38. PubMed Abstract | Publisher Full Text
66. Haller S, Radue EW: What is different about a radiologist’s brain? Radiology. 2005; 236(3): 983–989. Publisher Full Text
67. Buhmann JM, Malik J, Perona P: Image recognition: visual grouping, recognition, and learning. Proc. Natl. Acad. Sci. U. S. A. 1999; 96(25): 14203–14204. PubMed Abstract | Publisher Full Text | Free Full Text
68. Castelhano MS, Rayner K: Eye movements during reading, visual search, and scene perception: an overview.Rayner K, Shen D, Bai X, et al., editors. Cognitive and Cultural Influences on Eye Movements. Tianjin:Tianjin People’s Publishing House; 2008; pp. 3–33.
69. Henderson JM, Weeks PA Jr, Hollingworth A: The effects of semantic consistency on eye movements during complex scene viewing. J. Exp. Psychol. Hum. Percept. Perform. 1999; 25(1): 210–228. Publisher Full Text
70. Henderson JM: Human gaze control during real-world scene perception. Trends Cogn. Sci. 2003; 7(11): 498–504. PubMed Abstract | Publisher Full Text
71. Nodine CF, Kundel HL, Mello-Thoms C, et al.: How experience and training influence mammography expertise. Acad. Radiol. 1999; 6(10): 575–585. Publisher Full Text
72. Strohbehn GW, Hoffman SJK, Tokaz M, et al.: Visual arts in the clinical clerkship: a pilot cluster-randomized, controlled trial. BMC Med. Educ. 2020; 20(1): 481. PubMed Abstract | Publisher Full Text | Free Full Text
73. Joseph GM, Patel VL: Domain knowledge and hypothesis generation in diagnostic reasoning. Med. Decis. Mak. 1990; 10(1): 31–44. PubMed Abstract | Publisher Full Text
74. Norman GR, Brooks LR, Colle CL, et al.: The benefit of diagnostic hypotheses in clinical reasoning: experimental study of an instructional intervention for forward and backward reasoning. Cogn. Instr. 1999; 17(4): 433–448. Publisher Full Text
75. Norman G: Research in clinical reasoning: past history and current trends. Med. Educ. 2005; 39(4): 418–427. PubMed Abstract | Publisher Full Text
76. Pelaccia T, Tardif J, Triby E, et al.: An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med. Educ. Online. 2011; 16: 5890. PubMed Abstract | Publisher Full Text | Free Full Text
77. Norman GR, Eva KW: Diagnostic error and clinical reasoning. Med. Educ. 2010; 44(1): 94–100. Publisher Full Text
78. Brunyé TT, Drew T, Weaver DL, et al.: A review of eye tracking for understanding and improving diagnostic interpretation. Cogn. Res. Princ. Implic. 2019; 4(1): 7. PubMed Abstract | Publisher Full Text | Free Full Text
79. Drew T, Võ ML, Wolfe JM: The invisible gorilla strikes again: sustained inattentional blindness in expert observers. Psychol. Sci. 2013; 24(9): 1848–1853. PubMed Abstract | Publisher Full Text | Free Full Text
80. Norman G, Eva K, Brooks L, et al.: Expertise in medicine and surgery.Ericsson K, Charness N, Feltovich P, et al., editors. The Cambridge Handbook of Expertise and Expert Performance. Cambridge (UK):Cambridge University Press; 2006; pp. 339–354.
81. Cooper N: Human factors.Cooper N, Frain J, editors. ABC of Clinical Reasoning. Chichester (UK):John Wiley & Sons; 2017; pp. 27–32.
82. Croskerry P: Metacognition and cognitive debiasing.Cooper N, Frain J, editors. ABC of Clinical Reasoning. Chichester (UK):John Wiley & Sons; 2017; pp. 33–38.
83. Sowden PT, Davies IR, Roling P: Perceptual learning of the detection of features in X-ray images: a functional role for improvements in adults’ visual sensitivity? J. Exp. Psychol. Hum. Percept. Perform. 2000; 26(1): 379–390. PubMed Abstract | Publisher Full Text
84. Nodine CF, Krupinski EA: Perceptual skill, radiology expertise, and visual test performance with NINA and WALDO. Acad. Radiol. 1998; 5(9): 603–612. PubMed Abstract | Publisher Full Text
85. Evans KK, Cohen MA, Tambouret R, et al.: Does visual expertise improve visual recognition memory? Atten. Percept. Psychophys. 2011; 73(1): 30–35. PubMed Abstract | Publisher Full Text | Free Full Text
86. Brazeau-Lamontagne L, Charlin B, Gagnon R, et al.: Measurement of perception and interpretation skills during radiology training: utility of the script concordance approach. Med. Teach. 2004; 26(4): 326–332. PubMed Abstract | Publisher Full Text
87. Evered A: Perceptual and adaptive learning modules and their potential to transform cytology training programmes. Cytopathology. 2018; 29(4): 371–374. PubMed Abstract | Publisher Full Text
88. Aldridge RB, Glodzik D, Ballerini L, et al.: Utility of non-rule-based visual matching as a strategy to allow novices to achieve skin lesion diagnosis. Acta Derm. Venereol. 2011; 91(3): 279–283. PubMed Abstract | Publisher Full Text | Free Full Text
89. Krasne S, Hillman JD, Kellman PJ, et al.: Applying perceptual and adaptive learning techniques for teaching introductory histopathology. J. Pathol. Inform. 2013; 4: 34. PubMed Abstract | Publisher Full Text | Free Full Text
90. Krasne S, Stevens CD, Kellman PJ, et al.: Mastering electrocardiogram interpretation skills through a perceptual and adaptive learning module. AEM Educ. Train. 2021; 5(2): e10454. PubMed Abstract | Publisher Full Text | Free Full Text
91. Parker EU, Reder NP, Glasser D, et al.: NDER: A novel web application for teaching histology to medical students. Acad. Pathol. 2017; 4: 2374289517691061. PubMed Abstract | Publisher Full Text | Free Full Text
92. Rimoin L, Altieri L, Craft N, et al.: Training pattern recognition of skin lesion morphology, configuration, and distribution. J. Am. Acad. Dermatol. 2015; 72(3): 489–495. PubMed Abstract | Publisher Full Text
93. Romito BT, Krasne S, Kellman PJ, et al.: The impact of a perceptual and adaptive learning module on transoesophageal echocardiography interpretation by anaesthesiology residents. Br. J. Anaesth. 2016; 117(4): 477–481. PubMed Abstract | Publisher Full Text
94. Slaught C, Madu P, Chang AY, et al.: Novel education modules addressing the underrepresentation of skin of color in dermatology training. J. Cutan. Med. Surg. 2022; 26(1): 17–24. PubMed Abstract | Publisher Full Text | Free Full Text
95. Evered A, Walker D, Watt AA, et al.: To what extent does nonanalytic reasoning contribute to visual learning in cytopathology? Cancer Cytopathol. 2013; 121(6): 329–338. PubMed Abstract | Publisher Full Text
96. Sha LZ, Toh YN, Remington RW, et al.: Perceptual learning in the identification of lung cancer in chest radiographs. Cogn. Res. Princ. Implic. 2020; 5(1): 4. PubMed Abstract | Publisher Full Text | Free Full Text
97. Xu B, Rourke L, Robinson JK, et al.: Training melanoma detection in photographs using the perceptual expertise training approach. Appl. Cogn. Psychol. 2016; 30(5): 750–756. Publisher Full Text
98. Brown NH, Robertson KM, Bisset YC, et al.: Using a structured image database, how well can novices assign skin lesion images to the correct diagnostic grouping? J. Invest. Dermatol. 2009; 129(10): 2509–2512. Publisher Full Text
99. Guégan S, Steichen O, Soria A: Literature review of perceptual learning modules in medical education: What can we conclude regarding dermatology? Ann. Dermatol. Venereol. 2021; 148(1): 16–22. Publisher Full Text
100. Auffermann W, Mazurowski M: Perception and training.Samei E, Krupinski E, editors. The Handbook of Medical Image Perception and Techniques. Cambridge (UK):Cambridge University Press; 2018; pp. 470–482.
101. Jarodzka H, Balslev T, Holmqvist K, et al.: Conveying clinical reasoning based on visual observation via eye-movement modelling examples. Instr. Sci. 2012; 40(5): 813–827. Publisher Full Text
102. Kulatunga-Moruzi C, Brooks LR, Norman GR: Using comprehensive feature lists to bias medical diagnosis. J. Exp. Psychol. Learn. Mem. Cogn. 2004; 30(3): 563–572. Publisher Full Text
103. Katz JT, Khoshbin S: Can visual arts training improve physician performance? Trans. Am. Clin. Climatol. Assoc. 2014; 125: 331–341.
104. 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(3): 263–268. PubMed Abstract | Publisher Full Text
105. Batson CD: These things called empathy: eight related but distinct phenomena.Decety J, Ickes W, editors. The Social Neuroscience of Empathy. Cambridge (MA):MIT Press; 2009; pp. 3–15.
106. Borromeo M, Chiavaroli N, Gaunt H: The arts and visual thinking in education at the Melbourne Dental School.McLean CL, editor. Creative Arts in Humane Medicine. Edmonton (Alberta, Canada):Brush Education; 2014; pp. 40–54.
107. Karkabi K, Cohen CO: Deepening compassion through the mirror of painting. Med. Educ. 2006; 40(5): 462. PubMed Abstract | Publisher Full Text
108. Wald HS, Norman DR, Walker J: Reflection through the arts: focus on photography to foster reflection in a health care context. Living beyond―an interactive photographic exhibit. Reflective Pract. 2010; 11(4): 545–563. Publisher Full Text
109. Wikström BM: Nursing education at an art gallery. J. Nurs. Scholarsh. 2000; 32(2): 197–199. PubMed Abstract | Publisher Full Text
110. Wikström BM: Work of art dialogues: an educational technique by which students discover personal knowledge of empathy. Int. J. Nurs. Pract. 2001; 7(1): 24–29. Publisher Full Text
111. Wikström BM: Intuition and visual art: student nurses’ projection into experiences of elderly women. Aust. J. Holist. Nurs. 2002; 9(2): 24–31. PubMed Abstract
112. Baron-Cohen S, Wheelwright S, Hill J, et al.: The “Reading the Mind in the Eyes” Test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. J. Child Psychol. Psychiatry. 2001; 42(2): 241–251. Publisher Full Text
113. Rowe AD, Bullock PR, Polkey CE, et al.: ‘Theory of mind’ impairments and their relationship to executive functioning following frontal lobe excisions. Brain. 2001; 124(3): 600–616. PubMed Abstract | Publisher Full Text
114. Baron-Cohen S, Wheelwright S, Jolliffe T: Is there a “language of the eyes”? Evidence from normal adults, and adults with autism or Asperger syndrome. Vis. Cogn. 1997; 4(3): 311–331. Publisher Full Text
115. Pino MC, Mazza M: The use of “literary fiction” to promote mentalizing ability. PloS One. 2016; 11(8): e0160254. Published 2016 Aug 4. PubMed Abstract | Publisher Full Text | Free Full Text
116. Zeki S: Inner Vision: An Exploration of Art and the Brain. Oxford (UK):Oxford University Press;1999.
117. Bardes CL, Gillers D, Herman AE: Learning to look: developing clinical observational skills at an art museum. Med. Educ. 2001; 35(12): 1157–1161. Publisher Full Text
118. Wikström BM, Svidén G: Facial expressions in paintings as perceived by the student nurse. Aust. J. Holist. Nurs. 2005; 12(2): 5–12. PubMed Abstract
119. Gibson EJ: Principles of Perceptual Learning and Development. Englewood Cliffs (NJ):Prentice-Hall;1969.
120. Fahle M: Introduction.In:Fahle M, Poggio TA, editors. Perceptual Learning. Cambridge (MA):MIT Press; 2002; pp. ix–xx.
121. Kornell N, Bjork RA: Learning concepts and categories: is spacing the “enemy of induction”? Psychol. Sci. 2008; 19(6): 585–592. Publisher Full Text
122. Kornell N, Castel AD, Eich TS, et al.: Spacing as the friend of both memory and induction in young and older adults. Psychol. Aging. 2010; 25(2): 498–503. PubMed Abstract | Publisher Full Text
123. Kang SHK, Pashler H: Learning painting styles: spacing is advantageous when it promotes discriminative contrast. Appl. Cogn. Psychol. 2012; 26(1): 97–103. Publisher Full Text
124. Zulkiply N, McLean J, Burt JS, et al.: Spacing and induction: application to exemplars presented as auditory and visual text. Learn. Instr. 2012; 22(3): 215–221. Publisher Full Text
125. Girardi S, Gaudy C, Gouvernet J, et al.: Superiority of a cognitive education with photographs over ABCD criteria in the education of the general population to the early detection of melanoma: a randomized study. Int. J. Cancer. 2006; 118(9): 2276–2280. Publisher Full Text
126. Speelman C, Martin K, Flower S, et al.: Skill acquisition in skin cancer detection. Percept. Mot. Skills. 2010; 110(1): 277–297. PubMed Abstract | Publisher Full Text
127. Ark TK, Brooks LR, Eva KW: Giving learners the best of both worlds: do clinical teachers need to guard against teaching pattern recognition to novices? Acad. Med. 2006; 81(4): 405–409. PubMed Abstract | Publisher Full Text
128. Voeller M: The art of attending: arts-based observation training for health professions students at the University of South Florida.Costache I, Kunny C, editors. Academics, Artists, Museums: 21st Century Partnerships. Oxon and New York (NY):Routledge; 2018; pp. 99–110.
129. Acai A, McQueen SA, McKinnon V, et al.: Using art for the development of teamwork and communication skills among health professionals: a literature review. Arts Health. 2017; 9(1): 60–72. Publisher Full Text
130. Osman M, Eacott B, Willson S: Arts-based interventions in healthcare education. Med. Humanit. 2018; 44(1): 28–33. Publisher Full Text
131. Lake J, Jackson L, Hardman C: A fresh perspective on medical education: the lens of the arts. Med. Educ. 2015; 49(8): 759–772. Publisher Full Text
132. Belling C: Commentary: sharper instruments: on defending the humanities in undergraduate medical education. Acad. Med. 2010; 85(6): 938–940. PubMed Abstract | Publisher Full Text
133. Jaarsma T, Jarodzka H, Nap M, et al.: Expertise in clinical pathology: combining the visual and cognitive perspective. Adv. Health Sci. Educ. Theory Pract. 2015; 20(4): 1089–1106. Publisher Full Text

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 19 Jan 2023

Author details Author details

Faculty of Economics, Nagoya Gakuin University, 1-25, Atsuta-nishi-machi, Atsuta-ku, Nagoya, Aichi, 456-8612, Japan

Koji Matsumoto
Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This study was supported by JSPS KAKENHI Grant Number JP20H01685.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (2)

version 2

Revised

Published: 19 Mar 2025, 12:79

https://doi.org/10.12688/f1000research.129219.2

version 1

Published: 19 Jan 2023, 12:79

https://doi.org/10.12688/f1000research.129219.1

© 2023 Matsumoto K. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Download

Export To

metrics

	Views	Downloads
F1000Research	-	-
PubMed Central Data from PMC are received and updated monthly.	-	-

Citations

SEE MORE DETAILS

CITE

how to cite this article

Matsumoto K. Appreciating visual arts may not foster medical diagnosis skills [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:79 (https://doi.org/10.12688/f1000research.129219.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

track

receive updates on this article

Track an article to receive email alerts on any updates to this article.

Open Peer Review

Version 1

VERSION 1

PUBLISHED 19 Jan 2023

Views

Reviewer Report 21 Jun 2024

Margaret S. Chisolm, Department of Psychiatry and Behavioral Services, and of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

Approved with Reservations

https://doi.org/10.5256/f1000research.141887.r292047

Abstract
The abstract is lacking in conceptual clarity/relevance and presentation of replicable methods and clearly stated results. The aim of this article as stated is to review intervention studies that used "appreciation" of visual arts to foster observation skills AND discussed impact on diagnostic accuracy. This aim contains at least two concepts that are problematic for me: 1) the use of the word "appreciation" as most visual arts-based methods used in medical education are not concerned with art appreciation and 2) enhancement of observation skills is just one of many targeted skills and attributes that may improve patient outcomes, via diagnostic accuracy or other mechanisms, all of which are more "downstream." Thus, I'm concerned with the basic premise as articulated of the manuscript. However, putting that aside for the moment, and turning to the methods sentence of the abstract. This is not a systematic review yet the abstract implies it is as it includes the term "previous systematic reviews." Systematic reviews need to follow PRISMA guidelines, which this review does not. It has no clearly stated inclusion/exclusion criteria, database names, search terms, duplicate review system, no flow chart, no clear search start and end dates, no exact numbers of articles reviewed etc. this lack prevents replication and limits assessment of strength of evidence and conclusions that can be drawn. Again, the aim of affects of "appreciating" art on "diagnosis" accuracy are questionable aims to begin with and lack of rigor in review methods makes this manuscript's conclusions more problematic. Moving to the results section of the abstract, few results are presented and this is more of a discussion section making it challenging to assess whether conclusions are supported by evidence. The conclusions section of the abstract is not supported by results as presented in abstract. No presentation of evidence for medical cases/knowledge to impact learning as compared to visual art "appreciation." No evidence presented in results section of abstract to support verbalization skills enhancement, etc. In conclusion, the abstract is lacking in coherence and clarity.
Introduction
The manuscript would be enhanced by a clear articulation of the problem(s) that visual arts-based teaching is trying to solve and what the current non-visual arts-based methods are to address this problem. It would also be important to mention the international consensus that the arts and humanities are fundamental to medical education (as stated by WHO, NASEM and AAMC FRAHME reports) and the Moniz et al scoping review [Ref 1] and two papers on the Prism model describing the functions that the arts and humanities have served in medical education to date.
Although one of the primary goals of developing observations skills is to improve diagnostic accuracy, this is a very downstream outcome to which many other skills may contribute and also other downstream outcomes are clinically relevant as well (e.g., being able to observe nonverbals and so enhance communication skills to build rapport and enhance adherence with treatment recommendations, as one example). Also it appears that results are included in introduction prior to presenting methods and results later, and would avoid including results in the introduction and instead put this in context of literature more broadly. A research question needs to be articulated.
Methods
The previously mentioned review studies should be placed in the results, not in the Introduction or Methods sections. The Methods section should include the search terms, the databases searched, the exact search date, the number of abstracts/titles identified in search, exact inclusion/exclusion etc as presented in PRISMA guidelines. The reader should know how many non-duplicate abstracts/titles were identified, how many of those were included in full text review, etc.
Results
The word "around" should never be part of a systematic review, which this is not. More precision throughout is necessary. Not clear why the term "visual arts appreciation" is used as "appreciation" is not integral to teaching visual arts-based medical education.
The author mistates two of the three core questions of VTS. These are precisely researched and worded questions so getting two of them incorrect here is very concerning. These questions have the primary aim of holding the group in inquiry as well the aim as stated by the author of having the participants ground their inferences in visual evidence.
The penultimate paragraph of the Results section was the most informative of the manuscript, describing the study design and outcomes, which are suggestive of impact on observation skills. More precision in the text would be helpful here (i.e., % studies versus "most" AAMC or "some").
The last paragraph brings up diagnostic accuracy, which - again - the author declares as a primary aim of this work, but I'm not sure it is THE primary aim of any of the use of visual arts in medical education, and so it's not surprising that only one study measured this.
Discussion
Use of the word "target" in the first sentence to describe the work of art is an odd choice; perhaps just saying "artwork" would be clearer. The author raises some interesting ideas in this section. However the idea that observing for a longer period of time is not necessary for an accurate diagnosis among experts obscures the important role of taking time for beginners (presumably the target learners for most of these exercises) to avoid premature diagnostic closure via arriving at a diagnosis too quickly and not staying open to possibilities is important to good patient outcomes. Plus even among experts who can quickly diagnose most presentations accurately, instances exist where taking more time would have resulted in a more accurate diagnosis for an individual patient. Similarly the ability to look should precede the ability to know what to discard as relevant, so a beginner's inability to overlook irrelevant features seems a bit irrelevant to teaching beginners to look. At least one more recent study does support visual arts to make a statistically significant contribution to tolerance for ambiguity (Tackett et al, Med Ed Online).[Rev 2]
Again, the use of "appreciating" visual arts misses the mark of what visual arts-based teaching aims to do. Art appreciation is beside the point.
The author raises good questions about the limitations of transfer and the need for more research to study the transfer of skills from the museum or classroom to the clinic. They make a good point about the role of visual arts to foster communication skills (both listening and "verbalizing," which perhaps "speaking" or "articulately" would be a less awkward word choice) and team-building/perspective taking.
Conclusions
Although the methods/results presentation make it difficult to be sure that the conclusions reached are accurate, I would not be surprised by a lack of evidence on whether visual arts-based teaching aids diagnostic accuracy for the reasons outlined above. This is an emerging field whose focus has been on exploring the role of the arts in developing many clinically relevant skills and attitudes, which - taken as a whole - may support patient outcomes (including diagnosis and treatment planning) downstream. The field is in an exploratory phase and its aims are to explore an array of attributes that may have an effect on these and other "downstream" outcomes.
Limitations should include that this is not a systematic review in accordance with the PRISMA guidelines, and that relevant articles may have been missed by the search strategy etc
Clearly more rigor is needed in the field of visual arts-based medical education research. The author does well to point this out and give some ideas for future directions. However, the findings of the study and these recommendations for improvement should be place in the context of the broader literature on these research gaps as outlined in the Howley et al AAMC FRAHME report and the Moniz et al scoping review, which also suggests more research rigor etc. I would disagree with several conclusions. The conclusion that "adopting visual art appreciation is not encouraged" seems to me an overstatement given the limitations of this review and the exploratory nature of the field. Clearly innovation is needed that goes beyond medical cases and knowledge transfer to teach students an array of otherwise difficult-to-teach clinically relevant attributes, which may improve patient outcomes, whether via
diagnostic accuracy or other effects. I also see great value in increasing learners' awareness of what is an observation and what is an interpretation. The metacognitive skills of recognizing that an interpretation lacks visual evidence, raises awareness of possible biased thinking.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Moniz T, Golafshani M, Gaspar CM, Adams NE, et al.: How Are the Arts and Humanities Used in Medical Education? Results of a Scoping Review.Acad Med. 2021; 96 (8): 1213-1222 PubMed Abstract | Publisher Full Text
2. Tackett S, Eller L, Scharff S, Balhara KS, et al.: Transformative experiences at art museums to support flourishing in medicine.Med Educ Online. 2023; 28 (1): 2202914 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: museum-based health professions education

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 19 Mar 2025

Koji MATSUMOTO, Nagoya Gakuin University, Nagoya, Japan

19 Mar 2025

Author Response

Dear Reviewer,

Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the work.

I designed a ... Continue reading Dear Reviewer,

Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the work.

I designed a scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Inspired by your comments, I also expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): The abstract is lacking in conceptual clarity/relevance and presentation of replicable methods and clearly stated results.
Response (R): I designed the study following the PRISMA-ScR and revised the entire Abstract.

C: Not clear why the term "visual arts appreciation" is used as "appreciation" is not integral to teaching visual arts-based medical education.
R: According to a suggestion by another reviewer, I modified it to “visual art observation.”

C: It would also be important to mention the international consensus that the arts and humanities are fundamental to medical education.
R: I did not discuss this in this paper but did elsewhere (See Ref 1). I believe I understand this background.
[Ref 1] Matsumoto K. The use of arts in health professions education: applicability as a new teaching method. Igaku Kyoiku / Medical Education (Japan). 2023;54(3):235-243. Article in Japanese.

C: Enhancement of observation skills is just one of many targeted skills and attributes that may improve patient outcomes, via diagnostic accuracy or other mechanisms, all of which are more "downstream."
R: I agree; this paper examines the claim that the interventions also work “downstream,” as the advocates argued.

C: Although one of the primary goals of developing observations skills is to improve diagnostic accuracy, this is a very downstream outcome to which many other skills may contribute and also other downstream outcomes are clinically relevant as well.
Then, I added the “Technical knowledge and skills based on observation skills” subsection to insist that it is necessary to consider the technical knowledge and skills of the learners.

C: I'm not sure to improve diagnostic accuracy is THE primary aim of any of the use of visual arts in medical education, and so it's not surprising that only one study measured this.
R: The scope of the study extended to skills related to observation.

C: It appears that results are included in introduction prior to presenting methods and results later, and would avoid including results in the introduction and instead put this in context of literature more broadly.
C: The previously mentioned review studies should be placed in the results, not in the Introduction or Methods sections.
R: The reason for mentioning the prior reviews in the Introduction is to show the need for this review by presenting the attainments and unsolved issues of the previous reviews.

C: A research question needs to be articulated.
R: I added this to the Introduction.

C: The Methods should follow PRISMA guidelines.
R: I revised the Methods according to the PRISMA-ScR.

C: The word "around" should never be part of a systematic review, which this is not. More precision in the text would be helpful here (i.e., % studies versus "most" AAMC or "some").
R: I followed this suggestion and revised this section accordingly.

C: The author misstates two of the three core questions of VTS.
R: I revised this, thank you for pointing it out.

C: The penultimate paragraph of the Results section was the most informative of the manuscript, describing the study design and outcomes, which are suggestive of impact on observation skills.
R: In this revised version, the description was expanded in more detail.

C: In Discussion, use of the word "target" in the first sentence to describe the work of art is an odd choice.
R: In this version, this sentence was entirely revised.

C: The idea that observing for a longer period of time is not necessary for an accurate diagnosis among experts obscures the important role of taking time for beginners to avoid premature diagnostic closure via arriving at a diagnosis too quickly and not staying open to possibilities is important to good patient outcomes. Instances exist where taking more time would have resulted in a more accurate diagnosis for an individual patient.
R: I revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful. The previous studies cited in the subsection deny the idea. Additionally, please tell me the specific references you are referring to.

C: At least one more recent study does support visual arts to make a statistically significant contribution to tolerance for ambiguity.
R: As mentioned in the “Longer periods of careful and systematic observations for accurate diagnosis” subsection, the effectiveness of tolerance to clinical practice is debatable.

C: The ability to look should precede the ability to know what to discard as relevant, so a beginner's inability to overlook irrelevant features seems a bit irrelevant to teaching beginners to look.
R: I understood this suggestion to mean that teaching students how to look and then the knowledge or skills to identify the critical signs may be beneficial. If this is what you mean, I discussed this as scaffolding in the “Long-term effects such as scaffolding” subsection, as I did in version 1.

C: The author raises good questions about the limitations of transfer and the need for more research to study the transfer of skills from the museum or classroom to the clinic.
R: This was mentioned in the revised version as well.

C: They make a good point about the role of visual arts to foster communication skills (both listening and and team-building/perspective taking.
R: As a result of reanalysis, I stated that there is insufficient evidence that art observation helps with these skills in the Results and “Fostering verbalizing skills…” subsection of the Discussion.

C: "verbalizing," which perhaps "speaking" or "articulately" would be a less awkward word choice.
R: “Vernalizing” means making words out of what one sees, as the text states. Additionally, given the use of description as an outcome measure in the studies, I think “speaking” and “articulately” differ slightly from what I wished to express.

C: I would not be surprised by a lack of evidence on whether visual arts-based teaching aids diagnostic accuracy. The field is in an exploratory phase and its aims are to explore an array of attributes that may have an effect on these and other "downstream" outcomes.
C: The conclusion that "adopting visual art appreciation is not encouraged" seems to me an overstatement given the limitations of this review and the exploratory nature of the field.
C: The findings of the study and these recommendations for improvement should be place in the context of the broader literature on these research gaps as outlined in the Howley et al AAMC FRAHME report and the Moniz et al scoping review, which also suggests more research rigor etc.
C: Clearly innovation is needed that goes beyond medical cases and knowledge transfer to teach students an array of otherwise difficult-to-teach clinically relevant attributes, which may improve patient outcomes, whether via diagnostic accuracy or other effects.
R: I agree with these opinions and revised the Discussion and Conclusion from this standpoint. I tried to suggest directions and challenges for future research for developing this field. On the other hand, I did not provide suggestions for practice, judging that there is not enough evidence to apply them to practice.

C: Limitations should include that this is not a systematic review in accordance with the PRISMA guidelines, and that relevant articles may have been missed by the search strategy etc
R: I designed the study according to the PRISMA-ScR.
Dear Reviewer,

Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the work.

I designed a scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Inspired by your comments, I also expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): The abstract is lacking in conceptual clarity/relevance and presentation of replicable methods and clearly stated results.
Response (R): I designed the study following the PRISMA-ScR and revised the entire Abstract.

C: Not clear why the term "visual arts appreciation" is used as "appreciation" is not integral to teaching visual arts-based medical education.
R: According to a suggestion by another reviewer, I modified it to “visual art observation.”

C: It would also be important to mention the international consensus that the arts and humanities are fundamental to medical education.
R: I did not discuss this in this paper but did elsewhere (See Ref 1). I believe I understand this background.
[Ref 1] Matsumoto K. The use of arts in health professions education: applicability as a new teaching method. Igaku Kyoiku / Medical Education (Japan). 2023;54(3):235-243. Article in Japanese.

C: Enhancement of observation skills is just one of many targeted skills and attributes that may improve patient outcomes, via diagnostic accuracy or other mechanisms, all of which are more "downstream."
R: I agree; this paper examines the claim that the interventions also work “downstream,” as the advocates argued.

C: Although one of the primary goals of developing observations skills is to improve diagnostic accuracy, this is a very downstream outcome to which many other skills may contribute and also other downstream outcomes are clinically relevant as well.
Then, I added the “Technical knowledge and skills based on observation skills” subsection to insist that it is necessary to consider the technical knowledge and skills of the learners.

C: I'm not sure to improve diagnostic accuracy is THE primary aim of any of the use of visual arts in medical education, and so it's not surprising that only one study measured this.
R: The scope of the study extended to skills related to observation.

C: It appears that results are included in introduction prior to presenting methods and results later, and would avoid including results in the introduction and instead put this in context of literature more broadly.
C: The previously mentioned review studies should be placed in the results, not in the Introduction or Methods sections.
R: The reason for mentioning the prior reviews in the Introduction is to show the need for this review by presenting the attainments and unsolved issues of the previous reviews.

C: A research question needs to be articulated.
R: I added this to the Introduction.

C: The Methods should follow PRISMA guidelines.
R: I revised the Methods according to the PRISMA-ScR.

C: The word "around" should never be part of a systematic review, which this is not. More precision in the text would be helpful here (i.e., % studies versus "most" AAMC or "some").
R: I followed this suggestion and revised this section accordingly.

C: The author misstates two of the three core questions of VTS.
R: I revised this, thank you for pointing it out.

C: The penultimate paragraph of the Results section was the most informative of the manuscript, describing the study design and outcomes, which are suggestive of impact on observation skills.
R: In this revised version, the description was expanded in more detail.

C: In Discussion, use of the word "target" in the first sentence to describe the work of art is an odd choice.
R: In this version, this sentence was entirely revised.

C: The idea that observing for a longer period of time is not necessary for an accurate diagnosis among experts obscures the important role of taking time for beginners to avoid premature diagnostic closure via arriving at a diagnosis too quickly and not staying open to possibilities is important to good patient outcomes. Instances exist where taking more time would have resulted in a more accurate diagnosis for an individual patient.
R: I revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful. The previous studies cited in the subsection deny the idea. Additionally, please tell me the specific references you are referring to.

C: At least one more recent study does support visual arts to make a statistically significant contribution to tolerance for ambiguity.
R: As mentioned in the “Longer periods of careful and systematic observations for accurate diagnosis” subsection, the effectiveness of tolerance to clinical practice is debatable.

C: The ability to look should precede the ability to know what to discard as relevant, so a beginner's inability to overlook irrelevant features seems a bit irrelevant to teaching beginners to look.
R: I understood this suggestion to mean that teaching students how to look and then the knowledge or skills to identify the critical signs may be beneficial. If this is what you mean, I discussed this as scaffolding in the “Long-term effects such as scaffolding” subsection, as I did in version 1.

C: The author raises good questions about the limitations of transfer and the need for more research to study the transfer of skills from the museum or classroom to the clinic.
R: This was mentioned in the revised version as well.

C: They make a good point about the role of visual arts to foster communication skills (both listening and and team-building/perspective taking.
R: As a result of reanalysis, I stated that there is insufficient evidence that art observation helps with these skills in the Results and “Fostering verbalizing skills…” subsection of the Discussion.

C: "verbalizing," which perhaps "speaking" or "articulately" would be a less awkward word choice.
R: “Vernalizing” means making words out of what one sees, as the text states. Additionally, given the use of description as an outcome measure in the studies, I think “speaking” and “articulately” differ slightly from what I wished to express.

C: I would not be surprised by a lack of evidence on whether visual arts-based teaching aids diagnostic accuracy. The field is in an exploratory phase and its aims are to explore an array of attributes that may have an effect on these and other "downstream" outcomes.
C: The conclusion that "adopting visual art appreciation is not encouraged" seems to me an overstatement given the limitations of this review and the exploratory nature of the field.
C: The findings of the study and these recommendations for improvement should be place in the context of the broader literature on these research gaps as outlined in the Howley et al AAMC FRAHME report and the Moniz et al scoping review, which also suggests more research rigor etc.
C: Clearly innovation is needed that goes beyond medical cases and knowledge transfer to teach students an array of otherwise difficult-to-teach clinically relevant attributes, which may improve patient outcomes, whether via diagnostic accuracy or other effects.
R: I agree with these opinions and revised the Discussion and Conclusion from this standpoint. I tried to suggest directions and challenges for future research for developing this field. On the other hand, I did not provide suggestions for practice, judging that there is not enough evidence to apply them to practice.

C: Limitations should include that this is not a systematic review in accordance with the PRISMA guidelines, and that relevant articles may have been missed by the search strategy etc
R: I designed the study according to the PRISMA-ScR.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 19 Mar 2025

Koji MATSUMOTO, Nagoya Gakuin University, Nagoya, Japan

19 Mar 2025

Author Response

Dear Reviewer,

Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the work.

I designed a ... Continue reading Dear Reviewer,

Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the work.

I designed a scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Inspired by your comments, I also expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): The abstract is lacking in conceptual clarity/relevance and presentation of replicable methods and clearly stated results.
Response (R): I designed the study following the PRISMA-ScR and revised the entire Abstract.

C: Not clear why the term "visual arts appreciation" is used as "appreciation" is not integral to teaching visual arts-based medical education.
R: According to a suggestion by another reviewer, I modified it to “visual art observation.”

C: It would also be important to mention the international consensus that the arts and humanities are fundamental to medical education.
R: I did not discuss this in this paper but did elsewhere (See Ref 1). I believe I understand this background.
[Ref 1] Matsumoto K. The use of arts in health professions education: applicability as a new teaching method. Igaku Kyoiku / Medical Education (Japan). 2023;54(3):235-243. Article in Japanese.

C: Enhancement of observation skills is just one of many targeted skills and attributes that may improve patient outcomes, via diagnostic accuracy or other mechanisms, all of which are more "downstream."
R: I agree; this paper examines the claim that the interventions also work “downstream,” as the advocates argued.

C: Although one of the primary goals of developing observations skills is to improve diagnostic accuracy, this is a very downstream outcome to which many other skills may contribute and also other downstream outcomes are clinically relevant as well.
Then, I added the “Technical knowledge and skills based on observation skills” subsection to insist that it is necessary to consider the technical knowledge and skills of the learners.

C: I'm not sure to improve diagnostic accuracy is THE primary aim of any of the use of visual arts in medical education, and so it's not surprising that only one study measured this.
R: The scope of the study extended to skills related to observation.

C: It appears that results are included in introduction prior to presenting methods and results later, and would avoid including results in the introduction and instead put this in context of literature more broadly.
C: The previously mentioned review studies should be placed in the results, not in the Introduction or Methods sections.
R: The reason for mentioning the prior reviews in the Introduction is to show the need for this review by presenting the attainments and unsolved issues of the previous reviews.

C: A research question needs to be articulated.
R: I added this to the Introduction.

C: The Methods should follow PRISMA guidelines.
R: I revised the Methods according to the PRISMA-ScR.

C: The word "around" should never be part of a systematic review, which this is not. More precision in the text would be helpful here (i.e., % studies versus "most" AAMC or "some").
R: I followed this suggestion and revised this section accordingly.

C: The author misstates two of the three core questions of VTS.
R: I revised this, thank you for pointing it out.

C: The penultimate paragraph of the Results section was the most informative of the manuscript, describing the study design and outcomes, which are suggestive of impact on observation skills.
R: In this revised version, the description was expanded in more detail.

C: In Discussion, use of the word "target" in the first sentence to describe the work of art is an odd choice.
R: In this version, this sentence was entirely revised.

C: The idea that observing for a longer period of time is not necessary for an accurate diagnosis among experts obscures the important role of taking time for beginners to avoid premature diagnostic closure via arriving at a diagnosis too quickly and not staying open to possibilities is important to good patient outcomes. Instances exist where taking more time would have resulted in a more accurate diagnosis for an individual patient.
R: I revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful. The previous studies cited in the subsection deny the idea. Additionally, please tell me the specific references you are referring to.

C: At least one more recent study does support visual arts to make a statistically significant contribution to tolerance for ambiguity.
R: As mentioned in the “Longer periods of careful and systematic observations for accurate diagnosis” subsection, the effectiveness of tolerance to clinical practice is debatable.

C: The ability to look should precede the ability to know what to discard as relevant, so a beginner's inability to overlook irrelevant features seems a bit irrelevant to teaching beginners to look.
R: I understood this suggestion to mean that teaching students how to look and then the knowledge or skills to identify the critical signs may be beneficial. If this is what you mean, I discussed this as scaffolding in the “Long-term effects such as scaffolding” subsection, as I did in version 1.

C: The author raises good questions about the limitations of transfer and the need for more research to study the transfer of skills from the museum or classroom to the clinic.
R: This was mentioned in the revised version as well.

C: They make a good point about the role of visual arts to foster communication skills (both listening and and team-building/perspective taking.
R: As a result of reanalysis, I stated that there is insufficient evidence that art observation helps with these skills in the Results and “Fostering verbalizing skills…” subsection of the Discussion.

C: "verbalizing," which perhaps "speaking" or "articulately" would be a less awkward word choice.
R: “Vernalizing” means making words out of what one sees, as the text states. Additionally, given the use of description as an outcome measure in the studies, I think “speaking” and “articulately” differ slightly from what I wished to express.

C: I would not be surprised by a lack of evidence on whether visual arts-based teaching aids diagnostic accuracy. The field is in an exploratory phase and its aims are to explore an array of attributes that may have an effect on these and other "downstream" outcomes.
C: The conclusion that "adopting visual art appreciation is not encouraged" seems to me an overstatement given the limitations of this review and the exploratory nature of the field.
C: The findings of the study and these recommendations for improvement should be place in the context of the broader literature on these research gaps as outlined in the Howley et al AAMC FRAHME report and the Moniz et al scoping review, which also suggests more research rigor etc.
C: Clearly innovation is needed that goes beyond medical cases and knowledge transfer to teach students an array of otherwise difficult-to-teach clinically relevant attributes, which may improve patient outcomes, whether via diagnostic accuracy or other effects.
R: I agree with these opinions and revised the Discussion and Conclusion from this standpoint. I tried to suggest directions and challenges for future research for developing this field. On the other hand, I did not provide suggestions for practice, judging that there is not enough evidence to apply them to practice.

C: Limitations should include that this is not a systematic review in accordance with the PRISMA guidelines, and that relevant articles may have been missed by the search strategy etc
R: I designed the study according to the PRISMA-ScR.
Dear Reviewer,

Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the work.

I designed a scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Inspired by your comments, I also expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): The abstract is lacking in conceptual clarity/relevance and presentation of replicable methods and clearly stated results.
Response (R): I designed the study following the PRISMA-ScR and revised the entire Abstract.

C: Not clear why the term "visual arts appreciation" is used as "appreciation" is not integral to teaching visual arts-based medical education.
R: According to a suggestion by another reviewer, I modified it to “visual art observation.”

C: It would also be important to mention the international consensus that the arts and humanities are fundamental to medical education.
R: I did not discuss this in this paper but did elsewhere (See Ref 1). I believe I understand this background.
[Ref 1] Matsumoto K. The use of arts in health professions education: applicability as a new teaching method. Igaku Kyoiku / Medical Education (Japan). 2023;54(3):235-243. Article in Japanese.

C: Enhancement of observation skills is just one of many targeted skills and attributes that may improve patient outcomes, via diagnostic accuracy or other mechanisms, all of which are more "downstream."
R: I agree; this paper examines the claim that the interventions also work “downstream,” as the advocates argued.

C: Although one of the primary goals of developing observations skills is to improve diagnostic accuracy, this is a very downstream outcome to which many other skills may contribute and also other downstream outcomes are clinically relevant as well.
Then, I added the “Technical knowledge and skills based on observation skills” subsection to insist that it is necessary to consider the technical knowledge and skills of the learners.

C: I'm not sure to improve diagnostic accuracy is THE primary aim of any of the use of visual arts in medical education, and so it's not surprising that only one study measured this.
R: The scope of the study extended to skills related to observation.

C: It appears that results are included in introduction prior to presenting methods and results later, and would avoid including results in the introduction and instead put this in context of literature more broadly.
C: The previously mentioned review studies should be placed in the results, not in the Introduction or Methods sections.
R: The reason for mentioning the prior reviews in the Introduction is to show the need for this review by presenting the attainments and unsolved issues of the previous reviews.

C: A research question needs to be articulated.
R: I added this to the Introduction.

C: The Methods should follow PRISMA guidelines.
R: I revised the Methods according to the PRISMA-ScR.

C: The word "around" should never be part of a systematic review, which this is not. More precision in the text would be helpful here (i.e., % studies versus "most" AAMC or "some").
R: I followed this suggestion and revised this section accordingly.

C: The author misstates two of the three core questions of VTS.
R: I revised this, thank you for pointing it out.

C: The penultimate paragraph of the Results section was the most informative of the manuscript, describing the study design and outcomes, which are suggestive of impact on observation skills.
R: In this revised version, the description was expanded in more detail.

C: In Discussion, use of the word "target" in the first sentence to describe the work of art is an odd choice.
R: In this version, this sentence was entirely revised.

C: The idea that observing for a longer period of time is not necessary for an accurate diagnosis among experts obscures the important role of taking time for beginners to avoid premature diagnostic closure via arriving at a diagnosis too quickly and not staying open to possibilities is important to good patient outcomes. Instances exist where taking more time would have resulted in a more accurate diagnosis for an individual patient.
R: I revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful. The previous studies cited in the subsection deny the idea. Additionally, please tell me the specific references you are referring to.

C: At least one more recent study does support visual arts to make a statistically significant contribution to tolerance for ambiguity.
R: As mentioned in the “Longer periods of careful and systematic observations for accurate diagnosis” subsection, the effectiveness of tolerance to clinical practice is debatable.

C: The ability to look should precede the ability to know what to discard as relevant, so a beginner's inability to overlook irrelevant features seems a bit irrelevant to teaching beginners to look.
R: I understood this suggestion to mean that teaching students how to look and then the knowledge or skills to identify the critical signs may be beneficial. If this is what you mean, I discussed this as scaffolding in the “Long-term effects such as scaffolding” subsection, as I did in version 1.

C: The author raises good questions about the limitations of transfer and the need for more research to study the transfer of skills from the museum or classroom to the clinic.
R: This was mentioned in the revised version as well.

C: They make a good point about the role of visual arts to foster communication skills (both listening and and team-building/perspective taking.
R: As a result of reanalysis, I stated that there is insufficient evidence that art observation helps with these skills in the Results and “Fostering verbalizing skills…” subsection of the Discussion.

C: "verbalizing," which perhaps "speaking" or "articulately" would be a less awkward word choice.
R: “Vernalizing” means making words out of what one sees, as the text states. Additionally, given the use of description as an outcome measure in the studies, I think “speaking” and “articulately” differ slightly from what I wished to express.

C: I would not be surprised by a lack of evidence on whether visual arts-based teaching aids diagnostic accuracy. The field is in an exploratory phase and its aims are to explore an array of attributes that may have an effect on these and other "downstream" outcomes.
C: The conclusion that "adopting visual art appreciation is not encouraged" seems to me an overstatement given the limitations of this review and the exploratory nature of the field.
C: The findings of the study and these recommendations for improvement should be place in the context of the broader literature on these research gaps as outlined in the Howley et al AAMC FRAHME report and the Moniz et al scoping review, which also suggests more research rigor etc.
C: Clearly innovation is needed that goes beyond medical cases and knowledge transfer to teach students an array of otherwise difficult-to-teach clinically relevant attributes, which may improve patient outcomes, whether via diagnostic accuracy or other effects.
R: I agree with these opinions and revised the Discussion and Conclusion from this standpoint. I tried to suggest directions and challenges for future research for developing this field. On the other hand, I did not provide suggestions for practice, judging that there is not enough evidence to apply them to practice.

C: Limitations should include that this is not a systematic review in accordance with the PRISMA guidelines, and that relevant articles may have been missed by the search strategy etc
R: I designed the study according to the PRISMA-ScR.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Views

Reviewer Report 16 Feb 2024

Nicole J Fernandez, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

Approved with Reservations

https://doi.org/10.5256/f1000research.141887.r239810

This paper is a welcome addition to the literature on the humanities in medical education and attempts the daunting task of determining if art observation has a positive impact on medical diagnosis in novice learners. The approach to this question is logical, although in some areas, the reader would benefit from more explanation and context. The conclusion that there is little evidence to support improved diagnosis as a result of art observation is well-supported, although the broad reasons for this could be further detailed, and the statement that another approach would be better is outside the scope of the article.

The article could be improved by considering these further comments to the author:

Title: Use of “appreciating” -consider re-wording. This implies a casual approach to looking at art, while slow looking is an iterative rigorous process. Perhaps “art observation” instead of “appreciating visual arts”. Also “medical diagnostic skills” instead of “medical diagnosis skills”. Suggest including ‘who’ as well- medical students? Novice learners?
Possible revised title: Art observation may not improve medical diagnostic skills in novice learners

The writing style is inconsistent and unusual in some places. Usually in English scientific writing “I” or “the author” is not used- recommend rephrasing throughout. (For example: “The author collected information on…” becomes “Information was collected on…”.)

Abstract: The Background section of an abstract usually provides context for the study rather than describing what the study did.
Make sure that any changes to the body of the article are reflected in the abstract (eg changes to the conclusions).

There are opportunities throughout to provide more context and help the reader’s understanding of the subject- some of these are noted below. Being explicit is important- there may be assumptions that are not shared by all readers, especially regarding definitions and terms used.
-Define what you mean by intervention/empirical intervention study. This is important in helping the reader to know which studies you considered.
-Clarify what you mean by diagnosis- visual diagnosis only (eg radiology, gross pathology)? Clinical reasoning (which would be much broader)?
-Specifically outline your inclusion and exclusion criteria
-How did you decide about diagnostic evidence? Is improved diagnostic accuracy the only criterion? What about other elements of the diagnostic process or approach to complex cases in which the diagnosis is unclear?
-The term ‘expertization’ may not be familiar to readers and should be explicitly defined, including what is meant by ‘expertization studies’.
-In Methods, “features and tendencies” of the selected articles is mentioned- please explain what is meant by this.

The final paragraph of the introduction is not needed, as this is the standard format for a journal article.

Methods-
The first paragraph mentions “studies that used visual arts for cultivating observation skills” but was this the only goal of the included studies? This does not seem consistent with what is stated elsewhere in the article.
3^rd paragraph, second sentence “were excluded” needs to be moved to outside the parentheses
Suggest including a figure that shows how articles were selected, numbers of articles at each step of the process, that 12 articles were selected for full review. How many articles were found using the review articles vs by manual search? There are many examples of figures like this in the published literature.

Results-
Abbreviations need to be explained in the table (regardless of whether they are also explained in the text- the table should be able to stand alone).
Results could be strengthened by using numbers instead of terms like “most”

Discussion-
-Overall the discussion would benefit from a clearer focus on the original question- specifically diagnostic skills, not art observation studies in general.
-Why might improvement in diagnostic skills be difficult to demonstrate in a study? Provide context, difficulty of assessing long term effects. How could future researchers attempt this? (currently in conclusions)
-Consider that one might not see an improvement right after the intervention in 2^nd year, but could it be helpful once students have more diagnostic experience, eg in 4^th year?
-Clearly and briefly list what reported benefits of art observation are- the information is there, but scattered. It could be condensed, as this is not the original focus of the paper.
-If included studies were only those designed to improve observation skills, is it reasonable to assess them for improvement in diagnostic skills? How strong can any conclusions be? Only 1 study assessed diagnostic accuracy, and this was in a limited domain.

The relevance of expertization studies is unclear, since the art observation interventions were done with novice learners. Novices are not experts, one can’t teach them the same way. Just because experts are more likely to misdiagnose if they take longer, it doesn’t necessarily follow that the same is true for novices. If your position is that novices should be taught like experts, this needs to be explicitly stated and supported from the literature.
Throughout the discussion it needs to be made clear when you are referring to studies in experts vs studies in novices. This is not clear for a reader who is not already familiar with this literature.

The Discussion covers much material that does not seem closely related to the original goal and could be condensed and refined to focus on diagnostic skills. It is important to emphasize that only 1 art observation study explicitly looked at diagnosis, and did this in a limited way. The conclusion appears to be that the impact of art observation on diagnostic skill has not been adequately investigated, rather than that it is ineffective. I don’t agree that it has been “shown that appreciating visual arts may not have a direct effect on making an accurate diagnosis”; the statement “there is no concrete evidence on whether appreciating visual art contributes toward an accurate diagnosis” is more accurate.

Conclusions should be a single paragraph stating your major findings- the section titled Conclusions is not really a conclusion. This material is more appropriate in the Discussion.

The claim that “it would be better to…” was not the focus of this article- a review of this literature would need to be included in order to support this. It could be suggested that if improving diagnostic accuracy is the single goal, there may be other methods that are more effective than art observation. But is this the only goal of art observation interventions? I don’t believe so. Observation is the first part of the diagnostic reasoning pathway, but not the only part, certainly not a panacea. It seems simplistic to expect a single intervention to have a great and immediate impact on diagnostic accuracy.

Limitations:
-No veterinary medicine literature included, although nursing literature was included. Is there a reason for this? There are several relevant articles in the vet med literature.
-Studies that included other methods were excluded- can’t comment on what the effects of these studies are
-In methods you mention the limitations of eg thematic analysis, but there is no mention of the limitations of using quantitative population statistics

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Tolerance of ambiguity, teaching observational skills, case-based learning, clinical pathology

CITE

Report a concern

Author Response 19 Mar 2025

Koji MATSUMOTO, Nagoya Gakuin University, Nagoya, Japan

19 Mar 2025

Author Response

Dear Reviewer,
Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the article.

I added the scoping ... Continue reading Dear Reviewer,
Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the article.

I added the scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). I expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster. Therefore, I cannot sufficiently respond to your suggestions regarding diagnostic skills. However, inspired by the suggestions, I discussed the relationship between visual art observation and technical knowledge and skills acquired through education and training.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): In the title, use “art observation” instead of “appreciating visual arts”. Also “medical diagnostic skills” instead of “medical diagnosis skills”. Suggest including ‘who’ as well- medical students? Novice learners?
Response (R): I modified the title: “Effects of visual art observation on technical skills in novice healthcare learners: A scoping review.” I also revised the language to use “visual art observation” and “diagnostic skills” in the article. Moreover, I added the definition of novice medical learners in 4^th paragraph of the Introduction: “novice healthcare learners, namely, students, residents, trainees, or inexperienced workers in related majors or domains.”

C: Usually in English scientific writing “I” or “the author” is not used- recommend rephrasing throughout.
R: I appreciate this feedback. In some cases, I used the personal pronoun or the subject “the author” to avoid passive sentence construction. I tried to use the passive form as little as possible, according to the guidelines of some journals on medical education.

C: In the Abstract, The Background section of an abstract usually provides context for the study rather than describing what the study did.
R: I modified this, as you pointed out.

C: Make sure that any changes to the body of the article are reflected in the abstract.
R: I also modified the abstract.

C: Define what you mean by intervention/empirical intervention study.
R: I added the definition in 1st paragraph of the Introduction: “studies which include both training practices and corroborating its effects.”

C: “Expertization” should be explicitly defined.
R: I deleted the word and removed it from the article.

C: In Methods, “features and tendencies” of the selected articles is mentioned- please explain what is meant by this.
R: I revised research question one to make it clearer and more concise: What key features or trends characterize visual art observation training in intervention studies aimed at improving observation skills?

C: In Methods, the first paragraph mentions “studies that used visual arts for cultivating observation skills” but was this the only goal of the included studies? This does not seem consistent with what is stated elsewhere in the article.
R: As stated in Methods, I included the studies that primarily aimed to “evaluate the effect of the intervention on technical skills related to observation,” and the goals that the included studies stated clearly were listed in Table 2.

C: The final paragraph of the introduction is not needed.
R: The paragraph was written at the journal editor’s suggestion.

C: In Methods, 3rd paragraph, second sentence “were excluded” needs to be moved to outside the parentheses
R: These words were removed.

C: Specifically outline your inclusion and exclusion criteria. Include a figure that shows how articles were selected, numbers of articles at each step of the process, that 12 articles were selected for full review.
R: Following the PRISMA-ScR, I added information to the Methods and added Figure 1.

C: Abbreviations need to be explained in the table (regardless of whether they are also explained in the text- the table should be able to stand alone).
R: I modified Table 2 as per your recommendation.

C: Results could be strengthened by using numbers instead of terms like “most”
R: I modified this, as you pointed out.

C: Overall the discussion would benefit from a clearer focus on the original question- specifically diagnostic skills, not art observation studies in general.
R: As explained, the focus has changed.

C: Clarify what you mean by diagnosis- visual diagnosis only? Clinical reasoning (which would be much broader)? How did you decide about diagnostic evidence? Is improved diagnostic accuracy the only criterion? What about other elements of the diagnostic process or approach to complex cases in which the diagnosis is unclear?
R: Due to the change in the focus of this paper, I cannot directly answer these questions. On the other hand, as mentioned in the Introduction, the intervention studies claimed that the observational skills fostered by art observation could be applied to both medical imaging and clinical interviews. See also the next response.

C: If included studies were only those designed to improve observation skills, is it reasonable to assess them for improvement in diagnostic skills? How strong can any conclusions be? Only 1 study assessed diagnostic accuracy, and this was in a limited domain.
C: Observation is the first part of the diagnostic reasoning pathway, but not the only part. It seems simplistic to expect a single intervention to have a great and immediate impact on diagnostic accuracy.
R: I agree with you. However, the intervention studies claimed that art observation could facilitate diagnostic skills (directly or indirectly), as mentioned in the Introduction. This paper examined the claim. Moreover, in the “Technical knowledge and skills based on observation skills” subsection of the Discussion section, I argued that the relationship to technical knowledge and skills of learners should be considered to examine this clearly.

C: Why might improvement in diagnostic skills be difficult to demonstrate in a study? Provide context, difficulty of assessing long term effects. How could future researchers attempt this?
R: See the response immediately above. In addition, I added the subsection “Long-term effects such as scaffolding” to discuss this. See also the “Implications for future research” subsection.

C: Throughout the discussion it needs to be made clear when you are referring to studies in experts vs studies in novices. This is not clear for a reader who is not already familiar with this literature.
R: This seems to relate to the next comment. If not, I may have misunderstood your question. Please let me know if the subsequent response is not satisfactory, and I will do my best to address your question.

C: Novices are not experts, one can’t teach them the same way. If your position is that novices should be taught like experts, this needs to be explicitly stated and supported from the literature.
R: The revised version does not mention that novices should be taught like experts. Concerning this comment, I also revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful.

C: Consider that one might not see an improvement right after the intervention in 2nd year, but could it be helpful once students have more diagnostic experience, eg in 4th year?
R: This is discussed in the subsection “Long-term effects such as scaffolding.”

C: Clearly and briefly list what reported benefits of art observation are.
R: In the 2^nd paragraph of the Introduction, I listed the technical skills that intervention studies aimed at. I also added this as the result of this review in the subsection “Outcome measures and their results” in the Results section.

C: Conclusions should be a single paragraph stating your major findings.
R: I modified it as you pointed out.

C: The conclusion appears to be that the impact of art observation on diagnostic skill has not been adequately investigated, rather than that it is ineffective. The statement “there is no concrete evidence on whether appreciating visual art contributes toward an accurate diagnosis” is more accurate.
R: As a result of the reanalysis, such wording was used in the paper.

C: In Conclusions, the claim that “it would be better to use learning modules based on perceptual learning using cases to foster pattern recognition” was not the focus of this article.
R: This description was deleted.

C: No veterinary medicine literature was included. Is there a reason for this?
R: Three studies in veterinary education were included because they were comparable to training and experimental designs in human health professional education.

C: In Limitations, studies that included other methods were excluded- can’t comment on what the effects of these studies are. Also, there is no mention of the limitations of using quantitative population statistics.
R: I added these to the Limitations subsection.
Dear Reviewer,
Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the article.

I added the scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). I expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster. Therefore, I cannot sufficiently respond to your suggestions regarding diagnostic skills. However, inspired by the suggestions, I discussed the relationship between visual art observation and technical knowledge and skills acquired through education and training.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): In the title, use “art observation” instead of “appreciating visual arts”. Also “medical diagnostic skills” instead of “medical diagnosis skills”. Suggest including ‘who’ as well- medical students? Novice learners?
Response (R): I modified the title: “Effects of visual art observation on technical skills in novice healthcare learners: A scoping review.” I also revised the language to use “visual art observation” and “diagnostic skills” in the article. Moreover, I added the definition of novice medical learners in 4^th paragraph of the Introduction: “novice healthcare learners, namely, students, residents, trainees, or inexperienced workers in related majors or domains.”

C: Usually in English scientific writing “I” or “the author” is not used- recommend rephrasing throughout.
R: I appreciate this feedback. In some cases, I used the personal pronoun or the subject “the author” to avoid passive sentence construction. I tried to use the passive form as little as possible, according to the guidelines of some journals on medical education.

C: In the Abstract, The Background section of an abstract usually provides context for the study rather than describing what the study did.
R: I modified this, as you pointed out.

C: Make sure that any changes to the body of the article are reflected in the abstract.
R: I also modified the abstract.

C: Define what you mean by intervention/empirical intervention study.
R: I added the definition in 1st paragraph of the Introduction: “studies which include both training practices and corroborating its effects.”

C: “Expertization” should be explicitly defined.
R: I deleted the word and removed it from the article.

C: In Methods, “features and tendencies” of the selected articles is mentioned- please explain what is meant by this.
R: I revised research question one to make it clearer and more concise: What key features or trends characterize visual art observation training in intervention studies aimed at improving observation skills?

C: In Methods, the first paragraph mentions “studies that used visual arts for cultivating observation skills” but was this the only goal of the included studies? This does not seem consistent with what is stated elsewhere in the article.
R: As stated in Methods, I included the studies that primarily aimed to “evaluate the effect of the intervention on technical skills related to observation,” and the goals that the included studies stated clearly were listed in Table 2.

C: The final paragraph of the introduction is not needed.
R: The paragraph was written at the journal editor’s suggestion.

C: In Methods, 3rd paragraph, second sentence “were excluded” needs to be moved to outside the parentheses
R: These words were removed.

C: Specifically outline your inclusion and exclusion criteria. Include a figure that shows how articles were selected, numbers of articles at each step of the process, that 12 articles were selected for full review.
R: Following the PRISMA-ScR, I added information to the Methods and added Figure 1.

C: Abbreviations need to be explained in the table (regardless of whether they are also explained in the text- the table should be able to stand alone).
R: I modified Table 2 as per your recommendation.

C: Results could be strengthened by using numbers instead of terms like “most”
R: I modified this, as you pointed out.

C: Overall the discussion would benefit from a clearer focus on the original question- specifically diagnostic skills, not art observation studies in general.
R: As explained, the focus has changed.

C: Clarify what you mean by diagnosis- visual diagnosis only? Clinical reasoning (which would be much broader)? How did you decide about diagnostic evidence? Is improved diagnostic accuracy the only criterion? What about other elements of the diagnostic process or approach to complex cases in which the diagnosis is unclear?
R: Due to the change in the focus of this paper, I cannot directly answer these questions. On the other hand, as mentioned in the Introduction, the intervention studies claimed that the observational skills fostered by art observation could be applied to both medical imaging and clinical interviews. See also the next response.

C: If included studies were only those designed to improve observation skills, is it reasonable to assess them for improvement in diagnostic skills? How strong can any conclusions be? Only 1 study assessed diagnostic accuracy, and this was in a limited domain.
C: Observation is the first part of the diagnostic reasoning pathway, but not the only part. It seems simplistic to expect a single intervention to have a great and immediate impact on diagnostic accuracy.
R: I agree with you. However, the intervention studies claimed that art observation could facilitate diagnostic skills (directly or indirectly), as mentioned in the Introduction. This paper examined the claim. Moreover, in the “Technical knowledge and skills based on observation skills” subsection of the Discussion section, I argued that the relationship to technical knowledge and skills of learners should be considered to examine this clearly.

C: Why might improvement in diagnostic skills be difficult to demonstrate in a study? Provide context, difficulty of assessing long term effects. How could future researchers attempt this?
R: See the response immediately above. In addition, I added the subsection “Long-term effects such as scaffolding” to discuss this. See also the “Implications for future research” subsection.

C: Throughout the discussion it needs to be made clear when you are referring to studies in experts vs studies in novices. This is not clear for a reader who is not already familiar with this literature.
R: This seems to relate to the next comment. If not, I may have misunderstood your question. Please let me know if the subsequent response is not satisfactory, and I will do my best to address your question.

C: Novices are not experts, one can’t teach them the same way. If your position is that novices should be taught like experts, this needs to be explicitly stated and supported from the literature.
R: The revised version does not mention that novices should be taught like experts. Concerning this comment, I also revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful.

C: Consider that one might not see an improvement right after the intervention in 2nd year, but could it be helpful once students have more diagnostic experience, eg in 4th year?
R: This is discussed in the subsection “Long-term effects such as scaffolding.”

C: Clearly and briefly list what reported benefits of art observation are.
R: In the 2^nd paragraph of the Introduction, I listed the technical skills that intervention studies aimed at. I also added this as the result of this review in the subsection “Outcome measures and their results” in the Results section.

C: Conclusions should be a single paragraph stating your major findings.
R: I modified it as you pointed out.

C: The conclusion appears to be that the impact of art observation on diagnostic skill has not been adequately investigated, rather than that it is ineffective. The statement “there is no concrete evidence on whether appreciating visual art contributes toward an accurate diagnosis” is more accurate.
R: As a result of the reanalysis, such wording was used in the paper.

C: In Conclusions, the claim that “it would be better to use learning modules based on perceptual learning using cases to foster pattern recognition” was not the focus of this article.
R: This description was deleted.

C: No veterinary medicine literature was included. Is there a reason for this?
R: Three studies in veterinary education were included because they were comparable to training and experimental designs in human health professional education.

C: In Limitations, studies that included other methods were excluded- can’t comment on what the effects of these studies are. Also, there is no mention of the limitations of using quantitative population statistics.
R: I added these to the Limitations subsection.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 19 Mar 2025

Koji MATSUMOTO, Nagoya Gakuin University, Nagoya, Japan

19 Mar 2025

Author Response

Dear Reviewer,
Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the article.

I added the scoping ... Continue reading Dear Reviewer,
Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the article.

I added the scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). I expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster. Therefore, I cannot sufficiently respond to your suggestions regarding diagnostic skills. However, inspired by the suggestions, I discussed the relationship between visual art observation and technical knowledge and skills acquired through education and training.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): In the title, use “art observation” instead of “appreciating visual arts”. Also “medical diagnostic skills” instead of “medical diagnosis skills”. Suggest including ‘who’ as well- medical students? Novice learners?
Response (R): I modified the title: “Effects of visual art observation on technical skills in novice healthcare learners: A scoping review.” I also revised the language to use “visual art observation” and “diagnostic skills” in the article. Moreover, I added the definition of novice medical learners in 4^th paragraph of the Introduction: “novice healthcare learners, namely, students, residents, trainees, or inexperienced workers in related majors or domains.”

C: Usually in English scientific writing “I” or “the author” is not used- recommend rephrasing throughout.
R: I appreciate this feedback. In some cases, I used the personal pronoun or the subject “the author” to avoid passive sentence construction. I tried to use the passive form as little as possible, according to the guidelines of some journals on medical education.

C: In the Abstract, The Background section of an abstract usually provides context for the study rather than describing what the study did.
R: I modified this, as you pointed out.

C: Make sure that any changes to the body of the article are reflected in the abstract.
R: I also modified the abstract.

C: Define what you mean by intervention/empirical intervention study.
R: I added the definition in 1st paragraph of the Introduction: “studies which include both training practices and corroborating its effects.”

C: “Expertization” should be explicitly defined.
R: I deleted the word and removed it from the article.

C: In Methods, “features and tendencies” of the selected articles is mentioned- please explain what is meant by this.
R: I revised research question one to make it clearer and more concise: What key features or trends characterize visual art observation training in intervention studies aimed at improving observation skills?

C: In Methods, the first paragraph mentions “studies that used visual arts for cultivating observation skills” but was this the only goal of the included studies? This does not seem consistent with what is stated elsewhere in the article.
R: As stated in Methods, I included the studies that primarily aimed to “evaluate the effect of the intervention on technical skills related to observation,” and the goals that the included studies stated clearly were listed in Table 2.

C: The final paragraph of the introduction is not needed.
R: The paragraph was written at the journal editor’s suggestion.

C: In Methods, 3rd paragraph, second sentence “were excluded” needs to be moved to outside the parentheses
R: These words were removed.

C: Specifically outline your inclusion and exclusion criteria. Include a figure that shows how articles were selected, numbers of articles at each step of the process, that 12 articles were selected for full review.
R: Following the PRISMA-ScR, I added information to the Methods and added Figure 1.

C: Abbreviations need to be explained in the table (regardless of whether they are also explained in the text- the table should be able to stand alone).
R: I modified Table 2 as per your recommendation.

C: Results could be strengthened by using numbers instead of terms like “most”
R: I modified this, as you pointed out.

C: Overall the discussion would benefit from a clearer focus on the original question- specifically diagnostic skills, not art observation studies in general.
R: As explained, the focus has changed.

C: Clarify what you mean by diagnosis- visual diagnosis only? Clinical reasoning (which would be much broader)? How did you decide about diagnostic evidence? Is improved diagnostic accuracy the only criterion? What about other elements of the diagnostic process or approach to complex cases in which the diagnosis is unclear?
R: Due to the change in the focus of this paper, I cannot directly answer these questions. On the other hand, as mentioned in the Introduction, the intervention studies claimed that the observational skills fostered by art observation could be applied to both medical imaging and clinical interviews. See also the next response.

C: If included studies were only those designed to improve observation skills, is it reasonable to assess them for improvement in diagnostic skills? How strong can any conclusions be? Only 1 study assessed diagnostic accuracy, and this was in a limited domain.
C: Observation is the first part of the diagnostic reasoning pathway, but not the only part. It seems simplistic to expect a single intervention to have a great and immediate impact on diagnostic accuracy.
R: I agree with you. However, the intervention studies claimed that art observation could facilitate diagnostic skills (directly or indirectly), as mentioned in the Introduction. This paper examined the claim. Moreover, in the “Technical knowledge and skills based on observation skills” subsection of the Discussion section, I argued that the relationship to technical knowledge and skills of learners should be considered to examine this clearly.

C: Why might improvement in diagnostic skills be difficult to demonstrate in a study? Provide context, difficulty of assessing long term effects. How could future researchers attempt this?
R: See the response immediately above. In addition, I added the subsection “Long-term effects such as scaffolding” to discuss this. See also the “Implications for future research” subsection.

C: Throughout the discussion it needs to be made clear when you are referring to studies in experts vs studies in novices. This is not clear for a reader who is not already familiar with this literature.
R: This seems to relate to the next comment. If not, I may have misunderstood your question. Please let me know if the subsequent response is not satisfactory, and I will do my best to address your question.

C: Novices are not experts, one can’t teach them the same way. If your position is that novices should be taught like experts, this needs to be explicitly stated and supported from the literature.
R: The revised version does not mention that novices should be taught like experts. Concerning this comment, I also revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful.

C: Consider that one might not see an improvement right after the intervention in 2nd year, but could it be helpful once students have more diagnostic experience, eg in 4th year?
R: This is discussed in the subsection “Long-term effects such as scaffolding.”

C: Clearly and briefly list what reported benefits of art observation are.
R: In the 2^nd paragraph of the Introduction, I listed the technical skills that intervention studies aimed at. I also added this as the result of this review in the subsection “Outcome measures and their results” in the Results section.

C: Conclusions should be a single paragraph stating your major findings.
R: I modified it as you pointed out.

C: The conclusion appears to be that the impact of art observation on diagnostic skill has not been adequately investigated, rather than that it is ineffective. The statement “there is no concrete evidence on whether appreciating visual art contributes toward an accurate diagnosis” is more accurate.
R: As a result of the reanalysis, such wording was used in the paper.

C: In Conclusions, the claim that “it would be better to use learning modules based on perceptual learning using cases to foster pattern recognition” was not the focus of this article.
R: This description was deleted.

C: No veterinary medicine literature was included. Is there a reason for this?
R: Three studies in veterinary education were included because they were comparable to training and experimental designs in human health professional education.

C: In Limitations, studies that included other methods were excluded- can’t comment on what the effects of these studies are. Also, there is no mention of the limitations of using quantitative population statistics.
R: I added these to the Limitations subsection.
Dear Reviewer,
Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the article.

I added the scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). I expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster. Therefore, I cannot sufficiently respond to your suggestions regarding diagnostic skills. However, inspired by the suggestions, I discussed the relationship between visual art observation and technical knowledge and skills acquired through education and training.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): In the title, use “art observation” instead of “appreciating visual arts”. Also “medical diagnostic skills” instead of “medical diagnosis skills”. Suggest including ‘who’ as well- medical students? Novice learners?
Response (R): I modified the title: “Effects of visual art observation on technical skills in novice healthcare learners: A scoping review.” I also revised the language to use “visual art observation” and “diagnostic skills” in the article. Moreover, I added the definition of novice medical learners in 4^th paragraph of the Introduction: “novice healthcare learners, namely, students, residents, trainees, or inexperienced workers in related majors or domains.”

C: Usually in English scientific writing “I” or “the author” is not used- recommend rephrasing throughout.
R: I appreciate this feedback. In some cases, I used the personal pronoun or the subject “the author” to avoid passive sentence construction. I tried to use the passive form as little as possible, according to the guidelines of some journals on medical education.

C: In the Abstract, The Background section of an abstract usually provides context for the study rather than describing what the study did.
R: I modified this, as you pointed out.

C: Make sure that any changes to the body of the article are reflected in the abstract.
R: I also modified the abstract.

C: Define what you mean by intervention/empirical intervention study.
R: I added the definition in 1st paragraph of the Introduction: “studies which include both training practices and corroborating its effects.”

C: “Expertization” should be explicitly defined.
R: I deleted the word and removed it from the article.

C: In Methods, “features and tendencies” of the selected articles is mentioned- please explain what is meant by this.
R: I revised research question one to make it clearer and more concise: What key features or trends characterize visual art observation training in intervention studies aimed at improving observation skills?

C: In Methods, the first paragraph mentions “studies that used visual arts for cultivating observation skills” but was this the only goal of the included studies? This does not seem consistent with what is stated elsewhere in the article.
R: As stated in Methods, I included the studies that primarily aimed to “evaluate the effect of the intervention on technical skills related to observation,” and the goals that the included studies stated clearly were listed in Table 2.

C: The final paragraph of the introduction is not needed.
R: The paragraph was written at the journal editor’s suggestion.

C: In Methods, 3rd paragraph, second sentence “were excluded” needs to be moved to outside the parentheses
R: These words were removed.

C: Specifically outline your inclusion and exclusion criteria. Include a figure that shows how articles were selected, numbers of articles at each step of the process, that 12 articles were selected for full review.
R: Following the PRISMA-ScR, I added information to the Methods and added Figure 1.

C: Abbreviations need to be explained in the table (regardless of whether they are also explained in the text- the table should be able to stand alone).
R: I modified Table 2 as per your recommendation.

C: Results could be strengthened by using numbers instead of terms like “most”
R: I modified this, as you pointed out.

C: Overall the discussion would benefit from a clearer focus on the original question- specifically diagnostic skills, not art observation studies in general.
R: As explained, the focus has changed.

C: Clarify what you mean by diagnosis- visual diagnosis only? Clinical reasoning (which would be much broader)? How did you decide about diagnostic evidence? Is improved diagnostic accuracy the only criterion? What about other elements of the diagnostic process or approach to complex cases in which the diagnosis is unclear?
R: Due to the change in the focus of this paper, I cannot directly answer these questions. On the other hand, as mentioned in the Introduction, the intervention studies claimed that the observational skills fostered by art observation could be applied to both medical imaging and clinical interviews. See also the next response.

C: If included studies were only those designed to improve observation skills, is it reasonable to assess them for improvement in diagnostic skills? How strong can any conclusions be? Only 1 study assessed diagnostic accuracy, and this was in a limited domain.
C: Observation is the first part of the diagnostic reasoning pathway, but not the only part. It seems simplistic to expect a single intervention to have a great and immediate impact on diagnostic accuracy.
R: I agree with you. However, the intervention studies claimed that art observation could facilitate diagnostic skills (directly or indirectly), as mentioned in the Introduction. This paper examined the claim. Moreover, in the “Technical knowledge and skills based on observation skills” subsection of the Discussion section, I argued that the relationship to technical knowledge and skills of learners should be considered to examine this clearly.

C: Why might improvement in diagnostic skills be difficult to demonstrate in a study? Provide context, difficulty of assessing long term effects. How could future researchers attempt this?
R: See the response immediately above. In addition, I added the subsection “Long-term effects such as scaffolding” to discuss this. See also the “Implications for future research” subsection.

C: Throughout the discussion it needs to be made clear when you are referring to studies in experts vs studies in novices. This is not clear for a reader who is not already familiar with this literature.
R: This seems to relate to the next comment. If not, I may have misunderstood your question. Please let me know if the subsequent response is not satisfactory, and I will do my best to address your question.

C: Novices are not experts, one can’t teach them the same way. If your position is that novices should be taught like experts, this needs to be explicitly stated and supported from the literature.
R: The revised version does not mention that novices should be taught like experts. Concerning this comment, I also revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful.

C: Consider that one might not see an improvement right after the intervention in 2nd year, but could it be helpful once students have more diagnostic experience, eg in 4th year?
R: This is discussed in the subsection “Long-term effects such as scaffolding.”

C: Clearly and briefly list what reported benefits of art observation are.
R: In the 2^nd paragraph of the Introduction, I listed the technical skills that intervention studies aimed at. I also added this as the result of this review in the subsection “Outcome measures and their results” in the Results section.

C: Conclusions should be a single paragraph stating your major findings.
R: I modified it as you pointed out.

C: The conclusion appears to be that the impact of art observation on diagnostic skill has not been adequately investigated, rather than that it is ineffective. The statement “there is no concrete evidence on whether appreciating visual art contributes toward an accurate diagnosis” is more accurate.
R: As a result of the reanalysis, such wording was used in the paper.

C: In Conclusions, the claim that “it would be better to use learning modules based on perceptual learning using cases to foster pattern recognition” was not the focus of this article.
R: This description was deleted.

C: No veterinary medicine literature was included. Is there a reason for this?
R: Three studies in veterinary education were included because they were comparable to training and experimental designs in human health professional education.

C: In Limitations, studies that included other methods were excluded- can’t comment on what the effects of these studies are. Also, there is no mention of the limitations of using quantitative population statistics.
R: I added these to the Limitations subsection.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 19 Jan 2023

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2
Version 2 (revision) 19 Mar 25		read
Version 1 19 Jan 23	read	read

Nicole J Fernandez, University of Saskatchewan, Saskatoon, Canada
Margaret S. Chisolm, Johns Hopkins University School of Medicine, Baltimore, USA

Comments on this article

All Comments(0)

Add a comment

Browse by related subjects

Back to all reports

Reviewer Report

10 Views

26 Mar 2025 | for Version 2

Margaret S. Chisolm, Department of Psychiatry and Behavioral Services, and of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

10 Views Cite this report Responses(0)

Approved

Approved with no further suggestions

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

24 Views

21 Jun 2024 | for Version 1

Margaret S. Chisolm, Department of Psychiatry and Behavioral Services, and of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

24 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

museum-based health professions education

Respond to this report

Responses (1)

Author Response

19 Mar 2025

Koji MATSUMOTO, Nagoya Gakuin University, Nagoya, Japan

Dear Reviewer,

Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the work.

I designed a scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Inspired by your comments, I also expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): The abstract is lacking in conceptual clarity/relevance and presentation of replicable methods and clearly stated results.
Response (R): I designed the study following the PRISMA-ScR and revised the entire Abstract.

C: Not clear why the term "visual arts appreciation" is used as "appreciation" is not integral to teaching visual arts-based medical education.
R: According to a suggestion by another reviewer, I modified it to “visual art observation.”

C: It would also be important to mention the international consensus that the arts and humanities are fundamental to medical education.
R: I did not discuss this in this paper but did elsewhere (See Ref 1). I believe I understand this background.
[Ref 1] Matsumoto K. The use of arts in health professions education: applicability as a new teaching method. Igaku Kyoiku / Medical Education (Japan). 2023;54(3):235-243. Article in Japanese.

C: Enhancement of observation skills is just one of many targeted skills and attributes that may improve patient outcomes, via diagnostic accuracy or other mechanisms, all of which are more "downstream."
R: I agree; this paper examines the claim that the interventions also work “downstream,” as the advocates argued.

C: Although one of the primary goals of developing observations skills is to improve diagnostic accuracy, this is a very downstream outcome to which many other skills may contribute and also other downstream outcomes are clinically relevant as well.
Then, I added the “Technical knowledge and skills based on observation skills” subsection to insist that it is necessary to consider the technical knowledge and skills of the learners.

C: I'm not sure to improve diagnostic accuracy is THE primary aim of any of the use of visual arts in medical education, and so it's not surprising that only one study measured this.
R: The scope of the study extended to skills related to observation.

C: It appears that results are included in introduction prior to presenting methods and results later, and would avoid including results in the introduction and instead put this in context of literature more broadly.
C: The previously mentioned review studies should be placed in the results, not in the Introduction or Methods sections.
R: The reason for mentioning the prior reviews in the Introduction is to show the need for this review by presenting the attainments and unsolved issues of the previous reviews.

C: A research question needs to be articulated.
R: I added this to the Introduction.

C: The Methods should follow PRISMA guidelines.
R: I revised the Methods according to the PRISMA-ScR.

C: The word "around" should never be part of a systematic review, which this is not. More precision in the text would be helpful here (i.e., % studies versus "most" AAMC or "some").
R: I followed this suggestion and revised this section accordingly.

C: The author misstates two of the three core questions of VTS.
R: I revised this, thank you for pointing it out.

C: The penultimate paragraph of the Results section was the most informative of the manuscript, describing the study design and outcomes, which are suggestive of impact on observation skills.
R: In this revised version, the description was expanded in more detail.

C: In Discussion, use of the word "target" in the first sentence to describe the work of art is an odd choice.
R: In this version, this sentence was entirely revised.

C: The idea that observing for a longer period of time is not necessary for an accurate diagnosis among experts obscures the important role of taking time for beginners to avoid premature diagnostic closure via arriving at a diagnosis too quickly and not staying open to possibilities is important to good patient outcomes. Instances exist where taking more time would have resulted in a more accurate diagnosis for an individual patient.
R: I revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful. The previous studies cited in the subsection deny the idea. Additionally, please tell me the specific references you are referring to.

C: At least one more recent study does support visual arts to make a statistically significant contribution to tolerance for ambiguity.
R: As mentioned in the “Longer periods of careful and systematic observations for accurate diagnosis” subsection, the effectiveness of tolerance to clinical practice is debatable.

C: The ability to look should precede the ability to know what to discard as relevant, so a beginner's inability to overlook irrelevant features seems a bit irrelevant to teaching beginners to look.
R: I understood this suggestion to mean that teaching students how to look and then the knowledge or skills to identify the critical signs may be beneficial. If this is what you mean, I discussed this as scaffolding in the “Long-term effects such as scaffolding” subsection, as I did in version 1.

C: The author raises good questions about the limitations of transfer and the need for more research to study the transfer of skills from the museum or classroom to the clinic.
R: This was mentioned in the revised version as well.

C: They make a good point about the role of visual arts to foster communication skills (both listening and and team-building/perspective taking.
R: As a result of reanalysis, I stated that there is insufficient evidence that art observation helps with these skills in the Results and “Fostering verbalizing skills…” subsection of the Discussion.

C: "verbalizing," which perhaps "speaking" or "articulately" would be a less awkward word choice.
R: “Vernalizing” means making words out of what one sees, as the text states. Additionally, given the use of description as an outcome measure in the studies, I think “speaking” and “articulately” differ slightly from what I wished to express.

C: I would not be surprised by a lack of evidence on whether visual arts-based teaching aids diagnostic accuracy. The field is in an exploratory phase and its aims are to explore an array of attributes that may have an effect on these and other "downstream" outcomes.
C: The conclusion that "adopting visual art appreciation is not encouraged" seems to me an overstatement given the limitations of this review and the exploratory nature of the field.
C: The findings of the study and these recommendations for improvement should be place in the context of the broader literature on these research gaps as outlined in the Howley et al AAMC FRAHME report and the Moniz et al scoping review, which also suggests more research rigor etc.
C: Clearly innovation is needed that goes beyond medical cases and knowledge transfer to teach students an array of otherwise difficult-to-teach clinically relevant attributes, which may improve patient outcomes, whether via diagnostic accuracy or other effects.
R: I agree with these opinions and revised the Discussion and Conclusion from this standpoint. I tried to suggest directions and challenges for future research for developing this field. On the other hand, I did not provide suggestions for practice, judging that there is not enough evidence to apply them to practice.

C: Limitations should include that this is not a systematic review in accordance with the PRISMA guidelines, and that relevant articles may have been missed by the search strategy etc
R: I designed the study according to the PRISMA-ScR.

View more View less

Competing Interests

No competing interests were disclosed.

Back to all reports

Reviewer Report

34 Views

16 Feb 2024 | for Version 1

Nicole J Fernandez, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

34 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Tolerance of ambiguity, teaching observational skills, case-based learning, clinical pathology

Respond to this report

Responses (1)

Author Response

19 Mar 2025

Koji MATSUMOTO, Nagoya Gakuin University, Nagoya, Japan

Dear Reviewer,
Thank you very much for your thorough review. Your comments are really valuable and will contribute to improving the quality of the article.

I added the scoping reviews protocol in this revised version following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). I expanded my focus from diagnostic skills to the technical skills that the intervention studies claimed art observation can foster. Therefore, I cannot sufficiently respond to your suggestions regarding diagnostic skills. However, inspired by the suggestions, I discussed the relationship between visual art observation and technical knowledge and skills acquired through education and training.

I would like to address each of the points you raised (some of the comments are reordered, and duplicate comments were consolidated):

Comment (C): In the title, use “art observation” instead of “appreciating visual arts”. Also “medical diagnostic skills” instead of “medical diagnosis skills”. Suggest including ‘who’ as well- medical students? Novice learners?
Response (R): I modified the title: “Effects of visual art observation on technical skills in novice healthcare learners: A scoping review.” I also revised the language to use “visual art observation” and “diagnostic skills” in the article. Moreover, I added the definition of novice medical learners in 4^th paragraph of the Introduction: “novice healthcare learners, namely, students, residents, trainees, or inexperienced workers in related majors or domains.”

C: Usually in English scientific writing “I” or “the author” is not used- recommend rephrasing throughout.
R: I appreciate this feedback. In some cases, I used the personal pronoun or the subject “the author” to avoid passive sentence construction. I tried to use the passive form as little as possible, according to the guidelines of some journals on medical education.

C: In the Abstract, The Background section of an abstract usually provides context for the study rather than describing what the study did.
R: I modified this, as you pointed out.

C: Make sure that any changes to the body of the article are reflected in the abstract.
R: I also modified the abstract.

C: Define what you mean by intervention/empirical intervention study.
R: I added the definition in 1st paragraph of the Introduction: “studies which include both training practices and corroborating its effects.”

C: “Expertization” should be explicitly defined.
R: I deleted the word and removed it from the article.

C: In Methods, “features and tendencies” of the selected articles is mentioned- please explain what is meant by this.
R: I revised research question one to make it clearer and more concise: What key features or trends characterize visual art observation training in intervention studies aimed at improving observation skills?

C: In Methods, the first paragraph mentions “studies that used visual arts for cultivating observation skills” but was this the only goal of the included studies? This does not seem consistent with what is stated elsewhere in the article.
R: As stated in Methods, I included the studies that primarily aimed to “evaluate the effect of the intervention on technical skills related to observation,” and the goals that the included studies stated clearly were listed in Table 2.

C: The final paragraph of the introduction is not needed.
R: The paragraph was written at the journal editor’s suggestion.

C: In Methods, 3rd paragraph, second sentence “were excluded” needs to be moved to outside the parentheses
R: These words were removed.

C: Specifically outline your inclusion and exclusion criteria. Include a figure that shows how articles were selected, numbers of articles at each step of the process, that 12 articles were selected for full review.
R: Following the PRISMA-ScR, I added information to the Methods and added Figure 1.

C: Abbreviations need to be explained in the table (regardless of whether they are also explained in the text- the table should be able to stand alone).
R: I modified Table 2 as per your recommendation.

C: Results could be strengthened by using numbers instead of terms like “most”
R: I modified this, as you pointed out.

C: Overall the discussion would benefit from a clearer focus on the original question- specifically diagnostic skills, not art observation studies in general.
R: As explained, the focus has changed.

C: Clarify what you mean by diagnosis- visual diagnosis only? Clinical reasoning (which would be much broader)? How did you decide about diagnostic evidence? Is improved diagnostic accuracy the only criterion? What about other elements of the diagnostic process or approach to complex cases in which the diagnosis is unclear?
R: Due to the change in the focus of this paper, I cannot directly answer these questions. On the other hand, as mentioned in the Introduction, the intervention studies claimed that the observational skills fostered by art observation could be applied to both medical imaging and clinical interviews. See also the next response.

C: If included studies were only those designed to improve observation skills, is it reasonable to assess them for improvement in diagnostic skills? How strong can any conclusions be? Only 1 study assessed diagnostic accuracy, and this was in a limited domain.
C: Observation is the first part of the diagnostic reasoning pathway, but not the only part. It seems simplistic to expect a single intervention to have a great and immediate impact on diagnostic accuracy.
R: I agree with you. However, the intervention studies claimed that art observation could facilitate diagnostic skills (directly or indirectly), as mentioned in the Introduction. This paper examined the claim. Moreover, in the “Technical knowledge and skills based on observation skills” subsection of the Discussion section, I argued that the relationship to technical knowledge and skills of learners should be considered to examine this clearly.

C: Why might improvement in diagnostic skills be difficult to demonstrate in a study? Provide context, difficulty of assessing long term effects. How could future researchers attempt this?
R: See the response immediately above. In addition, I added the subsection “Long-term effects such as scaffolding” to discuss this. See also the “Implications for future research” subsection.

C: Throughout the discussion it needs to be made clear when you are referring to studies in experts vs studies in novices. This is not clear for a reader who is not already familiar with this literature.
R: This seems to relate to the next comment. If not, I may have misunderstood your question. Please let me know if the subsequent response is not satisfactory, and I will do my best to address your question.

C: Novices are not experts, one can’t teach them the same way. If your position is that novices should be taught like experts, this needs to be explicitly stated and supported from the literature.
R: The revised version does not mention that novices should be taught like experts. Concerning this comment, I also revised the subsection “Longer periods of careful and systematic observations for accurate diagnosis” to state clearly that teaching novice medical students systematic viewing is not helpful.

C: Consider that one might not see an improvement right after the intervention in 2nd year, but could it be helpful once students have more diagnostic experience, eg in 4th year?
R: This is discussed in the subsection “Long-term effects such as scaffolding.”

C: Clearly and briefly list what reported benefits of art observation are.
R: In the 2^nd paragraph of the Introduction, I listed the technical skills that intervention studies aimed at. I also added this as the result of this review in the subsection “Outcome measures and their results” in the Results section.

C: Conclusions should be a single paragraph stating your major findings.
R: I modified it as you pointed out.

C: The conclusion appears to be that the impact of art observation on diagnostic skill has not been adequately investigated, rather than that it is ineffective. The statement “there is no concrete evidence on whether appreciating visual art contributes toward an accurate diagnosis” is more accurate.
R: As a result of the reanalysis, such wording was used in the paper.

C: In Conclusions, the claim that “it would be better to use learning modules based on perceptual learning using cases to foster pattern recognition” was not the focus of this article.
R: This description was deleted.

C: No veterinary medicine literature was included. Is there a reason for this?
R: Three studies in veterinary education were included because they were comparable to training and experimental designs in human health professional education.

C: In Limitations, studies that included other methods were excluded- can’t comment on what the effects of these studies are. Also, there is no mention of the limitations of using quantitative population statistics.
R: I added these to the Limitations subsection.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Anderson N, Dietrich MR: Introduction: visual lessons and the life sciences.Anderson N, Dietrich MR, editors. The Educated Eye: Visual Culture and Pedagogy in the Life Sciences. Hanover (NH):Dartmouth College Press; 2012; pp. 1–13.

[2] 2. Braverman IM: To see or not to see: how visual training can improve observational skills. Clin. Dermatol. 2011; 29(3): 343–346. Publisher Full Text

[3] 3. Sandhu VK: Inspection—a fine art. JAMA Dermatol. 2018; 154(5): 630. PubMed Abstract | Publisher Full Text

[4] 4. Watson F, Rebair A: The art of noticing: essential to nursing practice. Br. J. Nurs. 2014; 23(10): 514–517. Publisher Full Text

[5] 5. Boisaubin EV, Winkler MG: Seeing patients and life contexts: the visual arts in medical education. Am. J. Med. Sci. 2000; 319(5): 292–296. PubMed Abstract Reference Source

[6] 6. Bardes CL, Gillers D, Herman AE: Learning to look: developing clinical observational skills at an art museum. Med. Educ. 2001; 35(12): 1157–1161. PubMed Abstract | Publisher Full Text

[7] 7. Pitman B: Art museum and medical school partnerships program descriptions. Richardson, TX:The Edith O’Donnell Institute of Art History, The University of Texas at Dallas;2020 [cited 2022 Oct 29].Reference Source

[8] 8. Pellegrino ED: Visual awareness: the visual arts and the clinician’s craft.Berg G, editor. The Visual Arts and Medical Education. Carbondale (IL):Southern Illinois University Press; 1983; pp. ix–xi.

[9] 9. Schaff PB, Isken S, Tager RM: From contemporary art to core clinical skills: observation, interpretation, and meaning-making in a complex environment. Acad. Med. 2011; 86(10): 1272–1276. Publisher Full Text

[10] 10. He B, Prasad S, Higashi RT, et al.: The art of observation: a qualitative analysis of medical students’ experiences. BMC Med. Educ. 2019; 19(1): 234. PubMed Abstract | Publisher Full Text | Free Full Text

[11] 11. Hoshiko BR: Nursing diagnosis at the art museum. Nurs. Outlook. 1985; 33(1): 32–36.

[12] 12. Jacques A, Trinkley R, Stone L, et al.: Art of Analysis: a cooperative program between a museum and medicine. J. Learn. Through Arts. 2012; 8(1). Reference Source

[13] 13. Gelgoot E, Caufield-Noll C, Chisolm M: Using the visual arts to teach clinical excellence. 1^st version. MedEdPublish. 2018; 7: 143. Publisher Full Text

[14] 14. Elhammoumi CV, Kellam B: Art images in holistic nursing education. Religions. 2017; 8(6): 1–8. Publisher Full Text

[15] 15. Perry M, Maffulli N, Willson S, et al.: The effectiveness of arts-based interventions in medical education: a literature review. Med. Educ. 2011; 45(2): 141–148. PubMed Abstract | Publisher Full Text

[16] 16. Mukunda N, Moghbeli N, Rizzo A, et al.: Visual art instruction in medical education: a narrative review. Med. Educ. Online. 2019; 24(1): 1558657. PubMed Abstract | Publisher Full Text | Free Full Text

[17] 17. Alkhaifi M, Clayton A, Kangasjarvi E, et al.: Visual art-based training in undergraduate medical education: A systematic review. Med. Teach. 2022; 44(5): 500–509. PubMed Abstract | Publisher Full Text

[18] 18. Dalia Y, Milam EC, Rieder EA: Art in medical education: a review. J. Grad. Med. Educ. 2020; 12(6): 686–695. Publisher Full Text

[19] 19. Turton BM, Williams S, Burton CR, et al.: Arts-based palliative care training, education and staff development: A scoping review. Palliat. Med. 2018; 32(2): 559–570. Publisher Full Text

[20] 20. Ike JD, Howell J: Quantitative metrics and psychometric scales in the visual art and medical education literature: a narrative review. Med. Educ. Online. 2022; 27(1): 2010299. PubMed Abstract | Publisher Full Text | Free Full Text

[21] 21. Coderre S, Mandin H, Harasym PH, et al.: Diagnostic reasoning strategies and diagnostic success. Med. Educ. 2003; 37(8): 695–703. PubMed Abstract | Publisher Full Text

[22] 22. Kellman PJ, Jacoby V, Massey C, et al.: Perceptual learning, adaptive learning, and gamification: educational technologies for pattern recognition, problem solving, and knowledge retention in medical learning.Witchel HJ, Lee MW, editors. Technologies in Biomedical and Life Sciences Education. Cham (DK):Springer; 2022; pp. 135–166. Publisher Full Text

[23] 23. Myles-Worsley M, Johnston WA, Simons MA: The influence of expertise on X-ray image processing. J. Exp. Psychol. Learn. Mem. Cogn. 1988; 14(3): 553–557. Publisher Full Text

[24] 24. Green MJ, Myers KR: Graphic medicine: use of comics in medical education and patient care. BMJ. 2010; 340: c863. PubMed Abstract | Publisher Full Text

[25] 25. Anglin C, Halpin-Healy C, Rosenfeld P: Reflecting art in nursing practice: developing visual arts programs to transform and strengthen practice. J. Nurs. Adm. 2020; 50(5): 274–280. Publisher Full Text

[26] 26. Agarwal GG, McNulty M, Santiago KM, et al.: Impact of Visual Thinking Strategies (VTS) on the analysis of clinical images: a pre-post study of VTS in first-year medical students. J. Med. Humanit. 2020; 41(4): 561–572. PubMed Abstract | Publisher Full Text

[27] 27. Dolev JC, Friedlaender LK, Braverman IM: Use of fine art to enhance visual diagnostic skills. JAMA. 2001; 286(9): 1020–1021. PubMed Abstract Reference Source

[28] 28. Garino A: Improving observation skill in physician assistant students. J. Physician Assist. Educ. 2008; 19(1): 47–52. Publisher Full Text

[29] 29. Goodman TR, Kelleher M: Improving novice radiology trainees’ perception using fine art. J. Am. Coll. Radiol. 2017; 14(10): 1337–1340. PubMed Abstract | Publisher Full Text

[30] 30. Griffin LL, Chiang NYZ, Tomlin H, et al.: A visual literacy course for dermatology trainees. Br. J. Dermatol. 2017; 177(1): 310–311. PubMed Abstract | Publisher Full Text

[31] 31. Grossman S, Deupi J, Leitao K: Seeing the forest and the trees: increasing nurse practitioner students’ observational and mindfulness skills. Creat. Nurs. 2014; 20(1): 67–72. PubMed Abstract | Publisher Full Text

[32] 32. Gurwin J, Revere KE, Niepold S, et al.: A Randomized controlled study of art observation training to improve medical student ophthalmology skills. Ophthalmology. 2018; 125(1): 8–14. PubMed Abstract | Publisher Full Text

[33] 33. Huang JT, Reynolds SD, DiGiovanni EB, et al.: Fine arts curriculum improves observational skills of dermatology trainees: a pilot study. Br. J. Dermatol. 2016; 175(4): 815–817. PubMed Abstract | Publisher Full Text

[34] 34. Jasani SK, Saks NS: Utilizing visual art to enhance the clinical observation skills of medical students. Med. Teach. 2013; 35(7): e1327–e1331. PubMed Abstract | Publisher Full Text

[35] 35. Klugman CM, Peel J, Beckmann-Mendez D: Art Rounds: teaching interprofessional students visual thinking strategies at one school. Acad. Med. 2011; 86(10): 1266–1271. PubMed Abstract | Publisher Full Text

[36] 36. Pellico LH, Friedlaender L, Fennie KP: Looking is not seeing: using art to improve observational skills. J. Nurs. Educ. 2009; 48(11): 648–653. Publisher Full Text

[37] 37. Poirier TI, Newman K, Ronald K: An exploratory study using Visual Thinking Strategies to improve undergraduate students’ observational skills. Am. J. Pharm. Educ. 2020; 84(4): 7600. PubMed Abstract | Publisher Full Text | Free Full Text

[38] 38. Ferrara V, De Santis S, Manicone F, et al.: The visual art as a learning tool in medical education. Senses Sci. 2020; 7(2): 1028–1040.

[39] 39. Honan L, Shealy S, Fennie K, et al.: Looking is not seeing and listening is not hearing: a replication study with accelerated BSN students. J. Prof. Nurs. 2016; 32(5S): S30–S36. PubMed Abstract | Publisher Full Text

[40] 40. Kirklin D, Duncan J, McBride S, et al.: A cluster design controlled trial of arts-based observational skills training in primary care. Med. Educ. 2007; 41(4): 395–401. PubMed Abstract | Publisher Full Text

[41] 41. Naghshineh S, Hafler JP, Miller AR, et al.: Formal art observation training improves medical students’ visual diagnostic skills. J. Gen. Intern. Med. 2008; 23(7): 991–997. PubMed Abstract | Publisher Full Text | Free Full Text

[42] 42. Nease BM, Haney TS: Evaluating an art-based intervention to improve practicing nurses’ observation, description, and problem identification skills. J. Nurses Prof. Dev. 2018; 34(1): 2–7. PubMed Abstract | Publisher Full Text

[43] 43. Yenawine P: Visual Thinking Strategies: Using Art to Deepen Learning across School Disciplines. Cambridge (MA):Harvard Education Press;2013.

[44] 44. Kundel HL, Nodine CF, Conant EF, et al.: Holistic component of image perception in mammogram interpretation: gaze-tracking study. Radiology. 2007; 242(2): 396–402. PubMed Abstract | Publisher Full Text

[45] 45. Nodine CF, Mello-Thoms C, Kundel HL, et al.: Time course of perception and decision making during mammographic interpretation. AJR Am. J. Roentgenol. 2002; 179(4): 917–923. PubMed Abstract | Publisher Full Text

[46] 46. Norman GR, Rosenthal D, Brooks LR, et al.: The development of expertise in dermatology. Arch. Dermatol. 1989; 125(8): 1063–1068. Publisher Full Text

[47] 47. Kok EM, Jarodzka H, de Bruin AB , et al.: Systematic viewing in radiology: seeing more, missing less? Adv. Health Sci. Educ. Theory Pract. 2016; 21(1): 189–205. PubMed Abstract | Publisher Full Text | Free Full Text

[48] 48. van Geel K , Kok EM, Dijkstra J, et al.: Teaching systematic viewing to final-year medical students improves systematicity but not coverage or detection of radiologic abnormalities. J. Am. Coll. Radiol. 2017; 14(2): 235–241. Publisher Full Text

[49] 49. Krupinski EA: Visual scanning patterns of radiologists searching mammograms. Acad. Radiol. 1996; 3(2): 137–144. PubMed Abstract | Publisher Full Text

[50] 50. Kundel HL, Nodine CF, Krupinski EA, et al.: Using gaze-tracking data and mixture distribution analysis to support a holistic model for the detection of cancers on mammograms. Acad. Radiol. 2008; 15(7): 881–886. PubMed Abstract | Publisher Full Text

[51] 51. O’Neill EC, Kong YX, Connell PP, et al.: Gaze behavior among experts and trainees during optic disc examination: does how we look affect what we see? Invest. Ophthalmol. Vis. Sci. 2011; 52(7): 3976–3983. PubMed Abstract | Publisher Full Text

[52] 52. Al-Moteri MO, Symmons M, Plummer V, et al.: Eye tracking to investigate cue processing in medical decision-making: a scoping review. Comput. Hum. Behav. 2017; 66: 52–66. Publisher Full Text

[53] 53. Evered A: What can cytologists learn from 25 years of investigations in visual search? Br. J. Biomed. Sci. 2005; 62(4): 182–192. PubMed Abstract | Publisher Full Text

[54] 54. Nodine C, Mello-Thoms C: Acquiring expertise in radiologic image interpretation.Samei E, Krupinski E, editors. The Handbook of Medical Image Perception and Techniques. Cambridge (UK):Cambridge University Press; 2018; pp. 167–187.

[55] 55. Norman GR, Coblentz CL, Brooks LR, et al.: Expertise in visual diagnosis: a review of the literature. Acad. Med. 1992; 67(10(suppl)): S78–S83. Publisher Full Text

[56] 56. Wu CC, Wolfe JM: Eye movements in medical image perception: a selective review of past, present and future. Vision (Basel). 2019; 3(2): 32. PubMed Abstract | Publisher Full Text | Free Full Text

[57] 57. van der Gijp A , Ravesloot CJ, Jarodzka H, et al.: How visual search relates to visual diagnostic performance: a narrative systematic review of eye-tracking research in radiology. Adv. Health Sci. Educ. Theory Pract. 2017; 22(3): 765–787. PubMed Abstract | Publisher Full Text | Free Full Text

[58] 58. Drew T, Evans K, Võ ML, et al.: Informatics in radiology: what can you see in a single glance and how might this guide visual search in medical images? Radiographics. 2013; 33(1): 263–274. PubMed Abstract | Publisher Full Text | Free Full Text

[59] 59. Gachon J, Beaulieu P, Sei JF, et al.: First prospective study of the recognition process of melanoma in dermatological practice. Arch. Dermatol. 2005; 141(4): 434–438. PubMed Abstract | Publisher Full Text

[60] 60. Groves M, O’Rourke P, Alexander H: The clinical reasoning characteristics of diagnostic experts. Med. Teach. 2003; 25(3): 308–313. PubMed Abstract | Publisher Full Text

[61] 61. Kellman PJ: Adaptive and perceptual learning technologies in medical education and training. Mil. Med. 2013; 178(10 suppl): 98–106. PubMed Abstract | Publisher Full Text

[62] 62. Ericsson KA: Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad. Med. 2015; 90(11): 1471–1486. PubMed Abstract | Publisher Full Text

[63] 63. Lesgold A, Rubinson H, Feltovich P, et al.: Expertise in a complex skill: diagnosing x-ray pictures.Chi MTH, Glaser R, Farr MJ, editors. The Nature of Expertise. Hillsdale (NJ):Lawrence Erlbaum Associates; 1988; p. 311–342.

[64] 64. Taylor PM: A review of research into the development of radiologic expertise: implications for computer-based training. Acad. Radiol. 2007; 14(10): 1252–1263. PubMed Abstract | Publisher Full Text

[65] 65. Waite S, Farooq Z, Grigorian A, et al.: A review of perceptual expertise in radiology-how it develops, how we can test it, and why humans still matter in the era of artificial intelligence. Acad. Radiol. 2020; 27(1): 26–38. PubMed Abstract | Publisher Full Text

[66] 66. Haller S, Radue EW: What is different about a radiologist’s brain? Radiology. 2005; 236(3): 983–989. Publisher Full Text

[67] 67. Buhmann JM, Malik J, Perona P: Image recognition: visual grouping, recognition, and learning. Proc. Natl. Acad. Sci. U. S. A. 1999; 96(25): 14203–14204. PubMed Abstract | Publisher Full Text | Free Full Text

[68] 68. Castelhano MS, Rayner K: Eye movements during reading, visual search, and scene perception: an overview.Rayner K, Shen D, Bai X, et al., editors. Cognitive and Cultural Influences on Eye Movements. Tianjin:Tianjin People’s Publishing House; 2008; pp. 3–33.

[69] 69. Henderson JM, Weeks PA Jr, Hollingworth A: The effects of semantic consistency on eye movements during complex scene viewing. J. Exp. Psychol. Hum. Percept. Perform. 1999; 25(1): 210–228. Publisher Full Text

[70] 70. Henderson JM: Human gaze control during real-world scene perception. Trends Cogn. Sci. 2003; 7(11): 498–504. PubMed Abstract | Publisher Full Text

[71] 71. Nodine CF, Kundel HL, Mello-Thoms C, et al.: How experience and training influence mammography expertise. Acad. Radiol. 1999; 6(10): 575–585. Publisher Full Text

[72] 72. Strohbehn GW, Hoffman SJK, Tokaz M, et al.: Visual arts in the clinical clerkship: a pilot cluster-randomized, controlled trial. BMC Med. Educ. 2020; 20(1): 481. PubMed Abstract | Publisher Full Text | Free Full Text

[73] 73. Joseph GM, Patel VL: Domain knowledge and hypothesis generation in diagnostic reasoning. Med. Decis. Mak. 1990; 10(1): 31–44. PubMed Abstract | Publisher Full Text

[74] 74. Norman GR, Brooks LR, Colle CL, et al.: The benefit of diagnostic hypotheses in clinical reasoning: experimental study of an instructional intervention for forward and backward reasoning. Cogn. Instr. 1999; 17(4): 433–448. Publisher Full Text

[75] 75. Norman G: Research in clinical reasoning: past history and current trends. Med. Educ. 2005; 39(4): 418–427. PubMed Abstract | Publisher Full Text

[76] 76. Pelaccia T, Tardif J, Triby E, et al.: An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Med. Educ. Online. 2011; 16: 5890. PubMed Abstract | Publisher Full Text | Free Full Text

[77] 77. Norman GR, Eva KW: Diagnostic error and clinical reasoning. Med. Educ. 2010; 44(1): 94–100. Publisher Full Text

[78] 78. Brunyé TT, Drew T, Weaver DL, et al.: A review of eye tracking for understanding and improving diagnostic interpretation. Cogn. Res. Princ. Implic. 2019; 4(1): 7. PubMed Abstract | Publisher Full Text | Free Full Text

[79] 79. Drew T, Võ ML, Wolfe JM: The invisible gorilla strikes again: sustained inattentional blindness in expert observers. Psychol. Sci. 2013; 24(9): 1848–1853. PubMed Abstract | Publisher Full Text | Free Full Text

[80] 80. Norman G, Eva K, Brooks L, et al.: Expertise in medicine and surgery.Ericsson K, Charness N, Feltovich P, et al., editors. The Cambridge Handbook of Expertise and Expert Performance. Cambridge (UK):Cambridge University Press; 2006; pp. 339–354.

[81] 81. Cooper N: Human factors.Cooper N, Frain J, editors. ABC of Clinical Reasoning. Chichester (UK):John Wiley & Sons; 2017; pp. 27–32.

[82] 82. Croskerry P: Metacognition and cognitive debiasing.Cooper N, Frain J, editors. ABC of Clinical Reasoning. Chichester (UK):John Wiley & Sons; 2017; pp. 33–38.

[83] 83. Sowden PT, Davies IR, Roling P: Perceptual learning of the detection of features in X-ray images: a functional role for improvements in adults’ visual sensitivity? J. Exp. Psychol. Hum. Percept. Perform. 2000; 26(1): 379–390. PubMed Abstract | Publisher Full Text

[84] 84. Nodine CF, Krupinski EA: Perceptual skill, radiology expertise, and visual test performance with NINA and WALDO. Acad. Radiol. 1998; 5(9): 603–612. PubMed Abstract | Publisher Full Text

[85] 85. Evans KK, Cohen MA, Tambouret R, et al.: Does visual expertise improve visual recognition memory? Atten. Percept. Psychophys. 2011; 73(1): 30–35. PubMed Abstract | Publisher Full Text | Free Full Text

[86] 86. Brazeau-Lamontagne L, Charlin B, Gagnon R, et al.: Measurement of perception and interpretation skills during radiology training: utility of the script concordance approach. Med. Teach. 2004; 26(4): 326–332. PubMed Abstract | Publisher Full Text

[87] 87. Evered A: Perceptual and adaptive learning modules and their potential to transform cytology training programmes. Cytopathology. 2018; 29(4): 371–374. PubMed Abstract | Publisher Full Text

[88] 88. Aldridge RB, Glodzik D, Ballerini L, et al.: Utility of non-rule-based visual matching as a strategy to allow novices to achieve skin lesion diagnosis. Acta Derm. Venereol. 2011; 91(3): 279–283. PubMed Abstract | Publisher Full Text | Free Full Text

[89] 89. Krasne S, Hillman JD, Kellman PJ, et al.: Applying perceptual and adaptive learning techniques for teaching introductory histopathology. J. Pathol. Inform. 2013; 4: 34. PubMed Abstract | Publisher Full Text | Free Full Text

[90] 90. Krasne S, Stevens CD, Kellman PJ, et al.: Mastering electrocardiogram interpretation skills through a perceptual and adaptive learning module. AEM Educ. Train. 2021; 5(2): e10454. PubMed Abstract | Publisher Full Text | Free Full Text

[91] 91. Parker EU, Reder NP, Glasser D, et al.: NDER: A novel web application for teaching histology to medical students. Acad. Pathol. 2017; 4: 2374289517691061. PubMed Abstract | Publisher Full Text | Free Full Text

[92] 92. Rimoin L, Altieri L, Craft N, et al.: Training pattern recognition of skin lesion morphology, configuration, and distribution. J. Am. Acad. Dermatol. 2015; 72(3): 489–495. PubMed Abstract | Publisher Full Text

[93] 93. Romito BT, Krasne S, Kellman PJ, et al.: The impact of a perceptual and adaptive learning module on transoesophageal echocardiography interpretation by anaesthesiology residents. Br. J. Anaesth. 2016; 117(4): 477–481. PubMed Abstract | Publisher Full Text

[94] 94. Slaught C, Madu P, Chang AY, et al.: Novel education modules addressing the underrepresentation of skin of color in dermatology training. J. Cutan. Med. Surg. 2022; 26(1): 17–24. PubMed Abstract | Publisher Full Text | Free Full Text

[95] 95. Evered A, Walker D, Watt AA, et al.: To what extent does nonanalytic reasoning contribute to visual learning in cytopathology? Cancer Cytopathol. 2013; 121(6): 329–338. PubMed Abstract | Publisher Full Text

[96] 96. Sha LZ, Toh YN, Remington RW, et al.: Perceptual learning in the identification of lung cancer in chest radiographs. Cogn. Res. Princ. Implic. 2020; 5(1): 4. PubMed Abstract | Publisher Full Text | Free Full Text

[97] 97. Xu B, Rourke L, Robinson JK, et al.: Training melanoma detection in photographs using the perceptual expertise training approach. Appl. Cogn. Psychol. 2016; 30(5): 750–756. Publisher Full Text

[98] 98. Brown NH, Robertson KM, Bisset YC, et al.: Using a structured image database, how well can novices assign skin lesion images to the correct diagnostic grouping? J. Invest. Dermatol. 2009; 129(10): 2509–2512. Publisher Full Text

[99] 99. Guégan S, Steichen O, Soria A: Literature review of perceptual learning modules in medical education: What can we conclude regarding dermatology? Ann. Dermatol. Venereol. 2021; 148(1): 16–22. Publisher Full Text

[100] 100. Auffermann W, Mazurowski M: Perception and training.Samei E, Krupinski E, editors. The Handbook of Medical Image Perception and Techniques. Cambridge (UK):Cambridge University Press; 2018; pp. 470–482.

[101] 101. Jarodzka H, Balslev T, Holmqvist K, et al.: Conveying clinical reasoning based on visual observation via eye-movement modelling examples. Instr. Sci. 2012; 40(5): 813–827. Publisher Full Text

[102] 102. Kulatunga-Moruzi C, Brooks LR, Norman GR: Using comprehensive feature lists to bias medical diagnosis. J. Exp. Psychol. Learn. Mem. Cogn. 2004; 30(3): 563–572. Publisher Full Text

[103] 103. Katz JT, Khoshbin S: Can visual arts training improve physician performance? Trans. Am. Clin. Climatol. Assoc. 2014; 125: 331–341.

[104] 104. 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(3): 263–268. PubMed Abstract | Publisher Full Text

[105] 105. Batson CD: These things called empathy: eight related but distinct phenomena.Decety J, Ickes W, editors. The Social Neuroscience of Empathy. Cambridge (MA):MIT Press; 2009; pp. 3–15.

[106] 106. Borromeo M, Chiavaroli N, Gaunt H: The arts and visual thinking in education at the Melbourne Dental School.McLean CL, editor. Creative Arts in Humane Medicine. Edmonton (Alberta, Canada):Brush Education; 2014; pp. 40–54.

[107] 107. Karkabi K, Cohen CO: Deepening compassion through the mirror of painting. Med. Educ. 2006; 40(5): 462. PubMed Abstract | Publisher Full Text

[108] 108. Wald HS, Norman DR, Walker J: Reflection through the arts: focus on photography to foster reflection in a health care context. Living beyond―an interactive photographic exhibit. Reflective Pract. 2010; 11(4): 545–563. Publisher Full Text

[109] 109. Wikström BM: Nursing education at an art gallery. J. Nurs. Scholarsh. 2000; 32(2): 197–199. PubMed Abstract | Publisher Full Text

[110] 110. Wikström BM: Work of art dialogues: an educational technique by which students discover personal knowledge of empathy. Int. J. Nurs. Pract. 2001; 7(1): 24–29. Publisher Full Text

[111] 111. Wikström BM: Intuition and visual art: student nurses’ projection into experiences of elderly women. Aust. J. Holist. Nurs. 2002; 9(2): 24–31. PubMed Abstract

[112] 112. Baron-Cohen S, Wheelwright S, Hill J, et al.: The “Reading the Mind in the Eyes” Test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. J. Child Psychol. Psychiatry. 2001; 42(2): 241–251. Publisher Full Text

[113] 113. Rowe AD, Bullock PR, Polkey CE, et al.: ‘Theory of mind’ impairments and their relationship to executive functioning following frontal lobe excisions. Brain. 2001; 124(3): 600–616. PubMed Abstract | Publisher Full Text

[114] 114. Baron-Cohen S, Wheelwright S, Jolliffe T: Is there a “language of the eyes”? Evidence from normal adults, and adults with autism or Asperger syndrome. Vis. Cogn. 1997; 4(3): 311–331. Publisher Full Text

[115] 115. Pino MC, Mazza M: The use of “literary fiction” to promote mentalizing ability. PloS One. 2016; 11(8): e0160254. Published 2016 Aug 4. PubMed Abstract | Publisher Full Text | Free Full Text

[116] 116. Zeki S: Inner Vision: An Exploration of Art and the Brain. Oxford (UK):Oxford University Press;1999.

[117] 117. Bardes CL, Gillers D, Herman AE: Learning to look: developing clinical observational skills at an art museum. Med. Educ. 2001; 35(12): 1157–1161. Publisher Full Text

[118] 118. Wikström BM, Svidén G: Facial expressions in paintings as perceived by the student nurse. Aust. J. Holist. Nurs. 2005; 12(2): 5–12. PubMed Abstract

[119] 119. Gibson EJ: Principles of Perceptual Learning and Development. Englewood Cliffs (NJ):Prentice-Hall;1969.

[120] 120. Fahle M: Introduction.In:Fahle M, Poggio TA, editors. Perceptual Learning. Cambridge (MA):MIT Press; 2002; pp. ix–xx.

[121] 121. Kornell N, Bjork RA: Learning concepts and categories: is spacing the “enemy of induction”? Psychol. Sci. 2008; 19(6): 585–592. Publisher Full Text

[122] 122. Kornell N, Castel AD, Eich TS, et al.: Spacing as the friend of both memory and induction in young and older adults. Psychol. Aging. 2010; 25(2): 498–503. PubMed Abstract | Publisher Full Text

[123] 123. Kang SHK, Pashler H: Learning painting styles: spacing is advantageous when it promotes discriminative contrast. Appl. Cogn. Psychol. 2012; 26(1): 97–103. Publisher Full Text

[124] 124. Zulkiply N, McLean J, Burt JS, et al.: Spacing and induction: application to exemplars presented as auditory and visual text. Learn. Instr. 2012; 22(3): 215–221. Publisher Full Text

[125] 125. Girardi S, Gaudy C, Gouvernet J, et al.: Superiority of a cognitive education with photographs over ABCD criteria in the education of the general population to the early detection of melanoma: a randomized study. Int. J. Cancer. 2006; 118(9): 2276–2280. Publisher Full Text

[126] 126. Speelman C, Martin K, Flower S, et al.: Skill acquisition in skin cancer detection. Percept. Mot. Skills. 2010; 110(1): 277–297. PubMed Abstract | Publisher Full Text

[127] 127. Ark TK, Brooks LR, Eva KW: Giving learners the best of both worlds: do clinical teachers need to guard against teaching pattern recognition to novices? Acad. Med. 2006; 81(4): 405–409. PubMed Abstract | Publisher Full Text

[128] 128. Voeller M: The art of attending: arts-based observation training for health professions students at the University of South Florida.Costache I, Kunny C, editors. Academics, Artists, Museums: 21st Century Partnerships. Oxon and New York (NY):Routledge; 2018; pp. 99–110.

[129] 129. Acai A, McQueen SA, McKinnon V, et al.: Using art for the development of teamwork and communication skills among health professionals: a literature review. Arts Health. 2017; 9(1): 60–72. Publisher Full Text

[130] 130. Osman M, Eacott B, Willson S: Arts-based interventions in healthcare education. Med. Humanit. 2018; 44(1): 28–33. Publisher Full Text

[131] 131. Lake J, Jackson L, Hardman C: A fresh perspective on medical education: the lens of the arts. Med. Educ. 2015; 49(8): 759–772. Publisher Full Text

[132] 132. Belling C: Commentary: sharper instruments: on defending the humanities in undergraduate medical education. Acad. Med. 2010; 85(6): 938–940. PubMed Abstract | Publisher Full Text

[133] 133. Jaarsma T, Jarodzka H, Nap M, et al.: Expertise in clinical pathology: combining the visual and cognitive perspective. Adv. Health Sci. Educ. Theory Pract. 2015; 20(4): 1089–1106. Publisher Full Text

Appreciating visual arts may not foster medical diagnosis skills

Abstract

Keywords

Introduction

Methods

Search strategy and selection criteria

Data collection

Data analysis

Table 1. The features, research design, and key results of the selected intervention studies.

Results

Discussions

Longer periods of careful and systematic observations

Cultivating tolerance for ambiguity

Discovering more visual features or signs

Observing carefully for reducing misdiagnoses

Transfer of observation skills to identifying different objects

Is there a more effective way?

Fostering verbalizing skills for diagnoses

Considering patients’ contexts and perspective-taking

Conclusions

Limitations

Implications for future research and practice

Data availability

Acknowledgments

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Browse by related subjects

Competing Interests Policy

Stay Updated