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September 13, 2019 by Rose Olson | BMJ Opinion

Rose Olson: It’s not all black and white––can art help doctors navigate medical uncertainty?

The practice of art appreciation may help doctors’ decision making by alleviating the demonisation of uncertainty, says Rose Olson

I remember crawling in paint until I was coated from elbow to shin. My father’s massive shoulders would be bowed over stretched canvas, paintbrush curled into his left hand. With each strike, colour would flood the fabric while I’d watch in awe to see what image would appear. Art runs in the family—my mother worked at the local art museum, where on lucky summer days, I’d be set free in its endless marble hallways. I’d march alongside ancient Japanese suits of armor, tiptoe past Francis Bacon’s sinister papal shadows, and swing in Vincent Van Gogh’s twisted olive tree branches. Growing up in a home where art was a profession meant the unpredictable artistic process was profoundly valuable. That bare stretch of canvas may look insignificant to some, but to me it teemed with vivid possibilities.

I carried that passion for art with me into medical school. During my white coat ceremony, the speaker introduced me to the “art of medicine” as the physician’s highest achievement, a mastery of the craft exemplified by the fathers of medicine who stood before us. Yet soon after receiving my first white coat, medical school’s creeping demands and anxieties overtook me. Success was now measured in quantifiable, predetermined forms: honours on clinical rotations, high USMLE Step scores, and research publications. Eventually, my youthful enchantment of art was rebranded as a diversion or, in medical student speak, “low yield.” 

Does art have any place in medicine? In the age of evidence based medicine, abstract creative processes like art may seem irrelevant. Yet a careful look into medicine’s “objective data” reveals its often nauseating number of presumptions and limitations. So when a patient’s signs and symptoms fail to follow the textbooks, and all clinical algorithms have been exhausted, how is the doctor to proceed? This is exactly where art can lend great value—by teaching us comfort with ambiguity. While artists may have a specific message in mind when crafting their work, similar to medicine, each viewer is affected in a distinct and often unpredictable way. Interpreting art is a meditation in seeing things from multiple points of view and growing to respect that others may not agree with your interpretation. Physicians have a lot to gain from learning to navigate these grey areas.

Tolerance for medicine’s ambiguity is rarely included in medical education and training. Medical students and trainees are placed in high pressure contexts where clinical prowess is often judged by the number of correct answers marked on multiple choice exams or uttered in response to pimping questions on rounds. Such an environment can programme students and trainees to view ambiguity as failure and creativity as frivolous. Residents and early career physicians are often made anxious by uncertainty and feel pressured to minimise it, whether as a way to reduce frustration in unclear patient cases or appear confident when consulted by colleagues. Patient expectations may also contribute to the physician’s drive to give a precise diagnosis and treatment. We want to give our patients an unequivocal answer, even when there is none.

This culture comes with its risks: when ambiguity is intolerable, the associated frustration and stress may only be relieved by attempting to piece together certainty where it doesn’t exist. This may result in the overordering of diagnostic tests and empiric treatments in attempts to find “the one solution.” Or it may lead to rigidity in clinical problem solving, even in the face of data discrepancies. Patients may shoulder these harmful consequences when they experience delayed and missed diagnoses or the side effects of unnecessary medications, tests, and procedures. Healthcare workers who struggle with ambiguity are less likely to engage their patients in shared decision making, avoiding candid discussions of the uncertainties, caveats, and risks of their diagnoses and treatment options.

A growing body of research suggests that early exposure to art interpretation in medical education may in fact increase students’ ability to tolerate ambiguity. The educational approach known as Visual Thinking Strategies (VTS) involves group discussion of art images where learners are encouraged to carefully observe pieces, verbalise their personal interpretations, and interact with their peers’ viewpoints while affirming the co-existence of multiple possible meanings. Research suggests that tolerance for ambiguity is a “state” not a “trait.” This means that our ability to admit uncertainty—whether in art or in medicine—can be taught, and that programmes such as VTS may help us to hone these skills.

Can art grant doctors all the wisdom they’ll need to navigate medicine’s infinite uncertainties? Probably not. But appreciating art may help doctors to react to medicine’s ambiguities with more comfort, intrigue, and motivation than frustration, disillusionment, and burnout. In turn, physicians may develop a more flexible process of problem solving, an honest understanding of medicine’s limits, and an ability to openly share these realities with colleagues and patients.

If our teaching and training embraced ambiguity, it would help to challenge medicine’s pursuit for absolute certainty, and make doctors more comfortable in admitting when we are unsure. Giving art legitimacy in the medical world will require reframing what trainees have been taught is “high yield” and imagining new success measures beyond the multiple choice test. But maybe then more doctors will realise what artists have known all along: there are many more colours to choose from than black and white.

Rose Olson is an internal medicine resident physician at Brigham and Women’s Hospital in Boston. She also works as a research consultant on gender based violence for the World Health Organization. She is passionate about social medicine, gender equity, and all forms of art. 

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