Every Patient Tells a Story (16 page)

Noticing What You See

Sherlock Holmes perhaps expressed most succinctly the lesson I learned. “I have trained myself,” Holmes tells his amanuensis, Dr. John Watson, “to notice what I see.” It’s an important distinction.

“You have been in Afghanistan, I perceive.” With these first words Holmes initiated the quirky relationship with the man who would become his closest friend and most devoted follower. Watson, in London recovering from war wounds sustained in Afghanistan, is shocked by the man’s declaration.
How could he possibly have known this? Had he been told? “Nothing of the sort. I
knew
you came from Afghanistan.” He retraces his reasoning. Watson’s military bearing suggested some time spent in the armed services, Holmes tells him. The deep tan indicated a recent return; his wasted physique, some kind of intestinal fever. And his injured arm pointed to a war zone.

Of course it is an easy enough trick to pull off in fiction. However, Arthur Conan Doyle based his most famous character on a Scottish surgeon named Joseph Bell, for whom he’d worked during his medical training. Like Holmes, Bell frequently wore a deerstalker cap, smoked a pipe, and was often observed using a magnifying glass. But the most important trait they shared was a keen eye for detail combined with remarkable deductive powers.

Stories about Bell sound like snippets straight out of a Holmes story. In a preface to one of his books, Doyle describes his debt to Bell in developing Holmes as a character and provides examples of Bell’s Holmes-like abilities. Seeing one patient, a young man in street clothes, Bell immediately asks the man if he was recently discharged from the military. He was. Was he a noncommissioned officer in the Highland Division? He was. Stationed in Barbados? Yes, how did he know all this? Like Holmes, Bell delighted in revealing his observations to the patient, the medical students, and the doctors observing him. Doyle quotes Bell’s response: “‘You see gentlemen,’ he explain[ed], ‘the man was a respectful man but did not remove his hat. They do not in the army, but he would have learned civilian ways had he been long discharged. He has an air of authority and he is obviously Scottish. As to Barbados, his complaint is elephantiasis, which is West Indian and not British.’ To his audience of Watsons it all seemed quite miraculous until it was explained and then it was simple enough. It is no wonder that after the study of such a character I used and amplified his method when in later life I tried to build up a scientific detective.”

Doyle clearly recognized that Bell’s powers of observation were extraordinary. He referred to himself and the other doctors who witnessed these remarkable instances of detection as “Watsons.” Yet Holmes and his model, Bell, firmly believed that this kind of close observation of significant details
could be taught and sought to instruct those around them. “From close observation and deduction you can make a correct diagnosis of any and every case,” Bell wrote in a letter to his now famous student, Arthur Conan Doyle. With practice, he suggested, the power of observation can be sharpened, improved. Doctors, he seemed to suggest, can teach themselves to “notice what they see.”

Learning How to See

Medical schools across the country have recently joined ranks with the historic Joseph Bell in striving to teach medical students to be better observers. One of the first efforts came from Yale. Dr. Irwin Braverman, a professor of dermatology for over fifty years, had long been frustrated by the difficulty students had in describing findings of the skin. It might have been a knowledge deficit—easily remedied with books, pictures, and tests. But Braverman suspected that what his students principally lacked was the skill of close observation. Too often they wanted to cut straight to the answer without paying attention to the details that took them there.

“You teach students to memorize lots of facts,” he told me. “You say: ‘Look at this patient. Look at how he’s standing. Look at his facial features. That particular pattern represents one disease, and this pattern represents another.’ We teach those patterns so that the next time the doctor comes across it, he or she comes up with a diagnosis.” What’s missing, says Braver-man, is how to think when an oddity appears. That requires careful and detailed observation. After years of teaching he still wasn’t certain he’d found the best way to communicate that complex set of skills.

In 1998 Braverman came up with a way to teach this skill. What if he taught these young medical students how to observe in a context where they wouldn’t need any specialized knowledge and so could focus on skills that couldn’t be learned from a book, where the teaching would force students to focus on process, not content? He realized that he had a perfect classroom right in his own backyard, in Yale’s Center for British Art. The course, now
part of the curriculum, requires first-year medical students to hone their powers of observation on paintings rather than patients.

As I entered the cool soft light of the museum’s atrium, a dozen first-year students were standing around in small groups, waiting to enter the conference room to find out what they were doing in this unusual setting. Braverman, a round-faced man with a comb-over and an impish smile, sat at the head of a long table of lustrous dark wood like a folksy CEO of some big corporation. Their job that afternoon, he told them, was to look at the pictures they were assigned to and then just describe them. Not too hard, right? He looked around hopefully. A few students sitting near him smiled and nodded enthusiastically. The rest of the table was a harder sell. “It’s always like that,” Braverman told me as we followed the students up the stairs to the third floor, where most of the nineteenth-century paintings he liked to use were on exhibit. “A handful of students either get it right away or are just habitually enthusiastic. The rest of the students here need to be convinced. But, you watch, by the end of the afternoon, I’ll have some converts. Wait and see.”

Once stationed at their assigned pictures the students reviewed the rest of the rules. They were not to read the little labels next to the paintings. They’d have ten minutes to look at the pictures and then together the class would discuss the images, one by one. Each of the pictures would have a story to tell. It was the student’s job to figure out what that story was and relate it to the rest of the group, using only concrete descriptive terms. If you think a character looks sad, he told them, figure out what you are seeing that makes you think that and describe it. If you think that the picture suggests a certain place or class, describe the details that lead you to that conclusion.

A tall young man with a sweet face and a prominent Adam’s apple peered at the image of a slender man whose upper torso was hanging limply over the side of a bed, his right hand touching the floor. His eyes were closed. Was he asleep? asked Braverman.

“No,” he announced decisively to his fellow medical students gathered around the scene. “He could be drunk—he has a bottle in his hand—but he’s not asleep. I think he’s dead.” “How do you know that?” asked Braverman.
“His coloring—it’s not right. He looks green,” he answered thoughtfully. “And there’s death all around him.” He described the sad scene. The young man lies in a small, unadorned garret apartment. An indifferent landscape of rooftops dark in the changing light of a setting sun is silhouetted outside the narrow dirt-encrusted windows. Petals of a dying rose ornament the windowsill, their color gray in the fading light. Shreds of torn papers are strewn across the floor. “I think he’s taken his own life,” he concluded triumphantly.

“Excellent,” agreed Braverman. Linda Friedlaender, curator of education, spoke briefly about the painting (
The Death of Chatterton
, Henry Wallis’s rendition of the suicide of the seventeen-year-old poet of the eighteenth century, Thomas Chatterton) and then they moved on to the next painting.

After the class, Braverman and I talked over coffee about his innovative teaching technique. “Astute observational skills are usually acquired only after several years of being in medical practice,” Dr. Braverman said. “Suddenly, all of the accumulated experience leads doctors to see things they have not been taught before. They become terrific observers—eventually. With this course, I hope to jump-start these special diagnostic skills right from the beginning.” Even though they’re looking at paintings, not patients, what they learn here can be applied to medicine, Braverman asserted.

He knows this because he tested it. For two years Braverman had participants write a description of what they saw in a dozen photographs picturing individuals with visible abnormalities. After the class they were given a different set of photographs with the same instructions. Tests were scored based on the description of specific aspects of the photographed abnormalities. Correctly identifying the disease or condition did not affect the score; identifying and describing the visual data was all that counted. Before-and-after test scores were compared, and students improved by an average of 56 percent after spending this afternoon in the museum.

To ensure that this was not simply due to better test-taking skills the second time around, the same two-part test was given to a group of students before and after a lecture on physical examination. These students also improved—you don’t get to medical school if you can’t learn how to take a test—but not nearly as much.

Even before I heard about this study, I knew from personal experience that these skills could be taught. I was in my third or fourth year of medical school when I suddenly started seeing people with abnormalities everywhere. It was as if I had suddenly been transported into a world populated with the ill, the injured, the aberrant. Of course they were there all along—why hadn’t I seen them? Certainly knowledge plays a role. When you learn a new word or name, it suddenly seems to be everywhere.

But it’s more than that. We are trained from a very early age to avert our eyes from abnormalities. Children are fascinated by people whose appearance differs from what they’ve come to expect. And we teach them to ignore that interest. My daughter, Tarpley, once asked a cashier if she was a man or a woman. My husband flushed with shame for the discomfort it caused the homely, hirsute woman. He apologized but recognized that the damage was done. Afterward he explained to our daughter just how much that kind of comment must have hurt the woman. She doesn’t ask those kinds of questions anymore. She’s learned not to stare.

Medical school forces you to undo that training. You mustn’t avert your eyes from abnormality. You need to seek it out. You need to figure it out. And it doesn’t just turn off when you leave your office. I frequently (quietly, I hope) point out to my husband pathology that I see on the street—the rolling gait of a man with an above-the-knee prosthesis; the strange gray-toned tan of a man with iron overload syndrome, known as hemochromatosis, the schizophrenic woman’s restless lips and mouth, a long-term side effect of many antipsychotics. I now live in a world filled with abnormality. It’s fascinating.

How is it possible to see something without noticing it? Dr. Marvin Chun, a professor in the Visual Cognitive Neuroscience Lab at Yale, has devoted his career to trying to answer that question. When I visited him on a warm fall afternoon, he invited me to view a video already quite famous in his field of vision and attention. On a monitor I saw six adults standing in the midst of some strange game, their actions frozen by technology. There appeared to be two teams—one dressed in white, one in black. Each team had a basketball.
Strangely, they weren’t on a court but in the corridor of an unidentified office building. Closed elevator doors were clearly visible in the background.

My task, once the video started, was to watch the white team and keep track of how many times the ball was passed between players—keeping separate counts of when it was passed overhead and when it was bounced from person to person. The image started to move and I kept my eyes glued to the white team’s basketball as it was passed silently among the moving mass of black and white bodies. I got up to six overhead passes and one bounce pass and I lost track. Determined not to give up, I kept going until the thirty-second video was complete.

Eleven overhead passes and two bounce passes? I ventured. I told Chun that I got a little confused in the middle. Despite that, I’d done a good job, he told me. I missed only one overhead pass. Then he asked, “Did you see anything unusual in the video?” Other than the unusual setting for the game, no, I saw nothing at all out of the ordinary.

“Did you see a gorilla in the video?”

A gorilla? No, I had definitely not seen a gorilla.

“I’m going to show you the video again, and this time, no counting, just look at the game.” He restarted the video. The white and black teams sprang back into action. Eighteen seconds into the game—around the time I lost my concentration—I saw someone (a woman, I find out later) in a gorilla suit enter the hallway court on the right. She strolled casually to the middle of the frame, beat her chest like a cartoon gorilla from a children’s TV show, then calmly exited out of the left side of the picture. Her on-camera business lasted eight seconds and I hadn’t seen her at all.

If you had asked me if I thought that I could miss a gorilla—or even a woman in a gorilla suit—strolling through the picture, I would have agreed that it was impossible to overlook such an extraordinary event. And yet I did. So did more than half of those who were given the same task by Daniel J. Simons in his lab at the University of Illinois at Urbana-Champaign. How is that possible?

We have tremendous faith in our ability to see what is in front of our eyes. And yet the world provides us with millions of examples that this is not the case. How often have you been unsuccessful in looking for an object
and recruited the help of someone who finds it immediately right in front of you? Or had the embarrassing encounter with a friend who confronts you angrily after you “ignored” his wave the night before while scanning for an open seat in a crowded movie theater? According to the Federal Highway Administration, there are over six million car accidents every year. In many of these crashes, drivers claim that they had looked where they were going and simply hadn’t seen the object with which they collided—evidence that people are regularly capable of not seeing what’s in front of their eyes, what Sherlock Holmes might have called seeing without noticing.