If you’re anything like me, you don’t spend very long looking at paintings in museums. A minute or two, three tops. I like art; I find it interesting, but there’s only so much I really feel I need to see. Orawan Gardner, NUR ’18, is the same way. Raised nearby in Guilford, Conn., she came to the Yale University Art Gallery often growing up, “a hundred times, maybe.” One painting she recalls fondly is Edward Hopper’s Western Motel. She says she likes visiting galleries, enjoys looking at artwork, but rarely looks at one thing for very long.
In 2015, during the fall term of her first year at the Yale School of Nursing (YSN), Gardner revisited the Gallery with her classmates. In small groups led by trained docents, they examined the artwork she had seen so many times before. They arrived at Western Motel. The nursing students spent 10 long minutes looking at the painting in silence. The forest green car, the sun-blanched Western landscape, the stately woman looking dead ahead, and the blue pants draped neatly over the armchair in the corner.
Gardner found herself thinking in terms of colors: blue, green, red, brown, blonde. “Color is so thematic in the painting,” she points out. When her group came together after the allotted time and each student shared their own observations, Gardner was struck by the things her classmates pointed out. The time of day, the way the light is angled, how the woman’s hand grips the edge of the couch. In the many collective minutes she had spent looking at Western Motel over the years, she had never noticed these things before.
According to Linda Honan, a longtime professor at YSN, this is a pretty common phenomenon: people do not see the same way. And while this has few implications on a leisurely museum visit—so what if you missed the hand?—for nursing students this isn’t a day off. It’s a required part of their first year of professional school.
Nursing is traditionally a profession rooted in scientific knowledge and thinking. But at YSN, the integration of arts and humanities is helping students learn to see, hear, feel, and understand their patients, their people, more completely.
In 1999, Linda Friedlaender, the Curator of Education at the Yale Center for British Art (YCBA), and Irwin Braverman, a professor of Dermatology at Yale School of Medicine, found themselves talking about how Braverman’s students weren’t doing a very good job of describing their cases. As Friedlaender put it, “We decided that medical students in particular needed to learn how to look more slowly and more carefully when they are working with patients, and we thought that if we brought them to an art museum and we had them look at paintings they had never seen before and don’t know anything about” then that might help them hone their observational skills. Enhancing Observational Skills, the flagship Yale program between the YCBA and the School of Medicine, was born.
When medical students arrive at the YCBA to participate in Enhancing Observational Skills, a mandatory part of the School of Medicine curriculum, they begin by dividing up into small groups of four to six students, each with its own trained volunteer docent. Together, the group sits in front of a preselected painting, its accompanying placard concealed by a post-it, and for approximately 10 minutes they observe in silence. Notepads are available for taking notes or sketching what they see, but they aren’t required to write anything down. The only thing they need to do is look closely.
After this period of silent observation, the group comes back together and the students are asked to describe everything they see; to take inventory of the painting, if you will. How many people are in the painting? How many objects? What colors do you see? There are three things they cannot do: state opinions, draw conclusions, and make interpretations. For instance, if a student looking at a portrait says, “This looks like a woman who is very sad,” the docent stops them. “Sad” is an interpretation of her facial expression. Instead, Friedlaender says, she might ask the student, “Tell me what you see that makes her look sad without using the word sad.” In turn, they might cite her droopy eyes, or the fact that the corners of her mouth are turned down.
Once the medical students have completed taking an objective “inventory” of the painting, they move into the subjective phase of the exercise. Now, they are asked to take all of their observations, all of the visual information, put it together, and craft a narrative for the painting. “What we’re trying to do is to get them to find the words to articulate what it is they’re looking at,” Friedlaender tells me.
In Enhancing Observational Skills, the medical students then gather in a classroom, where they look at and discuss photos of patients; for example, those with skin lesions. The effects of the day are instantaneous. “What we found is that there’s a common vocabulary,” said Friedlaender. “They talk about the color of the rash, the texture, is it raised, is it flat, is it scaly, is it smooth, and these are the same kinds of words they can use to talk about the paint on the canvas that they’re looking at, or the colors.” The goal is to identify and closely examine details. By looking at images of patients immediately after their gallery visit, the medical students can see the relationship between their conversation about art and that about diagnoses right away.
Enhancing Observational Skills was the first program of its kind when it began in 1999. Friedlaender and Braverman first did a three year controlled study in which they found that students who spent three hours in the galleries with the program had far better observational skills than those who did not. These results were published in the Journal of the American Medical Association in 2001, and in the years since, at least seventy other medical schools and museums have implemented similar programming, according to Friedlaender. From the start, she says, the program has been required for every first-year medical student at Yale. These days, they also work with residents and fellows from different departments, and even faculty from the School of Medicine who want to be able to reinforce the ways of looking that medical students are taught at the YCBA.
While the program enjoyed early success with medical students, it really found its home with the School of Nursing. It all began with a lecture on musculoskeletal trauma. Linda Honan was discussing the lasting effects of breaking one’s pelvic bone on the body, when one of her students piped up and asked, “Did you ever think about using an image of Frida Kahlo to talk about that?” At the time, Honan says, she did not even know who Kahlo was. (On the day Honan and I meet, she is wearing bright red socks with Kahlo’s portrait on them, a gift from her students.) But after class she made a visit to the YUAG to look at Kahlo’s artwork. “Frida Kahlo had fractured her pelvis and lived in pain, and drew images of what she saw as her internal organs around her head,” Honan points out. This got her thinking about the use of art in teaching nursing.
Honan had heard about the work that Friedlaender and Braverman were doing, teaching what she calls “the practice of deep looking,” so she went to Friedlaender and floated the idea of developing a program specific to nursing students. They called it “Looking is Not Seeing.” While the program for nursing students is similar to that for doctors, both Honan and Friedlaender mentioned a few key differences. Doctors typically see patients when they make rounds in the morning and at the end of the day, and perhaps somewhere between if a problem arises. Nurses work on a shift, seeing the same group of patients all throughout. As such, they have a very different relationship. Often, nurses are the ones who notice subtle changes over the course of a day.
“I want [my students] to look at the entire palette of the patient,” Honan tells me. “We don’t want to ignore other symptoms that may not seem to cluster with a diagnosis.” In other words, observe everything closely before drawing conclusions about what the diagnosis is, rather than observing with a particular issue already in mind. Honan calls this a “differential diagnosis.” Following their time in the galleries, the nursing students, who participate in the program during the fall of their first year, go back to a classroom with Honan and practice their deep seeing on actual patients with disease processes. Gardner remembers, with a laugh, how Honan included a photo of her own perfectly healthy father, to see whether she could trick her students into diagnosing him with something he didn’t have.
Honan studies every educational initiative she tries out, and the results of “Looking is Not Seeing” have been staggering. After three hours of looking at art, she has proven that nursing students’ observations become more objective and they are able to write more of a differential diagnosis. They are less likely to rush to judgment, and to really see the people they are working with.
Honan believes that using the arts to teach nursing has been particularly effective at a school like YSN. Yale’s nursing program was the first one to have no prerequisites required for admission. As a result, Honan says, 78 percent of the students at YSN, on average, come from non-science backgrounds. Gardner is one such student. After graduating from Vassar with degrees in film and philosophy, she spent time working in film and television before she “got interested in doing something more meaningful.” Though she was admitted to other nursing programs, she chose Yale’s because she wanted to study alongside people from diverse educational backgrounds.
Generally, prerequisites for nursing school are science-based—anatomy, physiology, chemistry, and such. Honan praises a BA background because, unlike the often-deductive scientific model of reasoning, students in the arts are encouraged to think inductively. And, after all, a patient never presents with just one issue at hand. A diagnostician must consider biological problems and psychological ones, issues of access, sociological implications, and more. They need to think broadly. For this reason, Honan says an arts degree is “a perfect background for nursing.” Her students come in with the right ways of thinking already in place. Her task is to figure out how to teach them the information they need to know, and it has helped her to get a little bit creative.
The success of “Looking is Not Seeing” got Honan thinking further about how else she could make use of her students’ creative backgrounds. Learning to listen to the body’s sounds, a fundamental part of nursing, can be incredibly challenging. Often, it takes years just to learn to hear a heart. Eager to accelerate this learning process, Honan emailed then-Dean of the Yale School of Music (YSM), Thomas Duffy, and paid him a visit. “I told him I had an idea, and my intuitive sense was this is going to rock, but I had absolutely no funding. He said, ‘Okay, no money, good idea, I’m in!’”
Honan’s vision was to create a program, in collaboration with Duffy, in which her students would learn how to hear heart, lung, and bowel sounds better by learning to hear from a musician. Duffy recalls that when Honan first played him a series of heartbeats with anomalies, he told her, “The dumbest person in my marching band could hear the difference; this is low-hanging fruit!” For this reason, working with musicians was a natural move for Honan. “Why wouldn’t we go to expert musicians or music scholars to say, ‘How do you figure out things?’” she asks. “Aren’t body sounds music in some way?”
The program, called “Listening is Not Hearing,” is conducted during the first fall of nursing school, much like “Looking is Not Seeing.” In it, Duffy provides nursing students with “a visual, spatial, oral, and intellectual approach to what rhythm is and how we measure and divide the passing of time.” Rather than fixating on technicalities or terminology, he provides them with the fundamental tools to hear carefully and thoroughly.
Bowel sounds, Duffy tells me, are the first he teaches because they are relatively straightforward. There are only three: normal, hyperactive, and hypoactive. The difference between the three is partly their pitch, but mostly it is a question of how many times the bowel clicks per minute. A normal bowel clicks between five and thirty times in a minute, where if it is hypoactive it might click only once. Lung sounds come next. Learning to hear these means paying attention to timbre and variations in sound, but rhythm is pretty unimportant. After all, lungs are binary: inhale, exhale. Duffy teaches heart sounds last. They’re the most complicated rhythmically, and require that one pay attention to timbre and pitch as well.
Once nursing students have learned about each individual sound, Duffy also instructs them in picking one out of a chorus—simulating a real human body. Duffy synthesizes artificial samples of the bowels, lungs, and heart and plays them all at once, forcing his students to, as Honan puts it, “swim in and find the lungs,” or whichever body sound they are being asked to look for. Duffy remarks that these masking exercises are somewhat akin to listening for the voice of one’s spouse at a party “amidst the nonsense.”
As with “Looking is Not Seeing,” the effects of Honan and Duffy’s collaboration have been remarkable. For every three hours nursing students spend with Duffy, bowel sound recognition goes from 10 percent to 75 percent, heart sound recognition from 20 percent to 40 percent, and lung sound recognition from 30 percent to 60 percent. Duffy recalls that after they released the results of the study, the control group insisted on getting the same training because it had proven to be so effective.
Most nurses learn to hear the body well only after years in the field. But until you reach that level of proficiency, what do you do? Often, nurses end up ordering tests or taking x-rays when their patients are perfectly normal. So, Duffy says, if nursing students can learn to hear body sounds better and more quickly, “we can cut the time in half or a third,” and save a significant sum of money that might otherwise be spent running unnecessary tests. Honan agrees that poor hearing skills cost money. More importantly, it’s not a hard fix. Right now, she says, most programs are “not training you to use what God gave you!” Especially given that many of her students will go on to work in underserved communities that might not have the funds, time, or technology to run unnecessary tests, Honan sees this training as essential.
Duffy works with Honan and her students at YSN on his own time. It’s not exactly in the job description. But his work has been incredibly important. The “Listening is Not Hearing” program—in Duffy’s words, the Duffy-Honan Intervention—has gotten rave reviews from everyone involved. Developing it is “the first time I kind of felt that I had a primary impact on improving people’s lives,” Duffy tells me.
Being able to hear a body well isn’t just a question of saving money, or even of diagnosing the patient more quickly and accurately. It’s also integral to developing the physician-patient relationship. If we have machines that can record and analyze body sounds, what’s the use of a regular old stethoscope? A doctor at the medical school told Duffy that the reason one uses a stethoscope is that “by moving in, we put our hands on people, and we get inside their personal space and break down that boundary.” “If we’re going to do that,” Duffy says, “let’s teach people how to do it better.”
This fall, “Listening is Not Hearing” was integrated into the curriculum at the medical school as well. Honan and Duffy have also travelled and given talks together, bringing the program to other schools. Thanks to the Yale-China Association, they even flew to Xiangya to conduct a three-day seminar. Over the next year, students there will start learning their beginning stethoscope skills with the Duffy-Honan Intervention. And hopefully, with more funding, Duffy and Honan will be able to expand the program further. Recognizing conditions associated with slight changes in pitch and mucus-related lung sounds are among the things that Duffy is looking to focus on next. “I’ve got to figure out how to do all of that stuff and see if we can make it more efficacious,” he comments, earnest to the core.
Beyond expanding the hearing program, Honan is also looking to complete the trifecta with a new initiative: “Touching is Not Feeling.” Her vision is to improve tactile clinical observation, specifically learning to feel and palpate heartbeats. We have pulses all over our bodies, she points out. “We even have little ones down [in our feet] that are really important for you to learn how to palpate.” Research shows that traditional methods of teaching palpation are woefully ineffective. This, in turn, means that clinicians enter the profession with “inconsistent skill levels and unpredictable clinical exposure.”
So, in the fall of 2015, Honan teamed up with students in “MENG/BENG 404: Medical Device Design and Innovation,” an advanced Biomedical and Mechanical Engineering undergraduate course in the School of Engineering and Applied Sciences. In the class, “interdisciplinary teams of students [work] with physicians from the Yale School of Medicine and Yale-New Haven Hospital to address unmet clinical needs,” according to the course description.
Honan’s vision was to create a device that would help students in nursing and medicine to practice feeling for pulses at different grades while also mimicking the color and temperature changes that accompany each pulse. Once the students in MENG/BENG 404 decided to take on her project, she brought them to the anatomy lab to see where the pulses that need to measured are on the body. Then, she took them to the trauma unit at Yale-New Haven Hospital and had them feel pulses on real patients. Once the engineering students felt people who “either had so much swelling they had to learn how to dig deep [to get the pulse], or had really poor circulation,” they understood how difficult it is to learn these tactile skills.
At the end of the semester, after working extensively with Honan and some of her nursing students, the engineering students presented the BeatBox. The box “features a silicone sheet to simulate skin and a speaker to simulate the pulse,” and there is also “a layer of hydrogel to simulate all the tissues and fat that can make finding a pulse difficult,” according to the class’s website. There are four different grades of pulse that students can practice with. Zero is no pulse, 1 is barely there, 2 is normal, 3 is full and bounding, and 4 is “for those kids whose fingers really need a drum for them to feel it,” says Honan. Students can connect their smartphones to the BeatBox to practice feeling these different pulses.
This year, Honan is testing the efficacy of the BeatBox on her nursing students. She pre-tested all 105 of her first-year students in the first week of the school year, asking them whether they could feel a pulse. Half of the class then has two hours to go practice with the BeatBox by themselves, whenever they want to. In June, she will test all 105 students again and see whether these two hours on the machine made a difference. “When it finishes, then we really will have a curriculum that is tested and reliable for improving the perceptive ability of clinicians. It’s cool!”
Honan has already revolutionized seeing, hearing, and feeling, but she is as committed to nurturing the whole person when it comes to her students as she is with her patients. In Honan’s time at YSN, there is one other interdisciplinary initiative she has been instrumental in developing: creative writing. For a long time, Honan has urged her students to keep journals of their experiences. To this day, she says, she is haunted by some of her former patients, perhaps because she no longer remembers what their stories were. She does not want her students to be haunted in the same way. “I tell them I will do everything I can to help them be successful,” but in return “they will go out and get a 99 cent notebook, and they promise me that if they have nightmares about something that happened, or they’re even walking down the street and they smell their patient that they took care of seven hours before,” they’ll write about it.
Honan eventually decided to ask her students to write her a story at the end of the year instead of filling out a course evaluation. Eventually, she had hundreds of stories. Catherine Gilliss, then-Dean of YSN, discovered this student writing, and she and Honan decided to make a point of celebrating creating writing and nursing. They first began recognizing students’ writing in 2003, and in 2004 three students were presented with the first Yale School of Nursing Creative Writing Awards.
Every year since, students and faculty from YSN, and others, have come together on a Thursday in April for the presentation of these Creative Writing Awards to the top three writers at YSN, as well as an accompanying keynote address. A chapbook of the noteworthy entries is put together, and the three winners receive a cash prize. This year the keynote speaker will be Mary Catherine Bateson. One hundred and nine nursing students have submitted their writing to the contest.
Beyond the annual contest, there are also voluntary creative writing workshops twice a month at YSN, facilitated by hematologist-turned-writer Lorence Gutterman. Gardner has not submitted to the contest, but has attended some of Gutterman’s classes. He has even emailed her with prompts to respond to on her own time, like “I walked into the patient’s room and heard…”
Lisa Rich, NUR ’18, one of the winners of the Creative Writing Award in 2016, remarks that “the act of writing helps me to process a lot of the feelings that being a health care provider brings up.” On Honan’s advice, Rich began keeping a journal while in her first year at YSN. Her award-winning piece was an excerpt from one of those entries. “If I’ve had a bad day at work, it’s because someone else has had one that will profoundly change the rest of their lives… I think part of it is definitely that those of us who go into these fields do so because we are ‘helpers,’ and inherent to that type of personality is this kind of taking on the mantle of other people’s problems.”
Writing can help the students parse the difficult moments but also reflect on the deep connection they can feel with their patients. “The intimacy in our profession is sometimes more than between two lovers. Yet you’re a stranger,” Honan remarks. At its heart, nursing is a profession rooted in examining, understanding, and relating to people. As Gardner points out, “Your patient isn’t just somebody who is a set of symptoms. They’re a person with a whole complex presentation that you have to interpret, and then you have to treat them as a person.”
At YSN, the understanding that patients are people is fundamental. Gardner adds that while doctors treat the disease, nurses are the ones who treat the patient. “I think the idea that we’re getting people from many different backgrounds speaks to that ethos,” she says. Training nurses to see like an artist sees the way the light hits, to hear like a musician hears a sonata, or to feel a beating heart, is brilliant in its obviousness.
“I also think it’s great for the public to hear our stories,” Honan tells me. “You stay with us, do you know that? Do you know that your stories live on in us, and are used to either teach the next generation or learn from to be better? I don’t think you know that.”