The impact of visual thinking in medical education [Görsel dü ş ünmenin t ı p e ğ itimine etkisi]

Background: Considering medical humanities, medicine and art are two areas that resemble each other at several features. Clinical diagnosis involves the observation, description and interpretation of information of which visual ones take an important one. The skills described are important skills in the field of visual arts, as well. Under-lying a good clinical practice; clinical examination and observation skills constitute an important place. Although in several studies, these skills are shown to be improved by analyzing visual art pieces, courses intended to improve visual thinking skills are not that much common in medical faculty curriculums. Materials and methods: In this article, we share our opinion about the use of visual thinking in medical education by providing preliminary reflection results of learners from the second year of medical education about the visual thinking course that we have recently started to apply in Faculty of Medicine in collaboration with Faculty of Fine Arts in Izmir University ofEconomics in order to improve the observational skills of learners. Results: Reflection results of the learners support the view that training art-viewing skill is helpful to improve observational and descriptive skills. Conclusions: Increasing interdisciplinary programs on visual thinking in medical curriculums have the potential to overcome several professional development challenges in clinics.


Introduction
Observation is an important component of clinical diagnosis and reasoning [1]. Direction of data gathering and diagnosis are among the major clinical reasoning difficulties [2,3], in which observational skills are used. Gathering visual information from the patient, recognition of patterns and interpretation of data together with patterns is required for a rigorous clinical decision making. Therefore, along with critical thinking, the use of visual thinking skills is also necessary during clinical reasoning.
When artistic themes such as color, line, symmetry, texture and pattern are considered, one can say that several physical examination elements such as vision, gait, cranial nerves and dermatology also focus on similar themes during visual diagnosis [4]. Several sources support the idea that the use of visual thinking strategies improves observational skills based on visuals during clinical examination [5][6][7][8][9][10].
Although courses which are intended to improve visual thinking skills in medical education are not that common, some medical schools use art-viewing in a clinical concept [5]. We have reviewed visual thinking courses in several medical schools (Table 1) and designed a unique visual thinking course in collaboration with the Faculty of Fine Arts, which we recently started to apply in our medical curriculum as an elective course. Seventeen students from the second year of medical education took the course which lasted for 16 weeks. The learners were trained for art viewing in the first half of the course and for observation of health-related photos/situations to apply their artviewing skills into clinical conditions that depend on visual observation. The course was designed as interactive, students centered sessions during which students were trained in skills like art-viewing, empathy, communication and clinical areas such as dermatology, radiology and orthopedics where visual evaluation can be helpful for physical diagnosis. The clinical part of the course only concentrated on training for the visual recognition of the patterns in various clinical cases by using the art-viewing skills. Interdisciplinary nature of the lecture was critical for our educational strategy. Learners' reflections after the course support the potential of the use of visual thinking strategies to improve observational skills and empathy.

Discussion
By engaging with art works, we believe that learners start to develop more empathy and consider different opinions more mindfully since the training also encourages critical thinking. We think that learning how to look at an art-work and sufficient observational exercise considering art pieces will help to improve the observational skills of learners in clinics. Our opinion is supported by a recent randomized controlled study, which shows that art observation training for first year medical students can improve ophthalmologic observation skills [8].
Although the number of learners who took our course is low, which is a weakness for a precise conclusion, preliminary reflection results of the learners support the view that training art-viewing is helpful to improve observational and descriptive skills ( Table 2). We also think that incorporating humanity in medical education affects the empathy, awareness and sensitivity features of the learners towards clinical conditions, which is supported by several studies [4,7]. There does not exist any contrary information in the literature about visual thinking strategies in physical

Conclusions
In the literature, the use of visual thinking strategies during medical education seems to enhance several observational skills of learners and is helpful in performing clinical diagnosis. Reflections of the learners who took our course seems to be in line with this view. To our knowledge, our designed course is among the forerunners in Turkey and we think that increasing these interdisciplinary programs in medical curriculums have the potential to help to overcome several professional development challenges.