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02/14/2013

Diagnosing Art

Craig Klugman, Ph.D.

Every fall, I teach 30 medical and nursing students observation skills in our institution’s Art Rounds course. My colleagues and I take these students to one of our local museums where they learn how to observe their environment and patients by looking at works of art, learning about the role of observation in medicine, and by observing real life models.

Last month, an Art Round student told me that she spent part of her winter break touring the Smithsonian where she viewed a large portrait by the American painter Chuck Close of his father-in-law. The painting was so accurate that when the painting had hung at the Whitney Museum in New York, a visiting ophthalmologist was able to discern carcinoma in the painted figure’s eye. Subsequently, Close’s father-in-law was diagnosed and his sight preserved.

My student’s ethical question was whether she would have to do that as well. Was she required, on her off hours, to tell people on the street when she noticed something about them that was medically suspicious?

This true story is part of what are now called “unintended findings.” In other words, discoveries about a person that has medical implications but was found either (a) outside an established physician-patient relationship or (b) were not being searched for, such as diagnosing carcinoma from a painting.

First, unless under an emergency, physicians have no obligation to provide care for a patient with whom they have no established relationship. Such a relationship is formed when a physician agrees to consult, offer a diagnosis, manage treatment, or accept payment among other actions. Looking at a portrait in a gallery does not exactly create such a relationship. If there is such a relationship, then a physician does have a greater obligation to provide necessary care.

The second point to consider is the increasing number of artifacts found in medical tests. The resolution of medical imaging keeps improving and technology allows ever more detailed views inside the body.  For example, a person gets an MRI as a result of reporting back pain and the scan shows a small kidney tumor. Normally these tumors would be surgically removed, but new thinking suggests that may not be the best course of action. If not for the scans, people may have lived and died for unrelated reasons without ever suffering from the small tumor. Just because there is an anomalous reading on a test does not mean that a person is suffering from ill health. New studies show that some of these artifacts are best left alone and observed.

Third, much research today is done on tissue samples procured from subjects and also from discarded medical waste (what is leftover after a clinical test is completed). In working with these samples, sometimes researchers learn that the source of the tissue has a disease or genetic anomaly. Is the researcher obligated if there is no physician-patient relationship? What if the researcher is also the MD but not the patient’s physician?

Fourth, what if you are wrong? What if in walking down the street the physician sees a person as having a reddish butterfly-shaped rash that goes over the bridge of the nose (often a sign of lupus). That individual, who may not have any symptoms other than a rash, goes through a series of tests, experiences worry and may find nothing wrong. The harm of time, money, and worry should not be discounted easily. As a future patient (aren’t we all), the idea that some random stranger on the street may come up to me and suggest that I see a doctor because of something suspicious is not an encounter I look forward to. What if their finding is something I am aware of but is stigmatizing and I do not want others to know about it? I may be enticed to wear a full parka all the time, and in the heat of Texas that is saying quite a lot.

Fifth, if physicians were required to report on all of their suspicious findings during a day, the physician would never be off duty. Being married to a physician, I know that what to me is standard social conversation, often has him looking at people for signs of disease asking himself “Why are they talking so slowly? What is that glassy sheen to their eyes? Does that mole on their upper lip look a little irregular?” When one spends so many years learning the medical gaze, turning it off is no simple matter. If this habit became a requirement, I can envision physicians not leaving their homes except for work or moving out to remote rural clinics. Or a patient with cancer suing every doctor she passed on the street because no one said anything sooner. No, a world where doctors are never off duty is not realistic.

Every one of these points is a complicated social and professional matter worthy of further discussion and debate. Points two and three are still in the early stages of societal conversation. In the end, my student and I decided that in the art museum, the ophthalmologist did a very nice deed, but was under no obligation to do so. There was no established physician-patient relationship and no imminent emergency.  For the moment, then, museums remain safe spaces for physician to visit.

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