CHICAGO – Medicine, perhaps uniquely among the highly skilled professions, requires the practitioner to use his or her senses on a daily basis. Dermatologists and dermatopathologists rely on visual skills – pattern recognition, gestalt or “gut” first impressions, and step-by-step deliberations – to care for their patients.
Dr. Christine Ko
But, like all human cognitive processes, visual assessments are error prone. The same brains that can parse a field of blue and pink dots to discern melanoma on a slide are also capable of glaring errors of omission: All too often, the brain follows a cognitive path for the wrong reasons.
Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., became interested in the meta-cognition of her trade; that is, she sought to learn how to think about the thinking that’s needed to be a dermatologist or a dermatopathologist.
In a wide-ranging discussion at the summer meeting of the American Academy of Dermatology, Dr. Ko took attendees through The path led through lessons learned from cognitive science to the fine arts, to lessons learned from other visually oriented medical disciplines.
“Deliberate practice in dermatology is augmented by knowledge of specific cognitive principles that affect visual perception,” Dr. Ko said at the meeting. “This session will open your eyes to the world of visual intelligence that underlies expert dermatologic diagnosis.”
To begin with, what constitutes deliberate practice of dermatology or dermatopathology? Practically speaking, seeing many patients (or reading many slides) builds the base for true expertise, she noted. Physicians continue to hone their learning through independent reading, journal clubs, and meeting attendance, and seek opportunities for deliberate review of what’s still unknown, as in grand rounds – where, ideally, feedback is instantaneous.
Deliberate practice, though, should also include honing visual skills. “We find only the world we look for,” said Dr. Ko, quoting Henry David Thoreau. To sharpen the pattern recognition and keen observation that underpin dermatology and dermatopathology, she said, “We can train the brain.”
Radiology, another medical discipline that requires sustained visual attention, has a significant body of literature addressing common visually-related cognitive errors, she pointed out. In radiology, it’s been shown that deliberate observation of visual art can improve accuracy of reading films.
She observed that dermatologists and dermatopathologists need to think in color, so they may need to develop slightly different visual skills from radiologists who largely see a gray-scale world while they’re working.
Dr. Christine Ko
Cognitive psychology also offers lessons. One seminal paper, “The invisible gorilla strikes again: Sustained inattentional blindness in expert observers,” issues a stern admonition: “[A] high level of expertise does not immunize individuals against inherent limitations of human attention imperception” (Psychol Sci. 2013 Sep;24[9]:1848-53). Inattentional blindness, Dr. Ko explained, occurs when “what we are focused on filters the world around us aggressively.” First author Trafton Drew, PhD, and his colleagues added: “Researchers should seek better understanding of these limits, so that medical and other man-made search tasks could be designed in ways that reduce the consequences of these limitations.”
How to overcome these limitations? “Concentrate on the camouflaged,” said Dr. Ko, taking a page – literally – from “Visual Intelligence: Sharpen Your Perception, Change Your Life” (Houghton Mifflin Harcourt, 2016), a book by Amy Herman, JD. Ms. Herman devised the mnemonic “COBRA” to identify several steps that can prevent cognitive error from visual observation: