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ABOVE AND BELOW – THE ART OF OBSERVATION

06 Apr

The weekend before Easter my daughter treated me to a weekend in Paris primarily to see films she has been working on which are being shown  at the ‘Louvre’ and a smaller trendier gallery ‘the Bal’. She felt very pleased as Le Monde had recommended this as one of the 10 things to do in Paris for that weekend. imageimage Le Monde – Dix raisins de sortir ce weekend Difficile de ne pas être hypnotisé par les vidéos du Canadien Mark Lewis, qui, en une petite dizaine de minutes, vous emportent comme sur les ailes d’un oiseau au-dessus d’une forteresse italienne perchée sur une montagne, ou lelong d’une autoroute urbaine qui défigure la ville de Sao Paulo au Brésil. Le silence règne, qui rend les mouvements de caméra d’autant plus fascinants. Les micro-événements de la vie – des joggeurs qui transpirent, un homme qui fume tranquillement dans un café – prennent tout à coup un relief étonnant. L’artiste présente ses œuvres au BAL à Paris ainsi qu’au Louvre où il a réalisé des films à l’intérieur du musée. image image Mark Lewis the director is a Canadian Artist, who makes short films that take stillness and explore it in motion. Many of these films have been shot in London, where he has lived since 1997 as a professor of fine art at Central Saint Martins. On viewing it is not difficult to be hypnotised by them. The exhibition we saw are his recent productions: in one of them for about 10 mins you feel as if you on on the wings of a bird flying over an Italian fortress perched on a mountain. He uses various techniques with the camera to get a serpentine effect. One video was filmed inside the Louvre in the foyer and then concentrating on several paintings in detail as if it was through the eyes of a fly circling around and then settling.  Invention au Louvre   – exhibited until August 31st, 2015 at Le Louvre, Paris The video that particularly interested me was filmed above and below an elevated highway which passes through the city of São Paulo in Brazil. – Above and Below – exhibited at Le Bal,  6, impasse de la Défense, 75018 Paris http://www.le-bal.fr/ image image The Minhocão, officially Via Elevada Presidente Costa e Silva, is a 2.2-mile (3.5 km) elevated highway in São Paulo, Brazil, which travels within metres of residents flats. Following a protest suggesting that the proximity of the road was an invasion of residents privacy it was decided that between  9:30 PM and 6:30 AM on weekdays and all day on Sundays, the highway would be closed to car traffic, allowing dedicated use by pedestrians and cyclists. The road is named after the minhocão, a quasi-fictitious earthworm-like creature. Local urban planners have long advocated tearing down the road in order to promote urban renewal. The film is silent which makes the movements of the camera  imore fascinating. The trivial events of life – above perspiring joggers passing by and underneath a man wandering under the highway chatting on his mobile phone and visiting a café. We watched the video reclining on large beanbags on the floor allowing you to ‘people watch’ as they passed by; watching families and their interactions, people taking their dogs for a walk , cyclists as well as those just stopping and sitting to chat on the central reservation. Apparently, a visitor to the exhibition had actually recognised someone walking on the highway validating the authenticity and the closeness of observation.

The reason this video particularly fascinates me in that my job as a doctor is all about observing people not only the physical signs of disease but  facial expressions, personal interactions and their demeanor.

The great Canadian Physician, William Osler said, ” medicine is in observation… but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man  on the right path, is all that we can do.”

Many great medical teachers through the ages have emphasized the paramount importance of the art of observation. Chief among these were Joseph Bell – the Edinburgh surgeon who inspired the creation of Sherlock Holmes.  I’m sure you’ll agree that Joseph Bell’s lesson on the art of observation is one that should never be forgotten.

I distinctly remember in my early days of medicine when attached to a respiratory medicine firm ( as we called it then) how it was my job each morning to examine every patient’s sputum noting the quantity, colour, consistency and smell and report this on the ward round.

It was instilled into us by senior doctors that we should go through the ritual of observation of the patient firstly at a distance and then at closer quarters, observing and examining  every part of the body. It still remains my practice to observe the patient from the minute I set eyes on the patient in the waiting room as I call them to the consulting room. In my first practice  the patients sat on a bench against the wall.

I remember on one occasion going out to call the next patient and as I observed the row of patients my eyes caught sight of one gentleman who looked distinctly grey and pale with his eyes closed and was propped up by patients either side. As I called him I realised he was seriously ill, infact he was having a heart attack and had to be admitted urgently to hospital.

When I teach medical students, the younger students on meeting the patient want to find out what is their diagnosis and want to obtain clues by asking about medication. As a teacher I have to train them to observe and build a picture bit by bit so that by the time they reach finals this becomes second nature and something to build on for the rest of there career. When they leave the surgery I tell them that when they board a bus or tube to get used to looking and observing the people around them perhaps working out if someone has a medical condition simply by observation.

.“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.” – William Osler

Yet learning the art of observation is difficult, and may seem an insurmountable task to the novice. Osler well knew the size of this challenge, and he encourages us from the past to persist. Only by observing countless patients over many years can we learn to truly see, and our mastery will grow until the day we each hang up our stethoscopes. Yet, no matter how feeble and immature our talents of observation are, exercising them can reap unimaginable rewards.

As Dr livingston and myself were trained in the same way,  if we are puzzled by the diagnosis of a patient we get together with the patient and go back to basic observation and examination and by doing this  between us are able to formulate a plan to obtain the diagnosis .

Similarly, if we come across a new or unusual observation we make a point of sharing it to perpetuate our ongoing learning. “Get the patient in a good light. Use your five senses. We miss more by not seeing than we do by not knowing. Always examine the back. Observe, record, tabulate, communicate.” – William Osler

I started to really understand medicine when I qualified and alongside more experienced doctors who passed on their observations. I was on a wardround as a junior attached to an Obstetric and Gynaecology firm and as we arrived at the bedside of a pregnant lady she suddenly started to exhibit bizarre movements, wherby she stared straight ahead and then her eyes deviated upwards then converged as her neck arched backwards and laterally, she then opened her mouth and protruded her tongue. The consultant became quite alarmed and asked the sister accompanying us on the ward round to summon the medical registrar immediately. ” Excuse me sir, this patient is taking Metoclopramide I think this is an oculo – gyric crisis which is a side effect to this drug and will be reversed by taking another drug or simply stopping the Metoclopramide”. At that point the medical registrar entered who agreed with my diagnosis. The reason I knew about this was because  a medical colleague had called around the night before and had described the condition, albeit unusual, in a patient he had seen that day, but the consultant had never seen this before.

“Medicine is learned by the bedside and not in the classroom. Let not your concepts of the manifestations of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first. No two eyes see the same thing. No two mirrors give forth the same reflection. Let your word be your slave and not your master.” – William Osler

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1 Comment

Posted by on April 6, 2015 in Training and Advice

 

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One response to “ABOVE AND BELOW – THE ART OF OBSERVATION

  1. Abbie PM

    April 24, 2015 at 2:03 pm

    In relation to your notation “Only by observing countless patients over many years can we learn to truly see…”, I find the distinction between observing and seeing interesting also from the patient perspective, specifically the notion of “truly seeing”. “Seeing” is embedded in language – as patients or health consumers we talk about “seeing the doctor” or if something is wrong, someone might say “have you been seen by a doctor”. In the context of your article, I would like to reference the essay – “Seeing is Believing” by Alan Dundes. He talks about “the primacy of vision in American culture” and that “seeing the doctor” has more validation for a patient rather than a “telephone conversation”, for example, as he explains how other senses are not valued as much as vision. In a world where patient evaluation can take place remotely by electronic means, how does “observing” evolve in order to “truly see”?

     

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