Bleakley Alan, Farrow Richard, Gould David, Marshall Robert
Cornwall Postgraduate Education Centre, Royal Cornwall Hospitals Trust, Truro, Cornwall, UK.
Med Educ. 2003 Jun;37(6):544-52. doi: 10.1046/j.1365-2923.2003.01542.x.
Close noticing, as keen discrimination and judgement between qualities, is a key capability for work in visual domains in medicine. This generic capability is normally assumed, and its specifics are left to develop through experience, as traditional apprenticeship in a specialty. Discrimination is an outcome of learning in the affective domain, and introduces a vital aesthetic dimension to clinical work that aligns with the interests of the medical humanities. An aesthetic approach to clinical reasoning, however, remains largely unexplored as an explicit focus for medical education.
We offer a framework for an explicit education of perceptual discrimination in the visual domain as a form of practice 'artistry', turning a surface 'looking' into a deeper 'seeing'. Such an education, however, raises certain paradoxes. While novices typically 'see' what they expect to see in visual images (sign and symptom), experts also make similar errors. Further, experts become familiar with the use of visual heuristics in diagnosis, such as vivid natural referents to aid in rapid pattern recognition in an encompassing diagnostic 'glance', yet this appears to defeat the first principle of describing what you see. Employing a model of imagination as a tacit form of knowing that 'prepares' and enhances perception, we suggest, however, that the judicious use of such heuristics can be positive. Moreover, the mechanics of the process of clinical judgement in visual domains can be detailed to inform educational agendas. A further paradox is that of experts using both idiosyncratic heuristics and protocol-driven practices, where these seem to offer contradictory approaches to gaining knowledge. We recognise this as a facet of medicine's inherent uncertainty, in the face of complex, ambiguous and unique material, that must be addressed through clinical education.
We equate 'aesthetics' with 'sensibility' and describe clinical expertise as 'connoisseurship' of informational images. Such connoisseurship, a particular form of knowing, can, in turn, be defined as an aesthetic sensibility informing practice artistry. It can be articulated and analysed to provide a basis for educational enhancement. Connoisseurship is not a technical-rational procedure but is inherently paradoxical and such paradox may be valued as an educational resource, rather than seen as a hindrance.
敏锐观察，即对各种特质进行敏锐的辨别和判断，是医学视觉领域工作的一项关键能力。这种通用能力通常被视为理所当然，其具体细节则留待通过经验来发展，就像传统的专科学徒制那样。辨别是情感领域学习的结果，它为临床工作引入了一个至关重要的美学维度，这与医学人文学科的兴趣相契合。然而，作为医学教育的明确重点，临床推理的美学方法在很大程度上仍未得到探索。
我们提供了一个框架，用于在视觉领域对感知辨别进行明确教育，将其作为一种实践“技艺”的形式，把表面的“看”转变为更深入的“洞察”。然而，这样的教育引发了某些悖论。新手通常会“看到”他们期望在视觉图像中看到的东西（体征和症状），专家也会犯类似的错误。此外，专家们熟悉在诊断中使用视觉启发法，比如生动的自然参照以帮助在全面的诊断“一瞥”中快速识别模式，但这似乎违背了描述所见内容的首要原则。不过，我们认为，运用想象力模型作为一种隐性的认知形式来“准备”并增强感知，明智地使用此类启发法可能是有益的。而且，视觉领域临床判断过程的机制可以详细阐述，以为教育议程提供信息。另一个悖论是专家既使用独特的启发法又采用协议驱动的实践，而这些方法似乎提供了相互矛盾的获取知识的途径。我们认识到这是医学固有不确定性的一个方面，面对复杂、模糊且独特的素材，必须通过临床教育来解决。
我们将“美学”等同于“敏感性”，并将临床专业知识描述为对信息图像的“鉴赏力”。这种鉴赏力，作为一种特殊的认知形式，反过来可以被定义为一种为实践技艺提供信息的美学敏感性。它可以被阐述和分析，以为教育提升提供基础。鉴赏力不是一种技术理性程序，而是内在地充满悖论，这种悖论可以被视为一种教育资源，而非障碍。
