The Use of Art Observation Interventions to Improve Medical Students’ Diagnostic Skills: A Scoping Review

Introduction: Clinical observation skills are fundamental to the practice of medicine. Yet, the skill of looking carefully is rarely taught within the medical curriculum. This may be a contributory factor in diagnostic errors in healthcare. A growing number of medical schools, especially in the United States, have turned to the humanities to offer visual arts-based interventions to foster medical students’ visual literacy. This research aims to map the literature on the relationship between art observation training and diagnostic skills of medical students, highlighting effective teaching methodologies. Methods: Based on the Arksey and O’Malley framework, a comprehensive scoping review was conducted. Publications were identified by searching nine databases and hand searching the published and grey literature. Two reviewers independently screened each publication using the pre-designed eligibility criteria. Results: Fifteen publications were included. Significant heterogeneity exists between the study designs and the methods employed to evaluate skill improvement. Nearly all studies (14/15) reported an increase in the number of observations made post-intervention, but none evaluated long-term retention rates. There was an overwhelmingly positive response to the programme, but only one study explored the clinical relevance of the observations made. Discussion: The review establishes improved observational acumen following the intervention, however, uncovers very limited evidence towards improved diagnostic abilities. There is a need for greater rigour and consistency within the experimental designs, through using control groups, randomisation, and a standardised evaluation rubric. Further research on the optimal intervention duration and the application of skills gained to clinical practice, should be performed.


Rationale
The humanities are becoming increasingly more prevalent in the medical school curricula in order to 'improve the communicative, metacognitive, and observation skills' of students (Rana, Pop, and Burgin 2020). These educational interventions are developed to help participants explore knowledge from a perspective that is different to the traditional scientific approach, hence encouraging a holistic professional formation.
Clinical observation is a fundamental part of medicine, yet its teaching is rarely included in the medical school curricula. Contrary to the belief that diagnostic skills are solely developed through years of practice, there has been increasing evidence that these skills can in fact be nurtured using the right interventions.
Arts-based interventions in health care education may, amongst other things, help improve clinical diagnostic skills. At the moment such programs exist in a number of medical schools globally, however these are mostly advertised as elective modules. A preliminary search on this topic indicated significant literature available, however there is no scoping review that exists in this field to date. This further emphasises the importance of this study to map the current evidence in order to adequately inform on future research needed.
Objectives 1. To map the existing literature in order to understand the relationship between art observation training and diagnostic skills of medical students. 2. To explore how the findings of this review can influence the way the current medical curriculum is designed to benefit both students and their patients. 3. To identify the gaps in the current literature and make recommendations about future research accordingly.

Key words
A. Scoping reviews are becoming an increasingly popular tool to systematically map the breadth of evidence in a particular body of literature. Although no universal scoping study definition exists, Levac et al. (2010) define it as the 'synthesis and analysis of a wide range of research and non-research material to provide greater conceptual clarity about a specific topic.' Unlike a systematic review, the purpose of a scoping study is not to establish the quality of the evidence, but instead to identify gaps in knowledge and trends in the current evidence in order to underpin future research.
B. While the definition of art is widely disputed and has evolved over time, in its broad form, it may be considered as 'a form of communication' and 'an act of expressing feelings, thoughts, and observations' (Brewminate 2017). Art encompasses multiple modalities, including but not limited to literature, poetry, music, dance, and drama. This review focuses on 'visual art' which is appreciated through sight and opens a window into exploring human experience.
C. Observation is simply the 'art of seeing' (Shapiro, Rucker, and Beck 2006). It illustrates the ability to gather information from a primary source and derive meaning in what is inspected from an unbiased point of view. This same construct has also been referred to as 'visual literacy' by Naghshineh et al. (2008) and 'pattern recognition' by Shapiro et al. (2006).
D. Diagnostic skills rely on utilising observations in the context of domain specific knowledge and experience. In order to do so, one must 'recognise both the subtle and obvious visual details' that underpin the clinical presentation to form accurate diagnoses (Dolev, Friedlaender and Braverman 2001).

E.
A medical student is an individual who is following a course of study at a university in order to qualify as a physician. This study will look at medical students from both pre-clinical and clinical years globally.

Types of participants
Participants must be medical students, however they can be at any stage of their education, whether that is the pre-clinical or clinical phase. As well as this, they can be of any age, gender, and ethnicity as this will make the study more comprehensive. The background characteristics of the participants, in terms of medical conditions or socio-economic background for instance, is not relevant for this purpose.

Concept
The participants must be taking part in a formal art observation training programme, although this can be of any specified length of time. The main objective of the study should be evaluating the effect of the training programme on diagnostic skills, either directly or indirectly. For instance, a direct relationship can be seen as improvements in observation skills or reflective and analytical thinking. On the other hand, an Indirect relationship can be classified as a development in communication skills, teamwork, listening skills or even empathy. Including these various aspects add breadth to the scoping review and ensures a more comprehensive mapping of the existing literature.

Context
All studies, whether conducted nationally or internationally will be included in the review. As well as this, there will not be a limit to the publication dates. The specific setting of the study, whether that is a lecture theatre or a local museum, will vary depending on the facilities available, but this will not affect the eligibility criteria.

Exclusion criteria
Studies will be excluded if they have any of the following characteristics: -Studies where the participants are not medical students -Studies where the participants are taking part in another humanities-based curricula intervention, such as narrative writing or theatre -Data collected is not relevant, either directly or indirectly, to diagnostic skills -Articles where the full text cannot be obtained -Studies where the English translation cannot be obtained

Information sources
In order to map the existing and emerging evidence, any literature relevant to this subject will be screened and no filters will be added. All research designs, as well as websites pages, will be considered.

Search strategy
The search strategy will follow the three-step process recommended in the 2017 Guidance for the Conduct of JBI Scoping Reviews (Peters et al. 2015).
The first step is an initial limited search of NUsearch and Google Scholar. Following this, the key words that appear in the title and abstract of the studies will be analysed, as well as the index terms used to describe the article.
A second search will then be carried out using all the identified keywords and index terms across all included databases. This includes: -PubMed -Cochrane Library -EMBASE -Scopus -Web of Science -ASSIA -CINAHL Plus -ProQuest -PsycINFO -Open Grey and Open DOAR (grey literature) In the third step, the reference list of selected studies will be searched to identify any additional literature. Ideally, the bibliography of all identified studies should be searched for, however, due to the time constraints of the project, this will be limited to the studies that are included in the review. As well as this, the citation list of each included study will also be searched to minimise the risk of excluding relevant studies.
In the aim of conducting a comprehensive search on the topic area, grey literature will also be consulted. This will be done through accessing NUsearch for relevant conference papers, theses, and dissertations. As well as this, to identify any ongoing clinical trials, a search on CENTRAL will be carried out.

Study selection
All search result citations will be uploaded into EndNote software for ease of reference and tracking. This software will also enable all the duplicates to be deleted.
Firstly, the title and abstract of each study will be analysed to identify the ones that are directly relevant. If a study's relevance is not clear from the abstract, the whole paper will be read. As explained by Badger et al. (2000), 'abstracts cannot be assumed to be representative of the full article', hence the full text will be studied for chosen articles.
The predefined inclusion criteria will be strongly referred to when selecting articles which are to be included in the final review.

Data collection process
In a scoping review, data collection is known as 'extraction and charting'. According to Ritchie and Spencer, charting is a technique used to synthesize and interpret qualitative data according to key issues and themes.
In order to collect standard information from each study, a common analytical framework with eleven key points has been developed. This structure was taken from the Joanna Briggs Institute methodological guidance for Scoping Reviews (Peters et al. 2015) and has been adapted to fit the purpose of the study. Any further refinement during the data extraction process will be noted and justified in the methodology.

1.
Author and year of publication 2.
Academic staff involved 5.
Study population and sample size 6.
Number of sessions 7.
Total number of hours 8.
How outcomes are measured 10. Control group? 11. Key findings All the data collected will then be entered into the database programme Excel.

Presentation
The process through which studies will be included and excluded in of the results the review will be presented in the form of a flowchart. Furthermore, as the objective of this scoping review is to understand the impact of an art observation training programme on the diagnostic abilities of medical students, it may be useful to map the data collected in a tabular form. As well as this, a narrative summary will accompany the results to illustrate how this relates back to the objectives of the review.
Having said this, the exact framework will be developed further along the process when there is greater clarity on the contents of the included studies.

Risk of bias (quality) assessment
As per the proposed framework of Arksey and O'Malley (2005), as well as the Joanna Briggs Institute methodological guidance for Scoping Reviews (Peters et al. 2015), a quality appraisal for the selected studies will not be carried out.

Limitations
Only articles where an English translation is available will be used, so that means that there is a possibility to miss out of valuable literature.
Moreover, the quality of studies will not be considered, which therefore affects the reliability of the conclusions drawn.
NOTE: For citations in the protocol, please refer to the bibliography.