Two hours with a new patient could seem a bit excessive for many clinicians but in the field of Developmental and Behavioral Pediatrics (DBP) this is the norm. This unique pediatric subspeciality, focused on children with various chronic special healthcare needs, has an inherently close relationship to a museum based medical education strategy known as Visual Thinking Strategies (VTS). In both, we are tasked to help others make meaning around challenging topics, where ambiguity thrives, and in circumstances where a ‘picture perfect’ ending is often not afforded.  

Developmental and Behavioral Pediatricians regularly meet families with children at risk for chronic health conditions like Autism Spectrum Disorder (ASD), Intellectual Disability, and related neurodevelopmental conditions. Many families recognize early signs and symptoms in their child and embark on a long and complex journey to understand their child, while searching for services and treatments to promote their child’s progress. I, like many clinicians, regularly encounter parents who struggle to articulate what lies at the heart of their fears. I have worked with families who see me as a third or even fourth opinion, often confirming the same diagnosis each time, in an effort to make sure all the providers are actually “seeing” the same picture.

Nearly every parent of every patient I have worked with wants to know the answer to one question. Although phrased in a multitude of ways, it comes down to “What does the future look like for my child? Will they have friends?  Will they be bullied? Will they need to be in special education? Will they get married? Can they live independently? Will they have a job? What will their life look like when I am no longer here?”

On the opposite end of the spectrum are countless instances when this line of questioning is never raised. Yet under the surface, these very concerns remain present and sit quietly beside the parent, hoping to be unpacked. For some, these worries are too difficult to express out loud, as if verbally expressing the question will manifest an unwelcomed future. Unspoken questions stifle the flow of the clinical encounter and produce a series of speed bumps that impact the very heart of medicine – the physician patient relationship. For me, when it begins to feel like there is something unsaid that needs to be brought into the light, an internal dialogue flips on: “What is actually going on here? “What am I missing?”  A very similar version of these questions are the core of VTS: (1) What is going on in this image? (2) What do you see that makes you say that? (3) What more can we find?

When I was invited to take on the lead faculty role for a museum-based course for medical students, a colleague forwarded me information on the Harvard Macy Institute Art Museum-based Health Professions Education Fellowship. To say the fellowship had an impact on my professional career and how I practice medicine would be an understatement. The faculty and fellows in the program are not only impressive and talented, but warm, generous, and supportive. I quickly learned that VTS was another way to support clinical care and I needed more. I completed an additional VTS course, outside of the Harvard Macy Institute fellowship, which included professionals from a wide range of fields including media, design, and healthcare. This is where I began to understand how VTS could be applied in many professional and personal contexts. We trained in the numerous components of VTS including paraphrasing, confirming understanding, and highlighting larger themes that emerge in these facilitated group discussion. VTS went from something I knew a little about, to something I was practicing regularly. I soon found myself internalizing core VTS questions that would later emerge at timely moments throughout the day, whether I was in a clinical setting or not.

There is a patient and family I remember well, although the scenario is all too common. The parents had a young child with complex medical issues who had already been diagnosed with ASD. There were multiple professionals who had evaluated the child before me and confirmed the ASD diagnosis. It was now my first time seeing the patient. The parents wanted to know if the child had ASD. This patient was already receiving every evidence-based intervention available. These were bright, loving, and dedicated parents. They were impressive. Shortly after the visit started, I began debating if my usual line of questioning and checking off DSM-5 diagnostic criteria for ASD would be useful for this family. I thought to myself “What would they gain from the same information repeated to them yet again? Why does this visit feel… off?” “What is actually going on here?” “What am I missing?” 
I stopped typing and moved in a little closer to the parents. I paraphrased everything they just shared about their child, their journey, and their current concerns. I asked if I had that information correct. They nodded. I then relayed that it feels like they have some real worries about their child’s future - although they never stated that. I shared why I had this impression based on what they told me and the information in the medical chart. They nodded. The picture comes in a little clearer. The speedbumps fade and we move together in a different direction. The conversation that followed was difficult but for this family it was overdue.

Would I have responded the same without VTS and the Harvard Macy Institute Art Museum-based Health Professions Education Fellowship? Perhaps. There is no doubt that these programs have strengthened skills of attending and adapting that would have felt less natural for me a few years prior. In the end, VTS is another tool in my toolbox. A compass when the direction feels a little off. A moment of seeing, when something unsaid is simply waiting for you to take notice.   
Did you know that the Harvard Macy Institute Community Blog has had more than 330 posts? Previous blog posts have explored topics including the art of education, art as antidote, and can art reframe medicine?

Anson J Koshy

Anson J. Koshy, M.D., M.B.E. (Museum ’21) is a medical educator in the humanities and ethics, visual artist, and board certified developmental and behavioral pediatrician. Anson is currently Associate Professor at Baylor College of Medicine and serves as an adjunct associate professor at the McGovern Center for Humanities and Ethics. Anson’s areas of professional interest includes the intersection of the visual arts and healthcare, professionalism, and destigmatizing mental health in the South Asian community. Anson can be followed on Twitter or LinkedIn