Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

Medical education of attention: A qualitative study

Anna Harris & Eleanor Flynn

To cite this article: Anna Harris & Eleanor Flynn (2016): Medical education of
attention: A qualitative study of learning to listen to sound, Medical Teacher, DOI:
10.1080/0142159X.2016.1231916

To link to this article: http://dx.doi.org/10.1080/0142159X.2016.1231916

Published online: 27 Sep 2016.

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Download by: [University of California, San Diego] Date: 27 September 2016, At: 03:33
MEDICAL TEACHER, 2016
http://dx.doi.org/10.1080/0142159X.2016.1231916

Medical education of attention: A qualitative study of learning to listen to

ABSTRACT
Introduction: There has been little qualitative research examining how physical examination skills are learned, particularly
the sensory and subjective aspects of learning. The authors set out to study how medical students are taught and learn the
skills of listening to sound.
Methods: As part of an ethnographic study in Melbourne, 15 semi-structured in-depth interviews were conducted with stu-
dents and teachers as a way to reflect explicitly on their learning and teaching.
Results: From these interviews, we found that learning the skills of listening to lung sounds was frequently difficult for stu-
dents, with many experiencing awkwardness, uncertainty, pressure, and intimidation. However not everyone found this pro-
cess difficult. Often those who had studied music reported finding it easier to be attentive to the frequency and rhythm of
body sounds and find ways to describe them.
Conclusions: By incorporating, distinctively in medical education, theoretical insights into “attentiveness” from anthropology
and science and technology studies, the article suggests that musical education provides medical students with skills in sen-
sory awareness. Training the senses is a critical aspect of diagnosis that needs to be better addressed in medical education.
Practical approaches for improving students’ education of attention are proposed.

Background
The teaching and learning of physical examination skills in Practice points
medicine has become contentious. Some clinicians question
the usefulness of subjective, sensory examination techni-  Attention is an important dimension in developing
ques in an era of rapid technological advances in diagnosis physical examination skills.
(Russi 2005). Others argue that the performance of exami-  Musical training fosters skills in attentiveness.
nations remains an important aspect of medical care and  Attentiveness could be better articulated into the
requires training even though other modalities can provide curriculum, through practical exercises.
the same diagnoses (Verghese 2009). Despite the contro-  Theories from anthropology and science and tech-
versy, little is known about how physical examination skills nology studies on attention offer new perspec-
are, and have been, learned (Duvivier 2012), particularly the tives to medical education research.
sensory and subjective aspects of learning such skills.  Ethnographic interviewing is a useful method for
This gap led the authors to design a project to discover giving insights into practices.
the ways in which one set of physical examination skills –
the skills of listening during a respiratory and cardiovascu-
lar examination – were taught and learned. What the
authors did not set out to do, is to enter the debate on teaching practices of sensory observation. This paper deals
the relevancy of physical examination skills learning or the with the material from the interviews with teachers and stu-
accuracy of the physical examination compared to other dents that were conducted as part of this ethnographic
diagnostic tests, as this is thoroughly dealt with elsewhere study. The interviews focused on how individuals learned to
(e.g. JAMA’s The Rational Clinical Examination collection). listen to sounds.
This study was part of a larger international project about
the use of sonic skills across professions (see the Sonic Skills Theoretical framework
website [http://fasos-research.nl/sonic-skills/] for further
details). The specific objectives of the medical school Contributing to a shift in medical education that attempts
research were: to consider how knowledge of sounds was to broaden the repertoire of theories used (Wartman 1994;
shared between expert and novice, by observing and Eva 2008), the authors draw uniquely (for medical educa-
describing the learning and teaching of lung sounds in uni- tion) upon theoretical insights into “attentiveness” from sci-
versity and hospital contexts; to build theoretical insights by ence and technology studies (STS) and anthropology.
analyzing these findings in light of relevant social science By relating these theoretical frameworks to the findings
theories; and to contribute evidence that will enable investi- of the interviews, the authors argue that learning the
gation, consideration, and potential improvement of current traditional skills of physical examination has an important

CONTACT Anna Harris a.harris@maastrichtuniversity.nl PO BOX 616, 6200 MD Maastricht, The Netherlands
ß 2016 Informa UK Limited, trading as Taylor & Francis Group
2 A. HARRIS AND E. FLYNN

role in modern clinical medicine through its focus on sen- also made handwritten notes for each interview. A sensory
sory awareness. In particular it is imperative to address how interviewing technique was utilized which involved the use
medical students are taught to pay attention while perform- of prompts in order to understand more about listening
ing physical examinations, as well as consider how medical practices (for example, asking questions related to sensory
educators can use attentiveness when teaching skills to stu- experience or using sounds to elicit memories) (Harris
dents; skills which are increasingly perceived to be highly 2015).
“subjective,” with signs which are difficult to articulate, eli- The interviews were transcribed and anonymized by a
cited through techniques which are heavily dependent on student assistant. AH undertook the first stage of analysis
the abilities of the practitioner. after fieldwork had finished, immersing herself in the
material by hand-coding the transcripts for emerging
themes. Interpretive notes were also made on the tran-
Methods scripts. This thematic analytical process was repeated, work-
The project was undertaken in both the preclinical and clin- ing back and forth across the data and relevant theoretical
ical sites of a medical school involving students and their and empirical literature. A selection of the material was
clinical skills teachers. Students in their first and second then shared with EF and both authors engaged in further
years of a graduate entry course and sixth (final year of a thematic analysis selecting and verifying the important
previous school leaver entry course) year were available to themes. All decision-making was carefully documented. The
participate in the study, as they were present in the med- findings have been written up in accordance with the 21
ical school and hospital, and learning or practicing the skills items in the Standards for Reporting Qualitative Research
of physical examination. The second year students were in (SRQR) guidelines (O’Brien et al. 2014). The project had eth-
their first clinical (hospital based) year of the course. ics approval from both University and Hospital Research
The study involved an initial broad ethnography which Ethics Committees.
was undertaken through hundreds of hours of observation
of fieldwork in Melbourne by the first author (AH) immersing
Results
herself in clinical skills teaching sessions at both university
and hospital sites to observe the ways in which medical stu- From the thematic analysis of the interview material with
dents are taught and learn the skill of listening to sounds, teachers and students, the authors found three key findings
particularly lung and heart sounds, through practices such which are described in more detail below. (1) Learning the
as auscultation and percussion (as well as listening to other skills of listening to lung sounds was frequently difficult for
sounds such as cough or wheeze). The later part of the study students, with many experiencing awkwardness, uncer-
included detailed interviews with students and teachers tainty, pressure, and intimidation. (2) Learning to hear these
who had been involved in the ethnographic study. sounds meant learning to pay attention. (3) Not everyone
AH, a medical graduate and anthropologist, conducted found learning to listen to sounds difficult. Often those
the participant observation in Melbourne from July to who had studied music reported finding it easier to be
October 2013. She was not known to the participants of this attentive to the frequency and rhythm of body sounds and
research prior to the study and did not undertake any teach- find ways to describe them.
ing activities. The second author (EF), a doctor, educator, These findings have been analyzed in the context of the
and researcher, facilitated entrance into these settings and broader comparative ethnographic project which involved
collaborated during the fieldwork. She was not involved in fieldwork in both Melbourne and the Netherlands. The
recruitment, nor did she teach any of these students. Dutch findings are reported elsewhere (Harris and Rethans,
During the fieldwork, AH established good rapport with in progress) and focus on the creativity and improvization
participants and 15 semi-structured interviews were con- of teachers sharing sounds with students.
ducted with eight students and eight teachers (note: one
interview was with a student and teacher together; note:
Difficulties in learning to listen
identifying numbers in results section are labeled from the
Melbourne ethnographic study, where S is for student and Many clinical educators (CE) and students (S) expressed the
CE is for clinical educator – therefore numbers extend difficulties they found in hearing sounds for the first time
beyond 8). and in the early stages of learning. One student encapsu-
One student interviewed was from first year, one from lated the sentiments of many: “at the start you can’t really
final year, and the rest from second year. The interviews hear anything … I didn’t know what I was hearing, or sup-
explored in more detail the observations made during the posed to be listening for” (S2). Several CEs remembered
fieldwork as the participants were asked to articulate their feeling awkward as students learning to listen, having diffi-
current listening practices, as well as reflect on their learn- culty not only in finding patients on the ward who were
ing and teaching in the past. Questions asked during the not too exhausted by medical students listening to their
interviews were iterative, with the information from early “auditory sign,” but also learning to use techniques such as
interviews and fieldwork modifying the questions in later percussion and auscultation. They described difficulties
interviews, although all interviews included questions about such as:
techniques and strategies of learning and teaching sounds, Getting access to the patient, getting exposure – gender
and what was challenging and what was helpful. issues, female patients – you know – how to you place your
AH conducted all interviews at the medical school cam- stethoscope (CE4)
puses either at the university, hospital, or clinic. Interviews Clinical educators also remembered “not hearing” the
were audio-recorded and lasted on average one hour. She sounds they were meant to hear once they did have a
 MEDICAL TEACHER 3

chance to listen. Added to these difficulties were the noisy then the following conversation ensues, as pieces of paper
environments they found themselves practicing listening in, spit out of the nearby printer:
the hospital wards very different from quieter tutorial Consultant: What did you hear?
rooms, as well as the harried and often intimidating nature Chris: Early respiratory rough crackles. There were a few
of some of their ward round teaching sessions: crackles on inspiration.
It was so frustrating when there was a particular sound Consultant: Are you sure that’s what you heard? You can
that you just couldn’t hear. So we’d give our interpretation hear the crackles throughout. That’s a pleural rub. That’s
and the consultant would say “oh no, this is what this quite rare. I can’t remember the last time I saw one. Its not
patient has. They have this and this” and I would think – crunchy like a pneumothorax, sounds more creaky. So that’s
why couldn’t I hear that? (CE4) a plural rub. Very rare. At least for me, I can’t remember the
One CE felt so much pressure as a student to hear the last time I heard one.
sounds, from his professor, he and his cohort were Chris: I wish you had told me what to look for.
“petrified” and pretended they had heard them. Several Consultant: That was the point, not to know so you can
students also described pretending to hear through peer- listen for yourself. That’s why I told you to pay attention, to
pressure: pay attention to what you hear. Listen again, wait for the
It’s a bit of a game, because sometimes you make the call analgesia to kick in then listen again.
when you weren’t convinced of it yourself – the best example Returning to the interview material, an important part of
of that is in a tute [tutorial] with a doctor who will tell you paying attention is also learning to describe the sounds,
what is there. And then of course you have to hear it. You and correlating this to what was heard:
can’t not hear it! (S11) How I was taught was “listen to this” – “what do you
Many desired the “aha” moment, when they would sud- hear?” … “Funny noises”. “What sort of noises – describe the
denly hear the sounds. For two CE, there was no noises. Ok, yes, what you’re hearing is rhales fine and crack-
“watershed moment” or “anything spectacular” as a stu- ling noises. Make sure you’re hearing what I’m describing”
dent, while another CE remembered the frustrations of not (CE10)
hearing and then “all of a sudden I think a kind of clarity of Here the difficulties were those of learning to become
having been told of something to hear and understanding attentive to the sounds, and then to be able to describe
what it was and hearing what it was.” them appropriately.
The difficulties students and their teachers reported
relate to pressures to hear something that they could not
The benefits of musical training
hear, as well as those related to approaching patients.
When it came to describing sounds, many of the medical
students who had some form of musical training found it
Being taught to pay attention
easier:
While many of the CE remembered frustrations as students I think a lot of it is also kind of learning the words you
trying to hear sounds, they also remembered how they should use to describe sound. Because as you learn music
gradually learned to attend to sounds, which happened you learn also about the difference – different words like fre-
with practice, as one teacher put it “the more you hear, the quency or pitch or intonation or … tone and timbre and all
more you hear, the more you hear” (CE10). Several these kinds of things. And having these words, forms that
described what could be identified as a form of pattern rec- kind of mental framework as to how you could describe
ognition: “once you’ve heard them a couple of times, you sounds as opposed to just saying “oh that was loud or that
never, you don’t forget them” (CE9). was soft or this was … like high pitch or low pitch“ (S12)
What was important was the guidance from teachers, in Not all students had these skills of sonic description:
being made aware of these sounds: So, I still don’t feel good about my heart sounds, and I
The other memorable experience was being told that look think – I don’t know why but I feel like a lot of people got it
this patient has an early diastolic murmur, its here – “listen … it might also be the fact that I’m not a very musical per-
with the stethoscope, if you can’t [find it], I’ll find it. Put this son and I think that might be a huge thing (S1)
in your ears, use my stethoscope. I’ll hold it on the spot. Ask The quote is from a student who explicitly described
the patient to exhale, lean the patient forwards … right you herself as a nonmusical person, who found listening diffi-
should be able to hear it now.” And it was those kind of cult. Many of the teachers also reported this observation
things that meant that I first heard – I first heard what I was amongst their students:
supposed to be hearing (CE9) Students who are a bit musical or play an instrument –
The doctors were being taught to pay attention. This they are a bit better at – you know – focusing in on the
process was perhaps best captured in a section of field- actual frequency of the sound (CE3)
notes detailing a learning moment on the wards, between The teachers also encouraged a musical kind of
a first year medical student and an emergency room listening:
consultant: I tell them that listening to murmurs is different to any
My mobile phone buzzes and I read a message from Chris other listening you’ve done, unless you’re a musician. It is not
(pseudonym), the student I am shadowing that day: “Hi like putting the stethoscope in your ears and letting the
[Anna], I just listened to a lung if you want to come down to sounds washing over you. You need to concentrate. You need
Resus 6.” I find Chris at the nursing station, standing next to to focus on frequency, on intensity. The sounds might be qui-
an Emergency Room consultant typing rapidly away on a eter than you think. You need to listen actively. Like when
ward computer. We wait patiently for a few moments, and you listen to classical music and listen for the era, the
4 A. HARRIS AND E. FLYNN

composer, whether it is a symphony or concerto, what key, enskillment theories of anthropologist Ingold (2000) who
what instruments. They are trumpets, there is the viola. This argues that skills are not cognitive and technical attributes
is active listening I tell them (CE16) acquired through transmission of information but rather
Students who had had musical training also thought embodied practices learned gradually while becoming
that they had an advantage when it came to learning lung attuned to one’s sociomaterial environment.
sounds: In his excellent study of how London students learn to
Well it’s just like if you learn any kind of music you learn listen to heart sounds, the anthropologist Rice (2013) also
how to listen … If you play music you listen to a lot of music draws from Ingold’s work and uses the practice-orientated
and you become really particular about … you hear the approach adopted in this study. His ethnographic study
phrasing. You can hear the rests, you can hear the pauses. showed that students found listening practices such as aus-
You become more skilled in listening to the nuances of the cultation extremely difficult. Rice recounts students’ frustra-
sound (S7) tions concerning first attempts to detect murmurs. His
Here the students describe not only honing their skills study does not focus on the challenges of developing lis-
of listening but also of paying attention to the details of tening skills, simply reporting on most students gradually
this sensory experience. For some of the students this was “acquiring” proficiency at auscultation. The authors wished
a very implicit aspect of their practices, something which to fill the gaps in Rice’s study by exploring the difficulties
was particularly revealed through the process of participat- that students encounter in learning to listen, and whether
ing in the ethnographic interviews: all students are able to learn the skill eventually. The study
I took a lot of practical music classes but I also took a lot also addresses a current gap in the skills literature in med-
of music theory classes as well. And so … you’ve got a score ical education, by attending to the sensory details of
of a piece of music and you’re actually listening to the piece learning.
of music and then you are watching it visually unfold. So you Rice is skeptical about whether auscultation will remain
can see how … that language is transcribed into the sound. a relevant practice in the future, amidst technologies such
And so … this is really particular … it’s a really particular as hand-held ultrasound machines. While the concern is
training … I guess it’s an advantage in a way. I would per- recognized, the authors suggest that the benefits of learn-
ceive it as such – although until I’ve had this conversation ing to listen to sounds are also tied into learning to pay
with you I never really thought about like that … And so I attention, a quality that is important for all sensory skills,
do find that when I listen [to patients] I tend to close my eyes not only those of auscultation and percussion. Students are
and get quite still … but then that’s how I used to listen to engaged in what the ecological psychologist Gibson calls
an “education of attention” (Ingold 1996), a term further
music. That repetition of phrasing or – like things popping
developed by STS philosopher Latour (2004) who writes of
out like all the way through a piece of music … (S7)
“training to be affected.” For Latour this means learning to
The benefits of a musical education were evident in the
attend to differences of smaller and smaller magnitudes.
students’ ability to have a framework to enable them to
Similarly Bleakley et al. (2003) discuss, drawing on the phil-
hear the sounds and to describe them.
osopher Polanyi, the notion of a sensory connoisseurship in
medical education, as an esthetic and imaginative approach
Discussion toward distinguishing differences.
Our analysis of the interview material showed that not
This study, based on interviews with teachers and students only was teaching and learning sounds challenging, and
conducted as part of an ethnographic study on how doc- required paying attention, but also that those who had
tors learn to listen to sound, showed the importance of studied music found it easier to be attentive to the fre-
skills of attentiveness in learning the subjective skills of quency and rhythm of body sounds and find ways to
physical examination. describe them. This connection between musical training
There have been many ethnographic studies of medical and physical examination skills is not new. Historians of
education which have shown the richness of this approach medicine have long pointed out the musical abilities of the
for helping to understand how teaching and learning plays physicians who developed the skills of auscultation and
out in everyday contexts (see Atkinson and Pugsley 2005; percussion, Leopold Auenbrugger and Rene Laennec
Pope 2005; Reeves et al. 2013 for overviews), as well as in (Vouh e 2011; Bosanquet et al. 2014; Pesic 2016). Some fam-
the assessment of competencies (Whitehead et al. 2015). To ous teachers, such as the cardiologist W. Proctor Harvey
date, ethnographies of medical education have tended to have also used classical music as a way to introduce stu-
focus on the professional identity formation of medical stu- dents to the principles and techniques of aural identifica-
dents, building upon foundational work such as Becker tion and sound classification (Harris and van Drie 2015).
et al.’s (1961) study of United States medical schools. The Interestingly, there has been more focus on the links with
study presented in this article, along with others, offers an classical music, and indeed all of the medical students and
alternative perspective, moving attention away from profes- teachers who mentioned music were referring to classical
sional identity toward medical practices; that is, what people music. Recently researchers such as Brown et al. (2012)
do, rather than how they think about their actions (Schatzki have attempted to move away from the predominant focus
et al. 2005). on classical music in therapeutic environments to consider
The anthropological approach adopted in this study was other forms of sound and music, a direction which would
used in order to understand the practices entailed in learn- also be useful to consider in medical education.
ing to listen to sounds. In doing so, multiple, subjective What is most important in respect to this finding in our
realities are assumed rather than a single objective truth. material, however, is not so much whether we can con-
The broader ethnographic project was guided by the clude that music is beneficial to learning auscultation
 MEDICAL TEACHER 5

(see others such as Pellico et al. 2012 who are researching this is a common approach in ethnographic and oral his-
this systematically), but rather that music training enhances tory interviewing and we believe that there is much rich-
the students’ skills in attentiveness. An important and ness in these auditory memories. The memories offer
beneficial aspect of musical training was a training of the insight into the everyday practices of learning to listen to
senses, a general education in sensory awareness that is sounds, which are triggered by active involvement in the
also important in learning the sounds of the body. The teaching program (see Harris 2015 for more detailed
attentiveness developed in musical training could also be approach to sensory memory methods).
of benefit in providing an ability to attend carefully to the
sounds from the stethoscope in spite of being in a noisy Practical implications
ward (Parbery-Clark et al. 2009). Learning to pay attention
was integral to learning to listen to murmurs and patho- There has already been important work on the sensory
logical breathing, a process which required guidance by training of medical students, often within the remit of med-
teachers. The clinical teachers needed to direct the ical humanities and particularly art classes for medical stu-
students’ attention toward what sounds to listen to, how to dents, since Braverman’s (2011) introduction of this
focus their attention. These skills in sensory awareness are approach in Yale. In Melbourne, Heather Gaunt and Eleanor
vital to good medical practice, yet difficult to teach in med- Flynn have introduced such a program in a collaboration
ical school. As Bleakley et al. (2003) write, “how one may between the Ian Potter Museum of Art and the Medical
educate a perceptual attention, or close noticing, is a long- School. There are also courses on improving students’ per-
standing problem in medicine.” ceptive attention through the teaching of skills of close
Attention is not only one of the bedrock goals of clinical reading of literature and through creative writing (Wellbery
teaching (Charon et al. 2016) but also fundamental in all our & McAteer 2015; Charon et al. 2016). Finally, some have
daily interactions with the world around us. Ingold (1996, attended to musical training as well, such as Pellico et al.’s
2000) argues that it is through situated and attentive (2012) study of aural training.
engagement that one becomes a skilled practitioner in daily Reports evaluating and reviewing art classes for medical
life. The role of any “tutor” in this process, he suggests, is to students describe evidence of improved observational skills,
set up situations in which the novice is instructed to attend which facilitate seeing in ways that improve diagnostic abil-
to the particularities of what can be seen, touched, heard ity (Perry et al. 2011; Gaunt et al. 2014; Wellbery & McAteer
and to get a feel for it themselves. He draws from Gibson’s 2015). Many of these studies find the importance of train-
notion of “education of attention” to make this argument, ing observation skills to be based on better pattern recog-
whereby a novice is trained to “pick up” aspects of their nition, viewed as a critical step in clinical reasoning. They
environment that they might otherwise fail to notice. draw from cognitive learning models in order to under-
For professionals such as doctors there is much at stake stand these findings. There is also a focus on how these
in training the senses through attentiveness, just as there courses train skills in empathy. While this article’s approach
are for other sensory experts. Latour (2004, p. 213) differs in regards to its focus on bodily, sensory learning,
describes how a novice perfumer can become “a nose” using anthropological models of skills training, it draws
through training their sense of smell with odor kits, which from descriptions of these arts-based courses and the find-
help them distinguish from very obvious to very small dif- ings of the ethnographic interviews to suggest that diag-
ferences: “the more you learn, the more differences exist.” nostic skills can be better developed through specific
Part of this process is learning to become more articulate, sensory training exercises.
which the medical students in this study noted, particularly A series of practical workshops for medical students that
those trained in music. The more training they had to listen focus their skills in attention and sensory awareness
to musical sounds, the better their skills in articulating through a curriculum of hands-on activities could be devel-
body sounds were perceived to be. oped and articulated into the existing curriculum. These
Pellico et al. (2012) write that “clinical competence could be drawn from classical music training and the art
begins by developing and sharpening skills that use the and writing sessions already mentioned in this article, but
senses: observing, palpating, hearing, and smelling” and also incorporate other forms of sensory training, such as
that “given that the skill of physical examination is multi- cooking classes, tea/coffee tasting lessons, mindfulness
sensory, curricula that enhance the skills of observing, training, nature walks, or contemporary dance classes. The
touching, and hearing logically have potential for improved aim of such sessions, led by a sensory expert in the
competency. Development of these skills is critical since respective field, would be to train the students to attend to
they are the basis for initial assessment, physical examin- differences (in sounds, sight, taste, smell, texture, move-
ation, diagnosis of a patient’s needs and evaluation of ment, etc.), to guide them to notice aspects of their body,
treatment impact.” A series of practical activities focusing materials, their environment, they might otherwise not
on sensory awareness, which would assist students to gain notice, to find ways to articulate these experiences and to
these skills, is discussed below. reflect on the skills of observation and attentiveness to
In summary, the authors do not advocate for or against those observations that are required for their work as doc-
the teaching and learning of physical examination skills; tors. Such sessions would have to be embedded in the clin-
instead they report on current and past practices of teach- ical skills practical classes so the students could “see” the
ers and students elicited from ethnographic interviews in a connections. The encouragement of reflection before, dur-
medical school. The study is limited in that it focuses ing, and after the sessions, through guided discussions with
mainly on second year students and teachers. While some the sensory expert and a medical educator and the docu-
may also consider the findings limited and subject to recall mentation of the observations and reflections would be a
bias in that they rely predominantly on sensory memories, necessary part of such sessions.
6 A. HARRIS AND E. FLYNN

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Anna Harris B Med Sci, MBBS, M Med Anthropology, PhD, is an Pellico LH, Duffy TC, Fennie KP, et al. 2012. Looking is not seeing and
Assistant Professor of Anthropology/Science and Technology Studies at listening is not hearing: effect of an intervention to enhance audi-
Maastricht University, the Netherlands. Previously trained as a doctor tory skills of graduate-entry nursing students. Nurs Educ Perspect.
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