Beyond the Image Frame: An Art-Based Pedagogical Framework for Teaching Diagnostic Reasoning in Breast Ultrasound to Medical Students

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

In order to investigate diagnostic reasoning in the context of "time poverty," the proposed paper offers a unique and intellectually challenging multidisciplinary educational intervention that combines art history, semiotics, and breast imaging instruction. The authors suggest a teaching paradigm based on "slow medicine" and thoughtful diagnostic practice by comparing modern breast ultrasonography interpretation with Italian High Renaissance paintings, especially Raphael's La Fornarina.
The subject is topical, creative, and in line with contemporary debates about diagnostic cognition, medical education, and the ethical application of AI in clinical processes. The manuscript exhibits excellent clinical engagement, ethical awareness, and significant intellectual depth. However, the work's current state has serious methodological and structural flaws that make it impossible to draw clear conclusions about how successful schooling is.

The manuscript is long and has some repetition, especially in the portions that deal with art history. Readability and focus would be enhanced by condensing background information.
The overall quality of the writing is good, while certain statements are too conceptually rich and complicated for a medical readership. There are still a few minor typographical and grammatical errors that should be fixed during editing. There are a lot of numbers. A few interpretive photos and artistic collages might be relocated to Supplementary Materials. For clarity, figure legends should be further standardised.

Other major observations are the following:

1. The title is evocative but overly broad and does not fully reflect the manuscript’s specific focus on breast imaging, diagnostic reasoning, and medical education. A more precise and methodologically explicit title is recommended to improve alignment with the abstract, keywords, and journal scope. A suggestion for the title should be: Beyond the Image Frame: An Art-Based Pedagogical Framework for Teaching Diagnostic Reasoning in Breast Ultrasound to Medical Students.
2. The abstract is conceptually rich and well written; however, following revision of the title toward a more specific pedagogical and diagnostic focus, the abstract should be correspondingly refined to explicitly emphasize diagnostic reasoning, breast ultrasound as the core modality, and the proposed art-based pedagogical framework.
3. There is no mention of randomisation or control in the distribution of students among groups and there are no quantitative or qualitative outcome measures, such as thematic coding, structured reflection analysis, diagnostic accuracy metrics, or pre/post evaluation. Therefore, it is impossible to ascertain if the described intervention produced quantifiable gains in clinical decision-making, interpretative abilities, or diagnostic reasoning. It is recommended that the authors expressly reframe the manuscript as either a conceptual pedagogical framework with clinical and educational examples, or a qualitative exploratory educational intervention or pilot research.

 

The manuscript presents a highly original and conceptually rich contribution at the intersection of medical education, diagnostic reasoning, and visual culture. However, its current form aligns more closely with a reflective pedagogical essay than with a rigorously designed educational study. With substantial revision - particularly regarding methodological framing, moderation of claims, and structural clarity - the manuscript has strong potential for publication.

Author Response

Reviewer’s 1 comments and Authors’ replies.

 

At the beginning, we thank the Reviewer very much for valuable contribution to revision of our manuscript. It definitely required a lot of time and attention to review it thoroughly, which will allow us to improve it.

 

Below you can find our responses to your remarks.

 

 

“The manuscript is long and has some repetition, especially in the portions that deal with art history. Readability and focus would be enhanced by condensing background information. 
The overall quality of the writing is good, while certain statements are too conceptually rich and complicated for a medical readership. There are still a few minor typographical and grammatical errors that should be fixed during editing. There are a lot of numbers. A few interpretive photos and artistic collages might be relocated to Supplementary Materials. For clarity, figure legends should be further standardised.”

 

Point-by-point replies:

 

To: “The manuscript is long and has some repetition, especially in the portions that deal with art history.”

 

Reply: We have moved some text parts into the Supplementary Materials Section (Supplementary Material S1).

 

To: “Readability and focus would be enhanced by condensing background information.”

 

Reply: We have slightly reorganized the manuscript according to your remark.

 

To: “The overall quality of the writing is good, while certain statements are too conceptually rich and complicated for a medical readership.”

 

Reply: We made some reductions by standardizing the key message of the article in all the sections.

 

To: “There are still a few minor typographical and grammatical errors that should be fixed during editing.”

 

Reply: The abovementioned errors are now fixed.

 

To: “There are a lot of numbers.”

 

Reply: We've tried to present the lesson protocol as clearly as possible, and we've slightly improved the diagram to make it easier to follow. In the future validation version, we'll try to simplify the message.

 

To: “A few interpretive photos and artistic collages might be relocated to Supplementary Materials.”

 

Reply: Thank you. This suggestion is in line with the other similar suggestions by Reviewers 1 and 2. They are now moved into the Supplementary Materials Section (Supplementary Material S3).

 

To: “For clarity, figure legends should be further standardised.”

 

Reply: We have attempted to do so as you requested.

 

 

 

“The title is evocative but overly broad and does not fully reflect the manuscript’s specific focus on breast imaging, diagnostic reasoning, and medical education. A more precise and methodologically explicit title is recommended to improve alignment with the abstract, keywords, and journal scope. A suggestion for the title should be: Beyond the Image Frame: An Art-Based Pedagogical Framework for Teaching Diagnostic Reasoning in Breast Ultrasound to Medical Students.”

 

Reply: We agree with the Reviewer. We have replaced the title with more comprehensive one after your precise suggestion. You can find the new abstract in a form of tracked changes to the previous one so we do not recall it here.

 

 

 

“The abstract is conceptually rich and well written; however, following revision of the title toward a more specific pedagogical and diagnostic focus, the abstract should be correspondingly refined to explicitly emphasize diagnostic reasoning, breast ultrasound as the core modality, and the proposed art-based pedagogical framework.”

 

Reply: Thank you for your valuable remark. We agree with the Reviewer. We have made substantial effort to improve the abstract. Thank you for your suggestion.

 

 

“There is no mention of randomisation or control in the distribution of students among groups and there are no quantitative or qualitative outcome measures, such as thematic coding, structured reflection analysis, diagnostic accuracy metrics, or pre/post evaluation. Therefore, it is impossible to ascertain if the described intervention produced quantifiable gains in clinical decision-making, interpretative abilities, or diagnostic reasoning. It is recommended that the authors expressly reframe the manuscript as either a conceptual pedagogical framework with clinical and educational examples, or a qualitative exploratory educational intervention or pilot research.”

 

Reply: We are at the beginning of our journey to using Renaissance paintings as teaching materials. The reviewer's comments have given us pause. For now, in accordance with our original intention, we agree with the suggested title and other suggested changes. Therefore, we have expanded the limitations section, trying to incorporate the above comments (see the Limitations below).

 

Limitations (continued):

 

This article presents a pedagogical outline of a lesson on the intersection of Re-naissance art and ultrasonography, in which non-randomized groups of students are introduced to interpreting painted images in a way that engages them in "imaging" exercises. A weakness of the study is that, despite its length, the lesson is too short to measure the effectiveness of this teaching method. More groups who undergo artwork and medical images interpretation should be involved, and the students' decision-making abilities should be tested using patient case studies pre and post intervention in the form of an OSCE (Objective Structured Clinical Examination) or another type of evaluation.

 

 

 

 

We believe we have made substantial effort to improve this article after your suggestions.

 

If it is not the case, we kindly ask you for reviewing the article again and suggest what can be improved further.

 

Thank you again for your time and effort!

 

Authors

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript presents a highly innovative and thought-provoking educational protocol that intersects art history, semiotics, and breast cancer diagnostics. The study design is original, leveraging Renaissance art to cultivate diagnostic reasoning skills in medical students. The concept of "slow education" as an antidote to "time poverty" in clinical practice is timely and well-articulated. The manuscript is generally well-written and structured. However, several major concerns regarding methodology, results presentation, and ethical considerations must be addressed before publication can be considered.

Major Points:

1. Study Design and Methodology:
• Clarity and Rigor:​ The description of the study groups (A, B, C, D) and the interventions they received (Lessons I, II, III) is confusing. A clear, consolidated flow diagram summarizing the protocol for each group is essential. The current Figure 2 is insufficient.
• Control and Comparison:​ The premise involves comparing groups with and without methodological preparation (art interpretation lesson). However, the results do not present a clear, comparative analysis of the outcomes between these groups. For instance, how did the diagnostic interpretations of Group A (with preparation) differ substantively from Group B (without) in Session III? The data presented reads more as a descriptive case series of four patients rather than an analysis of an educational intervention.
• Assessment of Educational Impact:​ The manuscript lacks a robust pre- and post-intervention assessment to measure the actual educational impact. How was the improvement in diagnostic skills quantified or qualified? Subjective student interpretations and creative "homework" (Figures 9-12) are interesting but are not validated measures of learning efficacy.
2. Results Section:
• Integration of Findings:​ The results are currently fragmented into descriptions of lessons, patient cases, and student outputs. This section needs significant reorganization to present a coherent narrative. The findings from each session should be synthesized to directly address the study's central goal: demonstrating how students transform signs into meanings.
• Figure-Text Consistency:​ Several figures are referenced but their captions and relevance to the surrounding text are unclear. For example, Figure 8 (the ultrasound workshop) is described in the "Discussion" section (3.8), which is methodologically unsound. Methodology belongs in the Methods section.
• Patient Cases:​ While the four patient cases (Figures 4-7) are illustrative, their connection to the art-based educational intervention is not explicitly demonstrated in the results. The narrative jumps from art interpretation to standard clinical case descriptions without bridging the two concepts effectively in the results.

  Recommendation:

  Major Revision Required.​ The conceptual framework is excellent and has significant potential. However, the manuscript requires substantial revisions to strengthen its scientific rigor and clarity. The authors must:

  1. Re-structure the Methods and Results sections to provide a clear, comparable analysis of the educational intervention's outcomes.
  2. Integrate the art interpretation theme more cohesively throughout the results.
  3. Provide essential ethical oversight documentation and clarify consent procedures.
  4. Conduct a thorough language and formatting review.

  The innovative approach of using Renaissance art to teach diagnostic reasoning is valuable to the field of medical education. I am enthusiastic about the potential of this work once these concerns are addressed.

Author Response

Reviewer’s 2 comments and Authors’ replies.

 

At the beginning, we thank Reviewer very much for valuable contribution to revision of our manuscript. It definitely required a lot of time and attention to review it thoroughly, which will allow us to improve it.

 

Below you can find our responses to your remarks.

 

 

1. “Study Design and Methodology:

Clarity and Rigor:​ The description of the study groups (A, B, C, D) and the interventions they received (Lessons I, II, III) is confusing. A clear, consolidated flow diagram summarizing the protocol for each group is essential. The current Figure 2 is insufficient.”

 

 

Our response: Thank you, we agree. We indicated at the beginning of the Methods section what this work is and what our intention was. We have also redrawn our diagram (Figure 2).

 

 

“Control and Comparison:​ The premise involves comparing groups with and without methodological preparation (art interpretation lesson). However, the results do not present a clear, comparative analysis of the outcomes between these groups. For instance, how did the diagnostic interpretations of Group A (with preparation) differ substantively from Group B (without) in Session III? The data presented reads more as a descriptive case series of four patients rather than an analysis of an educational intervention.”

 

Our response:

 

 

“Assessment of Educational Impact:​ The manuscript lacks a robust pre- and post-intervention assessment to measure the actual educational impact. How was the improvement in diagnostic skills quantified or qualified? Subjective student interpretations and creative "homework" (Figures 9-12) are interesting but are not validated measures of learning efficacy.”

 

Our response:

We have added a short paragraph in Methods explaining that the following were analyzed:

• the way diagnostic responses were formulated,
• the change in the language of description (from a simple diagnosis to an attempt at interpretation),
• consideration of the patient's context.

 

In another section of the paper (Results, 3.7. “Fourth Session”) we emphasized that the student works previously presented in Figures 9–12 (now Figures S3.1–S3.4 in the Supplementary Material S3 following suggestion of Reviewer 1):

• demonstrates the learning process,
• are not a measure of teaching effectiveness.

 

2. “Results Section:

Integration of Findings:​ The results are currently fragmented into descriptions of lessons, patient cases, and student outputs. This section needs significant reorganization to present a coherent narrative. The findings from each session should be synthesized to directly address the study's central goal: demonstrating how students transform signs into meanings.”

 

Our response: We have improved the overall structure of the results. We have rebuilt Results so that they are not a record of subsequent classes, but a collection of the most important observations.

 

We have grouped the current subchapters (3.1–3.10) into thematic blocks, so that they match the points of the meeting (I-VII), for example:

• initial student interpretations (At starting session)
• introduction to image interpretation (Lesson Ia, Ib; II session),
• clinical cases as teaching material (III session, Lesson III),
• student work (IV session).

 

 

 

“Figure-Text Consistency:​ Several figures are referenced but their captions and relevance to the surrounding text are unclear. For example, Figure 8 (the ultrasound workshop) is described in the "Discussion" section (3.8), which is methodologically unsound. Methodology belongs in the Methods section.”

 

Our response: We have attempted to address this weakness of the article, which was not obvious to us. To illustrate the workshop, we have moved Figure 8 to Supplementary Materials (SM 2).

 

Patient Cases:​ While the four patient cases (Figures 4-7) are illustrative, their connection to the art-based educational intervention is not explicitly demonstrated in the results. The narrative jumps from art interpretation to standard clinical case descriptions without bridging the two concepts effectively in the results.

 

Our response:

We agree with the comment. The aforementioned comment was addressed to sections 3.1 "First Session" (now: At Starting Session), 3.2 "Second Session" (now: 3.3), and to some other sections:

• Where possible, we have added a direct comparison of the responses of groups A and C with those of groups B and D,
• with the emphasis on the way conclusions are formulated, not the diagnosis itself.
• We added sentences summarizing the differences after each of these sections, especially a conclusion that was missing after the most important part of the meeting (the same comment as for remark entitled “Control and Comparison”:​

 

"All groups made similar interpretations given the opportunity to explore the entire case, starting with a live patient. Despite the fact that groups B and D were "cut off" from the interpretation lesson and were only given a semblance of insight into the art (a painting by Dürer without art-historical commentary), they performed similarly. The only differences were visible in groups A and C before and after the interpretation lesson. This may indicate that, despite suggestions of a possible diagnosis, the student groups are attentive and resistant to artistic intervention, trying to avoid diagnostic errors when meeting the patient."

 

In addition:

 

After each case description, we added a short sentence explaining:

• what the case taught students,
• how it was used in the sign interpretation process.

 

 

“Major Revision Required.​ The conceptual framework is excellent and has significant potential. However, the manuscript requires substantial revisions to strengthen its scientific rigor and clarity. The authors must:

 

Re-structure the Methods and Results sections to provide a clear, comparable analysis of the educational intervention's outcomes.

Integrate the art interpretation theme more cohesively throughout the results.

Provide essential ethical oversight documentation and clarify consent procedures.

Conduct a thorough language and formatting review.”

 

Our response: We've made every effort to improve the text and address all concerns. If we haven't made enough improvement, please give us advice how to make this article sufficient for publication.

 

Thank you again!

 

Authors

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors made all the required changes. The article is now ready for publication.

Reviewer 2 Report

Comments and Suggestions for Authors

I have no more comments.