T h e P r a c t i c e o f R a d i o l o g y Pe r s p e c t i ve

Koontz and Gunderman Gestalt Theory and Radiology Education The Practice of Radiology Perspective

Gestalt Theory: Implications for Radiology Education

Nicholas A. Koontz1 Richard B. Gunderman
Koontz NA, Gunderman RB

OBJECTIVE. The Gestalt theory of modern psychology is grounded in the ideas that holistic rather than atomistic approaches are necessary to understand the mind, and that the mental whole is greater than the sum of its component parts. Although the Gestalt school fell out of favor due to its descriptive rather than explanatory nature, it permanently changed our understanding of perception. For the radiologist, such fundamental Gestalt concepts as figureground relationships and a variety of grouping principles (the laws of closure, proximity, similarity, common region, continuity, and symmetry) are ubiquitous in daily work, not to mention in art and personal life. CONCLUSION. By considering the applications of these principles and the stereotypical ways in which humans perceive visual stimuli, a radiology learner may incur fewer errors of diagnosis. This article serves to introduce several important principles of Gestalt theory, identify examples of these principles in widely recognizable fine art, and highlight their implications for radiology education. or many physicians, the term Gestalt theory evokes several associations, including the familiar aphorism the whole is greater than the sum of its parts and images of Necker cubes, Rubin vases, and indistinct-appearing Dalmatians. For those who enjoy a background in psychology, this term conjures up such names as Wertheimer, Koffka, and Khlermen whose seminal work helped define the modern notion of perception. However, it often goes unnoticed that several principles of Gestalt psychology are ubiquitous in our daily life and work and have played a crucial role in defining our contemporary understanding of perception. From organizational development to Internet security, and from educational psychology to clinical medicine, our daily work is powerfully shaped by the principles of Gestalt theory. As one of modern medicines paradigmatically visual fields, radiology can be illuminated by Gestalt theory and its implications for visual perception. For that reason, radiologists in training should enjoy the opportunity to develop a basic familiarity with Gestalt principles. The Gestalt movement developed in Austria and Germany near the turn of the 20th century, largely through the work of Max Wertheimer, Kurt Koffka, and Wolfgang Khler. Translated

Keywords: education, Gestalt, image interpretation, perception, psychology, radiologists, radiology DOI:10.2214/AJR.07.3268 Received October 8, 2007; accepted after revision November 18, 2007.
1 Both authors: Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr., Rm. 1053, Indianapolis, IN 46202-5200. Address correspondence to R. B. Gunderman (rbgunder@iupui.edu).

AJR 2008; 190:11561160 0361803X/08/19051156 American Roentgen Ray Society

from German, Gestalt can be taken to mean whole or form, an apt summary of this psychologic approach [1]. Expanding on the ideas of earlier theorists, these psychologic pioneers developed an encompassing definition of perception that differed quite strikingly from that of atomism, the predominant psychologic theory at the time. Atomists such as Wilhelm Wundt, regarded by many as the father of modern psychology, believed that perception could be broken down into discrete units, each playing a finite role in shaping the conscious experience. Gestalt theorists criticized this perspective and argued for a more holistic approach [2]. They believed that the perception of any given object or experience exhibits intrinsic qualities that cannot be completely reduced to visual, auditory, tactile, olfactory, or gustatory components. Gestalt psychologists held that perceptions are not constructed in a bottomup fashion from such elements but are instead perceived globally, in a more top-down fashion. They proposed that we have an innate tendency to organize sensory inputs in a manner that creates the most coherent, seamless perception possible [2]. The term Gestalt is familiar to many physicians [3]. For example, medical students and residents learn to develop a global impression of a patients health status within seconds

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Gestalt Theory and Radiology Education of entering the room. To arrive at such an assessment, there is not sufficient time for bottom-up processing. Radiologists, too, have recognized the importance of Gestalt. For example, an experienced radiologist typically engages in two distinct processes when interpreting a chest radiograph: a rapid global search, which quickly identifies normal anatomic content and identifies suspicious deviations from it (i.e., pathologic abnormalities), and a secondary systematic scan, which involves a careful, algorithmic study of the radiograph [4]. The first phase of radiographic interpretation exemplifies a Gestalt perspective. This global approach plays in invaluable role in the detection of lung lesionsa role so important that its absence cannot be compensated for by a careful algorithmic analysis of the radiograph [5]. There is evidence that a Gestalt approach plays an important role in the interpretation of other types of radiologic examinations, such as nuclear medicine ventilationperfusion lung scans [6]. Although Gestalt theory did not completely explain how perception works, it elucidated several perceptual principles that remain vital to contemporary perceptual psychologists and radiologists alike. These include the principle of figureground relationship, and the grouping principles of closure, proximity, similarity, common region, continuity, and symmetry [2, 7, 8]. By exploring these principles and the benefits and risks associated with them, we can help radiology learners gain a better understanding of visual perception, potentially improving their diagnostic performance. FigureGround According to Gestalt theory, one of the most important principles organizing our perception is the figureground relationship. It is an automatic feature of the visual system in which the focus of attention becomes the figure and all other visual input becomes the ground [8]. For any given image, the same visual stimulus can trigger multiple perspectives, depending on what is taken to be figure and what is taken to be ground [1]. Consider the classic illusion of the Necker cube, an object that withholds the depth and spatial cues that we rely on for static perception (Fig. 1). Depending on where we train our eyes, the spatial characteristics of the Necker cube appear to change markedly, a phenomenon commonly referred to as figureground reversal [9]. The Gestalt principle of figureground relationship is exemplified brilliantly in the work of the Dutch artist M. C. Escher (18981972), are recognizable in the mirror that is hanging behind princess Margarita. Faulty figureground processing in interpreting radiologic images can lead novices astray, as when our eyes are drawn to the bright heart at the center of a chest radiograph, causing us to neglect a thorough scan of the darker and more peripheral lung fields and surrounding soft tissues. Likewise, a neophyte interpreting an abdominal CT examination may focus excessively on bright areas of contrast enhancement, while ignoring darker features such as pneumoperitoneum. Poor appreciation of our stereotypical ways of handling figureground relationships can lead to misdiagnosis and detrimental outcomes for patients. Developing an appreciation for the implications of this Gestalt principle may represent a vital step in the transformation of a novice into a competent radiologist. Closure Another key Gestalt principle is closure, which suggests that our minds have a tendency to fill in empty spaces in an apparently incomplete image to create a complete and unified figure [8] (Fig. 2). To visualize this principle, consider the Cubist movement in Modern art. The works of Pablo Picasso (18811973) and Georges Braque (18821963) rely heavily on this grouping principle, which is observed readily in Braques Violin and Candlestick (1910) (see collections.sfmoma. org/OBJ89.htm). A prototypic example of analytic cubism, this painting is constructed of multiple open geometric figures that serve as 2D reductions of the objects true 3D forms. Through the principle of closure, an observer can effortlessly identify both the violin and the candlestick in this painting.

Fig. 1Necker cube. In this cube drawn without crucial spatial and depth clues, an observer may perceive his or her vantage point to be either above or below the cube.

who was a master at creating ambiguous figureground relationships [8]. Escher, who is best known for his clever study of impossible constructions and challenging tessellations, relied on this perceptual indeterminacy in many of his best-known works, such as Relativity (1953) (see www.nga.gov/collection/gallery/ ggescher/ggescher-53972.0.html). Consider also Salvador Dals (19041989) surrealist work Slave Market with the Disappearing Bust of Voltaire (1940) (see salvadordalimuseum. org/collection/collection_highlights.html), a painting that continues to serve as a prototype for the study of perception [10]. The figureground principle is manifest in our tendency to focus on objects that are smaller, brighter, and more centrally located in an image [2]. This phenomenon is exemplified brilliantly in Las Meninas (1656) (see www.museodelprado.es/en/bienvenido/15masterpieces /ficha-obra /the-family-offelipe-iv-or-las-meninas) by Diego Velzquez (15991660), famous portrait of the Spanish court of King Philip IV. At first glance, the viewers eyes are drawn to the infanta Margarita, because of her central location and radiant gown [9]. On further inspection, however, we realize that the young princess is not the focal point of the portrait, but an observer of another portrait that is in the process of being painted. Even closer inspection reveals that the artist positioned off to the left side of the canvas is none other than Diego Velzquez, who is painting a portrait of someone who shares the same vantage point as the observer. If princess Margarita is not the subject of this portrait, then who is? A thorough search reveals the answerKing Philip IV and Queen Mariana, whose figures

Fig. 2Principle of closure. The human mind will fill in gaps in incomplete image to create a unified figure, thus allowing an observer to perceive these objects as a rectangle, a triangle, and a circle rather than strict perception of their true forms.

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Koontz and Gunderman For the radiologist, the principle of closure is at play when we review and interpret sequential axial images from a CT or MRI examination. Such planar images of internal anatomy differ markedly from the 3D appearance of each organ, yet the experienced radiologist instantly perceives the whole organs morphology, which novices may find difficult or even impossible. The principle of closure is also at work in numerous imaging artifacts. Often radiologists are called on to interpret imaging studies that contain artifacts, such as beam-hardening artifact on CT, which distort the appearance of adjacent tissues. Consider, for example, the impact of the dense skull base on visualization of the posterior fossa and brainstem [11]. Similar pitfalls can be iatrogenic, such as the orthopedic hardware that can compromise interpretations of MR angiograms [12]. In such cases the novice not only must search for lesions but also must be mindful of the principle of closure and its quality control implications. Proximity The principle of proximity states that image components that are physically near each other tend to be perceived as belonging to a group [2] (Fig. 3). This principle is ubiquitous in personal life as well as in art, and it describes perhaps the most basic definition of a groupnamely, multiple objects in close spatial proximity. Consider, for example, the allegorical painting Fight with Cudgels (18201823) (see eeweems.com/goya/cudgels.html), by the Spanish painter Francisco Goya (17461828). Widely regarded as both the last of the Old Masters and the father of modern art, Goya painted this work as a reaction to the civil war and class disputes that had embroiled Spain. Painted late in his life and after a series of illnesses that left him deaf, this work stands out among the Black Paintings because of its expansive background and small, simplistic figures. In this work, the principle of proximity is intentionally used twice. At first glance, we notice two men engaged in brutal combat; however, when visualized against the expansive backdrop of the meadow landscape, the principle of proximity causes the observer to perceive the combatants as belonging together, suggesting some degree of alliance. In this case, Goya used the principle of proximity to create a perception that the two fighters are fellow countrymen. The mens legs also disappear deep into the quagmire below them. This fusion with the earth creates the perception that these men share a strong association with the very land (i.e., the Iberian Peninsula) they are fighting over. The principle of proximity plays an important role in radiology. When evaluating the chest CT examination of a patient with suspected bronchogenic carcinoma, a novice radiologist may naturally assume that an enlarged hilar lymph node near the pulmonary mass is a metastatic focus. However, physical proximity does not necessarily imply a causal relationship, and a radiology student must learn to appreciate that proximity can prove misleading. A similar situation occurs in breast cancer, when the lymph nodes nearest the primary lesion are not necessarily the most closely connected physiologically. The use of sentinel node lymphoscintigraphy in staging such diseases is a creative imaging response to this pitfall. The principle of proximity has metaphoric applications as well. It is common for physicians to perceive radiologists as isolated from the rest of the hospital. The radiology department is often located on a different floor or in a different wing and generally exhibits a highly distinctive ambience, including very low levels of ambient lighting and noise. Such factors can lead to the impression that radiologists are medical outsiders. Means of counteracting such an impression would include locating radiologists work areas nearer to or even inside patient care areas and getting radiologists out of the radiology department and into patient care areas on a regular basis (e.g., holding ICUradiology rounds in the ICU) [13]. In the increasingly crowded environment of medical imaging, it is vital that we remind radiology residents of the importance of their own visibility. Similarity The principle of similarity holds that likeappearing objects tend to be perceived as a group [1] (Fig. 4). This Gestalt principle can be appreciated artistically in The Burial of the Count of Orgaz (15861588) (see www. wga.hu/frames-e.html?/html/g/greco_el/09/ index.html) by Domnicos Theotokpoulos (15411614), better known as El Greco. This painting depicts the burial of the pious Don Gonzalo Ruz de Toledo, who, according to legend, was laid to rest by Saints Augustine and Stephen [14]. One of the striking features of this work is the delineation of subjects into groups based on their similar appearances. For example, centered at the bottom of the painting are two men (St. Augustine and St. Stephen) whose brilliant gold and red vestments allow them to be instantly perceived as belonging to a group entirely different from the men in black civilian dress (the gentlemen of Toledo) or those wearing cassocks and chasubles (the priests). The principle of similarity plays an important role in radiology education because the ability to formulate an extensive and appropriate differential diagnosis is an important factor that separates a novice from a competent radiologist. A major component of formulating a differential diagnosis is

Fig. 3Principle of proximity. Objects that are physically near each other tend to be perceived as belonging in a group rather than as individual objects, thus allowing observer to perceive this image as three groups of four circles rather than 12 independent circles.

Fig. 4Principle of similarity. Objects that bear a similar resemblance tend to be perceived as belonging in a group. In this case, an observer readily perceives five columns of black squares and five columns of white squares rather than four rows containing black and white squares.

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Fig. 5Principle of common region. Objects that are enclosed within common region are likely to be perceived as belonging in a group, regardless of similarity or nearness of constituent objects. In this case, unrelated objects are perceived as belonging to a group because they are confined in a common structure, whereas similar objects outside this structure are not perceived as belonging with their mates.

perceiving similarities and differences between imaging findings. Consider the finding of an abnormally increased cardiothoracic ratio on a frontal chest radiograph. Presented with such a finding, the neophyte may immediately launch into a differential diagnosis of cardiomegaly, including congestive heart failure, dilated cardiomyopathy, valvular heart disease, metabolic disorders, and so on. Only with experience does the learner appreciate that there are a number of important cardiomegaly mimics, including anteroposterior technique, underinflation, pectus excavatum, and pericardial effusion. Moreover, only with experience does the radiology student become adept at correlating the perception of similar appearing abnormalities with accurate differential diagnoses. Common Region The Gestalt principle of common region states that objects or stimuli that are enclosed in a common region are likely to be perceived as a group, regardless of similarity or nearness of the constituent objects or stimuli [7] (Fig. 5). This principle is evident in the challenging artwork of the Belgian surrealist painter Ren Magritte (18981967), who is best known for taking ordinary objects and injecting them into unrealistic and impossible settings. Magritte frequently placed unrelated objects in common environs, causing the observer to perceive them as related to one another [15]. One such example is his painting Les Valeurs personnelles (Personal Values) (1952) (see www.sfmoma.org/msoma/artworks/5139.html), a surrealist investigation into the relationship between humans and ordinary personal items of daily life. When the artist places larger-than-life, incongruous objects such as a comb, a bar of soap, a wine glass, a matchstick, and a shav-

ing brush within the confines of a bedroom, the observer perceives these seemingly unrelated objects as intrinsically connected, albeit a connection that the observer cannot readily identify. Magritte draws the observer into the work by inviting us to draw on our own experiences in seeking a unifying theme among the objects. The principle of common region is a key grouping principle for the radiology learner because of its implications for the formation of appropriate differential diagnoses. For example, the mediastinum can be divided spatially into three compartments: anterior, middle, and posterior. When a mediastinal mass is identified on chest radiography or a chest CT scan, we attempt to locate it according to this anatomic scheme. Likewise, in interpreting images of the CNS, classifying a mass as intraaxial or extraaxial is a crucial step in formulating a differential diagnosis. The same can be said for intra- and extraperitoneal processes, arterial versus venous processes, and abdominal versus pelvic processes. By developing an appreciation of our natural tendency to perceive objects compartmentally, a learner may become more adept at correlating imaging findings with pathologic processes. Continuity The principle of continuity states that smooth, continuous lines can be perceived more effortlessly than interrupted lines [2] (Fig. 6). This Gestalt principle was used by the enigmatic Marcel Duchamp (18871968) in his controversial work Nude Descending a Staircase (No. 2) (1912) (see www.philamuseum.org/collections /permanent /51449. html). Composed solely of interrupted lines painted in successive planes, we cannot perceive a static image of the nude figure due to

perceptual limitations imposed by this principle. Instead, we perceive these broken lines in a staccato fashion, imparting the perception that the figure is in motion. One of the earliest artists to attempt to represent motion in paint, Duchamp used the hallmark techniques of analytic cubism (i.e., limited palette and form deconstruction) both to transcend the static confines of cubist art and to rebuke its pretensions [16]. This principle plays an important role in the interpretation of skeletal radiographs, such as clearing a cervical spine in a trauma patient or attempting to detect child abuse on a skeletal survey. When reading a lateral cervical spine radiograph, we learn to see imaginary anatomic lines: the anterior vertebral line, posterior vertebral line, spinolaminal line, and posterior spinal line. Using the imagination to create such mental images enables radiologists to reliably detect cervical injuries. However, when deviations from these lines are subtle, perceiving signs of injury can be painstakingly difficult. Particularly in the case of suspected child abuse, the radiology student must exercise great care in scanning for subtle deviations from the normal bone contours, because the principle of continuity suggests that slight deviations (such as bucket-handle fractures and periosteal reaction) may be difficult to detect in the setting of otherwise normal findings. By emphasizing the implications of the principle of continuity at an early stage of radiology education, we help learners guard against perceptual pitfalls. Symmetry The Gestalt principle of symmetry holds that symmetric objects or stimuli tend to be perceived as a group regardless of proximity (Fig. 7). This is perhaps one of the most
D A

C B
Fig. 6Principle of continuity. Visual stimuli consisting of smooth, uninterrupted lines can be perceived more effortlessly than interrupted lines. In this case, lines AB and CD are more easily perceived than lines AC, AD, BC, or BD.

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Prentice Hall, 2002 3. Feddock CA. The lost art of clinical skills. Am J Med 2007; 120:374378 4. Kundel HL, Nodine CF. Interpreting chest radiographs without visual search. Radiology 1975; 116:527532 5. Oestmann JW, Greene R, Bourgouin PM, Linetsky L, Llewellyn HJ. Chest Gestalt and detectability of lung lesions. Eur J Radiol 1993; 16:154157 6. Hagen PJ, Hartmann IJC, Hoekstra OS, Stokkel MPM, Teule GJJ, Prins MH. How to use a Gestalt interpretation for ventilationperfusion lung scintigraphy. J Nucl Med 2002; 43:13171323 7. Coon D. Essentials of psychology: exploration and application, 7th ed. Cincinnati, OH: Brooks/ Cole, 1997 8. Halonen JS, Santrock JW. Psychology: contexts of behavior, 2nd ed. Chicago, IL: Brown & Benchmark, 1996 9. Sayre HM. A world of art, 3rd ed. Upper Saddle River, NJ: Prentice Hall, 2000 10. Bonnar L, Gosselin F, Schyns PG. Understanding Dalis Slave Market with the Disappearing Bust of Voltaire: a case study in the scale information driving perception. Perception 2002; 31:683 691 11. Earnest F, McCullough EC, Frank DA. Fact or artifact: an analysis of artifact in high resolution computed tomographic scanning of the sella. Radiology 1981; 140:109113 12. Fidelman NA, Wilson MW, Bloom AI, Kerlan RK, LaBerge JM, Gordon RL. Orthopedic spinal and hip prostheses: effects of magnetic susceptibility artifacts during MR arteriography and venography of abdomen and pelvis. Radiology 2006; 240:894899 13. Friedenberg RM. Au revoir, but not goodbye. Radiology 2004; 232:319323 14. Miranda R. Toledo: its art and its history. Toledo: Artes Grficas Toledo, SAU, 1999 15. Gohr S. Magritte. New York, NY: Harry N. Abrams, Inc., 2000 16. Stafford A. Three paintings. Making sense of Marcel Duchamp. www.understandingduchamp. com. Accessed August 5, 2007

Fig. 7Principle of symmetry. Symmetric objects or stimuli tend to be perceived as belonging to a group regardless of their proximity to one another. In this case, the observer will perceive both the brackets and the triangles as belonging with their mirror image because of principle of the symmetry. Crescent and hexagon form asymmetric image; therefore, they are not perceived as belonging together.

ubiquitous of the Gestalt grouping principles encountered in fine art and in daily life. Consider the iconographic painting The Marriage of Giovanni Arnolfini and Giovanna Cenami (1434) (see www.nationalgallery. org.uk/cgi-bin/WebObjects.dll/Collection Publisher.woa /wa /work?work Number= NG186) by Jan van Eyck (c. 13851441). At first glance, the symmetric positioning of the subjects, including the centrally located dog, leads us to suppose that the subjects belong together as a group. With further study, however, we can appreciate a hidden symbolism, which strongly suggests that the painting reflects either an engagement or marriage [9]. Consider also The Last Supper (c. 14951498) (see www.cenacolovinciano. it/html/eng/home. htm) by Leonardo da Vinci (14521519). The symmetry of the composition contributes to a one-point linear perspective, and it allows the apostles to be instantly perceived as belonging to a group, with all attention focused on Christs head, the paintings focal point [9]. Radiologists use the principle of symmetry regularly in evaluating the lungs, bones, and cerebral hemispheres, which are normally relatively symmetric. With experience, a competent radiologist will judiciously use

this principle to detect various abnormalities that disrupt the anatomic symmetry. However, the same principle can mislead a novice when the pathology is bilateral and symmetric. Consider, for example, isodense bilateral subdural hematomas, or cleidocranial dysplasia, with the absence of the clavicles. To the veteran radiologist, these might represent rather straightforward diagnoses, but we must be mindful that learners can be fooled by pathology that is symmetric. Conclusion Gestalt principles of visual perception play an integral but often underappreciated role in both radiology practice and the training of future radiologists. By familiarizing ourselves with these ubiquitous principles at an early stage of training, we can help radiology students better understand the unconscious work involved in interpreting radiologic images and prepare them to avoid common perceptual pitfalls. References
1. Myers DG. Psychology, 5th ed. New York, NY: Worth Publishers, 1998 2. Davis SF, Palladino JJ. Psychology: media and research update, 3rd ed. Upper Saddle River, NJ:

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