Visual perception and consciousness in dermatopathology: mechanisms of figure-ground segregation account for errors in diagnosis.

Visual perception has been the object of research in psychology for almost a century. Little has been written, however, about the effects of perceptive phenomena on methods in medicine that utilize interpretation of two-dimensional images for diagnosis. Starting from the work by Edgar Rubin in the beginning of the last century, this article gives a summary of observations of psychologists who investigated the mechanisms of so-called "figure-ground segregation." These unconscious mechanisms follow rules that explain why certain structures are perceived consciously as a figure, whereas other structures surrounding such a figure are neglected and not perceived consciously in detail. Perception of a structure as a figure can be due to, for example, a convex shape of its contour, proximity of lines around it, closed contours, a simple shape, and attribution of meaning to a structure. In examples from the practice of dermatopathology, those unconscious mechanisms of figure-ground segregation will be shown to be relevant to diagnosis of sections of tissue. The mechanisms help to explain why, for example, ill-defined and concave-shaped structures, stromal differences of neoplasms, interstitial infiltrates and deposits, and simulators of common diseases are often difficult to recognize at first sight. Teachers of dermatopathology need to be aware of these unconscious mechanisms of visual perception because they explain why novices struggle with certain diagnoses and differential diagnoses. Proper instruction about these phenomena, early in the process of training, will prevent a student from being frustrated with misperceptions.