The Art and Science of Medicine – a critical but troubled marriage

“I always feel better after talking to the doctor.”

The first time I recall hearing this statement, it was many years ago, spoken by an elderly lady emerging from the inner office of our family physician. I also recall it leaving me me a little confused, and a little intrigued.

Dr. Mitchell practiced in Collingwood for many years and looked after any malady that might befall members of my family. I was waiting to get my biweekly “allergy shot” (another story). With Dr. Mitchell, you didn’t really have an appointment; you just showed up and read magazines until called. No one ever complained. There seemed to be acceptance that the order was based on some greater principle than “first come, first served”. As I was leafing through a New Yorker searching for the cartoons, I overheard the lady make that statement to her waiting husband as they got ready to leave. I wasn’t really eavesdropping; she seemed to intend the comment for everyone in the room. She’d been in there only a few minutes. She entered clearly worried and upset. She emerged looking considerably relieved and energized.

What, I wondered, had happened in there? Clearly, there had been no time for any treatment to have been administered, let alone take effect. All he could have done was talk to her. And yet, she was better. She was relieved. She was grateful. Whatever happened was effective and made a difference to her. Some talking! I was intrigued, and whatever process eventually led to my decision to consider a career in Medicine probably started, or was at least advanced, that day.

I’ve since heard variations of that statement many times. During medical school and residency I heard it applied by patients to many of the excellent physicians I had opportunity to train with over the years. I heard it applied to many of the highly skilled colleagues I’ve worked with. I consider it to be one of the simplest but also purest ways patients can acknowledge the effectiveness of their encounters with their physician. Simply put, they feel better afterward than they did before.

This ability is not the exclusive domain of physicians. People emerge everyday from their encounters with nurses, therapists, pharmacists with similar feelings of well being and renewed energy.

What’s going on?

To the skeptical, this could be dismissed as some sort of placebo effect, a psychological delusion or defense mechanism that those desperate for help construct for themselves in order to deal with their malady. After all, no concrete intervention has occurred. No pathophysiologic process has been medically or surgically influenced. It doesn’t really make logical sense.

On the other hand, it doesn’t always work, and we’re all aware that making the correct diagnoses and applying appropriate therapy can often be inexplicably ineffective. Patients tell us repeatedly how frustrated and abandoned they feel after encounters where they’re told “everything’s fine”, or “take this medication and you’ll be fine” but are unconvinced, and feel no better afterward. Moreover, sound recommendations may be completely ignored by patients, leaving their doctors baffled, or perhaps never even knowing and therefore content in the false knowledge of a job well done.

All this relates, of course, to the fundamental and critical duality of the physician role – what we’ve come to regard as the “art” and the “science” of Medicine. It’s been appreciated since ancient times that, in order to be effective, physicians must combine their knowledge of medical science with personal qualities and skills that provide and promote a human relationship, a personal link with their patients, and it’s in the context of that relationship (and only in that context) that scientific therapies are effectively applied.

The importance of these humanistic “healing arts” has been well described.

Hippocrates is credited with the aphorism “it is more important to know what sort of person has a disease than to know what sort of disease a person has.”

William Osler is famously quoted as proclaiming, “the good physician treats the disease, the great physician treats the patient who has the disease”.

Abraham Flexner, the non-physician educator who so profoundly transformed medical schools in the early 20th century is famous for championing the inclusion of fundamental science in medical education. He’s less well known for his views on what were termed the “empiric” aspects. The following is taken from his 1910 report:

“The practitioner deals with facts of two categories. Chemistry, physics, biology, enable him to apprehend one set; he needs a different…appreciative apparatus to deal with the other, more subtle elements. Specific preparation in this direction is more difficult; one must rely for the requisite insight and sympathy on a varied and enlarging cultural experience. Such enlargement of the physician’s horizon is otherwise important, for scientific process has greatly modified his ethical responsibility.”1

It’s interesting that 15 years later he tried to correct what he perceived to be an over-emphasis on his recommendations regarding science and technology. The following is taken from Medical Education: A Comparative Study (1925):

“In respect to the position I have thus far taken, a curious misapprehension not uncommonly arises. The careful scrutiny, reflection, and decision (which is the essence of the scientific method), the employment of every weapon by means of which the causation of disease may be ferreted out and health restored (which is the essence of the scientific procedure) – these are sometimes regarded as in conflict with the humanity which should characterize the physician in the presence of suffering. Assuredly, humanity and empiricism are not identical; with equal assurance, one may assert that humanity and science are not contradictory…It is equally important and equally possible for physicians of all types to be humane, and at the same time to employ the severest intellectual effort that they are severally capable of putting forth…The art of noble behaviour is thus not inconsistent with the practice of scientific method”2

The late Bernadine Healy, prominent American physician, academic leader and former head of the NIH, spoke eloquently on this subject and is perhaps more pragmatic: “the art of medicine transcends all else when an anxious individual confronting death or disability looks to the physician and asks, ‘What’s right for me?’” In an excellent article on the subject, she goes on to describe four key components: Mastery, Individuality, Humanity and Morality. Her description of Mastery seems particularly apt: “expertise, not just experience; wisdom more than knowledge; and a creative way of thinking, ever alert to the reality that sickness is not as obvious as it seems.”3

It would seem that the importance of maintaining the “art” as we engage the ever expanding “science” of medicine is critical and fundamental to effective practice. It is what elevates the profession beyond the simple application of remedies or technical interventions. It is, to be more pragmatic, what the public expects, and what it feels it is paying for. It is also what makes the teaching and learning of medicine so very challenging. Knowledge, these days, is easily within our grasp. Technical skill comes to the appropriately skilled with dedication and practice. The ability to understand patients as individuals, establish relationships of trust, and apply treatments with sage wisdom are all much more difficult to identify in applicants, to teach and to assess.

At this point in our history, it seems we’re at a critical juncture. Our dual roles appear to be heading in opposite trajectories. Medical science is in unprecedented ascendency. In virtually every discipline, new and highly effective therapies are available. Conditions previously untreatable are being cured or at least improved. People are living longer and better. All this is wonderful. At the same time, we have many indications that the “art”, the humanistic components of medicine, are under threat and in decline.

The threats are both multidimensional and unintentional.

Time pressure. I know no physician who doesn’t feel under over-extended and under pressure to do more in less time. The provision of “timely”, “efficient” and “cost effective” care has become the paramount objective. Although this may seem necessary and even noble, the result is that our clinics, emergency departments, hospital wards, procedural units, are all under intense pressure to deal with high volumes expeditiously. We fall back on corporate, business- based approaches to deal with these practical issues. It becomes easy to forget that those “high volumes” are individual people experiencing what they perceive to be a time of great personal crisis. They often do not feel the centre of care, but rather something more akin to components on an assembly line. It’s not all bad – necessary care is provided, conditions are treated and usually resolved. But patients too often emerge wondering what happened, and even who was treating them.

The harsh reality is that the medical/technical aspects of care are more easily and more efficiently applied devoid of the need for interpersonal interaction. In our multidisciplinary and team based approach, compassion can come to be regarded as a delegated act.

The primacy of therapeutics over diagnostics. The practice of medicine has gradually and unceremoniously shifted over the past several decades from a largely diagnostic to therapeutic endeavor. This is a function of the greatly expanding therapeutic options, medical, interventional and surgical, now available for many conditions previously not treatable. In addition, many diagnostic tests and procedures are now available that can establish a diagnosis with a minimum of historical information. This is all obviously good, to the benefit of our patients and society at large. However, a consequence of this change is that the communication skills, personal contact and relationships required ferreting out a useful history and differential diagnosis is a less prominent, less essential physician skill, particularly in procedurally heavy specialties. Conditions previously diagnosed by historical and physical examination features alone are now established (even defined) on the basis of laboratory or imaging studies. This may have advantages in terms of time required and objectivity, but the “art” of establishing a diagnosis through insightful questioning and insight (still essential in all but completely straightforward situations) is gradually being eroded and, with it, the necessary human interaction.

Specialization. The dramatic expansion of knowledge and therapeutic options has required physicians to specialize in specific applications of medical service. Medical school graduates in Canada currently select between about 30 entry disciplines, many of which branch further resulting in well over a hundred very different practice options. This, again, is a function of our success and provides advanced, effective service to patients. However, a consequence of this specialization is that, for many physicians, their engagement of patients is exclusively in the context of a very specific, often predetermined, service. The need to establish that interpersonal connection may not be seen as necessary or welcome and, amazingly, may even be seen to be inappropriate to the encounter. This has important consequences. Patients are at risk of being deprived of individual consideration during these encounters. Perhaps more profoundly, the practice of medicine is finding a home for individuals who are unable, or unwilling, to engage the humanistic aspects. In essence, what was previously requisite is becoming optional.

Our award system. In terms of both prestige and monetary compensation, we clearly value situational, specialized technical or procedural expertise over primary patient contact and continuing care. We may value the art and science equally from a theoretical perspective, but our practical choice is very clear. Our learners and young physicians, both astute and aware, are faced with unbalanced choices.

Medical school admissions and curricula. Despite decisions and efforts to make medical education more broadly available to individuals with backgrounds and interests in the broader human experience, it remains largely the domain of those with scientific backgrounds. In fact, pre-medical courses in the humanities are seen as disadvantageous to potential admission since they generally provide much lower marks than science or math courses. Medical school curricula themselves are very much, and understandably, directed to knowledge and skill acquisition, and increasingly to career exploration. The “arts” are simply being squeezed.

These issues, although rather daunting, are nonetheless individually approachable and our profession lacks neither the imagination nor capacity to approach them. However, this brings us to the most significant issue of all. Do we see this as a problem? Is the gradual erosion of humanism within the practice of medicine a threat we must marshal our efforts to reverse, or do we see it as a natural evolutionary change, a natural consequence of how medicine and health care in general must adapt to a vastly expanding base of interest and the resource constraints we’re all only too familiar with? Are those who raise these concerns simply pining nostalgically for a bygone era?

In posing this question, I recognize that my contemporaries and I are not the ones who must provide the answer and necessary commitment to change. It is, in fact, our students and young colleagues who will face this choice and determine the direction of our profession. They will need to consider what’s left without the humanistic “art” of medicine, how it will be regarded by their patients, and how it will be valued by society. The choice is perhaps best summarized by Thomas Lewis, a former medical school Dean and frequent essayist and writer, who wrote:

“The uniquely subtle, personal relationship has roots that go back into the beginnings of medicine’s history and need preserving. To do it right has never been easy; it takes the best of doctors, the best of friends. Once lost, even for as short a time as one generation, it may be too difficult a task to bring it back again. If I were a medical student or intern, just getting ready to begin, I would be more worried about this aspect of my future than anything else. I would be apprehensive that my real job, caring for sick people, might soon be taken away, leaving me with the quite different occupation of looking after machines. I would be figuring out ways to keep this from happening.”4

So, does your patient feel better after seeing you?

 

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

  1. Medical Education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Abraham Flexner. Arno Press &The New York Times. New York. 1910. Page 26.
  2. Medical Education: A Comparative Study. Abraham Flexner. The MacMillan Company. New York. 1925. Page9-10:
  3. http://www.cbsnews.com/news/medicine-the-art/
  4. The Youngest Science: Notes of a Medicine Watcher. Thomas Lewis. Alfred P. Sloan Foundation Series.1983.

10 Responses to The Art and Science of Medicine – a critical but troubled marriage

  1. Sheila Pinchin says:

    Wow! What a terrific and thoughtful article! Once more your metaphor is so apt. I’m one of those patients who leaves my family doctor’s office feeling better, even when I’m feeling worse. It’s a tribute to her skill and her relationship building that I do.

    If the linking of humanism and medicine is a troubled marriage, then perhaps some of the steps married folk take are in order. I haven’t had the benefit of marital coaching, but I know that in any therapy there are some key steps:
    1. Awareness–in many areas of education and problem-solving awareness of an issue is an important first step to correcting.
    2. Questioning and reflection–using tools to ask oneself about issues such as time, focus constantly ever inward, etc, and how one is responding to these.
    3. Taking steps to correct. I can see that those in medical educatoin have already started to offer some steps that beginning physicians can take. I know that here at Queen’s Dr. Renee Fitzpatrick, Dr. Laura Milne and you Tony, have worked with our students on thoughtful career selection, and reslience–key aspects that would help a beginning physician. Our Learner Wellness Office has a large number of really qualified counsellors who can discuss these issues with students.

    But I’m a lay person in a strange land here…

    I’ll be interested to hear what physicians have to say about Lewis Thorne’s quotation. And I’ll add the plea of a patient: Please don’t give up on us and start listening only to the machines.

  2. David Walker says:

    Well said Tony. And you know and practice well that of which you speak. I hope you consider sharing this with each first year class; and for a wider audience

  3. Adam Mosa says:

    Thank you for this thought provoking piece, Dr. Sanfilippo. As students, we are fortunate to be under the guidance of a Dean who thinks and practices in this way. Reading your essay prompted me to return to my dusty bookshelf.

    The quote above is actually from an essay entitled, ‘Leech Leech, Et Cetera’ by Lewis Thomas. It appears in a collection of essays, ‘The Youngest Science: Notes of a Medicine Watcher’. Thomas’s life spanned an interesting point in the history of medicine. His father was a General Practitioner in the 1920s in Flushing, Long Island. He made house calls and practiced medicine in a time when medical science had much less to offer. Thomas writes, “In my father’s time, talking with the patient was the biggest part of medicine, for it was almost all there was to do… when I was an intern and scientific technology was in it’s earliest stage, the talk was still there, but hurried, often on the run”. Thomas was an intern in the late 1930s.

    A point worth emphasizing is what Thomas writes in the sentence immediately preceding the quote you included above. The art, the conversations, and personal understanding “may turn out to be too great a loss for the doctor as well as for the patient”. Despite the greatest burden of poor communication being felt by patients, doctors themselves likely come in close second place. Perhaps, an equally important question to be asking, is whether we, as healthcare providers, feel better after seeing (and hearing) our patients?

    I agree that students can champion the cause -but that was also true in 1983, when Lewis Thomas published this essay. It’s reassuring to have met many clinicians at our school who clearly champion the importance of medical humanism.

    • Thanks Adam, for the insightful commentary (and for helping me realize I’d inadvertently transposed Thomas’s name). His writings are, indeed a great read. His essays were regular features of the New England Journal when I was a student. As you point out, the threat has always been present to some extent, and works both ways, affecting both patients and physicians. As long as students like yourself recognize and engage this issue, the future would seem to be in good hands.

  4. Matt Simpson says:

    On the third visit to my family doctor in a summer for an ear infection I caused by scuba diving:

    Doc: How can I help you today Matt?
    Me: I seem to have another ear infection.
    Doc: What do you want me to do about it?

    I certainly didn’t feel better after talking to her that day… but long term, that visits tough love and lack of reassurance that “everything would be ok” ultimately made me better. I haven’t had an ear infection since. 😀

    As always, great read Dr. Sanfilippo.

  5. Russell Hollins says:

    Thank you Tony, the historical perspective and insight into the evolution of how we are caring for patients very much aligns with my observation of how medicine has been changing even in the short time I’ve been in practice. Technology is in many instances superseding humanism, such that decisions are directed by investigations sometimes without understanding the individual. In some areas, decisions driven by incidental radiologic findings are leading to procedures that have more complications that benefits, even though the basis of the interventions is to diagnose and/or treat disease.

    Despite the pressures towards efficiency and throughput, I encourage students to take the time to get to know their patients, even if briefly, and to listen to their stories before making notes. Although challenging, I have slowly allowed myself to put the chart down when speaking with patients. It is clear to me that this small step leads to better encounters with the majority of patients. Even though we use machines for much of our work, we are not caring for them and this must be kept in mind at all times.

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