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MEDICAL ART, MEDICAL SCIENCE, MEDICAL POETRY:
Current concepts are inverted, but can be corrected.

Doctors and patients seem to believe there are two sets of clinical skills each clinician should master—the art of medicine and the science of medicine.  The “art” of medicine is seen to consist of intuitive skill for dealing with patients and their families.  Skill in the “art” of medicine is not taught because it is thought to come from innate talent and sensitivity, enhanced by experience in dealing with people.  The “science” of medicine is seen to be very different from the “art,” especially in that its parts are known rather than intuited.  It is expected that the deficiencies of medical “science” will be fulfilled by research and development of new techniques, equipment and substances.  It is commonly believed that the “science” of medicine is constantly evolving, becoming newer, bigger and better.

Perhaps we can question these assumptions about art and science in medicine, now that we are beginning to see that they have produced hugely expansive institutions and professions which, despite their size and expense, have left none of us with reliable or safe medical care.  Physicians, despite their prestige and sincere motivations, often experience a feeling of inadequacy in their practices, which is shared by patients and their families who have been incompletely helped.

To talk of new techniques as if they constituted science, to talk of behavior unknown, unchanging and mysterious as if it were art—these are risky misconceptions.  Art need not be mysterious, innate and unteachable.  Although proficiency in various arts may depend on some measure of innate talent and interest, techniques can indeed be examined and taught.  As a student I learned of the distinction between one kind of art and another, between τεχνη (techne) and ποιεσις (poiesis).  Certainly the art of the artisan can be understood, can be developed (it is not unchanging), and even though innate talents may differ, anyone who is interested can learn such an art and work at it.  This is skillful technique, skillful doing. 

The art inspired by the muses, suffused with emotion from both the artist and the audience, may better be characterized as poetry, the making or doing of something unique.  It is the successful practice of such ποιεσις which often has been considered innate, inspired, unteachable and unique.  This is the skill of aesthetic expression.

There is also a sense of art as duplicity, trickery, slickness and illusion.  We often use “artful” this way.  This art is like salesmanship or sophistry.  (Consider calling it “eristic,” from ερεις the Greek word for argument.)  It is skillful persuasion.

I will call these separate arts technique, poetry and persuasiveness.  Each of them can be used by a clinician for good or ill, but no one of them (nor all confused together) is exactly what should be referred to as “the art of medicine.”

Science has to do with knowledge, but what it is is understanding.  All phenomena can be studied and understood with some success so long as the student of that science keeps her mind open to its own fallibility and ignorance, looking for new understanding not already formulated as established dogma.  This is love of wisdom, φιλοσοφια (philosophia), whose principle was characterized by Socrates as, “I know that I do not know.”1  Science is a process of understanding, not a body of knowledge.  Today’s body of knowledge is an ephemeral projection of understanding.  It is not the same as yesterday’s or tomorrow’s, but it is not necessarily better than yesterday’s nor worse than tomorrow’s.

What is called “medical science” is not what it is thought to be, but a body of knowledge amalgamated with technology, always in flux.  True medical science is a coherent process of understanding, not a changing pool of data applied by skilled technique.  True medical science must be medical understanding; and it exists, and we possess it.  It consists not at all in data, but in basic principles for understanding the types of phenomena we encounter.  We have believed clinicians encounter the phenomena of anatomy, biochemistry, et cetera but although we do meet such things these do not constitute clinical phenomena.

The labels are quite old enough:  “patient” means “sufferer” from Latin, the opposite of which would be “agent” or “actor” (or “agonist” or “protagonist”--but let us not stretch these terms even in jest to “victim” and “victor”).  Clinician is literally “the one at the bedside,” from the Greek κλινειν (klinein) “to lean or recline” which comes to be κλινη (kline) “bed;” whence also the English word “client” (or “dependent one”) now used often instead of “patient.”

Clinical phenomena are the elements of a clinical relationship.  That is all.  Given the two persons in the relationship, clinician and patient, clinical phenomena are those underlying assumptions with which they deal and those events which take place between them.  (Real life is never quite so simple; see the chapter “The Clinical Team” for hints about the elaboration of the persons in the clinical relationship.)  It is through understanding and management of these assumptions and processes that all diagnosis and treatment take place.  Clinical phenomena can be identified, researched and taught.

Clinical judgment refers to judgment in unique circumstances, as legal judgment refers to unique cases in which precedents may be helpful for guidelines but their outcomes are not foregone conclusions.  Judgment of these kinds cannot be made by merely formal application of standard protocols (“cookbook medicine”) but refers to a complex process of understanding applied to a unique situation.

We have somehow convinced ourselves of many foolish things.  We believe there is an inherent conflict between the account of creation in Genesis, and evolutionary theory.  We believe that human history must be understood either as determined by biologic law, or as the result of conscious human choices.  We act as if what we deal with through our clinical behavior is a disease rather than a person.  We look for answers on single levels, simplistically, rather than looking to comprehend the whole of what we face.  Complex events in human persons’ bodies and minds are not adequately explained on single levels, nor are disparate explanations on multiple levels adequate; overall explanations are needed in order to take practical actions which will be productive of good.

In clinical settings we deal only with persons, and we owe our respect and loyalty to them.  When we do not recognize such simple truth, patients feel hurt and they are hurt.  There is no necessity that a patient come with only one disease or with any disease, but we have structured our speech, thinking and action toward a diagnostic label rather than toward the person of whose life the disease is a part.

Do not despair.  Although we have usually acted in error, misidentifying the subject of our science, we are not completely ignorant of true clinical science.  We know a great deal about persons who are afflicted or fear they will be.  We know their expectations of clinicians, the ways in which they are likely to be helped, the ways in which they are likely to be hurt, their families, their real lives, their feelings—as well as their anatomies, physiologies, pathologies, biochemistries, et cetera.

Now I feel better, but you may not.  You may be reluctant to agree that the subject of medical science is clinical relationships and their elements, rather than disease and its components.  But please remember I am speaking of patients who have diseases as well as life-histories.  I do not propose that we do anything very different or give up much, rather that we look for fruitful different perspectives at a time when the old ones are unsatisfactory.  (The “old” ones are perhaps a century old; my “ new” ones thousands of years.  I have shown in “In Defense of the Oath” that the “Hippocratic principle” does indeed reside in the Hippocratic corpus, and that it is valid and applicable today.)

In his classic work The Doctor, His Patient, and the Illness Michael Balint describes the elements of the clinical relationship as re-derived in seminars on psychotherapy with general practitioners in England after the Second World War.  He suggests that the clinician is the essential tool of diagnosis and treatment.  The literary corpus of Hippocrates (my very real legendary teacher) considers the patient in his physical and social environment, and considers what the clinician should do or recommend.

With these and other clinicians in mind, let me refer to examples from my own clinical experience to illuminate the broad statements I have made.

A frustrated surgeon who had wished to be a famous pioneer of open-heart surgery allowed an old woman whose rectal carcinoma he had previously successfully resected to convince him to subject her to radical mastectomy, although he had not done that procedure in many years.  On rounds during her recuperation he unconsciously suffered great pain as he repeatedly blamed her to tears for her slow recovery.

The patient expected the “medical science” of the clinician to save her from disease.  It was not basic understanding of clinical phenomena she trusted in him (for he had very little) but an unfortunately limited technology.  He relinquished the poetic medical art, that which can respond to the unique and emotional, that which can seem intuited in one person by another.  He misused his power to persuade, making her undergo frozen-section biopsy and radical surgery under the same anesthesia, signing away her options before she knew the facts.  (The language of my description reflects the ineluctability of the clinical relationship, that he was pained along with her, unprotected either by his practiced callousness or his white-jacketed entourage.)

A less dramatic example, one reflecting good clinical understanding without drastic action:

My son reminds me of the good action of not one doctor but two, “…when that doctor took me out of Mom’s vagina, and the other doctor came and said I had a bifid uvula.”  The obstetrician had our confidence; he had bucked all tradition to get me into the delivery room (in those old days when fathers, even if they were themselves doctors, were barred from the delivery suite).  Labor was long and difficult.  Calmly and patiently he overcame our resistance to narcotics so my wife could get enough relief to complete the delivery.  The pediatrician examined our son carefully, announced the bifid uvula (a detail of no pathologic significance), thereby dramatizing the precise attention he offered and the normal health of our infant.

What we knew as patients was that the doctors skillfully used technique (doing well in delivery and in assessment), poetry (perceiving and expressing with feeling what is unique to the case), and persuasion (convincing us to allow the good use of narcotics, convincing us of the basic health of our child).  We assume each of those clinicians had mastery of medical science (the understanding of the phenomena of the clinical relationship) but we cannot know to what extent that success came about as a result of conscious processes.

An example that clinical phenomena can be understood, and conscious judgments made regarding them:

A woman who has come to my clinic rarely, for documentation of disability, suffers from massive obesity, diabetes mellitus, severe hypertension, ischemic heart disease, dysfunctional uterine bleeding and gout, all untreated, resulting in anemia, angina, congestive heart failure, and all the other symptoms and signs of her complex disease.  At our most recent encounter I experienced and expressed a mixture of thoughts and feelings:  that she and I had long known she is quite ill; that we both believe her illness can be improved; that she has taken no action to improve it; that I honestly respect her right not to care for herself (that it does not hurt me directly) but that it saddens me for her sake and mine; that I have come to believe strongly a doctor should have some basic understanding of what is happening with a patient, but that I don’t understand what is happening with her (why she seems unable to care for herself).  She responded brightly and sincerely with an account of family pressures, responsibility for grandchildren, which had kept her from attending to her own welfare.

I recognized a pattern of denial of illness expressed in lack of action, justified by perceived needs of others.  I knew my honest expression of real interest would be more persuasive than sermons against disobedience.  I was careful not to compromise her autonomy, the most potent factor of successful treatment, but I also did not reject her active adoption of dependency (“I will do whatever you say, Doctor,”) as it might offer her only transition toward health.

Consider that the obscurity of clinical experiences may come from the nature of reality itself such as these four: 1) the truth we apprehend in mystical stories, 2) the reality which transcends the limited dimensions of logic-on-paper, and 3) the reality we protect ourselves from seeing lest we be blinded, and 4) that which contains its own contradictions.

I came in at the end of an interview when a first year medical student was meeting a patient in pain.  The patient averred he had climbed twenty 14,000-foot peaks with a cane, chain-smoking, during the several months he had delayed a recommended abdominal surgery.  He asked the young doctor to ask me (the old doctor) if his life insurance policy would consider dying on the operating table an accidental death.  Neither the student nor I responded to the concrete question.  After a brief silence the patient said, “I guess I was thinking of something else unconsciously (sic).”  The articulate patient ended the interview with wordless firm sincere handshake, thanking the young doctor.  In our discussion of the interview the students began to ask whether the man was afraid or unafraid.  They quickly understood the clinical truth, that he was afraid and unafraid, and that neither horn of the dilemma would reflect the reality of his being.  To comprehend the paradox was their task.

I have proposed something simple that belongs to each of us as patients and clinicians and has always been available to us for as long as we can know.  I have said that medical science is not special technology but understanding of clinical principles.  I have said that the “art of medicine” is not that which makes a clinician personable or trustworthy—for that is the science.  The art of medicine is good skill at doing (technique), expressing the uniqueness of the patient through emotional sensitivity (poetry), and proper and responsible persuading.

It is important to see that the art of persuading should rarely be used on a patient, who certainly has the right to make her own judgments, rational or not.  The clinician may need to use artful persuasion on family members, and especially may need to use persuasion on professionals not already on the patient’s side, to gain the attention of specialist consultants or other staff members.  Third parties, insurers, bureaucrats and attorneys require much time and energy to understand the true needs and values of the patient—the teaching of which is also is the clinician’s task (see “The Clinical Relationship in Occupational Medicine” for a discussion of Hippocrates’ First Aphorism, “Life is short, the art intricate, experiment slippery, decision hard to come by.  The physician must be ready not only herself (or himself) to do what must be done, but also to engage the patient or any outsider--even third parties.”)

It is important to see that not all doctors can be clinicians at all times, subject to the priorities that I have outlined.  Consultants, sub-specialists and researchers have a different status in relation to the patient from that of the primary clinician.  It is always important for the consultant or specialist to coordinate recommendations and treatment through the clinician to avoid distortion of the simple clinical relationship.

On the other hand, not all clinicians are doctors.  Some are other health professionals who have taken on personal responsibility toward patients, never claiming omnipotence, but never “copping out” with “That’s not in my job-description.” 

Very often non-professionals act as clinicians, offering afflicted persons loyalty and understanding, support in their struggle with pain, fear, impotence and disease in their lives.

Thus, current conceptions of the art of medicine and of the science of medicine are upside-down.  Art is of three sorts:  technique (the art of doing), poetry (the art of expressing), and the art of persuadingScience is the process of basic understanding, and knowledge is an ever-changing projection of understanding.  The science of medicine has as its subject clinical phenomena (which occur in therapeutic relationships between persons) rather than anatomy, physiology, pathology, biochemistry, et cetera.  Not all health care professionals are clinicians (some being researchers, specialists or professors) and not all clinicians are professionals (some being merely friends).  All clinicians should use that science of medicine which produces understanding of the patient.  It is not an intuitive “art” of medicine we use, but an understanding of patients that can be taught, learned, researched, developed, scrutinized and consciously applied.


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1From Plato’s Republic 354b., Perhaps Lao Tzu and a lot of others have said this sort of thing; I don’t know.

 

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