From our earliest days in medical school we are told that the practice of medicine is a science and an art. This takes into account that scientific information is used, and often necessary, for the modern practice of medicine. But it also nods to the nonscientific aspects of medicine. Some believe and practice as if the science is more important and others as if the art is more important; the standard response however is that one needs both.
However, what if one asks which of these features more accurately characterizes how medicine is, or should be, actually practiced? In this column, I will make the case that art is the heart and soul of medical practice, and explain why I believe this is an important distinction.
But let me be clear: I am speaking of medicine not as a scientific discipline in a research laboratory, but caring for patients, the professional practice of medicine—what happens when a physician speaks with or touches a patient.
In the world of art, a poet uses words, a painter uses paints, and a sculptor uses solid matter that can be shaped. No one would argue that words, paint, and solid matter are the heart of these artists' profession. They are important tools that are used to create a fresh vision of life, death, and world around us. Experience, practice, study, and imitation all play a role in the artists' creative processes, but intuition, wisdom, and a personal vision are central to great, or even good, art.
One of my favorite poets, W.S. Di Piero, published a series of comments on the art of writing poetry.1 It struck me that many of his opinions also apply to the practice of medicine. His words are in italics:
Why the scenic in poetry matters: it tells the world (like telling a story) by saying how it looks, tastes, moves, smells. Tell the world well, even if it is an unhappy telling, and you reveal the invisible life of things.
I cannot count the number or times some apparently trivial aspect of what the patient or parent said or expressed by body language led to an important insight in the patient's or family's condition, just by watching and listening, and then probing. To a greater or lesser degree, we all learn that art of detection that cannot be found in any electronic medical record.
Practice makes perfect. Revision is a poet's practice, as musician's practice hours a day, reiterating sounds of those who have come before and internalized, while also testing unknown cord changes, tempi, combinations, etc. while playing (as a child plays in a sandbox) over and over the sound one knows. [In the latter case] Practice makes imperfect.
Knowing when to abandon a long-standing routine or therapy and venture to new approaches at the right time and with the right skills is a reflection of the art of medicine. It is difficult to move from a comfortable chemotherapy regimen to one that evidence shows is better. When changing to a new regimen, something unexpected can happen no matter how careful one is.
Science advises the change, but an artist-physician must decide for herself that this is the right time and the right patient to try it. And she must decide if she is the best one to apply such a change.
Does poetry follow the shape of the times, the energies and evaluations? [Ezra] Pound's Cantos is knowledge-heavy. Too heavy. Our own information-driven culture is companioned by a poetry that's information-heavy, and data isn't knowledge, which is driven by imagination, not by archival busyness. People talk about poems as if they were cleverly designed, efficient data centers, or delivery systems. The musical and the mythy may be effectively gone for good.
The warning in the last sentence above could be said about medical practice. The physician who spends more time looking at the computer screen than talking with the patient may be information-heavy or data-heavy, but neither is knowledge. The risk of accessing so much data, much of it useless, is “archival busyness.”
In a recent column, David Brooks2 summarizes the words of Nassim Taleb, who wrote Antifragile: “As we acquire more data, we have the ability to find many, many more statistically significant correlations. Most of these correlations are spurious and deceive us when we're trying to understand a situation. Falsity grows exponentially the more data we collect. The haystack gets bigger, but the needle we are looking for is still buried inside.” Brooks also points out that “data struggles with the social.”
The human brain is much more adept than masses of collected data at social cognition such as understanding emotional states, the context of behavior, and the values involved.
Science provides data, mounds of data, but the physician-artist must filter and frame it. Although much of medical practice can become humdrum, at its best practicing medicine is elegant, as in pleasingly ingenious and simple. The use of repetitious and often unnecessary MRIs or any other diagnostic test is far from elegant; it is more like using a sledgehammer—the antithesis of art.
The voluminous data that we now can collect on our patients come from a data tool chest; we reach in to grab a screwdriver when that is the right tool needed. We don't take all the tools out of the chest and try them one by one to see which one works.
That is why I believe that the practice of medicine is an art. I believe this distinction is important because the focus should remain on patients—and not only their symptoms and signs, but also the context of their lives, their values, and their perceptions.
Hear Joe Simone on BBC Radio!
Joe Simone was recently interviewed by the BBC radio program “Soul Music,” following up about his 5/10/12OTcolumn about Peggy Lee's song “Is That All There Is?,” written by Jerry Leiber and Mike Stoller. Hear him talk about why this devastating song about disillusionment inspires him nonetheless: http://www.bbc.co.uk/programmes/b01qgr4h
The series recently won a U.K. Broadcasting Press Guild Award for Best Radio Program for its continuing exploration of music with a powerful emotional impact.