In his book Generation Rx: How Prescription Drugs Are Altering American Lives, Minds, and Bodies (reviewed in the last post), Greg Critser includes a quotation from a physician (in a self-help book [1]) that I found really striking:
In your search ... you are going to come across physicians who may initially be skeptical of any medication, technique, or new technology that has not already been proven to be successful with an indisputable double-blind study. This would not be the right physician for you. The very essence of Vitality Medicine has to do with flexibility, change, and a willingness to "experiment".
What's striking about this passage is that the physician writing it seems explicitly to be distancing himself from evidence-based medicine.*
Now, I've frequently heard it said that medicine is an art, not a science. In light of the passage quoted above, I'm starting to wonder what precisely is meant by this characterization of medicine as a discipline.
Assuredly, the human body is a wildly complex system, and our knowledge of its workings is nowhere near complete. Perhaps calling medicine an art is meant to capture the gappy nature of our knowledge here?
Or maybe the characterization is not a matter of how complete or incomplete medical knowledge is at present. Instead, perhaps it's a matter of the attitude it's proper for the physician to take given the uncertainty and unpredictability inherent in treating humans. If you waited for "indisputable" evidence before taking any therapeutic action (as you might if you help yourself to the same evidential standards as scientists**), you'd run a good chance of your patient being dead (of old age, if nothing else) before you could proceed. In other words, medicine is a practice that, at least in its modern incarnation, involves not just observing patients but providing interventions. If the data cannot tell us conclusively (and scientifically) which interventions will be useful, perhaps doctoring becomes an art because the doctor must use intuition to select interventions in a particular case.
Is this where the "art" in medicine lies, in having "good intuitions" about how to intervene given less than perfect information? If so, what precisely makes a physician's intuitions "good" rather than just lucky?
Are there specific ways that physicians are trained to have better intuitions, and if so is there a connection between the cultivation of these intuitions and the filling in of some of the gaps in medicine's evidence-based knowledge? If such a connection exists, does that mean that eventually medicine might become a science (or at least less of an art and more of a science)?
I'd be thrilled to hear from some physicians on this one.
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[1] Steven Lamm, M.D., and Gerald Secor Couzens, Younger at Last: Discover the Age-Defying Powers of Vitality Medicine, New York: Pocket Books, 1997.
* "Evidence-based medicine, " I'm given to understand (from a story in Time or Newsweek or something similar that I was perusing in a waiting room the other day, is the preferred euphemism, since calling it "scientific medicine" raised the hackles of a bunch of M.D.s who took the term to imply that what they were practicing must be unscientific medicine.
** It's worth noting that scientists are often OK drawing conclusions even if there's a slim chance that contradictory evidence might present itself.
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Perhaps one of the more common examples is identifying patients that are drug seeking. People get hurt all the time and doctors don't have imaging technology to see much beyond a true fracture, especially on a quick cost effective basis. I am a premed student and from what I have heard recognizing those that are genuinely in pain vs those acting for a easy and 'legal' high would be more of an art as opposed to evidence based science.
I'll take a shot at addressing the art of medicine in the context of evidence-based medicine. I'm not a physician yet, but am in the midst of my medical training. Since starting my program 6 years ago, I have observed 'evidence-based medicine' skyrocket as a litmus test for the value of treatments - both new ideas and those that are standard of care. The problem is that there is not enough money, there are not enough biostatistitions, and generally there doesn't seem to be enough academic interest in evaluating every treatment to the standards that are needed to meet the criteria of evidence-based.
My medical education thus far has introduced me to two components of the art of medicine. The first is linked to the topic in this post - namely feeling for the right approach for the individual patient. An openness to
as advocated by Greg Critser (I have not read his book) should be rooted both in clinical experience and honest communication with the patient. Short on its grounding in clinical acumen or scientific procedures, 'experimentation will only be quackery. Different care strategies will work for different people. Diabetes treatment may need interventions involving drugs, exercise, diet, and social support. Deciding which components to pursue first is part of the art of medicine.
The other aspect of medicine I have been introduced to as 'art' is the unpredictable nature of human interaction. Social network theory and psychology are still a long way from scientific explanations of the white coat effect, the wide range of provider-patient interactions or even the placebo effect. The art of medicine involves orchestrating a choreography of these and other factors with scientifically derived or empirically tested therapies in a way that benefits the patient.
Others take a more metaphorical interpretation of art in medicine - namely that devising patient's therapies are acts of creation. Not yet having had exclusive responsibility for a patient, I cannot say I have experienced this artistry. But if were the case that the patient and his/her problems is a blank canvas, I could see how a medical student might be the brush with which an attending physician paints. Or maybe the student is the basin of water or solvents in which the brush gets cleaned at the end of the day...
I have been seeing a psychiatrist for "medication management" for quite a number of years now. Because of this, I have been trying to keep up to date with academic literature regarding various treatments. From my studies and from my experience with the psychiatrist (who is really wonderful), it seems that
'flexibility, change, and a willingness to "experiment"'
are essential (at least in this field) because there simply isn't enough data out there to make evidence-based decisions about every medication and every situation. This, I think, is partially because the number of medication combinations are very high making it difficult to find a study based on the exact combination you are making, and because we still don't have all of the answers for how and why these drugs work. My psychiatrist's solution to this is to tell me up front what the options are and why she is suggesting them including whether there is in fact data to support that option or if this is something she has seen work well in patients (but there is no data for it), or if this is information she recently obtained from a talk at a conference. Through several years of experience, I have learned to trust her instincts. This seems to be a very sensible model and one that works well for me. Whether or not this is a practical approach for every physician or every patient is not something I can speak to.
Humans: The Best Animal Model Evar.
Medicine is a trade (art?). At no point in a medical school education is one required to actively participate in science. No mandatory course requires an understanding of the scientific method. No general certification requires science experience or critical evaluation of scientific literature. (some subspecialities do have explicit science components).
Yes, many M.D.'s go above the job requirements and either directory or indirectly follow the science because it helps their practice and treatment of patients. Thus you get doctors who can practice the way they learned in school/residency or pick up skills that others teach, but can't critically evaluate new information on their own.
At least in veterinary medicine, there seem to be two general areas where the shades of grey can stretch into all the regions of EBM (clinician experience, evidence based therapies, and client preferences/beleifs.)
That is, short of clear evidence- vets often have to work the various levels of the evidence "wedge" in search of the best available, scientifically plausible modalities. Here it is more like a gap issue that may close through time.
The other, is less clear and deals with that ellusive ideal mix between the individual human/patients situation and the available science based therapies- these roads are often unclear. This "interface" can be straightforward (got a cut- stitch it up) but can flucuate wildy (ie, navigating the "whats right for them may not be for me doc" cancer therapy scenario). This entails a nonjudgemental understanding of the human condition and an effort to find, within the larger scientific framework, the "right" approach. At the same time, these bonds need to be navigated under the direction of critical thought and honest discourse. Otherwise, false hope and quackery can thrive (ie, Vitality Medicine sounds a bit fishy...).
bsci writes:
This is not true at my university, where a course titled Critical Reading and Evaluation of the Medical Literature (CREM for short) is as required as biochemistry, physiology and genetics. This is not to say that CREM is very popular with the students. Those who like the course are derogatively called CREM Masters.
Anyway, the course introduces students to the basics of reading papers, like looking for controls, finding proper statistical analysis and understanding how meta-analyses are conducted. This information is then brought back throughout the later organ systems courses to challenge students to assess whether standard of care is the best option.
I also argue with:
Sure some geniuses or individuals with photographic memories can get through medical school by rote, but the rest of us rely in part on understanding how the scientific method characterized diseases and the treatments that we will encounter as physicians.
The art of medicine arises because people don't read the books. You have some people walking around with 95% LAD stenoses who are just fine, and those with 75% stenoses, (which are supposed to be asymptomatic, dropping dead. Some folks can be walking and talking with a BAC of .559, whilst others are comatose with one of .226. Some folks succumb early to cancers, others hang on for a while. Everything you do as a physician has to take that into account, you can't reduce medicine to a cookbook, protocol driven matter.
I do, though, insist on evidence, and data, and I think using treatments that are shown to be better than chance is a good idea. Anything else is depending on the placebo effect.