“Clinicians who discourse upon the ‘spirit of medicine’ will always point out that,
while there is a large and profoundly important scientific element in the practice of medicine, there is also an indefinable artistry, an imaginative insight,
and medicine (they will tell us) is born of a marriage between the two.”
-Sir Peter Medawar, President Royal Postgraduate Medical School, UK, 1958
Recent articles about the rise of medical artificial intelligence have sparked my interest in the age-old debate about the importance of the art of medicine versus the science of medicine, especially in primary care where physicians see large number of patients with often diffusely defined problems. This discussion is heightened by our rapid technological advances, the plethora of diagnostic and treatment computer sites available to physicians AND patients, and the hype, and more recently the increasing concerns, about medical artificial intelligence (AI).
The term “evidence-based medicine” emerged in the 1990’s as the description of clinical recommendations based on averaged data collected from select populations. It implied that if the physician had enough scientific information (data) from a large population, he or she could make correct decisions about the diagnosis and treatment of an individual patient. Some clinicians criticized these clinical guidelines, protocols, and recommendations from population-based data as “cook-book medicine” which could ignore the needs of individual patients. The term “art of medicine” implies that the physician will intuitively make the right decisions for the individual patient, or in our current culture WITH the patient, taking into account all the special traits of that patient and their environment.
This dichotomy of art versus science is a false one. It is based in part on our memory of the painting of the gentle, wise, old doctor gazing at a dying child surrounded by its family because penicillin had not yet been discovered compared to today’s image of an ICU patient lying mute, infested with tubes, surrounded by blinking lights and computer screens with the family hovering down the hall in a waiting room, and a nurse at her computer ZOOMing with the consultant specialist 50 miles away.
The truth is that neither one alone, art or science, is adequate to ensure the best care of the patient. The art of medicine may include physician emotion, bias, and paternalism which can muddle the decision-making, and we are now recognizing the significant potential for muddled decision-making by AI programs developed from biased data bases. An artful patient care note is brief, but understandable by colleagues and the writer him/herself in the future and reflects the reasoning behind medical decisions. Voluminous computerized notes based on checked boxes, while very useful to insurance payors and regulatory reviewers, can often obscure the physician’s thinking, and even sometimes the patient’s actual clinical status, in a blizzard of data.
Clinical judgement develops through experience. In primary care it requires a good deal of tolerance of ambiguity by the PCP (primary care provider – MD, NP, or PA). Good clinical judgement in primary care often grows out of good intuition.: Features of intuition (1)
• rapid, unconscious process
• comes with practice
• involves selective attention to small details
• cannot be reduced to cause-and-effect logic (i.e. B happened because of A)
• addresses, integrates, and makes sense of, multiple complex pieces of data
One author defined the intuitive practitioner as the one “who may not always know why he is doing something.” I believe that the most common diagnostic test used by the primary care provider is the “tincture of time”; the admission that one is not always certain as to what is exactly going on at the first patient encounters.
Clinical judgement is hard to measure in the practitioner, and it is hard to teach. How does one teach clinical judgement and clinical intuition? One emerging method is the use of “narrative medicine” training in medical school pioneered by Rita Charon, (MD 1978 and 1998 PhD in English) of Columbia University Physicians and Surgeons. Narrative medicine involves practitioners listening to patients’ stories and retelling (or writing) them to other clinicians after self-reflection informed by the practitioners’ understanding of literature, ethics, and psychology. Balint groups for family practitioners in the U.K. and U.S. are reflective discussions of patient cases by small, facilitated clinician support groups. Both methods seek to strengthen the doctor-patient relationship by enhancing the practitioners’ senses of creativity, self-reflection, and intuition.
Clinical judgement builds over time based upon scientific knowledge, basic learned skills, learning from clinical experience, but also on reflective thinking, writing, reading, and the telling of stories. The art of medicine in primary care is as essential today to excellent patient care as is the advancement of the science of medicine.
1. Intuition and Evidence – Uneasy Bedfellows?, Trisha Greenhalgh, Br. Jour. of General Practice, May 2002, pg. 395-400