AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. January 2011, Volume 13, Number 1: 52-54.

Medicine and Society

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Is There Room for Art in Evidence-Based Medicine?

Today’s great doctors are part of a long tradition of physicians who have valued the art of medicine and married attention to the patient with rigorous medical investigation.

Richard Colgan, MD

John Arbuthnot served as physician to Queen Anne of England at the turn of the eighteenth century. He was careless about his business affairs and often let others take credit for his work. In doing so, he suffered financially. Upon the death of the queen, Arbuthnot lost his job, causing his friend, the writer Jonathan Swift, to lament, “he knew the art but not the trade.” Two hundred years ago, as well as today, there is no higher praise for a physician than being said to know the art of medicine.

In this era of evidence-based medicine, clinical guidelines and outcome measures, one may wonder what has become of the patient-physician relationship? Whom do we serve: a review board, the insurance company, the public, or the patient? Whatever happened to the “art” of medicine? Is it lost? No, it is still here, being practiced every day by great healers, and by great I mean the nonfamous, Clydesdale-workhorse physicians. They are part of a long tradition of doctors who have understood that rigorous medical science and humane patient care share a common core: observation.

Evidence-based medicine is not, in fact, new. The “father of medicine,” Hippocrates of Cos, advocated for the scientific investigation of patients’ ailments, breaking away from the previously held belief that a person who was sick had displeased the gods. Although Hippocrates probably cannot take sole credit for the ideas in the Corpus Hippocraticum, from this compilation of his works we learn that he had more to say than “primum non nocere.”

Hippocrates believed that good observation made physicians better prognosticators. His own observations were apt; some of his aphorisms have been borne out by modern medicine: “Pneumonia coming on pleurisy is bad” [1] and “Patients who are naturally fat are apt to die earlier than those who are slender” [1]. Hippocrates also advocated that physicians practice ethical behavior when caring for patients. Just as many physicians do today upon graduating from medical school, physicians of his day willingly took an oath committing to these practices.

Rhazes, one of the greatest physicians of the Middle Ages, was recognized for both his contributions to medical science and his dedication to the art of medicine. Rhazes strongly encouraged scientific inquiry, particularly the observation of patients. He challenged Galen’s theory of the four humors and was later vindicated.

Rhazes not only promoted the practice of evidence-based medicine in the Middle Ages, but was known as much for his kindness and compassion to others as for his intelligence. He famously treated the impoverished sick free of charge, and was so troubled by poverty and suffering that he gave away his fortune and died in destitution.

Avicenna, another healer from the Middle Ages, was known for advocating the practice of observation and experimentation—to ethical ends. He wrote of the necessity of studying drugs before exposing the public to them. Furthermore, recognizing that many could not afford to see a doctor, he wrote self-help manuals so that the poor could have a practical resource for coping with health problems and cared for those who needed help at no cost.

The twentieth century also saw its share of great healers who knew both the art and the science, such as Canadian medical educator Sir William Osler and American educator Francis Weld Peabody. Peabody was director of the Thorndike Memorial Laboratory at Boston City Hospital during a time marked by astounding progress and discovery in the science and technology of medicine. Though an active researcher, Peabody exhorted physicians not to neglect the human elements of medicine; he felt that the “art of medicine and the science of medicine [were] not antagonistic but supplementary to each other” [2]. He wrote that “one of the essential qualities of the clinician is interest in humanity, for the secret in the care of the patient is in caring for the patient” [3].

History confirms that evidence-based medicine has been with us for a long time, and that evidence is never enough. From the time of Hippocrates forward, observation of the patient, the search for an imbalance of humors or other signs and symptoms, uncovered evidence of what the cause of the illness might be. Today, we have what might seem like a strange situation, in that the evidence that some physicians value most highly comes not from the patient but from lots of other people, e.g., participants in randomized controlled trials (RCTs), the so-called gold standard for evidence.

But in fact, this is in many ways traditional: the practice of evidence-based medicine is rooted in the observation of human beings both sick and well. The art lies in using those skills to assess whether the RCT evidence fits or does not fit the person sitting across from you in the exam room, taking into account the patient’s biopsychosocial and spiritual makeup and the previous experiences of both the patient and the physician.

The question of whether or not the art of medicine has been lost is best answered not by looking outward to tally what percentage of today’s physicians are scientists or artists of medicine, but by looking inward and constantly taking an inventory: “How am I doing? Could I do better? Did I do what was truly needed for this patient?”

I would like to think that I have learned the art of medicine, but I know that being a healer is not a destination but a journey. In the words of Robert Browning, I confess to you that “that which I strive to be and am not comforts me” [4]. As long as we continue to work towards being whole doctors, the art of medicine will remain very much alive.



References

  1. Adam F, trans. The Genuine Works of Hippocrates. Vol 2. New York: W. Wood and Company; 1886: 283.
  2. Peabody FW. Doctor and Patient. New York: The Macmillan Company; 1930: 29.
  3. Peabody FW. The care of the patient. JAMA. 1927;88(12):877-888.
  4. Browning R. Rabbi Ben Ezra. The Oxford Book of English Mystical Verse. Oxford: The Clarendon Press; 1924: 194.

Richard Colgan, MD, is an associate professor and director of medical student education in the Department of Family and Community Medicine at the University of Maryland School of Medicine in Baltimore. He was the recipient of the school’s Golden Apple Award for teaching and is author of the recently released book Advice to the Young Physician: On the Art of Medicine, in which he discusses how to make the transition from technician to healer based on lessons from some of history’s greatest physician educators. Information on this book is available at www.advicetotheyoungphysician.com.

The Origins of Evidence-Based Medicine: A Personal Perspective, January 2011

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