Friday, August 13, 2010

Science and art in the practice of medicine

Medicine is said to be a mixture of science and art. The question is which part is science and
which part is art?
Science is knowledge based on information obtained through human senses (sometimes aided with various instruments) by observation and experimentation and by logical conclusions derived from this information. Its contents are measurable and reproducible (i.e. gives the same result when repeated by the same or a different person) and it follows strict rules and laws.
Art is a human activity which depends on ill defined characteristics like judgment, intuition, gift and experience. It is not readily measurable, not reproducible and does not usually obey strict rules and laws.

Science in the practice of medicine:
Modern medicine depends to a large extent on various biological sciences like physiology, biochemistry, anatomy, pathology, microbiology, pharmacology etc. It is also increasingly dependent on modern technology which in turn depends on sciences like physics, chemistry and mathematics. The modern doctor, at least the good one, is scientific in his approach to patient's problems. He does not presume that illness is produced by an evil spirit which he should rid the patient off by beating him, or that it is the result of some change in body mixtures for which he has no evidence. Instead he defines the problem, makes a preliminary hypothesis about diagnosis, collects evidence, formulates a main hypothesis, tests it, if valid applies it and if not rejects it and looks for another one. This approach is the same that modern scientists follow when they tackle their problems, the so called "the scientific method".

Art in the practice of medicine:
The first thing a doctor does when he meets a patient is to take the history of the illness. This doctor-patient encounter contains so many things that are not measurable, not reproducible and not controlled by strict rules and laws. The look on the face of the doctor, the tone of his voice, the choice of the questions and the wording of them, the way he listens or interrupts all fall more in the realm of art than science. The doctor tries to give the proper weights for various symptoms but can he measure pain, nausea, or dizziness? Through experience he may attach great importance to some symptoms and trivialize others.
When he feels the abdomen he does not have a measure of the pressure he applies with his hand, and no units with which he accurately measures the tenderness or the consistency of an enlarged liver. If he repeats the examination or some one else does, he may give a different estimate. When he listens to the heart or the chest, he does not usually use a device which measures heart sounds, breath sounds or murmurs in an accurate and reproducible way. The same thing applies to examination of reflexes, mentality, speech, joints, muscles, masses etc.
When he decides to do some tests, has he strict rules which tell him what test should be done and what should not? Or is it a matter of vague ill defined judgment on how much is the test likely to be useful and how much is it likely to be a waste of time and a cause of needless suffering and possible harm?
The same applies when he decides on treatment. Treatment may produce benefit and may do harm. The balance between the two usually depends on that vague thing we call "clinical judgment" which we cannot define, cannot measure and which may vary between different doctors and in the same doctor at different times. It is not measurable and not reproducible.
All these activities fall in the category of art. I can mention a lot more in various fields of medical practice like surgery, obstetrics, pathology etc. and about various procedures which require, beside judgment, manual skills.
This part of medicine, the art of it, is usually learned by experience and by working with someone who is good at it. Reading books and attending lectures is not the way to improve it. This is one of the defects in our medical education system. Students concentrate on the science part of medicine. The art of medicine, which is extremely important in medical practice, is to some extent neglected. We cannot put all the blame on students. Many examiners do not concentrate on the art of medicine when they assess students in clinical examinations. Assessing the art of medicine requires a skill which only experienced examiners have.

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