Is there still an art to practicing medicine?

Art is the subjective, interpretative creation of a subject (painting, monument, etc.) created by an artist. This piece is then seen through the lens of the viewer, who has a different set of thoughts and beliefs about what they are seeing based on their personal life events and history.

Medicine is the application of scientific data to treat disease. In modern medicine this has become defined as the standard of care, which is built by evidence-based recommendations within the construct of scientific truths. Practicing in medicine can take on many forms and styles, based upon what we’ve seen and learned.

In what world do these two constructs collide or intertwine? We have all heard of the mantra instilled in the teaching of medicine: “the art of medicine.” From our early days as medical students to our senior years as attendings, it has persisted. In a recent conversation with a medical student this topic came up, and the resultant conversation had us asking, “Is there still an art to medicine?”

The landscape of modern medicine

Medicine is complex and varies across specialties, so the answer is unlikely to be a black-and-white one. That being said, I favor those who say “the art of medicine” has no place in the modern landscape that we currently practice in.

Now let me explain, as I know some of you might immediately disagree. Medicine in its simplest sense is consideration of patient-reported details to formulate a thorough history, a physical exam with specifically detailed and described tests (McMurray, rebound tenderness, modified balance error scoring system, etc.) and development of a likely differential diagnosis with the resultant ordering of test, studies and consultations.

Within these building blocks, there is a right and a wrong way to do things. The resultant treatment phase of medicine is also guided by evidence-based recommendations, and sometimes based on nationally published guidelines. These best practices form the facets of treatment, from first-line pharmacological recommendations to surgical repair of athlete ACLs to lifestyle intervention for obesity based on patients’ BMI.

Education and communication lead to various approaches

In the day and age of litigation and standards of care, we recommend and educate our patients under these tenets.

Now, there are aspects to medicine that encompass a holistic and possibly artful approach, but these lie more within the realm of patient communication, conversation and education. The clinical direction of data collection can be a learned artful skill, which varies among physicians.

How to ask the right questions and the ability to obtain the important historical facts is imperative in medical scenarios. This requires understanding of the patient to obtain the correct objective information required to inform accurate diagnosis and development of appropriate treatment plans.

However, we have created standard template questionnaires in an attempt to decrease variation, i.e. date of injury/illness, symptoms, what has made your symptoms better or worse, etc. This is engrained into medical education again to standardize practice and reporting (OPQRST, OLDCARTS).

Perhaps one could say there is an art to manual medicine, such as osteopathic manipulative treatment (OMT). Although two physicians treating the same patient could perform different techniques with varying degrees of pressure or force, the physicians are still practicing techniques that have been described and supported within the literature.

Thus, even OMT as a skill is completed through a series of prescribed steps and with recommended position, direction and force. Medical literature and current evidence supporting the wide range of benefits of OMT again is very specific regarding the technique used to obtain the supporting evidence. The standard that is expected is tested by the American Osteopathic Board of Family Physicians with reliability and reproducibility through the OMT Performance Examination.

Perhaps there is still an art and style to medicine in the area of new diagnostic evaluation and treatment. Take the recent COVID-19 pandemic, for example: treatments have varied among regions, organizations and providers. Researchers tested hypotheses and clinicians shared educated opinions without the previously described standard of care.

Thankfully, as evidence became available and guidelines were created, practice styles became more uniform, allowing proper treatment of the illness.

We practice medicine that is shown by science to be effective. Also, medical litigation focuses on practice variation and draws attention to a more artful-type practice. Although treatment with the defense of guideline use does not protect a physician from litigation, the decreased variation of practice does provide some protection to both the physician and the patient.

How the art of medicine looks in today’s world

The romantic rhetoric of the art of medicine may exist, but this is only in the delivery of information, and in those fields of new discovery where evidence is minimal and hypotheses are still developing. As a community, we continue to change with our evolving and modernizing world.

However, so-called “cookbook medicine” — relying on guidelines and protocols rather than a comprehensive approach to the individual patient — is not entirely capable of evaluating all patients satisfactorily and considering those “zebras” we all chase. It also does not catch unlikely diagnoses or combinations of diagnoses that we know can cause morbidity and mortality.

If you have been evaluating current developments, you are aware of the convergence of human and artificial intelligence (AI) for the creation of machine-learning software.

We are on the horizon of a new challenge, with the utilization of big data that will begin to put on trial the evaluation and treatment of patients through the use of AI and machine learning. Objective measures can be constructed to aid in patient management through “modeling work.”

How will this influence our clinical practice? How will patients feel if it opens more access to care? We are at the precipice of modern medicine, the application of big data sets to teach models to aid physicians in evaluation and treatment. 

The goal of health data science is the progression toward an efficacious and cost-effective clinical tool. I would encourage everyone to take a step back and draw focus to the scientific medicine that is expected; the guideline-driven medical recommendations we all practice.

Related reading:

The DO Book Club: Heartsounds, Echoes of Heartsounds, Changing How We Think About Difficult Patients

Medicine as your Second Life: What happens when the game ends?