June 9, 2014

By Zackary Berger, MD, PhD

Medicine is an art, many a doctor has written, often meaning  that medicine is not “just” a science, not reducible to numbers. This is usually a veiled poke at evidence based medicine. “Those pencil-pushers and bean counters want to judge the quality of our care – but we know that high-quality care is more than just these checkboxes! There is something else.”

But what is that something else? You say medicine is not getting the hemoglobin A1C (a measure of blood sugar in diabetes) between 7 and 7.5%, but rather fitting the treatment to the patient’s individual wishes and needs? So do that, but then we can surely count how often this happens, and make sure it’s done as often as possible. You say your “art” consists of doing tests which there is no evidence for? Okay, but then specify why you are doing them. And that reason, presumably, is something that can be recorded and generalized to all applicable cases.

Perhaps what “medicine is art” practitioners mean, when they set this statement against evidence-based medicine, is that Art is subjective, wholly unmeasurable. But art involves quantifiable aspects too: discipline, rule making, judicious constraints. If medicine is really art, we should figure out what makes good art and bad art. Or, at any rate, how different skilled practitioners of the medium create healing.

In any case, medicine as art has always struck me as an inappropriate metaphor. Artists make art, for or perhaps together with their audience. But health is not a creation so much as a compromise, a hard-won trek over unforgiving terrain, a negotiation with angry neighbors over some precious piece of lost property whose whereabouts no one will admit to.

In other words, medicine – as least as practiced in the real world – is politics in its most basic definition: a debate for control. The pendulum swings back and forth. For many years, the physician was comfortably in control; now, for the past decades, the patient has sought to redress the balance of control kept from her for so long.

As in politics, we would like cooperation to be the goal in the service of larger aims. But we know that things are messy, we don’t always get what we want, and we leave wanting to get things right on the next time around. It’s not science – we are not aiming at eternal truths. Neither is it art: we are not looking to create something beautiful. No, we are just trying to make life better, within a set of rules and conventions, ideally recognizing that anyone suffering from a health complaint has citizenship (albeit unwanted) in the democracy of the ill.

Crossposted at Talking to Your Doctor: A Patient’s Guide to Communication in the Exam Room and Beyond Blog

berger300Zackary D. Berger, MD, PhD, is an internist and epidemiologist and an Assistant Professor in the Department of General Internal Medicine at Johns Hopkins School of Medicine, with joint appointments in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health and in the Berman Institute for Bioethics at Johns Hopkins. His research interests include doctor-patient communication, the role of the primary care provider-patient relationship in cancer, and how doctor and patient can navigate situations of medical uncertainty.

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Zack Berger

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