What doctors must learn: Doctor, look beyond science

Dr Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

It is said that change is the only constant. I joined medical college more than six decades ago and I have noticed a seachange in the science of medicine, medical teaching, and medical practice. The science of medicine has advanced so much that it is impossible to keep pace with it and no doctor can claim to know everything. It has paved the way to specialization and further, super-specialization. Technological advances helped in the diagnosis and management of many diseases. With such an advance, one would have expected a “cure” for many diseases resulting in satisfied patients and a healthier population. Has it happened?

In the past, when science had not yet developed, doctors cared though could not often cure, they showed empathy and concern for the patient, were responsible, accountable, transparent. They followed moral principles, true to Hippocratic oath and enhanced the image of the profession. Patients had faith in the doctors, respected doctors and were grateful to them, irrespective of the outcome.

The advancing science and technology was so attractive that medical practice became “high-tech” and soon traditional “high-touch” gave way to “no-touch”. Humanity was blunted. Patients don’t care to know how much doctors know but they want to know how much doctors care. They expect communication, counseling and time from doctors to answer their questions. Unfortunately, the traditional art of practice is lost in advancing science. While science is dynamic with frequent changes and uncertainties, the traditional art of practice has stood the test of time for generations. Doctors must look beyond science and it is the need of the hour to serve the community better and salvage the image of the noble profession. It is possible only if medicine is humanized.

Chapter 1. Is medicine a science or art?

Medicine is where science marries art – Aldous Huxley

Medicine is a science of experience – Samuel Hahnemann

Introduction

The medical mission -the calling of a doctor – is to feel connected with the purpose and value of the medical profession that is well represented by offering holistic care. A holistic approach needs the use of all faculties endowed by nature to all of us and they are body, heart, mind and soul. When translated into medical practice, the body refers to knowledge (science) while the heart as compassion, mind as commitment and soul as own conscience are all parts of art. Medical science without art remains short of a desired expected care.

Is Medicine a science?

Science is an intelligent activity encompassed with a systematically organized study based on evidence to acquire knowledge capable of accurate prediction. Science is not the absolute truth but the search for the truth that may often elude us. Unlike physics or mathematics, medicine is a science of uncertainty and so at best considered to be a scientific study. Medical science is dynamic and everchanging and its half-life of observed facts is short. Hence, we need to learn, unlearn and relearn all the time. The belief that medicine as science is further enhanced by development of “evidence-based” medicine. However, there are limitations even of double-blind randomized control trials (RCTs) and lack of evidence is not necessarily an absence of evidence. Moreover, evidence also has several grades and is often diverse in views. Consensus guidelines are at the best a summary of practical wisdom and not the evidence. Thus, there is a need for experience as well. In fact, evidence and experience are two sides of the same coin. Evidence and consensus guidelines are based on generalisation while an experience fine-tunes to suit the individual patient thus overcoming grey areas of science. Of course, bias and prejudice are inherent with experience and one must have an open mind and honesty to accept when wrong.

Uncertainties in spite of medical advances

There have been great strides in medicine helped by technological advances but most inventions that are supposed to result in cure still fall short of the desired, In fact, management of most diseases can be categorized into 3 P’s – placebo, palliative and plumbing. It is not only the uncertainty in the diagnosis of a disease because of the wide variation in presentation but also in its predictable outcome.

This is because the outcome of a disease depends on body, mind and genes and hence the study of the body alone cannot predict the outcome. Genuine “cure” is rare but care is always possible. Medical practice based on science alone often fails because it cannot deliver “care”. Bacterial infections and a few other infections can be cured but even then,the final outcome is not guaranteed for various reasons such as antibiotic resistance, host immune responses and genetic predisposition. Modern advances have improved our understanding, but a cure is still elusive in most diseases, besides the issues of accessibility and affordability. The present motto in medicine is thus “cure, if possible, but care always” and this is where the art of medical practice comes in to play a major role.

Medical practice an art based scientific study

Art involves skills developed by experience and observation in the application of science. The art of medicine has remained the same over generations and is the foundation of medical practice. It is permanent and evolved through centuries based on human values and intuition. Its thrust is to allay anxiety in the minds of patients. If you have human qualities of head and heart, they encourage the healing power of a patient. Healing of the damage is done by the human immune system, the stimulation for which comes from the mind of a sick person which in turn depends on the patient’s confidence and faith in his doctor. It is an art of caring and comfort. There has to be an ideal art-science ratio though the pendulum has swung too far towards science ignoring art and hence a disaster. Early on, medical practice was art like other arts such as poetry and painting, practiced with love and passion. However, today it is based on science alone ignoring the art of medicine.

Must integrate art into the science of practice

Basic components of the art of medical practice include skilled planning, time management, communication and counseling. Besides, philosophy (patient hearing and offering honest opinion), ethics (do not harm, do good, privacy and justice) and culture (courteous behavior and empathy) form important constituents of the art of practice. Science treats the body, art comforts the mind and soul. One without the other is incomplete. Medicine and meditation both mean healing and intended to offer “care” definitely, “cure” if possible.

Emotional side of medicine

Beyond every illness is a human being. Sir William Osler said “it is most important to know what sort of a patient has the disease rather than what kind of disease the patient has” It represents a simple definition of empathy. Empathy is rooted in humility and in being humble and humane. Empathy is not an emotion but cognition, it means recognizing the suffering of others and it is a prerequisite to compassion. It is compassion that generates the desire to help others. The secret of “care” of a patient lies in caring for the patient and it needs a human connection that helps to heal. It is as important as medical science and physicians’ competence. Especially, it comes to doctor’s rescue in case of poor outcome, complications or medical error. Empathy is the most under-appreciated human skill. It is present in every individual but further boosted by learning from role models. In medical practice, listening is the first step towards empathy. Detailed history-taking sets the tone for communication. Appropriate physical contact during physical examination boosts emotional connection. Counseling denotes compassion and generates faith. Physician must simply follow the art and offer help to patients without judgment.

Holistic approach

Humans are endowed upon by nature with multiple qualities which include body, heart,mind and soul. When applied to medical practice, body means knowledge, heart the compassion, mind the commitment and soul our inner conscience. Knowledge is important and as medicine is dynamic and ever-changing science, we must keep up-todate. But knowledge alone cannot deliver “care”. We need to commit to do the best for every patient with compassion. And finally, we are responsible to our own inner conscience. We must use brain and heart together – heart is referred to as “little brain” – it is innervated with large number of neurons. We must be honest, transparent, responsible and accountable. Thus, when every patient is treated in a holistic way with devotion (selfless dedication), it results in divine healing. It is easy to understand that healing is a natural process,mainly supported by the art of medical practice with rational use of science. Science alone fails.

Beyond art of humanities

The art of medical practice also involves the art of clinical medicine. Analysis of detailed history should be based on “thought in action” which means each question has a specific purpose of inquiry and answer to which should lead to the next question. History should give a clue to probable differential diagnosis in most cases and this should be followed up with focused physical examination that should be thorough and carried out the standard systematic way. The physician must learn to listen and not just hear, must observe and not just see and think not just collect information. Probable diagnosis must be based on Stutton’s law to follow what is most common.(When Mr Stutton – a bank robber was asked by the judge why he tried to rob the bank, Mr Stutton said that is because it is most common to find a large amount of money in the bank) Only after ruling out common conditions, one can think of an uncommon presentation of common problems and finally consider uncommon and rare problems, in that order. The patient is not an inanimate object that can be analysed by technology and computers. Telemedicine has its own limitations though useful in providing access to medical facilities in remote areas. Patients expect physical contact besides time and conversation with the doctor. It is a rational approach to medical practice and constitutes an important part of the art of medicine.

Past and present

A few decades ago, before modern science developed, physicians offered personal attention with compassion and concern for the patient that gave comfort if not cure. Recent medical practice has thrust health care into an era of modernisation with technological advances and computerisation that allows physicians to access everything at a fingertip. However, there is indisputable depersonalization of patient care. In this fast-growing modern medicine, physicians treat diseases ignoring a human being in whose body, disease resides but now, what is being treated is not the disease but test reports and numbers instead of a patient. This has resulted in patient dissatisfaction and disturbed patient-doctor relationships with its dire consequences including increasing cost of health care.

Motivation necessary to reverse this trend

Motivation is a psychological driving force that reinforces an action towards the desired goal. Intrinsic motivation should come from within, driven by enjoyment of work and pleasure without expecting a reward. Once intrinsic motivation gets started, habit sustains it. External motivation depends on reward/money or punishment/threat, it has a negative impact on life. Motivation determines what you do and attitude decides how well you do. Time management is the key along with communication, counseling and documentation. You must do to your patient what you would expect from your doctor if you were a patient. Mahatma Gandhi said, “recall the face of the poorest and weakest and ask yourself whether step that you are contemplating to take would help him”. If you apply this test, pride will be replaced by humility and dismay.

Personal notes

During my entire medical education and especially during post-graduate tenure, I was lucky to be exposed to the art of medicine from my teachers, besides learning the science of medicine from them. Though art was not taught in the curriculum, repeated exposure made a permanent impact. That was the time when I realized the art of medicine was as important as science or maybe even more relevant when science fell short of desired. I am aware that patients and parents of sick children facing serious or prolonged illness harbor fear, anxiety, frustration, often self-pity or self-blame that also should be addressed by talking to them with empathy. Many times, I would spend more time talking to parents of sick children as compared to time spent over history taking and physical examination. I recall many instances when parents would express their gratitude just because I showed empathy and answered all their queries to their satisfaction. It also made me very happy. Once I was asked by a pediatrician couple to see their child who had a fever for more than a month without a diagnosis. I spent an hour discussing with them the probable diagnosis and management plan and they were satisfied and happy. Two weeks later, as the child was better, they came to thank me. Knowing that they see the large number of patients each day giving very little time to patients, I asked them whether their patients were satisfied. I was surprised when they said they were. I told them that their patients were not aware how much you owed them but you definitely knew it. And so, I suggested they change. But old habits die hard!

Take home message

We should not allow medical science to blunt humanity, ignore ethics and the need for empathy. High-tech medicine can do wonders only to a few but high-touch medicine can comfort all. Don’t forget, doctors are criticized and manhandled due to lack of art of practice and not because of poor knowledge of science.