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Pri-Med 2003: An annual medical conference and trade show in Boston, co-sponsored by Big PhaRMA and the Harvard Medical School.

Many decades ago, on a planet far away, I attended medical school. My professors were learned and serious men. They frequently debated, over cafeteria coffee, a question which at the time I thought was rather silly. I now realize it represented a struggle for the life or death of the kind of medicine I came to love and try to practice. I fear the wrong side is winning. The question: is medicine a science or an art?

What exactly does this question mean? There is a great deal more subtlety here than first appears. To start, let’s look at the dictionary definitions of the words art and science.

Art (noun): something that is created with imagination and skill and that is beautiful or that expresses important ideas or feelings, or the methods and skills used for producing works of art.

Science (noun): the systematic study of the nature and behavior of the material and physical universe, based on observation, experiment, and measurement, and the formulation of laws to describe these facts in general terms.

Fildes' The Doctor

Sir Luke Fildes– “The Doctor”, 1887

So art is rooted in interior human qualities: imagination, skill, and aesthetics. The doctor I picture is an avuncular man, perhaps a little overweight, on the threshold of old age, in a slightly rumpled three-piece suit. His experience ranges back to ancient lore, but he keeps up-to-date through the medical journals and continuing education symposia at far-flung universities, to which he likes to travel with his wife. He knows everybody in your family, in your whole town even, and everybody respects and trusts him. His diagnostic skills are largely instinctive but unerring, and his therapeutic skills are encyclopedic, including some effective traditional techniques that today’s young bucks were never taught. You may recognize him from several Norman Rockwell paintings in which he has appeared. Of course he makes house calls. He practices the art of medicine.

doctorScience, on the other hand, arises from the universe at large, working back from specific observations to glean the general principles that determine how things work. I see a man in early middle age, clean-shaven and trim, who moves crisply in a long white lab coat, a stethoscope hanging from his neck. He commutes to his office in your town; he doesn’t know anyone there personally, and nobody really knows him, though he is respected for his training and skills. His diagnostic acumen is fact-based, making extensive use of lab and imaging studies to reinforce his clinical impressions.  His therapies have been verified in double-blind studies and are regularly updated to be sure they reflect the latest best practices. You’ve seen him in his pharmaceutical ads on TV. There is no point in his making house calls, since his kind of medicine is dependent on the clinical support services that are available at his office or the hospital, but not at your house. His medicine is a science.

Wait a minute. Those definitions don’t really tell the whole story. Sometimes the line between art and science is more uncertain.

chevreulcolor wheelMichel Eugène Chevreul (1786 – 1889) was a French chemist whose work with textiles and dyes led him to think scientifically about color and its perception. He published The Laws of Contrast of Colors, and devised the first color wheel. His ideas were taken up by the renowned neoimpressionist Georges Seurat (1859-1891), who expanded on them in an attempt to produce a comprehensive science of painting, which he called chromoluminarism. Seurat used these principles to paint in a style now known as pointillism, which includes his well-known mural Un dimanche après-midi à l’Île de la Grande Jatte. Is this painting the product of art, or science?

Georges Seurat: A Sunday Afternoon on the Island of Grande Jatte, 1884

Georges Seurat: A Sunday Afternoon on the Island of Grande Jatte

einsteinThen there is Albert Einstein (1875-1955), probably the best known scientist of his day, who famously did most of his experiments entirely in his mind, aided only by blackboard or pencil and paper. These grand mental expeditions, which he called gedankenexperimenten (thought experiments), involved no new observations, measurements, or physical experiments by Einstein himself. Such intense interior work produced beautiful ideas “created with imagination and skill” and “that [express] important ideas.”  These are supposed to be the hallmarks of art.  Einstein’s ideas became the general theory of relativity, the reality of which has been verified many times over by the real-world experiments of others. Is relativity the product of science, or art?

child labor 2Years ago, when I was a country doc still wet behind the ears, I cared for an aged widow who lived alone at the end of an narrow dirt road. Her husband had died a few years before, and her only son had not returned from Viet Nam. She was very slowly dying of pulmonary fibrosis, a slow but relentless lung disease that was the result a childhood spent in the textile mills.  Her mind was clear, and she had learned how to pace herself.  She still managed to prepare her own meals and keep her little cottage tidy. I visited her at home once a week after I’d finished my work in the office.  She told me how her symptoms were going while I listened to her heart and lungs.  That was the routine that allowed the housecall to proceed without embarrassment to to either of us, though strictly speaking it was not medically necessary; nothing ever changed much.woman of keene long

Then the real purpose of the visit began. She brought iced tea from her refrigerator and we sat in two antimacassared wing chairs in her little sitting room to watch The Price is Right or play Parcheesi, which she had played with her son when he was a boy. We watched the birds at the feeder outside the picture window; she knew the names of every one and could mimic their calls with uncanny fidelity. I spent an hour or so with her each week. In the summer, in her faded housecoat and frayed felt slippers, she would follow me out to my car and wave at me as I drove away, bunching her clothes up in front of her chest with her other hand while a few errant grey hairs blew backwards in the wind. There is no billing code for what I did; I never got a dime for it from Medicare. I think it extended her life a bit, though, and I know she was happier for it. That is the art of medicine.

High Tech: An aerial drone has dropped a defibrillator to help a man stricken on the golf course.

High Tech: An aerial drone has dropped a defibrillator to help a man stricken on the golf course.

One autumn day she followed me to my car, but before I could get into it she looked suddenly quizzical and made a brief little sound, not unlike the yelp a kitten might make, more startled than pained, when comfortable play gives rise to a painful nip.  Then she collapsed, pulseless and unresponsive, onto her threadbare lawn. I was well trained and equipped for this situation.  I took the defibrillator from my trunk, ran a strip (v. fib) and defibrillated. She responded to a single shock, and was soon alert again. I slipped an IV into veins like tissue paper and hung the bag of fluid from the mailbox.   I gave her a dose of a drug to support her now normal rhythm, and told her to lie still while I went into the house to call the Rescue Squad.

The science of medicine is brisk, efficient, and clear cut, if a little cold.  What drives it is success or failure, which can be measured and judged.  When metrics are applied this outcome would count as positive, although the widow might not agree.

I remember well what she said as I turned to go: “What the HELL did you do that for?”  she yelled after me.  It is the only time I ever heard her curse.

I went inside and made the call—the ambulance was rolling. When I got back to her she was lying still.  Her eyes were open, but they did not follow me.  A few dry leaves had blown up onto the edges of her housecoat where it had spread out carelessly on the struggling grass, in front of the little cottage on the edge of the woods where she had come as a bride; where she had raised a son who, right out of high school, had given his life for his country; where she had held the hand of the husband who had shared her sorrow as he too slipped away from her after fifty years together, for better or for worse.  A few minutes ago she had died there peacefully, only to be wrenched back into a world she was weary of by a doctor who was not yet born on her wedding day, and who was only now just beginning to understand the wisdom his patients brought to his practice, which would form the foundation on which he would build his ever changing understanding of the art of medicine.

While I was in her kitchen making the call, she had died again. Her final act had been to pull the IV line from her arm; its life-sustaining fluid was now making a dark, slowly growing stain as it seeped into the parched October soil on which she lay.  I made no further effort to revive her.

The art of medicine is rich and warm or cold as ice, and always rife with ambiguities.  It is filled with triumph and with pain, which are unsuitable subjects for measurement and analysis.

heisenbergA contemporary of Einstein’s, Werner Karl Heisenberg (1901 – 1976), noticed, while observing subatomic particles, that if their velocities were measured precisely then their positions appeared indistinct, but if their positions were closely measured, their velocities became fuzzy. Heisenberg posited that this was not because of a shortcoming of the observational technique, but a fundamental property of the universe itself.  Heisenberg offered no direct proof for this interpretation of his principle, and expressed the idea only informally and intuitively, though with mathematical precision.  Science, or art?  Whichever it is, his Uncertainty Principle it is now a key stone in the foundation of modern quantum mechanics.

Perhaps medicine is like this, a fundamental entity having art and science as complementary variables. The harder you look at the art of medicine, the softer the science looks. The closer you examine the science of medicine, the more the art recedes.  Uncertainty is a property inherent in the nature of medicine itself.  (Alert: This is a metaphor–art, not science–but you can see how they get mixed up.)

doctor hi techFor lots of us, technology serves as a proxy for science.  Science is an active pursuit, requiring the expenditure of considerable mental effort–something many are reluctant to do.  Technology, on the other hand, can be passively received, as Stephen Jobs so ably demonstrated.  Today we want the latest technology front and center in our healthcare, like nuclear magnetic resonance imaging and positron emission tomography. (Positrons? Really? Isn’t that antimatter? The stuff that fuels the Starship Enterprise? Cool! I want that.) We want our doctors to use “evidence-based” diagnostic and therapeutic tools and techniques.  I believe medicine has always striven to do this, but now “evidence” is narrowly defined (by people far smarter than we are) as statistical data derived from large-scale double-blinded crossover studies that have been subjected to peer review. (Except, of course, for the proprietary bits that the pharmaceutical companies sponsoring the research must withhold as industrial secrets to protect their market positions.)  A doctor’s personal experience, accumulated over a lifetime of practice, observation and personal growth, no longer counts for much.  Such twaddle, unseemly for the distinguished scientists we aspire to become, is left to artists (who, without our fresh enlightenment, don’t know any better).

lifescripthealthgrades

We patients (reborn now as “consumers”) check the internet to see how our doctors (excuse me, “providers”) measure up against dispassionate “performance-based” scientific metrics applied by our insurance companies, or the looser, more passionate metrics from those “Rate Your Doctor” websites or Angie’s List.  While observing our doctors in such an intensely measured, highly analytical, fiercely statistical manner, we look over our shoulders wondering where the old guy with the reassuring bedside manner and old time smarts has gone.

1950s House Call

Even as I look elsewhere for my art, I feel behind me the presence of the zombie that is all that remains of that other art I fell in love with in my youth, now lumbering soullessly toward a gray uniform mediocrity foretold by Delphic statisticians in cubicles across this nation, a nation held captive by the data miners and big-number technology that are consuming so much we once held dear, all in the name of political power and commercial gain.

Goodbye, old friend.