What is the Art of Medicine?

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” – William Osler

I have spent literally years of my life pouring over the “science of medicine.” I dedicated innumerable hours to memorizing biochemical pathways, pharmaceutical mechanisms, and equations for physiologic processes.

American Medicine assumes the science of medicine is the most important. We view it as an exceedingly important part of the training process. Yet, any physician will recognize the science only gets you so far.

Sadly, organized medicine dedicated much less of my formal training to learning the other part of medicine, the art. In medical school, the recommendation for learning the art of medicine was simply to watch someone who, in your opinion, was particularly good at it and emulate them.

Thanks, that’s helpful….

No one ever even defined what the art, in fact, was. Even now, when I search for a definition, a significant amount of variability in the definition floats around the internet.

Some say the art of medicine is the space in between the evidence and practice, the judgement we use when science cannot give us a clear answer. The art simply smoothes out the edges of the science in the real world.

On the other hand, others posit the art of medicine is the relationship, empathy, and emotional aspects of doctoring. It is the space we keep for humanity in the practice of medicine. The art of medicine is the properly placed hand on the knee, the right words said in comfort, the knowledge of the patient as a person beyond their disease.

I think both these definitions and all others that I have read sell the art short. They do not give the art its due place in the pantheon of our skills. Only recently have we began trying to teach medical students any skills which approximate the art of medicine.

What is Art, Anyway?

“Science and art,… they seek the truth and the meaning of life, they seek God, [and] the soul….” – Anton Chekhov

I don’t think we can truly answer the question of the what is the art of medicine until we actually understand the goal of art and the artist. Chekhov, who was both an artist and a physician, articulates the overlap of art and science well – seeking truth.

Science and art both quest for truth. Science seeks to understand the rules of the natural world so as to understand it, predict its outcomes, and hopefully influence them for our purposes.

Art, on the hand, seeks to create an entire world, the experiencing of which leads us closer to human truths. These are truths a scientific experiment cannot elucidate, because they exists only in human souls.

The human experience is often a reaction to the chaos of the world around us. Much of what plays havoc with our lives is beyond our control. Through art, humans create worlds where we mute the chaos, understand it, and give it meaning.

So, we will find the art of medicine in its truest form not in clinical judgement or in human actions, but in those moments where we the physician partner with patients to create new worlds in the pursuit of healing.

The Healing Art of Narrative

The essential task of the healing patient-physician relationship is the creation of a world where the destruction and chaos of illness is rendered understandable, and if possible, meaningful.

Which artform allows physicians and patients to create a world where healing is possible where only hours before there was only suffering? It is the art of narrative, of a story’s telling and untelling.

Make no mistake, the history is the first part of a patient encounter because it is the most important. The history, the patient’s narrative of the illness is what creates the backstory in which any healing must occur.

In the very moment when a patient tells you their story, they are creating the world in which their suffering exists and their healing must occur. Narrative must be heard to exist.

The act of hearing, of bearing witness, is just as integral the creation of the world as the telling. Notice the word bear/born in this context. Bearing witness midwives the world of the sufferer into existence.

The Use of Narrative

So, the patient has shared their story, you have born witness. The world has been created. As a clinician, you must accept the history. You can interpret it, but only for yourself.

If, as the clinician, you deny the truth of the history, you deny the existence of the patient and her story altogether. A person whose world has been denied cannot heal. We cannot “correct” the history. We must accept it and move forward in the pursuit of healing.

“A well-thought-out story doesn’t need to resemble real life. Life itself tries with all its might to resemble a well-crafted story.” 
― Isaac Babel

It is in these moments I believe a true practitioner of the physician’s art can shine. Through discussion, empathy, reframing, and a healing relationship the patient and the physician can together, begin to build a story about the illness, its affect on the patient and their world which opens the possibility for healing.

A New and Sudden Frailty

I am reminded of a man I saw in follow up for a hospital discharge after a heart attack, or MI. He was in his mid-sixties, generally healthy. No hypertension, no smoking, minimal lipid issues. The MI came out of nowhere.

The ED physician, cardiologist, and hospitalist had all done exemplary science. The physicians diagnosed quickly, treated appropriately, and discharged him with minimal loss of function. Nonetheless, he was in a stupor, rudderless.

Despite being grateful for all that his hospital team had done for him, he still felt less a person than he was before. He was struggling with the sudden transition from being a healthy, active, strong man to a man with a chronic disease. He went from no medicines to at least four daily pills.

As the physician, you must acknowledge the loss. What this man lost was his health innocence. He lost his ability to take his health for granted. He lost his ability to feel strong, vital.

And Now We Create

So, here is the exposed fulcrum of healing. You can imagine how this could go. He retreats into himself and begins to hide from activity that he worries could bring on another heart attack. He gains weight, starts to feel depressed, his relationship suffers.

At this point, he loses more than a small amount of heart muscle, he starts to lose life itself.

This would be possibly as devastating as the MI itself. For what is life without vitality? The deepest art of medicine lies in this moment, when together, we help this man build a new narrative for his life.

Hopefully, the narrative is one rooted in his past and which does not ignore the transition that has occurred but allows him to re-engage with the world as the richer person he now is.

Jan Steen – The Doctor’s Visit

This process is alchemical, because it depends on everything that is individual about the person. It is a tenuous moment.

It is a verbal and emotional dance that weaves the story of healing out of the tattered fibers of loss.

We as physicians in this moment must engage directly with this loss, its grief, and our patients’ human frailty and help them build a road out of the fear. Some people can do this on their own, but many cannot.

That, I argue, is the art of medicine. That is what an algorithm cannot predict and metrics cannot tell us. Not clinical judgement, or acronyms of empathy, but a truly engaged art of healing.

Horseshoes and Hand Grenades

Reason for visit: cough – follow up from urgent care

6 weeks from the end of my intern year, I met B first time.  I walked into the room and saw a healthy appearing 33 year old, dressed in the uniform of kitchen staff from my training hospital .

B had visited a local urgent care twice in the last month for a cough and shortness of breath.  He received azithromycin and a cough suppressant both times.  The second time, the urgent care doctor referred him to the residency clinic so that he could have a more thorough evaluation if it hadn’t resolved.  The cough and shortness of breath had not improved.

I proceeded to do my normal initial patient visit history and physical.  B had a couple of interesting past medical history items.  He was being treated for glaucoma and had had his spleen removed as a child for Idiopathic Thrombocytopenic Purpura.  Interesting, but nothing directly related to his chief complaint.  He denied any history of asthma or other chronic lung problems.

History of present illness

Me:  What has been going with your cough and breathing?

B:  For the past few weeks, I have had an annoying cough and feel increasingly winded doing simple activity.

Me:  Can you describe how winded you feel?

B: well, like on my way over here, I had to stop and rest coming up the stairs in this building.

Now, my clinic rooms were only on the second floor.  I checked his vital signs again: heart rate, respiratory rate, and oxygen were normal.  His lungs were clear, his heart sounds were normal.

An otherwise healthy 33 year old should be able to walk up a flight of stairs, even with bronchitis.  Maybe not with a significant pneumonia, but his vitals didn’t suggest that.

a closer look

I turned and just looked at B.  Up and down, looking for some other clue in his visage that might point me in a direction.  He had short cropped sandy-blond hair, wearing wire-rimmed glasses.  He looked comfortable.  His skin was a bit pale, not hemorrhaging GI bleed anemic pale, but enough to favor a portrait of a Victorian-era consumptive.

I didn’t know much as an intern, but I had learned people who get rare diseases tend get other rare diseases.  I was nonplussed.  Other than the fact that his story just made me worry, I didn’t have a direct line of inquiry.  Just to give myself some time to think, I had my nurse take him up the stairs with a pulse ox, see if that pointed anywhere.

He started up the stairs, oxygen stayed steady, but within a few steps, his pulse shot up to 120.  Something isn’t right here.  I talked to my faculty (still an intern – have to precept every case).  My thought process had frozen, I knew something wasn’t right, but what other tools do I have in clinic?  She helped me out, “how about a chest x-ray and an EKG?”

ORDERs: CXR and EKG

His chest x-ray wasn’t very impressive. I thought maybe his heart seemed a little big for a 33 year old, but the radiologist wasn’t impressed.  His EKG was a different story.

EKG didn’t show any ischemic changes, he had sinus rhythm and no conduction problems.  Those were pretty much the only normal parts.

Axis was confusing, but seemed rightward, P waves were huge, T waves were either inverted or gigantic. He didn’t have obvious hypertrophy, but voltage on his precordial leads seemed moderately elevated. To this day, it was the most bizarre EKG I have seen.  I wish I had a copy.

admit to hospital

I went into the exam room.

“B,” I said, “There is something not right with your EKG.  I am not sure what it means.  It doesn’t look like a heart attack or anything like that, but I think we need to get you to the hospital to figure out is going on.”

B seemed neither relieved nor worried, “Okay.”

I called my fellow on-call intern and the chief resident.  Presented the case and arranged for B to admitted to the hospital.  The work up began in earnest.  Most favored a pulmonary embolus as the cause of B’s symptoms.  The team ordered the requisite CT Angiogram of the chest.  The read came back.

NO pulmonary emboli identified.  pulmonary arterial trunk measures 4.5 cm, highly concerning for severe pulmonary hypertension.

The echocardiogram the next day confirmed that B did indeed have severe, end-stage pulmonary hypertension (PH).  Right ventricular hypertrophy. The cardiologist and pulmonologist were called in.  The work up provided no treatable cause of B’s PH.  The label became “Idiopathic,” which is doctorspeak for “we don’t know.

Henry Vandyke Carter [Public domain], via Wikimedia Commons
When the cause of a problem is unknown, treating it very effectively becomes rather difficult.  The cardiologist scheduled a heart catheterization for an arterial dilation test.  This was to determine which therapy might be appropriate.

His pressures were too high to complete the test safely.  The cardiologist aborted the procedure.  He arranged transport to the nearest university medical center.  B needed to be on a transplant list.  33 years old.

good catch, man!

My classmates congratulated me on my “good catch.”  A well appearing man walked into my clinic with a rather benign complaint and I started a work up that caught a zebra.  We rapidly identified a diagnosis, involved the correct specialists and provided, I do believe, excellent care.

I went to see B in the hospital the day before his transfer out of the city I trained in.  He was cautiously optimistic and glad to have an answer and to be getting to where he needed to be.   He thanked me.

I asked him if he had family coming.  He said his parents would meet him at the university hospital and his sister was flying in from out of state.

“That’s good,” I reflected, “Family is important when you are going through something like this.” We shook hands and said goodbye.

Nothing puts swagger in an intern’s step like catching a zebra where one least expects it.  I felt pretty damn good.

when your best isn’t good enough

One of my favorite things about traveling around rural parts of the country is picking up rural aphorisms.  One that I grew up on in my household was, “Close only counts in horseshoes and hand grenades.”

Two weeks after B left our care and hospital, I went into his chart to show a colleague his EKG.  The computer attacked my vision with the notice:

YOU ARE ENTERING A DECEASED PATIENTS CHART. 

I sat back stunned.  We came close, but medicine isn’t horseshoes or hand grenades.

Later that day, I talked with my fellow intern who cared for B in the hospital.  I let him know the news, he had a similar reaction.  We had felt so good about the care we had provided to B.  We were at the top of our intern game and yet, he died.

humility is a punch to the gut

Did we do anything wrong?  I certainly don’t think so.  Diagnosis, treatment, transport to appropriate care in a timely manner.  All done better than average, I would argue.  We were proud, especially for a team of family medicine residents and interns.

By Rama – Own work, CC BY-SA 2.0 fr, https://commons.wikimedia.org/w/index.php?curid=3632261

By the stars aligning, my fellow intern’s significant other was an ICU nurse who moonlit in the university ICU.  On her next shift, she asked around.  It turns out B was admitted there, kept in the ICU for monitoring.  One night, shortly after his arrival, he went into ventricular tachycardia, an unstable cardiac rhythm.

The ICU team attempted to revive him for 2 hours through the use of every life saving medication and procedure they had.  Codes are normally called after 30-45 minutes.  He was 33 years old.

reconciling polar opposites

Sitting in my bed one night, staring at the ceiling, I talked about B’s death with my wife.  I don’t talk about patients with my wife often.  So, when I do, she knows the patient affected me deeply.

Usually, when someone dies or there is a bad outcome, I am able to derive a lesson for honing my art.  Next time, I will do XYZ, and it’ll go better.  I make sense of the loss through striving for improvement.  It helps add meaning.

What happens when you did better than would be expected and it still goes south?  “Nothing we could have done better, that is just life in medicine” seemed like a poor salve for my wounds.

Overtime, I thought back to the last conversation I had with B.  His family was coming to see him, they new the diagnosis by the time he died.  The grief doesn’t disappear because of knowledge, but every removed uncertainty helps, I think.

Most importantly, I believe they had a chance to see their son and brother before he might have suddenly died of a cardiac arrest.  That was a gift I gave him and his family: some answers, and some time.  We can’t always save, but we can always heal.

the dead are never gone

Having now gone through my own loss, my perspective on B’s story has evolved.  Families carry the care and comfort we give to patients who die, just as they carry the memories and lessons of their loved one.   This can be a blessing, and it can be a burden.

If we can give patient’s families memories that their loved one’s time under our care was full of support, strength, and understanding – it can be a great gift.   It is invaluable in their grief and healing.

Anger is an all too easy trap for grief.  It is a natural and normal part of the process, but it can be seductive.  Anger is often easier to feel than the unending sadness or permanent loss. Anything we do as healers that makes the transition from anger to the other parts of grief easier, is of immeasurable value to patients and their families.

I now know this all too personally.  Death is not an option, only a matter of time.  Yet, we as human beings, and especially as physicians, have the power to meet it in different ways.  We can meet death with love and the support of family and community, it can strengthen the bonds between those who are left behind.

As physicians, we have the power to facilitate that journey.  It is a terrifying journey, people need guides.  We have that power, if we choose to use it.

If we choose to help people meet death on their own terms, we choose to help them know life in the richest way possible.

Does the H&P Impede Care of the Chronically Ill?

History and Physical (H&P) – The Cognitive Structure of Medical Training

Medical training generally works like this:
  • 2 Preclinical years – this is the “drinking out of a fire hose,” where you just try and cram as much as possible into your brains.
  • 2 Clinical years – this where you are supposed to learn how to think like a doctor, get exposed to all the different specialities, and decide what to do for the rest of your life (don’t worry – no pressure).
  • 3-5 Residency years: learn the tools, procedures, and knowledge specific to your specialty and how to apply them.
What is the H&P?

The H&P is the cognitive form that medical training drills into you starting at the end of our preclinical years.  All those questions that your doctor asks you that you don’t understand why she is asking them – they are from the H&P.  It generally looks likes this:

Chief Complaint – One word/phrase about why you are there

History of Present Illness (HPI) – paragraph about what has been going on

Review of Systems (ROS) checklist of symptoms from body systems not directly related to the HPI

Past Medical/Past Surgical/Family History medical events in your personal or your family history

Social History – Smoking/other drugs/alcohol/ maybe profession and/or marital status if someone is being thorough

Vital Signs/Physical Exam/Objective Data – the laying of hands, the stethoscope, and any lab/X-ray data.

Assessment/Plan – What the doctor thinks is going on and what she plans to do about it

The H&P is very useful for communicating a patient’s story between doctors, its original purpose.  It is also useful for helping us remember to ask/do certain things.  Unfortunately, it has also become the basis for the billing of non-procedural physician work.  Physicians base their billing on the documentation in their H&P.  No longer just a communication tool, the H&P has become a billing sheet.  Nonetheless, even as a communication tool, it is limited.

The H&P does not demand this kind of information:
  • Recently laid off
  • Homeless
  • Non-literate
  • Going through a divorce
  • Friend just got diagnosed with cancer
  • Sexually Abused as a child
  • Closest full-service grocery store is 5 miles from house requiring a 1.5 hour bus trip with 3 transfers

Source: https://nonprofitquarterly.org/2017/11/28/nonprofit-says-communities-not-doctors-must-lead-improve-health-outcomes/

Some would say all of the above is social history.  A reasonable assertion, but Social History is culturally undervalued in medical training – it is not “hard medical fact.”  Also, per billing regulations, social history is worth significantly less than ROS or Physical Exam points. It is literally worth less money to ask about the aspects of a patient’s life that most affects their health (see Figure).  The social determinants of health deserve, and will probably get, an entirely separate post.

 

the h&P assumes a certain level of baseline health

The very nature of the headings: Chief Complaint and History of Present Illness create the assumption acute illness.  Especially in primary care, this is often not the case.

Currently, even in acute care settings, most problems are actually an exacerbation or destabilization of chronic disease.  The very structure of the H&P helps blind us, and by extension patients, to this fact.  The H&P helps place our brains into the cognitive trap of trying treat chronic problems as acute ones.

In the middle of a rough primary care clinic day, I often wished I could have used the Chief Complaint of “Same Shit, Different Day.”  I don’t mean to invalidate patients’ suffering – but it is CHRONIC, not ACUTE.  It has been going on for YEARS and will not improve when treated as an acute problem. Yet, that is what physicians are programmed to do.  At a system level, that is what we are forced to do.

The “explanatory models approach,” which is widely used in American medical schools today, as an interview technique….that tries to understand how the social world affects and is affected by illness. …. We’ve often witnessed misadventure when clinicians and clinical students use explanatory models. They materialize the models as a kind of substance or measurement (like hemoglobin, blood pressure, or X rays), and use it to end a conversation rather to start a conversation. – Anthropology in the Clinic  By Arthur Kleinman and Peter Benson

THis tendency has been recognized before

Arthur Kleinman, MD has been trying since the 1970s to get medical training to build more of the psychosocial aspects of patient’s lives into the basic cognitive framework we use in treating patients. He popularized “explanatory models” as a way to delve into the patient’s psychosocial world. Explanatory models are popularly taught in US Medical Schools, but they often fall flat (see quote above).

Personally, I saw some of that influence in my medical school, but it was presented perfunctorily, once or twice.  Whereas the basic formulation for the H&P is drilled into you on every rotation. By the end of medical school, it would be like forgetting how to tie your shoes. Effectively, little has changed. By omission, psychosocial aspects are taught to be fluff, stuff that is nice to know – if you have the time.

So, I ask: Is it possible that a format based on the assumption of acute illness is failing us in the era of chronic disease?