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.

Who Built This Leaky Ship?

People who don’t use it, that’s who.

On a recent shift out in the great wide open, I saw a patient who I see frequently in this location. He is a chronically ill man in his 70s with chronic kidney disease and multiple sclerosis (MS).

His MS took his ability to walk, so he is wheelchair bound. On top of this, he has bilateral indwelling nephrostomy tubes which frequently are the source of infection.

He should be receiving dialysis, but he refuses to move to a city where it is an option. Dying in his hometown is preferable to moving to the City to receive dialysis.

He lives in the nursing home (NH), which is attached to the hospital and emergency department. Whenever he becomes febrile, the nurses in the nursing home send him to the ED where we culture his urine, start him on antibiotics and either send him back to the nursing home with follow up or admit him to the hospital.

When he is through with his course of antibiotics, he often goes to the City as an outpatient and has his nephrostomy tubes exchanged. This buys him about 2-4 weeks before his next infection sets in.

It appears we are purposely trying to breed some sort of resistant bacteria in his urine by this rodeo. All of his acute care is generally done by the ED physicians (locums), whereas his chronic care is managed by his regular physician.

Despite the chronic, repetitive nature of his ailments, both teams of physicians treat each infection as isolated, acute events. This is sadly the standard in American Healthcare.

Welcome to the Norm

All over America, we treat patients for their acute issues and then send them on their way. Rarely do we address the underlying issues at play, which have led to the causes of the acute issues.

Even in hospitals, most acute issues we treat are exacerbations of chronic disease: COPD exacerbations, CHF, MI, GI bleeds from chronic anticoagulation or NSAID use, infections related Diabetes or the above chronic diseases. It is the rare patient in the hospital who has a new onset, isolated, acute problem.

Even in medical school, our cognitive training focuses on isolated cases of acute illness because it is difficult to teach concepts of diagnosis and treatment in the milieu of the chronically ill. So, our brains become accustomed to looking for the single, acute issue.

Search satisfaction is a strong bias.

Moreover, the way the systems reimburses us emphasizes episodic, not longitudinal care. This method of care delivery works very well for acute, isolated incidents of illness in otherwise healthy people. Sadly, these people are exceedingly rare.

I posed this question to an ED nurse friend recently and he guessed otherwise healthy, financially secure people made up about 2% of the patient’s he sees. That is in an acute care setting.

So, who came up with this crazy system?

“We build a broken system and then ask people to try to fit into the system instead of tailoring a system around people’s actual needs.” – David Brooks

The roots of our system date back to isolated private health insurance companies. Those companies inherently catered to otherwise healthy individuals with money (those people make insurance companies money, after-all).

However, I think the root of the problem is deeper. Generally healthy and wealthy people designed our system. Chronically-ill 80-year olds are not in government and insurance boardrooms.

Therefore, episodic acute care makes up the bulk of the decision makers’ personal healthcare experience. They don’t know the professional patient, or if they do, they assume he/she is an abnormality.

Indeed, in the broader population, the hospital-dependent, chronically ill are a minority. However, at least in my practice, I spend more than half of my time with people who would fit this description.

So, we have a system designed for the people who aren’t using it, or use it only rarely.

Meanwhile, the people who depend on the system for their continued survival have to make do with a system which treats their care inappropriately. It rewards treating their problems, rather than managing their total package of care.

Is there hope?

In the short term, I don’t see much cause for hope. Too many people are making an absurd amount of money off the inappropriate care of the chronically-ill. And if I am honest, I have to include myself in that group. Effort vs. money, acute care is easier because the system incentivizes it.

I tried to do global care as a primary care doc, but the model of the outpatient setting is one doctor and one-two nurses/medical assistants. You cannot provide the necessary basket of services and harangue all the help you need with such an anemic team.

The system is trying to move more care to the outpatient setting because it is cheaper. However, we have ignored and underfunded the primary care clinic for decades.

As a care delivery model, it is severely atrophied. So, the system is moving sicker and sicker people to the outpatient setting without first strengthening it. As such, people will burn out and turn over and the attempt will fail.

Until the system incentivizes keeping people healthy over treating the sick, any changes will only be a veneer.

Direct Primary Care, Healthcare Costs, and Financial Independence

Disclosure:  I currently do not have any financial interest in any direct primary care businesses and have no plans to do so.  This may change in the upcoming years.  I simply find the model interesting and provocative as a healthcare consumer and a physician.

healthcare costs, the great unknown

I was reading TPP’s financial interview #13 and found another mention of how healthcare costs are a great unknown in planning for retirement/financial independence.  We all know healthcare in this country is too expensive and is getting more so.  Physicians should know more than most.

What has struck me is how limited the conversation tends to be: Healthcare costs are hard to predict and are the big question mark in retirement financial planning.  End of discussion.  I have not read any discussions on creative ways to mitigate this other than funding a Health Savings Account (HSA) to the hilt.

direct primary care could play a role

Direct Primary Care (DPC) is an emerging model of delivering primary care on a monthly prescription basis.  For a discreet set of primary care services a patient pays a monthly subscription fee (usually <$100), which covers all of those services.  Some additional services may be provided at cost or at a discount.  This varies practice to practice.

Most importantly, however, is the fact that DPC practices have a much smaller patient to physician ratio.  Usually 600:1, compared to 1,200-2,000:1 in traditional practices.  This means more time with the physician.  PCPs can save A LOT of money if they have the time to think through problems.

A well-trained internist should be able to handle the vast majority of nephrology, cardiology, and endocrinology without a referral – if they have enough time.  Anything task physicians do less frequently requires more time. Our current system incentives PCPs to refer as much as possible, because it saves the physician’s time, not the patient’s healthcare dollar.

Essentially, for those covered services, you are able to have a predictable monthly fixed cost for the length of the contract (likely to increase with inflation, etc).  To me, this seems preferable to the morass of opacities that is current health insurance and hospital billing.

Isn’t it appealing to avoid dealing with insurance companies for 80% of your healthcare?

DPC vs Concierge medicine

Many have critiqued DPC as “concierge medicine.”  This is unfair. Most specifically, concierge doctors tend to charge a monthly fee on top of what they bill insurance for increased access to the physician.  DPC charges the fee in lieu of charging insurance, getting rid of the middle man and increasing efficiency.

From a policy perspective, the one critique of DPC I feel has merit is DPC practitioners have “healthier” patients.  DPC proponents argue they have data showing their patients are just as chronically ill as the average primary care practice.  This may be true, but DPC patients are inherently more engaged in their healthcare.

Simply by taking the time to find an alternative model to obtaining primary care and putting some monthly income towards it, patients prove they value healthcare more than average.  Engagement in one’s healthcare is eminently more important in health outcomes than number of diagnoses.

brass tacks – DPC does not do everything traditional health insurance does
  1.  DPC does not fully replace insurance: Since DPC only covers primary care, you still should have some sort of health insurance.  Usually, this means purchasing a  catastrophic or high deductible policy.  On the other hand, health insurance is actually insurance (something paid for and hoped goes unused) and not coverage (something paid for and used as much as possible).
  2. DPC would not help a family afford expensive medications: For any diagnosis requiring a large number of branded medications, or even one or two monoclonal antibodies, DPC might not be sufficient.
  3. HSAs cannot fund DPC payments, though this might change.  If it does change, DPC would become a much more appealing option for higher earners.
  4. DPC practices are still emerging, they are not available in all locations.
  5. Obstetrics, for young families this is the most likely large healthcare expenditure.  Most DPC practices are unlikely to provide that service.
the pursuit of the perfect is the enemy of the good

Is DPC going to solve all of our systemic and personal healthcare issues?  Of course not.  At this point, any innovative model that saves cost and increases quality is worth discussing.

Especially for relatively healthy early retiree families, I think it is worth looking at in more detail.  Even for individuals with several common chronic problems DPC might be preferable to traditional primary care models.

Though I have yet to do the math, A less expensive high-deductible health insurance plan, coupled with a well-funded HSA (preferably holding at least your maximum deductible amount) and a DPC subscription could be a great “diversified healthcare portfolio.”

Why have I not purchased a DPC subscription?  Through my wife’s job I currently have access to very good and very reasonably priced insurance.  However, if this were to change, I would very likely be looking for a DPC practice in my area.  Also, see #5 above.

If anyone has looked at this in more detail or has strong opinions on the matter, I would be very interested to hear from them.

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?