What do people mean when they invoke the phrase, “The Art of Medicine”? Clay Jones has posted this excellent piece on sciencebasedmedicine.org that’s worth reading about the topic. He rightly points out that it is often a phrase used to justify anecdotal practice. Physicians are all too happy to recall the phrase because it implies that they have some special power or ability in their practice of medicine, as if they were Beethoven or Michelangelo. Because they are artists, they do not have to always justify their rationales or their methods. This type of trope fits well with the often-typical narcissistic personality of the physician. Yet medicine is not an art in this sense. I can train almost anyone with at least average intelligence to be a physician; but in an entire lifetime working with brilliant people, it’s unlikely that I would produce even one person who had half the abilities of Beethoven or Michelangelo. A student can be taught to play the piano or to sculpt or to paint, and they might become technically very excellent at these skills; but that is not what makes an artist. Being a masterful technician is not the same as being an inspired artist.
Is medicine a science or an art? If it is the former, then the rigors of the scientific method and scientific analysis should govern its practice. If it is the latter, then there may be no limit to the amount of individuality and individual expression, and therefore anecdotal practice, that is allowed to enter into the discipline.
Many have argued that the two are complementary and that medicine in it’s perfect form incorporates both aspects. This is the crux of S.C. Panda’s article Medicine: Science or Art, in which he argues art and science are like two sides of the same coin that form the discipline of medicine. In this context, the art of medicine relates to the human aspect of the equation, particularly involving communication and empathy, where the pure, empiric applied science of medicine might fail the emotional and human needs of the patient.
But that form of the art of medicine then should not spill over into things like the diagnostic process, therapeutics, and other questions of medicine that have strictly scientific answers. Sir William Osler said,
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. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.
The lofty quotes of Sir William Osler and others about the art of medicine sound elegant and tend to enrich the physician’s view of himself and of the profession, but they also reinforce the physician’s belief in his special abilities or special powers that grant him the right to practice medicine in a way that may disagree with widely accepted scientific principles. Who among us would not like to think of himself as Michelangelo or da Vinci? This particular quote also emphasizes a bygone-era of paternalistic medicine that most modern physicians should find abhorrent. A more interesting quote is from Paracelsus, who said,
Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.
It appears that Sir Osler was familiar with the quote from Paracelsus and interpreted and expounded upon it to emphasize his own view of himself: that he was strong and righteous and wise and that it was his job to treat the weak and wicked and foolish. Surely we should strive for a more mature view of ourselves and of our profession than this.
So how can we rationalize this dichotomy and understand the meaning of the Art of Medicine? The expression probably has its origin with Hippocrates. One of his most famous Aphorisms, in Latin, was “Ars longa, vita brevis,” or the Art is Long, Life is Short, in reference to the “Art of Medicine.” The full quote is:
Life is short, and art long, opportunity fleeting, experience perilous, and decision difficult.
This is an English translation from the Latin, but Hippocrates originally wrote in Greek. The Greek word for art or the Latin ars was techne. This Greek word means an art in the sense of a craft or a trade; indeed, a craft that is governed by a set of rules. It is the origin of the English word technical for example. It was not an art in the sense of the creative arts. This, in fact, is also the meaning of the Latin word ars.
So what did this aphorism of Hippocrates really mean? Well, let’s expound upon what he said. The life of any particular physician, and indeed the life of any particular patient, is short and limited; but the discipline of medicine and the need that patients have for physicians is ongoing and it exceeds and surpasses the lifetime of any one of us and it exceeds and surpasses the accomplishments of any one of us. Our own opportunities to learn are fleeting and therefore we need to rely upon the collective opportunities to learn of all physicians and from many different patients; indeed, from more patients than any one physician can ever individually treat. We do this today with large controlled studies and a population-based approach to medicine. This collective data far surpasses any one person’s anecdotal data. Therefore, our experience is perilous; our individual experience should not be trusted. It is our collective experience and our collective knowledge that has more value and authenticity. The decisions we make are difficult; they are difficult because we have to learn to not rely upon our own experiences and see past our own biases when we make them.
It seems, in fact, that the Hippocratic origin of the expression “the art of medicine,” when properly understood, is a fundamental rejection of the way many modern physicians now use the term and an endorsement of what has come to be called evidence-based medicine. Paracelsus, whose Latin was much better than Osler’s, understood this. His comment about the art of medicine, when read correctly, was an exhortation to integrating the basic sciences into the practice of medicine, which was not common in his day.
None of this is to say that some physicians do not possess a greater degree of empathy and interpersonal communication skills than others. This is obvious to anyone who has ever been to a doctor. We also should not under-emphasize the importance of these skills. They are harder to teach and seemingly less subject to the scientific process than many of the other competencies and knowledge-based skills of physicians (but they can be taught and can be studied). Nevertheless, these skills are not art. They are skills which are requisite to being a good physician and skills which we should strive to teach and model for all physicians. They are no more important than the skills of critical thinking, problem solving, statistical analysis, and the scientific method.
The aphorism “The Art of Medicine” should never be invoked by anyone to justify himself when he chooses to not practice evidence and science-based medicine. It is not a license to be anecdotal. It should not make a physician feel like she is unique or has special powers.