Sunday, February 1, 2015

Medicine is an Art and Science

Medicine is an art, not a science.  We’ve all heard that maxim before, but what does it actually mean for living, breathing patients?

Physicians rely upon knowledge and experience when we advise patients.   We try to stay current on relevant medical studies to guide us, knowing that the latest medical ‘breakthrough’ may be debunked in a few years.  Seasoned physicians resist the temptation to abruptly change their medical advice based on a single study, even if published in a prestigious journal.

Knowledge and experience are important, but judgment trumps them both, in my view.   The best clinicians are those who consistently exercise excellent medical judgment.

A knowledgeable physician may be able to recite a dozen explanations for your high calcium level.
An experienced doctor can expertly perform a colonoscopy having mastered the technique.
A physician with a high level of medical judgment knows that surgery is wrong for a particular patient, even though medical textbooks and journals recommend an operation. 

Judgement Outweighs Knowledge

Keep in mind that medical judgments are not right or wrong.  Physicians on the same case may have differing judgments and recommendations.  This is a typical scenario in the medical universe which can be vexing to patients and their family.

Consider a few typical patient vignettes which call for medical judgment.

A cardiologist recommends Coumadin , a blood thinner, to start today to treat a patient’s heart condition.  The gastroenterologist wants to delay this for a few weeks as the patient has a duodenal ulcer that could start bleeding once the blood thinner begins.   When should the Coumadin be started?

A man undergoes a CAT scan of the chest which shows a 1 cm nodule in the lung.  The nodule is slightly larger than it was 6 months ago.  The patient is a smoker.   The location of the nodule is at high risk for a serious complication if a biopsy is done.    Should the biopsy be done to determine if a cancer is present?  Considering the risk of the biopsy, should the lesion be watched with a repeat CAT scan done in 3 months to see if it is enlarging or remaining stable? 

A patient is seen by a surgeon after a severe attack of abdominal pain, which resolved.  The patient was immobilized during the pain and was seen in an emergency room where he was found to have a gallbladder full of gallstones.   The surgeon is not certain that the gallstones were responsible for the pain.  The patient is very frightened that if nothing is done, that the pain might return.  Should the surgeon remove the gallbladder, which might have nothing to do with the pain, or advise watchful waiting?

Medicine is art and science.  If I’m sick, I’ll skip the scientist.  Give me the artist.

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