The Art of Medicine: A Vanishing Treasure?
Like many of you, I consider myself lucky to have trained at a medical school that prided itself in having many outstanding professors, some of whom are still considered to be “giants” in their respective areas of expertise. Although the technology available at that time was less precise and at times more invasive, there was particular focus on detail—taking a thorough history and doing a complete physical examination were the hallmarks of good medical practice. I remember gathering around the bed of a patient as my professor described “interesting wave forms” in the neck; maneuvers were second nature to help us distinguish between various cardiac murmurs. Watching my professor in neurology perform a neurological examination and elicit a history was like watching a maestro conducting an orchestra. I remember witnessing many “difficult” conversations about life and death while my professors attempted to teach me the intangible “art of medicine” and the importance of observation, body language, and communication skills. Although perhaps more difficult to learn than my textbook physiology or anatomy, over the years I strived to master these tools as best as possible and to incorporate them into my daily practice. They have become the hallmark of my clinical approach to patients, and I believe they have served me well in dealing with patients with complex and interacting problems. I have tried to pass these tools on to my students and residents, and hope that in this small way I can continue the long and proud tradition of medicine.
The past three decades have brought much change; new technology has simplified our ability to diagnose many illnesses, and computerized medical records and ordering have brought a way to organize and retrieve data. I often think about how medicine will continue to change in this new era. We must move ahead and integrate new methods with old, but hopefully never forget our basic medical tools, skills, and the art of medicine. This fragile balance was brought to mind when I recently observed a group of residents using a new computerized ambulatory record. Information was to be added to pre-organized “templates” to reduce errors and make it easier for the clinician to record and retrieve pertinent data. It seemed like a reasonable goal. I was shocked, however, to frequently see the patient sitting behind the clinician as the physician was typing away, making sure all lines and spaces were completed on the computer.
Where did the power of observation go? This clinician could no longer “read” the patient’s expression or, for that matter, even “see” that a patient was in the room. New technology brought change, but in my humble opinion, the outcome was not all that was originally hoped. The physician was so absorbed in the new technology that he forgot that there was still a patient who had a story beyond what words could tell and who would benefit from a warm glance, a touch, or a smile. I have recently become fearful of the end result of another technological advancement: computerized charting and ordering. I am on a task force that is designing computerized “order sets” using the latest “evidence-based data.” This will soon become part of a Computer Physician Order Entry system to be integrated into a computerized medical record. Guidelines, order sets, and protocols clearly can make life easier and have been around for some time to help provide a structure to care for patients with specific diagnoses; they have been shown to reduce unnecessary testing and errors in many cases. I fear, however, that the physician of the future may lose the ability to care for the complex patient who may not easily “fit” into a specific category or guideline. This is more commonly the rule when caring for the older individual. In addition, depending on how the order sets are arranged, just how many additional tests will be ordered by the young physician eager to complete the task if these are presented as possibilities on a computer screen and not the result of his or her individualized thought process? How often will the physician of the future attempt to fit a complex patient into a limited guideline or order set, perhaps jumping to some conclusion and management pathway?
Medical education has become even more difficult and challenging, although the potential for improved health care has never been as great. I and many of my colleagues continue to try to emphasize the importance of the art of medicine when we interact with students and residents in training, while hopefully continuing to find ways to use modern technology to improve our clinical abilities and skills. I hope that as a new generation of physicians and medical educators develop from the current crop of trainees that they too will continue to value the intangible aspects of medicine, the “art” of which was taught to me long ago by those who were my teachers and mentors.
Send comments to Dr. Gambert at firstname.lastname@example.org.