Medicine: a Science and an Art

Science and art are usually thought of as distinct entities at opposing ends of the spectrum of human endeavors: science being based strictly on rational deduction and stringent methodology, art as being dominated by free association, empathy and emotion; the objective and subjective view of the world, the left and the right brain, Ying and Yang. Why then is medicine often said to be a science and an art?

Medicine applies the knowledge created by biomedical sciences to better understand and manage human diseases, i.e. medicine is an applied science like engineering. That said, unlike engineering, medicine deals with human beings and is applied in a doctor-patient relationship. Both, doctor and patient are individuals embedded in their own complex socio-cultural environment. Medicine therefore inherently requires interpersonal interactions across many belief and value systems and that is one way the art comes in.

Biomedical knowledge is fact based. Medical students internalize and memorize the basic facts by listening to various types of lectures, and by reading text books, scientific articles, and the like. Most important, perhaps, is the in-depth understanding of the underlying pathophysiological principles that will unlikely change in the near future and from which most (if not all) elements relevant to disease management can be derived. On the contrary, the detailed specifics of current disease management will often already be outdated when today’s learners will be licensed and enter practice some years down the road. The half-life of specialized biomedical knowledge is often quoted as amounting to not much more than 5 years.

Clinical training is learning the skill of how to apply the biomedical knowledge to a patient, i.e. the individual, suffering human being in front of us. This is the art of medicine. The art of medicine cannot be mastered by reading a text book or listening to a lecture. It has to be learned the hard way through supervised practice. Clinical training is an apprenticeship. This is obvious for interventional disciplines in which manual skills play a key role such as surgery, GI endoscopy or interventional cardiology, but applies equally to disciplines dominated by cognitive skills such as psychiatry and many subspecialty areas of internal medicine. The application of medicine, especially in (but not limited to) urgent situations, lives from pattern recognition and reflexively applying the action appropriate to the situation. Mastering this, requires repetitive exposure to as many conditions and situations as can be encountered in a given subspecialty.

Apart from manual and cognitive skills, finding the right tone and using the right vocabulary to communicate across different believe and value systems requires exercising and practice. Without this, the two parties in a patient-doctor encounter (in which there is often a lot at stake for the patient) will not be able to reliably talk the same language and understand each other’s message.

The notion that there is a dichotomy of learning and providing service is therefore a fundamental misunderstanding of clinical training. The clinical trainee, whether at the clerkship or PGY1-5 and beyond level, learns by providing service. Learning and providing service are inseparably intertwined. Without providing service the clinical trainee will not be able to learn the art of medicine.

To perform successfully, any artist, whether writer, painter or performing artist, requires to exercise and rehearse. Talent is required, but talent alone is not enough. Similarly, the clinical trainee will get better in applying their biomedical knowledge and gradually gain expertise by seeing and managing ever more patients – and being allowed to make mistakes from which one often learns the most (of course, within reason and risk mitigation by a supervisor).

The strict separation of learning and providing service in clinical teaching/learning that is so en vogue these days fundamentally lacks this understanding. By doing so, it prevents the learner from exercising as much as possible, thereby becoming a master in the art of medicine, i.e. it profoundly fails the clinical learner. For an artist, a hundred hours spent touring the galleries will never replace a hundred hours spent in front of the canvas. If medicine is a science and an art, the craft is what the clinical trainee is here to learn, and that craft is learned through practice.

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