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- The practice of clinical medicine as an art and as a science | Medical Humanities
- AMA Journal of Ethics
- Philosophy of Medicine
Thomas Huxley pointed out in his address at the opening of Mason's College in Birmingham in that applied science is nothing but the application of pure science to particular classes of problems. Yet the idea of the practice of clinical medicine as an art persists. Does it amount to anything more than romantic rhetoric—a nod in the direction of humanitarianism?
Like many large textbooks, Cecil's Textbook of Medicine begins with a discourse on medicine as an art. From this emerges the comment that for medicine as an art, its chief and characteristic instrument must be human faculty. What aspects of the faculty matter? We are offered the ability to listen, to empathise, to inform, to maintain solidarity: No one would want to dispute the desirability of these properties but I think they describe, firstly, moral dimensions to care—we listen because of respect for persons and so on: Interpersonal skills may be frequently lacking, just as technical skills may be.
But they can, at least, in principle, be observed, taught, tested, their value assessed, just like any practical technical skill. And I think we could probably say much the same about the third part of the mantra of medical teachers, attitudes.
While these may be more dependent on our upbringing and personalities, attitudes can be changed with education or appropriate legislation, can be observed and scored, can be evaluated in their contribution to patient care or diagnostic technique, at least in principle and even if these are crudely done. Part of the art of clinical medicine may lie in these areas, but not exclusively so: I want to suggest that the art and science of medicine are inseparable, part of a common culture.
Knowing is an art; science requires personal participation in knowledge. Intellectual problems have an impersonal, objective character in that they can be conceived of as existing relatively independently of the particular thought, experiences, aims and actions of individual people. Without such an impersonal, objective character, the practice of medicine would be impossible.
Without understanding people as objects in this way, there can be no such thing as medical science. Within the community of its discipline, this inter-subjectivity establishes the objectivity of science: We can sum up this approach as a doctrine of standard empiricism in which the specific aim of inquiry is to produce objective knowledge and truth—and to provide explanations and understanding. Science as pure science is knowledge of our natural environment for its own sake, or rather, for understanding.
Science as applied science or technology is the exercise of a working control over it. In its methodology, scientific thinking should, must, be insulated from all kinds of psychological, sociological, economic, political, moral and ideological factors which tend to influence thought in life and society. Without those proscriptions, objective knowledge of truth will degenerate into prejudice and ideology. Although the aim of standard empiricism is value-neutral truth, that does not imply that science is insulated from outside factors.
It merely states that such factors are not integral to it—social context, for example. Doctors and other health carers are, of course, enmeshed in the obligations and responsibilities of their profession. Such responsibilities may extend from the individual patient, to the health care system, or to society as a whole. Their role as technologically trained practitioners, according to the canons of standard empiricism, does not exclude them adopting other roles—as a consoler or healer, for example. Nevertheless I think we might consider what happens in practice.
In an entertaining, but enlightening, editorial, Anthony Clare points out that many doctors like to bask in the reflected glory of medicine as a scientific undertaking that transcends national barriers. Nevertheless much clinical practice is still heavily influenced by national culture and character. In the USA, if it exists at all, it is panic disorder.
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In Britain, it doesn't exist—so presumably sufferers in France might be cured by a trip on Eurostar. The Germans consume six times as many heart drugs as their British counterparts, with cardiac glycosides being the second most prescribed group of drugs after non-narcotic analgesics. Germans have 85 drugs listed for treatment of low blood pressure and annual consultation rates of per million. Hardly anyone in Britain gets treated for low blood pressure.
Doctors in the USA think treating low blood pressure amounts to malpractice. Fashion is another powerful influence. Hypoglycaemia comes and goes; chronic mononucleosis is probably on the way out, so is ME - even if chronic fatigue syndrome survives. Mitral leaflet prolapse syndrome caught our fancy in the s when everyone who had an echocardiogram had it; then we've had temporomandibular joint syndrome, post traumatic stress syndromes, osteoporosis, fibromyositis, candidiasis hypersensitivity syndrome, total allergy syndrome, Gulf War syndrome, repetitive strain injury—and so they go on, a disease of fashion almost every month.
One could make similar comments on treatment or investigations. Is this evaluation the art of clinical practice? Now this, one may object, is all rather unfair. Surely, it doesn't demonstrate any admirable art in medicine: It is science based on poor evidence, insufficient evidence or dogmas without evidence. And its practice is bad medicine; bad medicine pressured by the degree to which disease is the sustenance of TV dramas, magazines, commercial ads, the food industry, the publishing industry, sport and even the weather forecast.
Isn't what we need more and better clinical trials—the gold standard on which to base practice? The controlled, randomised clinical trial has been a powerful instrument in furthering medical knowledge and, of course, a doctor should know its results, but it is often not enough in recommending treatment for this patient.
The practice of clinical medicine as an art and as a science | Medical Humanities
The double-blind, randomised, controlled trial RCT is an experiment: A RCT would be inappropriate if the effect of random allocation reduces the effectiveness of the intervention when active participation of the subject is required, which, in turn, depends on the subject's beliefs and preferences. For example, in a trial of psychotherapy both clinicians and patients may have a preference, despite agreeing to random allocation.
As a result, the lack of any subsequent difference in outcome between the comparison groups may underestimate the benefits of the intervention. The RCT may also be inappropriate if the event is a rare one the number of subjects will not be sufficient or likely to take place far into the future it can't be continued long enough.
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For example, in the UK Atomic Energy Authority mortality study, , person years experience among radiation workers were examined. In interpreting low order risks, study situations are usually complex. In a multifactorial disease, a factor which increases the risk by less than half will almost certainly be undetectable. A RCT may be impossible if key people refuse participation, or if there are ethical, legal or political obstacles.
Finally it may be inadequate if the trial involves atypical investigators or patient groups or if patients in the RCT receive better care than they would otherwise receive, regardless of which arm they are in. Black argues 9 that the RCT provides information on the value of an intervention shorn of all context, such as patients' beliefs and wishes and clinicians' attitudes and beliefs, despite the fact that such aspects may be crucial to determining the success of the intervention.
By contrast, observational methods maintain the integrity of the context in which care is provided. How then does one balance the information from two different approaches? If they are complementary, what rules exist to decide how much one looks to one method rather than the other? The answer is surely none.
Good doctors use their personal judgment to affirm what they believe to be true in a particular situation. Their knowledge is not purely subjective, for they cannot believe just anything ; and their judgment is made responsibly and with universal intent, ie they take it that anyone in the same position should concur. It is practical wisdom. Medical practice demands such judgments on a daily basis. The good doctor is able to reflect on diverse evidence and to apply it in a particular context.
No computer could replace him, for the judgment cannot be reached by logic alone. Here medical practice as art and science merge. At least part of the art of medicine lies in those non-scientific rules of thumb that guide decisions in practice, that enable the good doctor to affirm what he believes to be true in a particular situation. These cannot be and aren't science. McDonald argues that these should be discussed, criticised, refined and then taught.
Perhaps we could subsume those two principles into the structures of science.
AMA Journal of Ethics
Certainly simplicity or elegance have long been recognised as important features of science. Or it works with one particular drug, so we argue it will work with another drug that has the same effect. For example, we assume that any drug that lowers blood pressure will offer benefits to the patient. Or we assume that only a drug of the same class will have the same benefits; we extrapolate from evidence about one statin drug or one angiotensin-converting enzyme inhibitor to all others in the same class.
Or we won't extrapolate in certain other cases. Practolol was shown to reduce deaths after acute myocardial infarction, 13 but other beta blockers were not assumed to be effective until huge trials had been mounted. Or we assume we know more than we do. Because nothing grew on throat swabs, we assumed sore throats were viral and avoided antibiotics. We now know from DNA sequencing data that many identifiable bacteria were not being isolated. Or we believe our tests are more discriminating than they are, for example the claim that no pulmonary embolism could occur if the arterial oxygen tension was over 80 mm Hg.
Pre-marketing safety data of drugs confidently reveal acute toxicities occurring more often than 1 in administrations. If the frequency is less than 1 in it will take six months to find out. And sometimes it is completely misunderstood. The purpose of this book is to show the reader not only that this is so, but how it is so as well. And he does a superb job. He provides numerous examples and clear explanations, covering many of the topics we have addressed on Science-Based Medicine.
Very little in his book will be new to our regular readers, but he ties a lot of information together into a convenient package. He explains the many ways in which clinical research can yield misleading results, the difference between absolute and relative risk, the difference between correlation and causation, the number needed to treat NNT , predictive value, the process of developing treatment guidelines, how the precision of new diagnostic technology is often mistaken for certainty , the dangers of false positive tests, the inability of doctors to predict how long an individual patient has to live, the hazards of unnecessary tests and overdiagnosis, how evolution prepared us to find narrative more compelling than statistics, confirmation bias, how our skill at pattern recognition makes us see patterns that are not real, pseudodiseases, the rationale for controlled trials with randomization and blinding, media malfeasance, illogical conspiracy theories, and much more.
He boils down the things we know for certain about maintaining our health to three principles: There is a lot of discouraging news here, but there is also hope. By understanding the principles in this book, patients can better judge the uncertainties of what they hear.
Philosophy of Medicine
They found that one in three news stories is a mere regurgitation of a press release that lacks critical information. Medicine is full of uncertainties, but doctors and patients can work in partnership to understand where a diagnosis or treatment falls on the uncertainty spectrum and that information can help them make rational decisions for individual health care. Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices.
During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS Director of Base Medical Services and did everything from delivering babies to taking the controls of a B