"Have you ever wondered why it can be difficult for a physician to come up with a diagnosis? For a moment let us shift gears. Imagine you bring your car to a mechanic and ask why it is making a particular noise. Most of the time they figure it out, but he or she is working with an automobile, a man–made object that has a blueprint. Mechanics should be able to figure out the problem if they are masters of the automobile design; yet, sometimes it still may be difficult to discover the mechanical problem. Physicians, on the other hand, are trying to master an understanding of the human body without the blueprint. Unlike cars, we did not personally design the human body. Despite the Human Genome Project and other advances in medicine during the last century, there is still more to learn. In fact, there are times when the field of medicine will contradict itself, such as withdrawing medications that were once thought to be helpful. To complicate matters, each individual patient has their own unique anatomy and physiology. Thus, the assessment of human beings and their ailments is very complex and requires artistic ability, not just scientific knowledge.
In the early days of medicine, doctors had torely on what modern physicians would considerbasic techniques to determine what was wrongwith patients. Modern technology has provideddoctors with a large number of tests with whichto diagnose conditions and an equally largenumber of treatments for these conditions. Althoughit may seem that these new technologieswould make the practice of medicine lessdifficult, this is not necessarily true. The historyand physical exam are essential to effectivelyand efficiently practice medicine; thus, there isstill an artistic component to medicine.
Every day, doctors encounter situationswhere there is no single correct answer. For example,when a 40–year–old smoker complains ofa new onset cough, but has no other signs or symptoms to suggestserious illness, should imaging studies be ordered? If an x–ray showssome nonspecific abnormality, should the patient undergo furthertesting? Consider another patient who is obese and complains ofknee pain. Should the patient be denied surgery until he can loseweight, or should he undergo surgery that may help reduce thepain, allowing him to exercise and thus lose weight more quickly?Clearly, there is no single answer to any of these questions. Thesescenarios highlight how physicians must put as much emphasis onpracticing the art of medicine as they do on practicing the scienceof medicine. While research can provide the answers to some questions,taking the time to know the patient is increasingly important.For the obese patient, failure of the doctor to take a thorough historymay prevent him from learning that the patient also is showingsigns of hypothyroidism. Treating the thyroid condition may helpthe patient lose weight, which could in turn reduce or eliminate thepatient’s knee pain.
Despite major advances in science, there are a number of treatmentsthat have side effects of which physicians and scientists remainunaware. Sometimes physicians need to use medications evenwhen their mechanisms of action remain unknown. For example,volatile anesthetics (which keep patients asleep during surgery) arenot fully understood, but the benefits seem to outweigh the risks.Also, the recent increase in the number of drugs receiving black–boxwarnings provides further evidence that science cannot yet providean answer for every question. Research may suggest that theseagents are safe, but without knowing how they work, how can webe sure? Moreover, some of the older, generic medications do notprovide incentives for pharmaceutical companies to do large–scaleresearch studies; yet, these drugs are used routinely. Remember, researchtypically involves groups of people, and while the statisticsare undeniably important, they cannot tell a doctor how to treat anysingle patient. When science cannot guide us, physicians must relyon art to care for their patients.
The spiraling cost of health care is another reason doctors cannotrely solely on science to treat their patients. Again, any numberof diagnostic tests can be done to rule in or out asuspected ailment. Of course, each test carries aprice—an oftentimes very large price. Failure ofthe physician to order only diagnostic tests thatare both necessary and appropriate may result inadditional costs that today’s health care systemcannot bear.
Medicine as an art form may be the most rewardingpart of the profession for many people.This includes forming relationships with one’s patients,which takes time and is an important reasonmany people work so hard to become physicians.These relationships are critical to helpingthe doctor decide how to treat individuals. Yet,managed care seems to be indirectly inflicting alimitation on the time a physician can spend witha patient. Some patients may be hesitant to undergotreatment, but having established a goodrelationship with their doctor, the patient mayfeel more comfortable with making decisions.Similarly, a good doctor–patient relationship maymake the physician feel more at ease to suggestthat the patient’s symptoms be monitored ratherthan ordering a large workup, or that the patient forego treatmentfor his metastatic pancreatic cancer. Such decision–making skillscannot be taught, but are vital to practicing medicine.
Modern science has greatly improved the quality of health care,but it has also made the job of the physician more difficult. Remember,we are merely humans trying to discover our own collectiveand individual blueprints. Physicians must know when diagnostictesting is warranted, and they must understand when a particulartreatment should be initiated. It is the physician’s relationship withthe patient and a thorough history and physical exam that will helpguide us closer to solving the mysteries of medicine. Thus, physiciansmust work to perfect the art of medicine with their patients,because science has its limitations.
Melissa Sneed, D.O. is a fourth–year, anesthesiology resident currently training in San Antonio, Texas. She earned her osteopathic medical degree in 2003 from the Texas College of Osteopathic Medicine, located in Fort Worth, Texas. For any questions or comments regarding this article, she may be contacted by email at: sneedm@uthscsa.edu.
