Over the years, my mind has been moulded to think that when it comes to how living things work, there are no absolute truths. In medical practice, this mentality is usually revered, however, the same cannot necessarily be said about basic science. I sometimes find myself having to defend why I question everything – even the ‘facts’ that I am taught come with a mental post-it note placed in the back of my mind that the ubiquity of exceptions is the only rule I accept. Today’s fact is tomorrow’s misguided observation, and what applies to one person may be irrelevant for the next. This post is my personal attempt to find the reason behind this difference in thinking between those who practice clinical medicine and basic science.
When I was in medical school, countless professors would tell us how medicine is more art than science. We were told how, although we did not understand the difference then, we would soon realize this fact after we graduated and began to practice. Now, one year into my masters in medical neuroscience course, buried under a never-ending pile of experimental data, I find myself thinking about what they said.
Clinical medicine involves much more than memorizing facts or remembering the details of drugs and diseases. It requires a special type of skill – an analytical and critical mind-set which is unique to the profession. Recalling long lists of symptoms and signs is one thing, but the ability to form connections between various observations, synthesize this knowledge and turn it into something practically useful and beneficial to patients is what lies at the heart of medical practice. Akin to solving a puzzle, going from the first encounter with a patient to being able to manage them as a whole is why medicine is often described as an art.
Experimental medicine is entirely different. I’m not saying that it lacks creativity or relies less on the analysis and criticism of observations at hand, but the discipline is firmly based on hypothesis testing – it depends on the use of statistics to make somewhat rigid yes or no decisions. I am currently reading Claude Bernard’s An Introduction to the Study of Experimental Medicine – Bernard’s representation of physiology and its study is entirely distinct from the way clinical medicine works. Observations are either present or not, they always mean something specific and can be manipulated to influence other observations in a predictable and consistent manner. Clinical medicine to me seems much more, for want of a better word, flexible – symptoms and signs are often out of place and there are always exceptions to every rule (an idea that Bernard criticizes in his book, referring to practicing physicians in particular).
Of course, the way that experimental medicine works is by simplifying everything to its most basic components – cause and effect are isolated and studied in a bubble so to speak, excluding other factors that influence the processes under study. I wouldn’t dare criticize this approach, but it is one that has no place in medical practice. The human body is an infinitely complex interplay of systems that interact with the external environment (an idea proposed and propagated by none other than Bernard himself). Thus, it is easy to imagine that those who deal with human beings as a whole and those who aim to dissect the intricate details of how the body works in health and disease do so in completely different ways. Let’s not forget that the immediate aims of these disciplines are quite different, and so it only makes sense that their approaches differ too.
The question comes up – does its complex nature make medicine an art? There are other, possibly more obvious reasons, to consider. Depending on their specialty, doctors rely to varying degrees on manual skills – be it something as simple as giving an intravenous injection or performing delicate surgery. This may be a part of what places medicine in the realm of art. However, one may argue that this also applies to basic scientists – stabbing a neuron with a tiny micropipette without damaging it probably requires at least as much manual dexterity than removing a tumour from the spinal cord (I have attempted neither, but that’s my impression!). Of course, we have to consider that the stakes are higher in the latter.
Thus far, I have only practiced clinical medicine for one year, but my memories of my time working in the hospital bring me to the same conclusion as my former professors. Sitting in the emergency room as patient after patient pile in, what I learned from lectures was of limited benefit. What truly made a difference was my experience – the further I was into a specialty rotation, the more able I was to take appropriate action and manage patients effectively. Recalling medical facts becomes less of an issue when faced with a clinical problem – second nature kicks in and takes over, usually for the better.
Here are a few quotes that I found relevant to the topic:
“Take care not to fancy that you are physicians as soon as you have mastered scientific facts; they only afford to your understandings an opportunity of bringing forth fruit, and of elevating you to the high position of a man of art.”
“Medicine consists of science and art in a certain relationship to each other, yet wholly distinct. Science can be learned by anyone, even the mediocre. Art, however, is a gift from heaven.”
Armand Trousseau
“No human investigation can be called true science without passing through mathematical tests.”
“Those who are enamoured of practice without science are like a pilot who goes into a ship without rudder or compass and never has any certainty where he is going. Practice should always be based upon a sound knowledge of theory.”
Leonardo Da Vinci (he was both a scientist and an artist)
“Even in the hands of the greatest physicians, the practice of medicine is never identified with scientific (laboratory) medicine, but is only an application of it.”
Rudolf Virchow
“The main cause of this unparalleled progress in physiology, pathology, medicine and surgery has been the fruitful application of the experimental method of research.”
William H Welsh
Ahmed A. Khalil 