The practice of clinical medicine as an art and as a science

Abstract

“Medicine in industrialised countries is scientific medicine,” write Glymour and Stalker.1 The claim tacitly made by US or European physicians and tacitly relied on by their patients is that their palliatives and procedures have been shown by science to be effective. Although physicians' medical practice is not itself science, it is based on science and on training that is supposed to teach physicians to apply scientific knowledge to people in a rational way. This distinction between understanding nature and power over nature, between pure and applied science, was first made by Francis Bacon in his Novum Organum of 1620.2(p28) Medicine as practiced today is applied science. Thomas Huxley pointed out in his address at the opening of Mason's College in Birmingham, England, in 1880 that applied science is nothing but the application of pure science to particular classes of problems.3 No one can safely make these deductions unless he or she has a firm grasp of the principles. Yet, the idea of the practice of clinical medicine as an art persists. What is this? Does it amount to anything more than romantic rhetoric—a nod in the direction of humanitarianism? Is this what the author of a guide to the membership examination of the Royal College of Physicians referred to as late as 1975 when a guide stated that its membership examination “remains partly a test of culture, although knowledge of Latin, Greek, French, and German is no longer required”?4 Like many large textbooks, Cecil Textbook of Medicine begins with a discourse on medicine as an art.5 Its focus is the patient, defined as a fellow human seeking help because of a problem relating to his or her health. 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 empathize, to inform, to maintain solidarity—for the physician, in fact, to be part of the treatment. No one would want to dispute the desirability of these properties, but they describe, first, moral dimensions to care—we listen because of respect for persons and so on—and second, skills. Interpersonal skills may be frequently lacking, just as technical skills may be. But they can, at least in principle, be observed, taught, tested, and their value assessed, just like any practical technical skill. We could probably say much the same about the third part of the mantra of medical teachers: attitudes. Whereas these may be more dependent on physicians' upbringing and personalities, attitudes can be changed with education or appropriate legislation, can be observed and scored, and 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: the art is not just practical performance. 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. Medical practice depends on generalizations that can be reliably applied and scientifically demonstrated. Without understanding people as objects in this way, there can be no such thing as medical science.”1 In the accumulation of such knowledge, physicians—like engineers—share experiences individually through meetings and publications. Within the community of its discipline, this intersubjectivity establishes the objectivity of science: it is knowledge that can be publicly tested. This approach can be summed up 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 the 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. Such is medicine. In its methods, scientific thinking should—must—be insulated from all kinds of psychologic, sociologic, economic, political, moral, and ideologic factors that tend to influence thought in life and society. Without those proscriptions, objective knowledge of truth degenerates into prejudice and ideology.