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AAOS Now

Published 5/1/2009
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Frank M. Griffin, MD

“The Art of Medicine”

We’ve all heard the phrase, but what does it mean?

Politicians constantly mention “science” and “technology” as the means to improve health care and decrease its cost. It seems like we should be able to computerize medicine. We could develop a computer program that uses the scientific literature to catalog symptoms and diseases and associates them with certain guidelines. The computer could then simply spit out the right treatment.

We could standardize medicine. Streamline it. Make it cheaper. Be like Wal-Mart. Our hospitals could be like a big department store. Instead of having a hardware section, there’d be an orthopaedic section. Why haven’t we done that?

Science isn’t all it’s cracked up to be
Let’s look at the science of medicine. I’ve contributed to the orthopaedic literature in my career. I did basic science research, received grants, wrote clinical studies, and got published. So what’s the problem? In my opinion, the literature is simply too confusing. Rarely do all of the studies on a subject draw the same conclusions.

One of my studies was on whether we should do total knee arthroplasty (TKA) in obese people. Simple question. In my study, the patients did pretty well. Many other studies done before and after my study, however, found both conflicting and concurring results. I honestly don’t think the answer is clear.

Each study has subtle biases. Regional variations in patient expectations might play a role. My patients lived in New York City. As big city dwellers, they probably had different demands compared to people in the rural Arkansas agricultural community where I grew up.

Researchers are biased. Some authors or their institutions stand to gain financially or professionally from the results of their studies. These biases may not always be properly disclosed, even in today’s environment. In the “publish-or-perish” academic world, quantity of publications is emphasized over quality. The weight of the professor’s curriculum vitae (CV) is often more important than its content. This has undoubtedly led to significant amount of “CV padding” literature that may or may not be clinically relevant or accurate.

Art is more than pretty pictures
Part of the “art” of medicine is sorting through this mass of information and applying it to our individual practices. “The more you know, the more you realize you don’t know” was one of my mentor’s favorite quotes. Sometimes the best scientific study may not apply well to a particular patient for reasons that are not always evident to a layperson.

Each physician brings a unique set of skills to the patient. Just because a foot-and-ankle orthopaedic subspecialist at an academic institution has a 95 percent patient satisfaction rate with a particular complex ankle reconstruction, can I expect the same ratio on the one patient that I see every 5 years who might benefit from that operation? If that patient can’t afford to travel to the nearest similarly trained subspecialist, should I try to do an operation that I have minimal experience performing?

The physician must be able to listen to the individual patient’s history with humility—particularly with regard to his or her own skill set—and to render the best treatment available based on the resources of the patient, the physician, and the community.

Mass-produced medicine doesn’t work
We could streamline the process so that patients go through the system like cars on an assembly line. That’s the most efficient way. The problem is that we are not all alike. There’s too much individuality in patients. Patients respond to diseases differently. One patient may have a swollen knee with a meniscal tear. The next may not. One may have a twisting injury. The next may not.

Patients respond to treatments differently, too. One patient with a TKA is up and walking the next day. The next limps around for weeks. I don’t understand why. I did them both exactly the same. Their tourniquet time was equal. Their implants were the same. So why are the outcomes so different?

Part of the “art” is recognizing the individuality of the patient and respecting the fact that people are not all the same. Different patients may respond to the same disease or injury in vastly different ways. In some cases, different treatments may provide different outcomes based on the individuality of each patient treated. Recognizing the individuality of disease or injury is one of the key components of the “art” of medicine.

The Wal-Mart model doesn’t work
Can’t we just box health care up and deliver it like Wal-Mart? I doubt it. Medicine is too personal. It isn’t like buying a commodity. I may “love” the new iPod that I bought at the department store, but not like I “love” my own life or sense of well-being.

Medicine affects the patient’s very existence. It affects the patient’s ability to live without pain. It often affects whether the patient lives or dies. Wal-Mart is not “life and death.” Medicine is.

Because health care is so personal, other factors come into play. The patient’s belief system and whether or not the patient has faith in the treatment may affect outcomes, as the “placebo effect” shows. It is the doctor’s job to bridge the gap between the individual patient’s belief system and science, to give the patient the faith necessary to benefit from the application of the science. Without that key role, the results may be very different.

By reaching out and touching their patients, doctors show compassion and solidarity with them. Patients begin the healing process simply by gaining a companion who is trying to help relieve their suffering. Doctors also encourage patients to participate actively in their care. Doctors have the authority to critique patients’ participation and act as guides.

We, as physicians, require our patients’ faith that we will steer them on the right course. If we cannot gain the patient’s faith and trust, the patient may be noncompliant and less likely to have a successful outcome.

The power to heal goes beyond curing the human body. Illness is not a biologic or physical entity alone. Science and technology alone can’t deliver the kind of health care that we want. Compassionate application of the “art of medicine” plays a role. Doctors and patients must be given enough time and freedom to apply the “art” along with the science for us to obtain the outcomes that we all desire.

Frank M. Griffin, MD, is an orthopaedic surgeon in Van Buren, Ark. He can be reached at fgriffin888@aol.com

This article is adapted with permission from The Journal of the Arkansas Medical Society.