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Blending art and science in healthcare, or the progressive blurring of traditional specialty boundaries
The American Journal of Surgery 183 (2002) 103–105
Editorial opinion
Blending art and science in healthcare, or the progressive blurring of traditional specialty boundaries Felicien M. Steichen, M.D.* Department of Surgery, St. Agnes Hospital, Institute for Minimally Invasive Surgery, 303 North St., Suite 103, White Plains, NY 10605, USA
Advances in basic and applied science have always been the foundation for improvements in the art or craft of healing disease and injury. In the second half of the 20th century, this relationship has experienced its most dramatic expression to date. The progress in optics, photography, sensors, recorders and biomedical instruments has significantly advanced the scope and precision of imaging and directly inspecting the human body, inside and out, so as to discover a pathologic condition and possibly remedy it. Additionally, measuring and monitoring of normal and abnormal physiologic activity, through noninvasive and invasive means, of practically any organ or body system have provided the clinician with reliable data in his or her quest to correct complex errant functions to levels compatible with survival. To see normal and altered anatomic form and measure baseline and abnormal physiologic function provide the clinician with diagnostic and therapeutic resources that have blurred the age-old distinction between cognitive thinkers and skillful doers. A point of progressive equality has been reached between the successors to ermine-collared, Latinspeaking doctors and laboring barber surgeons of yore. The inertia of tradition deters us, however, from recognizing fully that the schism between Medicine and Surgery– and the temporary subservience of the latter in the more distant past-carried a large burden of responsibility at any given period, for the poor transfer of available scientific knowledge to desirable concurrent improvements in the healing arts or craft. Ignoring this or other past mistakes could bear the historical stigma and future potential of inevitable repetition. Santayana’s malediction, however, has been offset, consciously and at times serendipitously, by the well-deserved esteem in which basic and clinical research is presently held. The faculty to transfer the results of such research to benefit our art or craft is but one example of the chameleon-
* Corresponding author. Tel.: ⫹1-914-686-1562; fax: ⫹1-914-9466226.
like powers of adaptation required of modern healers, regardless of an original affiliation to a more traditional background in either Medicine or Surgery. The clinical application of progress in physics for instance provides the ability to inspect form and measure function in health and disease with precision and reliance. Since this ability can be acquired through appropriate studies and training, its future potential in clinical healthcare is casting doubt on the usefulness of the present medicalsurgical dichotomy in our diagnostic and therapeutic efforts. This doubt leads to the recognition that the physiciansurgeon of new needs to be organ or system oriented, because complexity and volume of knowledge make a body-wide medicosurgical competence by a single individual impossible. Finally, such an orientation would provide a logical framework for the selection of care with the premium placed on the patient’s complaint and findings, rather than on the available response that is traditionally cast in a rigid medical or surgical mold. In other words, diagnosis and treatment would be demand oriented and not supply driven. A review of history shows that Hippocrates, founder of Western medicine (460 –361 BC), his followers and successors sustained a remarkably creative effort as physicians and surgeons that lasted some 700 years. This model was changed by Galen (130 –200 AD), who delegated the “scut” work of physical examination, handling of human secretions and excretions, and health-related procedures to helpers. The separation of doctors of medicine from barber surgeons was firmly established after the destruction of Salerno and its thriving school of medical art and surgical craft, by the crusaders of Henri IV in 1194. While it would be easy to conclude that the “divorce” was responsible for scientific dogma and censoring of curious minds, the first decline of Western medicine after Galen coincided with the downfall of the Western Roman Empire and the second one after the destruction of Salerno was due to the general contraction of resources, blind obedience to religious and political authority and compensatory priority given to spiritual values, expediently used to control
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 8 6 7 - 4
104
F.M. Steichen / The American Journal of Surgery 183 (2002) 103–105
many psychosomatic and social ills during the “dark” Middle Ages. However, as basic science applied to the clinical art progressed, this almost feudal concept of healthcare was challenged, as it was in the arts and political sciences during the Renaissance and Reformation. The scholarly efforts of Vesalius, Pare´ , Harvey, Morgagni, Hunter, Laennec, and so many other “greats” who have joined the pantheon of our glorious past history, elevated surgery from an art or craft only to join medicine as an equal branch of the health sciences, sometimes over the strenuous objections of our medical brethren. However the goal of equivalent status appears to have consecrated the dichotomy in the supply of care provided by parallel disciplines. And as more and more knowledge accumulated, separate specialties developed in each one of the main branches, often with interest in the same organ or system. There were some notable exceptions where the physician-surgeon model was preserved: ophthalmology, oto-rhino-laryngology, urology, gynecology, and orthopedics. Their development was based on the fact that seeing with an ophthalmoscope, a speculum and indirect light, a cystoscope and Roentgen rays allowed the practitioners of these specialties to see, establish a diagnosis and undertake treatment as indicated by their findings. Modern imaging, intraluminal and intracavitary endoscopy, various system or organ function tests and all the modern diagnostic and therapeutic means have changed the utility of separate physician and surgeon functions. Albeit that we should not relegate this mode to antiquity because it has brought us to our present level of excellence. The expertise required for most diagnostic and many therapeutic procedures can be mastered through diligent training and does not require the manual dexterity of a magician. In other words, the playing field between thinkers and doers has been leveled to the point where the diagnosis and procedure oriented cardiologist and member of the department of medicine has more in common with the cardiac surgeon similarly interested in operative and functional correction of a heart defect, than he or she has in common with the neurologist, also a member of the medical department. The neurologist in turn is closer to the neurosurgeon and shares with him or her common diagnostic and therapeutic skills. And so it goes for all and any specialties that so far have had a dual medical and surgical identification. The return to our origins as physicians-surgeons, albeit for an organ or system only, appears to make sense as the more rational response to the current challenges by both healthcare needs and priorities in resource allocation. (Plus c¸a change, plus c¸’est la meme chose.) It appears, therefore, appropriate to propose the same concept and model that has met the test of time in ophthalmology, otology and rhinolaryngology, urology and orthopedics for diagnostic and therapeutic: cardiology, angiology, pleuro-pneumology, gastroenterology,
colo-proctology, nephrology, endocrinology, neurology, maternal and child health, and gynecology. This redistribution of clinical competence can be adapted to the extremes of age, pediatrics and gerontology. The rapidly developing and diversifying field of interventional radiology could find any number of appropriate niches. However, in trying to be all things to all people, the modern general hospital has become encumbered by expensive inefficiencies and contradictory duplications of services and facilities. And yet, it remains the only purveyor of total, coordinated healthcare for the critically ill and injured, and the elderly or child presenting various co-morbidity factors. Clinical and basic research as well as education and training at all levels are possible within its walls. The building of highly specialized, free standing, albeit efficient health “boutiques,” often with a profit motive, will only further weaken the mission and financial basis of what is for the common good. The solution would, therefore, seem to incorporate the efficient boutiques, most often organized along the proposed lines of a diagnosis-treatment oriented unit, under the common roof of a general hospital and integrate their cost saving features into the purpose of providing optimal care while using human and material resources wisely and parsimoniously. With the proposed concept of clinical diagnostic-therapeutic practice units it becomes possible to have clinicians teach anatomy, physiology, biochemistry, pathology, immunology and microbiology, alongside an appropriate number of basic science teachers. This would allow clinicians to introduce students to the continuity that exists between basic sciences and clinical practice and to demonstrate the importance of basic knowledge and research. Conversely, such an arrangement could engage basic scientists alongside their clinical colleagues and provide a true scientific basis to the various disciplines in the daily clinical practice. The concept is attractive because it represents a natural evolution, encouraged by socioeconomic, technologic and ethical advances: From the physician-surgeon of the Greek period and the separate doctors and barber-surgeons of Greco-Roman and Medieval times, we have come to a single expression of surgical art or craft and medical science in the nineteenth century. This was reinforced in the 20th century by our ability to see directly or by imaging techniques without the need to gain extended anatomical access through the surgical art or craft, and by our scientific talent to measure and document body functions without the human imperfections of cognitive, deductive reasoning. This new alliance between the art or craft and science has simplified clinical practice, made it more accessible to all patients, by reducing the cost and time lost through duplications of services and wasteful use of goods, and has yet improved the quality of care through more rational time commitments and better employment of available technology. This change has become possible because of progress in
F.M. Steichen / The American Journal of Surgery 183 (2002) 103–105
technology and techniques that allow surgeon and physician alike to see anatomical form and pathological change by direct inspection or through imaging techniques, to monitor and document normal and abnormal physiological functions through noninvasive or minimally invasive procedures, to
105
trust the clinical and laboratory results because “seeing and measuring is believing” (St. Thomas, 33 AD), so as to come to an optimal therapeutic conclusion, nowadays often achieved by extending the diagnostic technique into a therapeutic procedure or operation.
Editorial opinion
Blending art and science in healthcare, or the progressive blurring of traditional specialty boundaries Felicien M. Steichen, M.D.* Department of Surgery, St. Agnes Hospital, Institute for Minimally Invasive Surgery, 303 North St., Suite 103, White Plains, NY 10605, USA
Advances in basic and applied science have always been the foundation for improvements in the art or craft of healing disease and injury. In the second half of the 20th century, this relationship has experienced its most dramatic expression to date. The progress in optics, photography, sensors, recorders and biomedical instruments has significantly advanced the scope and precision of imaging and directly inspecting the human body, inside and out, so as to discover a pathologic condition and possibly remedy it. Additionally, measuring and monitoring of normal and abnormal physiologic activity, through noninvasive and invasive means, of practically any organ or body system have provided the clinician with reliable data in his or her quest to correct complex errant functions to levels compatible with survival. To see normal and altered anatomic form and measure baseline and abnormal physiologic function provide the clinician with diagnostic and therapeutic resources that have blurred the age-old distinction between cognitive thinkers and skillful doers. A point of progressive equality has been reached between the successors to ermine-collared, Latinspeaking doctors and laboring barber surgeons of yore. The inertia of tradition deters us, however, from recognizing fully that the schism between Medicine and Surgery– and the temporary subservience of the latter in the more distant past-carried a large burden of responsibility at any given period, for the poor transfer of available scientific knowledge to desirable concurrent improvements in the healing arts or craft. Ignoring this or other past mistakes could bear the historical stigma and future potential of inevitable repetition. Santayana’s malediction, however, has been offset, consciously and at times serendipitously, by the well-deserved esteem in which basic and clinical research is presently held. The faculty to transfer the results of such research to benefit our art or craft is but one example of the chameleon-
* Corresponding author. Tel.: ⫹1-914-686-1562; fax: ⫹1-914-9466226.
like powers of adaptation required of modern healers, regardless of an original affiliation to a more traditional background in either Medicine or Surgery. The clinical application of progress in physics for instance provides the ability to inspect form and measure function in health and disease with precision and reliance. Since this ability can be acquired through appropriate studies and training, its future potential in clinical healthcare is casting doubt on the usefulness of the present medicalsurgical dichotomy in our diagnostic and therapeutic efforts. This doubt leads to the recognition that the physiciansurgeon of new needs to be organ or system oriented, because complexity and volume of knowledge make a body-wide medicosurgical competence by a single individual impossible. Finally, such an orientation would provide a logical framework for the selection of care with the premium placed on the patient’s complaint and findings, rather than on the available response that is traditionally cast in a rigid medical or surgical mold. In other words, diagnosis and treatment would be demand oriented and not supply driven. A review of history shows that Hippocrates, founder of Western medicine (460 –361 BC), his followers and successors sustained a remarkably creative effort as physicians and surgeons that lasted some 700 years. This model was changed by Galen (130 –200 AD), who delegated the “scut” work of physical examination, handling of human secretions and excretions, and health-related procedures to helpers. The separation of doctors of medicine from barber surgeons was firmly established after the destruction of Salerno and its thriving school of medical art and surgical craft, by the crusaders of Henri IV in 1194. While it would be easy to conclude that the “divorce” was responsible for scientific dogma and censoring of curious minds, the first decline of Western medicine after Galen coincided with the downfall of the Western Roman Empire and the second one after the destruction of Salerno was due to the general contraction of resources, blind obedience to religious and political authority and compensatory priority given to spiritual values, expediently used to control
0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 8 6 7 - 4
104
F.M. Steichen / The American Journal of Surgery 183 (2002) 103–105
many psychosomatic and social ills during the “dark” Middle Ages. However, as basic science applied to the clinical art progressed, this almost feudal concept of healthcare was challenged, as it was in the arts and political sciences during the Renaissance and Reformation. The scholarly efforts of Vesalius, Pare´ , Harvey, Morgagni, Hunter, Laennec, and so many other “greats” who have joined the pantheon of our glorious past history, elevated surgery from an art or craft only to join medicine as an equal branch of the health sciences, sometimes over the strenuous objections of our medical brethren. However the goal of equivalent status appears to have consecrated the dichotomy in the supply of care provided by parallel disciplines. And as more and more knowledge accumulated, separate specialties developed in each one of the main branches, often with interest in the same organ or system. There were some notable exceptions where the physician-surgeon model was preserved: ophthalmology, oto-rhino-laryngology, urology, gynecology, and orthopedics. Their development was based on the fact that seeing with an ophthalmoscope, a speculum and indirect light, a cystoscope and Roentgen rays allowed the practitioners of these specialties to see, establish a diagnosis and undertake treatment as indicated by their findings. Modern imaging, intraluminal and intracavitary endoscopy, various system or organ function tests and all the modern diagnostic and therapeutic means have changed the utility of separate physician and surgeon functions. Albeit that we should not relegate this mode to antiquity because it has brought us to our present level of excellence. The expertise required for most diagnostic and many therapeutic procedures can be mastered through diligent training and does not require the manual dexterity of a magician. In other words, the playing field between thinkers and doers has been leveled to the point where the diagnosis and procedure oriented cardiologist and member of the department of medicine has more in common with the cardiac surgeon similarly interested in operative and functional correction of a heart defect, than he or she has in common with the neurologist, also a member of the medical department. The neurologist in turn is closer to the neurosurgeon and shares with him or her common diagnostic and therapeutic skills. And so it goes for all and any specialties that so far have had a dual medical and surgical identification. The return to our origins as physicians-surgeons, albeit for an organ or system only, appears to make sense as the more rational response to the current challenges by both healthcare needs and priorities in resource allocation. (Plus c¸a change, plus c¸’est la meme chose.) It appears, therefore, appropriate to propose the same concept and model that has met the test of time in ophthalmology, otology and rhinolaryngology, urology and orthopedics for diagnostic and therapeutic: cardiology, angiology, pleuro-pneumology, gastroenterology,
colo-proctology, nephrology, endocrinology, neurology, maternal and child health, and gynecology. This redistribution of clinical competence can be adapted to the extremes of age, pediatrics and gerontology. The rapidly developing and diversifying field of interventional radiology could find any number of appropriate niches. However, in trying to be all things to all people, the modern general hospital has become encumbered by expensive inefficiencies and contradictory duplications of services and facilities. And yet, it remains the only purveyor of total, coordinated healthcare for the critically ill and injured, and the elderly or child presenting various co-morbidity factors. Clinical and basic research as well as education and training at all levels are possible within its walls. The building of highly specialized, free standing, albeit efficient health “boutiques,” often with a profit motive, will only further weaken the mission and financial basis of what is for the common good. The solution would, therefore, seem to incorporate the efficient boutiques, most often organized along the proposed lines of a diagnosis-treatment oriented unit, under the common roof of a general hospital and integrate their cost saving features into the purpose of providing optimal care while using human and material resources wisely and parsimoniously. With the proposed concept of clinical diagnostic-therapeutic practice units it becomes possible to have clinicians teach anatomy, physiology, biochemistry, pathology, immunology and microbiology, alongside an appropriate number of basic science teachers. This would allow clinicians to introduce students to the continuity that exists between basic sciences and clinical practice and to demonstrate the importance of basic knowledge and research. Conversely, such an arrangement could engage basic scientists alongside their clinical colleagues and provide a true scientific basis to the various disciplines in the daily clinical practice. The concept is attractive because it represents a natural evolution, encouraged by socioeconomic, technologic and ethical advances: From the physician-surgeon of the Greek period and the separate doctors and barber-surgeons of Greco-Roman and Medieval times, we have come to a single expression of surgical art or craft and medical science in the nineteenth century. This was reinforced in the 20th century by our ability to see directly or by imaging techniques without the need to gain extended anatomical access through the surgical art or craft, and by our scientific talent to measure and document body functions without the human imperfections of cognitive, deductive reasoning. This new alliance between the art or craft and science has simplified clinical practice, made it more accessible to all patients, by reducing the cost and time lost through duplications of services and wasteful use of goods, and has yet improved the quality of care through more rational time commitments and better employment of available technology. This change has become possible because of progress in
F.M. Steichen / The American Journal of Surgery 183 (2002) 103–105
technology and techniques that allow surgeon and physician alike to see anatomical form and pathological change by direct inspection or through imaging techniques, to monitor and document normal and abnormal physiological functions through noninvasive or minimally invasive procedures, to
105
trust the clinical and laboratory results because “seeing and measuring is believing” (St. Thomas, 33 AD), so as to come to an optimal therapeutic conclusion, nowadays often achieved by extending the diagnostic technique into a therapeutic procedure or operation.