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What is the art of medicine?
VOLUME
l%g! *American
79
NUMBER
Journal
3
SEPTEMBER
1985
of Medicines EDITORIAL
!/Yt%me FRANK
Art of Medicine? A. GRECO,
he question arises because of the distinction commonly drawn in the assertion that medicine is an art, not a science. Today we associate art with creativity and inspiration and science with instrumentation and logic. In common speech, the expression art of medicine includes those aspects that cannot be measured or reduced to syllogism: the ability to sense and respond to a patient’s emotions; the “gut feeling” that something else is going on; etc. Often what physicians do bears striking resemblance to the creative efforts of artists. For example, the demands placed on a physician who must console the family of a dying patient are similar to those on a playwright who tries to guide his audience through a tragedy without destroying hope. However, this use of the word art in medicine is recent, deriving from the romantic era. The older, classical meaning of art is quite different. The ancient Greeks distinguished art from science not by the ratio of ingenious intuition to cold logic but rather by the goal of the discipline. The scientist worked simply to understand first principles, the artist to apply those principles for some constructive purpose. For example, the Greeks would have said that physics is a science, engineering an art, whereas we would more likely say that one is pure science, the other applied. The Greek word for art is techne and its English derivatives carry the original sense more clearly than its translation. To the Greeks, medicine was an art instead of a science because physicians studied nature for a practical end. Physicians as artists were the technologists, the engineers, of physiology. Oliver Wendell Holmes expressed this sense of art very clearly in a speech delivered to the Massachusetts Medical Society in 1860 [Currents and counter-currents in medical science. Boston; Ticknor and Fields, 18601. “Nature, in medical language, as opposed to Art, means trust in the reactions of the living system against ordinary normal impressions. Art, in the same language, as opposed to Nature, means an intentional resort to extraordinary, abnormal impressions for the relief of dis-
T
M.D., Ph.D. ease.” That most modern writers would use technology instead of art in this context can cause confusion. Is it important to distinguish the classical and romantic meanings of art? For two reasons the answer is yes. First, Western medicine derives primarily from Greek tradition. To maintain the continuity of the art requires understanding what our predecessors meant. One who knew only the romantic meaning of art might interpret the Greek adage “Art imitates Nature” to mean that plays should have realistic plots and statues should look like actual people. What the Greeks meant is much deeper. Oliver Wendell Holmes would have seen in that adage how the “extraordinary, abnormal impression” of draining an abscess improves on the natural process of expelling pus or how dialysis imitates the ultrafiltration of the kidney. Thus, “technology imitates Nature” would come closer to what the Greeks intended, and “skillfully used technology imitates Nature” hits the mark. Second, the use of only the romantic meaning of art would tend to restrict it to those parts of medical practice that cannot simply be put into words. Calling the intuitive part of medicine artand the technical part science is only a minor deviation from Hippocratic tradition, no worse a breach than referring to a sailor’s ship as his boat. However, the romantic sense of art carries with it strong connotation. To transfer the romantic notion that this portion of medicine is somehow higher than that which can be reduced to algorithm entails considerable risk. Such a transfer undermines the motivation for critical examination of medical practice. When the chief of medicine makes a difficult diagnosis because “the patient looks like he has Crohn’s disease,” we accept his intuition out of respect for his experience. We smile when the intern says he started an IV because “the patient looked a little dry,” but who would smile at the engineer who would set the gas tank in a car where it “looked” right? In the final analysis, such arguments have no more place in the art of medicine than in the design of the Pinto.
From the Deparlment of Pathology, Harvard Medical School and New England Deaconess ton, Massachusetts. Requests for reprints should be addressed to Dr. Frank A. Greco, Pathology, New England Deaconess Hospital, 185 Pilgrim Road, Boston, Massachusetts
September
1985
The American
Journal
Hospital, BosDepartment of 022 15.
of Medicine
Volume
79
279
l%g! *American
79
NUMBER
Journal
3
SEPTEMBER
1985
of Medicines EDITORIAL
!/Yt%me FRANK
Art of Medicine? A. GRECO,
he question arises because of the distinction commonly drawn in the assertion that medicine is an art, not a science. Today we associate art with creativity and inspiration and science with instrumentation and logic. In common speech, the expression art of medicine includes those aspects that cannot be measured or reduced to syllogism: the ability to sense and respond to a patient’s emotions; the “gut feeling” that something else is going on; etc. Often what physicians do bears striking resemblance to the creative efforts of artists. For example, the demands placed on a physician who must console the family of a dying patient are similar to those on a playwright who tries to guide his audience through a tragedy without destroying hope. However, this use of the word art in medicine is recent, deriving from the romantic era. The older, classical meaning of art is quite different. The ancient Greeks distinguished art from science not by the ratio of ingenious intuition to cold logic but rather by the goal of the discipline. The scientist worked simply to understand first principles, the artist to apply those principles for some constructive purpose. For example, the Greeks would have said that physics is a science, engineering an art, whereas we would more likely say that one is pure science, the other applied. The Greek word for art is techne and its English derivatives carry the original sense more clearly than its translation. To the Greeks, medicine was an art instead of a science because physicians studied nature for a practical end. Physicians as artists were the technologists, the engineers, of physiology. Oliver Wendell Holmes expressed this sense of art very clearly in a speech delivered to the Massachusetts Medical Society in 1860 [Currents and counter-currents in medical science. Boston; Ticknor and Fields, 18601. “Nature, in medical language, as opposed to Art, means trust in the reactions of the living system against ordinary normal impressions. Art, in the same language, as opposed to Nature, means an intentional resort to extraordinary, abnormal impressions for the relief of dis-
T
M.D., Ph.D. ease.” That most modern writers would use technology instead of art in this context can cause confusion. Is it important to distinguish the classical and romantic meanings of art? For two reasons the answer is yes. First, Western medicine derives primarily from Greek tradition. To maintain the continuity of the art requires understanding what our predecessors meant. One who knew only the romantic meaning of art might interpret the Greek adage “Art imitates Nature” to mean that plays should have realistic plots and statues should look like actual people. What the Greeks meant is much deeper. Oliver Wendell Holmes would have seen in that adage how the “extraordinary, abnormal impression” of draining an abscess improves on the natural process of expelling pus or how dialysis imitates the ultrafiltration of the kidney. Thus, “technology imitates Nature” would come closer to what the Greeks intended, and “skillfully used technology imitates Nature” hits the mark. Second, the use of only the romantic meaning of art would tend to restrict it to those parts of medical practice that cannot simply be put into words. Calling the intuitive part of medicine artand the technical part science is only a minor deviation from Hippocratic tradition, no worse a breach than referring to a sailor’s ship as his boat. However, the romantic sense of art carries with it strong connotation. To transfer the romantic notion that this portion of medicine is somehow higher than that which can be reduced to algorithm entails considerable risk. Such a transfer undermines the motivation for critical examination of medical practice. When the chief of medicine makes a difficult diagnosis because “the patient looks like he has Crohn’s disease,” we accept his intuition out of respect for his experience. We smile when the intern says he started an IV because “the patient looked a little dry,” but who would smile at the engineer who would set the gas tank in a car where it “looked” right? In the final analysis, such arguments have no more place in the art of medicine than in the design of the Pinto.
From the Deparlment of Pathology, Harvard Medical School and New England Deaconess ton, Massachusetts. Requests for reprints should be addressed to Dr. Frank A. Greco, Pathology, New England Deaconess Hospital, 185 Pilgrim Road, Boston, Massachusetts
September
1985
The American
Journal
Hospital, BosDepartment of 022 15.
of Medicine
Volume
79
279