Medicine is an artful science

I recently saw a patient with cancer who came to the emergency room complaining of shortness of breath, who was coughing up small amounts of blood, had a racing heart and sharp chest pain that was worse when he took a deep breath. In deciding the likelihood that this patient had suffered a clot in his lungs, I turned to the Well’s criteria for predicting its probability in order to help direct the appropriate diagnostic testing. The score indicated that this patient was at high risk for a clot, and recommended the use of a CT scan with intravenous dye to investigate whether this was the case. Unfortunately, the test confirmed my suspicions, and so he was started on blood thinning therapy to prevent further clots. It was a clear example of the power of using evidence-based medicine (EBM) to direct effective patient care.

After trying to explain this success to my Dad, he asked me if doctors are allowed to ”think” these days and use their judgment in treating patients, instead of using a scoring system to tell them what to do? Are we relying solely on algorithms to direct our patient care?

In medicine, we are taught to use approaches to clinical presentations; these are a list of possible diseases that could cause a particular symptom that a patient is complaining of. We then organize these into categories usually based on the location of the organs in the body that could be causing the symptoms (although there are many other ways of doing it). This is used as a memory aid, and also as a flowchart to help us arrive at the most likely diagnoses. For example, if a patient is complaining of chest pain, we think about the heart, the lungs, the esophagus and the chest wall as possible sources of the pain.

We then use evidence from large studies to highlight the most important parts of the patient’s clinical history and physical exam to facilitate the creation of our differential diagnosis (i.e. the nature of the chest pain, the things that provoke it etc.). Diagnostic tests are then ordered based on this list to rule in/out the set of proposed diseases. This testing is also directed by large studies that determine which are the best tests to make a diagnosis (or rule another out). When we confirm the diagnosis, treatments are often directed by the corresponding specialty’s published, evidenced-based guidelines (The Canadian Cardiovascular Society guidelines on drugs for use in heart attacks, for example). Indeed, one could describe this process as algorithmic.

And it all sounds quite simple to follow, doesn’t’ it?

But my experiences as a medical student have highlighted that medicine is both an art and a science. The classroom teaching of the approaches to clinical presentations and the evidence to support it are fundamentally the science of making a diagnosis. Following an algorithm however, is not enough to provide good patient care. The application of the science of medicine can be perilous when not balanced by the art of medicine:  thoughtful clinical judgment combined with attention to, and respect for, patients values and well-being.

Clinical scoring systems like the Well’s criteria are taught to medical students and junior trainees because they are valuable tools when used correctly. Often students are not familiar with the studies that validated the score and are therefore not familiar with the study population and clinical setting in which the score was derived. This is essential in ensuring it is applied to the correct population of patients, which means that its results may or may not apply to the patient in front of you; and an incorrect application of a scoring system lessens or even nullifies its utility.

Part of our later education as residents is to teach us to critically appraise the literature, to determine the strength of a study and thereby make conclusions about its application to our clinical practice. Without this training, we would be blindly inputing patient variables into a clinical calculator. The outcome of an incorrectly applied score is much the same as the improper use of a calculator in a physics problem – it will always provide a numerical output, but it is up to the operator to determine (to think!) whether it makes any sense in the situation at hand.

The art of medicine is a concept that is not easily taught in the classroom, nor is it readily quantifiable in a physician who is particularly good at it, which makes it all the more difficult to define. My experiences as a clinical clerk thus far have led me to believe that “the art” comes with continued clinical experience and excellent senior mentorship.

For me, the true art of medicine lies in a physician’s ability to be aware of the bigger picture when faced with a clinical problem, to use value judgments when making the appropriate evidence-based decisions. This idea is described by Dr. Guy Gyatt (who coined the phrase evidence-based medicine) in a recent interview:

The initial areas of focus for EBM were the identification, critical appraisal and summarizing of evidence. However, evidence alone is not sufficient to make clinical decisions. They must not only attend to the best available evidence, but also to the values and preferences of the informed patient. [This] refers not only to the patients’ perspectives, beliefs, expectations, and goals for life and health, but also to the processes individuals use to consider the available options and their relative benefits, harms, costs, and inconveniences.

So Dad, I’d say that when I’m working on the wards or in the clinics and seeing my patients, I rely on the scientific approach to recognize and treat their conditions; but I am always trying to think about how to best fit that approach to their specific needs in the circumstances at hand.

The comments section is closed.

  • Alex Huebner says:

    I really like this explanation of how doctors are taught to integrate their technical physiology/anatomy knoweledge with EBM practices and the ‘creativity’ or wisdom they develop through many cases, continued reading, professional development and trial and error. This builds not only confidence, but the expertise to be able to ‘think outside the box’ when it comes to tough cases or determining the best-fit and personalized treatment for each patient.

    This mentality and practice is one of the underlying practices and principles of complimentary medicine. Many variables can mask or misdirect a diagnosis that it is hard to narrow down each patient’s symptoms and illness to one study or a diagnosis criteria rubric.

    The prolonged process of targeting root causes and trying personalized care for each patient takes time, whether through customizing dosage with your MD or working with an ND on lifestyle or nutrition. Right from the get go in the ED, heath professional needs to work as teams, sharing knowledge and integrating healthcare plans for patients master the art of medicine.

  • Rola Priatel says:

    Good article. I also see intuition as a large aspect of the Art of medicine! EBM is the core , almost the value, that health professionals should base their practice decisions on, but I see a portion of the art component as that inherent intuitive sense! Some have it and some don’t!

  • Kieran Quinn says:

    Hi Brian,

    Thank you for taking the time to respond to my article. My apologies if I wasn’t clear in the piece itself: the ‘art’ of medicine as I see it, is exactly as you described when you said it is the, “practical knowledge and skills that physicians gain through years of practice, through on-the-job learning and reflection.” It is this aspect that must be applied to the ‘science’, which is the clinical research we use to define our approaches to clinical problems, and the evidence from them used to direct therapy for our patients. In this way we learn to make value judgements in the best interest of our patients from both the scientific and individuals perspective.

    Your discussion of innovation in medicine, I think, can be a component of both the art and science. Innovation is critical in the lab where new therapies are forged, just as it is equally important in fitting the treatment plan to a given patient. You are absolutely correct that is the fundamental aspect to advancing the practice of medicine, and one that I take great joy in being a part of.

  • Brian Orr says:

    Kieran is right in identifying that medicine is more than a science and definitely requires a great deal of knowledge and judgement. However, the idea that medicine is a mixture of art and science over simplifies the situation as it fails to include a key missing component. Medicine is a profession that requires a solid foundation in science including clinical research. The missing piece in the article is the great deal of practical knowledge and skills that physicians gain through years of practice, through on-the-job learning and reflection, which is the craft critically important to the quality of care provided to patients. There is an art component to medicine, which is the creative insight and novel development of practices. The “art” portion is probably the least important of the three components in the day-to-day practice of medicine, although absolutely critical to advancing medical practice.

    • Jeremy Petch says:

      I think you and Kieran are saying largely the same thing. He uses the term 'art' in a very broad sense, to capture the kind of learning one acquires through clinical experience, which is quite different in nature than learning through experimentation and the review of RCTs. He could probably as easily have spoken in terms of the difference between knowledge and wisdom. While medical school can teach the former, the latter is just as important, but must be cultivated differently.

  • Andrew Holt says:

    Thank you Kieran for bringing a very human face to the challenging decision making environment physicians must navigate every day with their patients and colleagues. In my experience, truly exceptional physicians (and other health professionals) seamlessly integrate their humanity and a deep respect for each patients values into their highly developed evidence based decision making.


Kieran Quinn


Kieran Quinn is a general internist and palliative care physician at Sinai Health System and an early career health services researcher affiliated with the University of Toronto and the Institute for Clinical Evaluative Sciences (ICES).

Republish this article

Republish this article on your website under the creative commons licence.

Learn more