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.