Is the science of medicine superseding the art?
In the November issue of the GME e-Letter, we described rising concern whether medical science now overshadows the art of medicine, to the detriment of the doctor-patient encounter.
In a recent New York Times article, for example, Abraham Verghese, MD, argues that an overemphasis on technology and test results can supersede the invaluable personal connection made during the physical exam.
In JAMA, John J. Frey III, MD warns that rigid templates and copy/paste medical records can mask the personal patient narratives that reveal the human behind the symptoms of one's illness.
A recent blog posting by Susan Skochelak, MD, MPH (on the AMA's New Horizons in Medical Education forum) describes how technologies (even those as mundane as surgical gloves) may interfere with communication, compassion, and healing.
In response, we received the following comments from readers of the e-Letter.
It is a rather limited view of science to equate it with efficiency and safety. The problem of technology distancing patients from doctors is at least as old as Laennec and his stethoscope. It seems to me that we don't have enough science in our medicine, but more importantly, it is critical for doctors to have a scientific outlook, and to oppose this to art or humanism is a false dichotomy. There is nothing unscientific about the physical exam.
Having taught internal medicine for 30 years, it is wonderful to have CT scans, cardiac ECHO, and MRI scans to probe the recesses of the body, but it is shocking to me how poorly residents and students are at doing physical examinations. They will allow radiologists five minutes to agonize over whether there is a cutaneous fistula on a scan, when all they needed to do was look at the patient. Feeling pulses are a thing of ancient history, as is examining lymph nodes.
The residents and interns often do the exam together now, to save time. The fault is not in the students but in the time constraints imposed by duty hour regulations. I pity the public in the next decade.
It is clear that medical students and house staff members lose some of their enthusiasm and passion for “helping people” over the course of their education. I’ve taught a lot of medical school freshman over my 35 years as an academic, and they come to those early sessions with a huge amount of enthusiasm for human interaction that I do not see in them as much when they are residents.
However, I doubt that this can be laid—at least entirely—on the influence of technology over humanism. It seems to me that testing and technology can peacefully co-exist with the physical exam of talking with, and listening to, patients.
Medical students and first-year residents just seem so overwhelmed with all of the work—both the work it takes to learn and that involved in patient care. Then too, their faculty are pulled in multiple directions by the need to make clinical dollars, submit grant applications, perform research, write and submit papers, and administer programs, so they have less and less time to devote to the students and house staff—and learners tend to emulate their teachers. Learners and teachers alike shut down some of their curiosity and human interaction because of the exhaustion that comes with too much to do, too many tugs at their time and talents, and too many deadlines and obligations. It is the rare person who can really balance “a life” with the needs of a profession such as medicine, even though we talk about how one might do so all the time.
Concerning the diminishing role of the art of medical practice, the information you provide is not at all new. Science, technology, the rising powers of drug companies, the establishment of HMOs, the relegation of doctor-patient encounters to nurse practitioners and physician assistants, the changing conception of the physician as health care provider to a health care provider of unknown qualifications—all of these trends have overwhelmed the physicians in solo practice and eliminated the art of medical practice. In its place are hospitalists and clinical offices with doctors being employed by large university medical centers, attuned to science and technology.
The role of physicians giving one-on-one care to patients is gone for good. It is a great pity. That is what deters me from returning to medical practice. In the late 1970s and up to mid 1980s I used to make house calls!
Now so many nonmedical people—people with business degrees—are dictating how a physician may practice his or her craft or calling and are placing the physician under close scrutiny through a growing number of committees, rules, and regulations.
Progress in science and technology are good signs in a nation, but when the technological science is used entirely for business, then I would say that business in essence has no place in medicine. When I studied medicine there was no place in the curriculum about business; today’s its role in medicine has become too large and threatens to undermine the art of medical practice, to the ultimate detriment of the patient.