Medicine: Balancing Science and Art

Medical school was tough. Not so much because we were learning how to care for patients, but that we were learning the minutia of the human body. The sheer amount of detail that goes into understanding physiology, anatomy, and how all the organ systems interrelate in disease is, to say the least, intense and often intimidating. Yet, we all learn the science and through it all we learn that a thorough understanding of this science can make you a great Doctor. Why? Because you may find the answer that someone else missed, solely because your knowledge base was superior. This concept of Medicine as a pure science permeates through the clinical years and well into training and formal practice settings, where the view is always that Evidence-Based Medicine holds the answers to all clinical questions, and that straying from this path is tantamount to criminality. Yet, interestingly, some of the best Doctors out there don’t always follow Evidence-Based Medicine to the strict letter of the law. They understand that while things usually follow a common course, patients are individuals and the human body is far too complex to standardize. So, we have a situation where younger Doctors and many in Academic Practice typically tout Science and Evidence-Based Medicine, while those older and more experienced physicians, including many in Private Practice, have relied more on their experience and observations. Ideally, one would meld the two, using the Science and Evidence as a guide, but never forgetting the Art of Medicine that only comes from being creative, thinking ‘outside the box’, and using what you and others have observed and experienced. As we move towards a more structured and regulated health care system, which by its nature focuses on cost containment at the same time as universal coverage, those in power have viewed the Science of Medicine as the best way to provide both. There is no mention of the Art of Medicine. Hence, we have strict rules for nuclear stress testing and appropriateness for PCI that rely solely on what scientific evidence exists for their use. Yet we all know the amount of Science and Evidence out there, while enormous, likely only supports 20% of what we as Doctors legitimately do in practice. The government and insurance companies take this to mean that 80% of what we do is inappropriate and not payable, when in actuality some of that 80% is inappropriate while the rest is completely appropriate and, in many cases, the standard of care. In my own practice, a small part of this comes into play every time I order a stress test. Because of the cost of nuclear stress testing and fears of inappropriate use (which granted has and continues to occur), the insurance companies have placed strict rules for their authorization. Yet, the criteria are static and limited while our patients are variable and diverse. And, we as physicians are caught trying to live within the “rules” of Science and Evidence while we continue to appropriately prioritize both the Science and the Art. The real challenge will be cost containment and universal coverage while leaving leeway for the Art of Medicine. Can it be done? I think so, and progressive insurance companies should look for ways to do this going forward. If not, then cost will surely be contained at the expense of quality, creativity, optimal patient care and outcomes. Dr. Srihari S. Naidu is Director of the Cardiac Catheterization Laboratory, Interventional Cardiology Fellowship Program and Hypertrophic Cardiomyopathy Center at Winthrop University Hospital, and Assistant Professor of Medicine at SUNY – Stony Brook School of Medicine.