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President's Message -- Medicine: Art Versus ScienceN.H. Tucker, III, M.D., President |
| Medicine is an art. Medicine is a science. We all know this but over the ages this art/ science ratio has undergone a dramatic change. Using the 20th Century retrospectoscope, it would appear that medicine in the past was predominantly art with only a smattering of science thrown in. For example, during the European bubonic plague epidemics of the 14th century, the art practiced was "bleeding" the plague victims. The rationale for this was based primarily on the teachings of the Greeks Hippocratus and Galen, and of the Persian Avicenna. It was felt that the human body had four humors — blood, phlegm, yellow bile, and black bile. Each humor came from a specific organ — blood from the heart, phlegm from the brain, yellow bile from the liver, and black bile from the spleen. As long as one's bodily humors were in equilibrium, one was in good health. Illness occurred if one's bodily humors reached a state of dysequilibrium. The medieval physician's role was to restore this equilibrium and he did so by recommending rest and diet, and if this failed, he would proceed with various forms of bloodletting. Medicine at the time was based on Greek theory and philosophy rather than scientific observation. Physicians seemed to make no connection between the abnormally large number of dead rodents and the subsequent development of the bubonic plague and were ill prepared to have any effective impact on the recurring plague epidemics. One effect of these repeated bubonic plague outbreaks was the development of the "scientific method" which began at the University of Padua in the 15th century. Human dissection was occurring and, as a result, human anatomy was becoming both more accurate and important, as was surgery. The emphasis in medicine was changing from philosophy to practical physical science and anatomy. It is felt that practical surgery and anatomy were, at least in part, an important component in the development of the scientific method. The scientific method consisted of identifying a problem, postulating a hypothesis, testing the hypothesis by (most importantly) observing and experimenting, and then interpreting the data and drawing a conclusion. This became the basis for modern experimental science and in turn the basis for modern accurate medical science. With the invention of Laennec's stethoscope, Leeuwenhoek's microscopic methods, and Roentgen's x-rays, science was becoming more and more important in medicine. Harvey's scientific study of human circulation, Koch's scientific studies of microbes causing human diseases, and the Curies' studies of radium all were important medical advances based on science. Of course there have been many more than the few mentioned here. During the late 19th and early 20th centuries, Sir William Osler was recognized as one of the greatest medical teachers of all time. He strongly influenced the organization of the clinic at Johns Hopkins Hospital in Baltimore and perfected teaching medical students at the patient's bedside. He taught them the art of medicine utilizing the stethoscope, physical exam, and patient history with "the patient as his text." This possibly was the art of medicine at its finest. I had the good fortune to train under Tinsley Harrison of textbook fame, who was an outstanding medical educator at the University of Alabama during the 1950's, 1960's, and early 1970's. He was a clinician in the mold of Osler. He felt that most diagnoses could be made at the bedside by good detailed history taking and the use of the stethoscope and physical exam. He was a master at the nuances of murmurs, clicks, and bruits and it was amazing how he would usually have made the diagnosis before the lab and imaging results were known. Dr. Harrison was on the front line of the art versus science evolution. He felt that medical students and residents were becoming much too dependent on the various machines and technologies available and as a result were losing the art of being able to diagnose and treat at the bedside. Today, science and newer and newer technologies are obviously proliferating and changing the way we practice. We have excellent clinical trials to guide us and outcomes measurement studies are beginning to validate the usefulness of what we do. The gold standard for practice guidelines is to base them on scientific evidence. But, the caveat is that so much of what we do has not been scientifically studied, and even that which has requires clinical judgement as to the various options. The medical pendulum is swinging from the art to the science side. However, in my opinion, the best clinician is one that, armed with his scientific knowledge, practices using excellent clinical judgement (which of course is his art). Compassion and understanding are a large part of this art. References
December, 1999/ Jacksonville Medicine |
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