Friday, November 4, 2011

Preserving the Art of Medicine, When The Science is Paint-By-Numbers

The art of medicine, the ability to be therapeutic in your relationship with your patient's is rarely discussed as fundamental to the modern practice of medicine. Medicine is reputed to be a scientific discipline and the driver for evidence based medicine the desire to control costs by standardizing evaluations, treatments, and outcomes.

What if medicine were truly more an artistic endeavour than a scientific one? While my practice is grounded in clinical science and a rational world view, I find as I have matured in my art, I am more artistic and artful in practice than scientific. I am a great believer in the usefulness of patient relevant clinimetrics and the power of the clinical trial of n=1. Medicine practiced scientifically is all about careful serial observation of the patient in response to thoughtful and physiologically justifiable therapy.

However, increasingly I feel as if I were Vincent Van Gogh forced at the height of my powers to only produce Governmentally sanctioned color-by-the numbers artwork. The defining characteristic in my view of the 'Velvet Elvis' is it's quintessential mechanical reproducibility. Having seen one, you have seen them all. While a Van Gogh has stylistic similarities, family characteristics that make it recognizable as his art, it is hardly mechanistic nor predictable nor kitsch.

Do patient's really wish to have their medical care delivered as an industrial product, or do they instead wish to have an experience with their doctor more akin to a romance than an encounter? I of course do not mean a romance in the conventional fashion, erotic in nature, but rather an emotionally satisfying experience in which rapport amplifies the therapeutic efficacy of the drug or treatment prescribed.

This is then the art of medicine, the development of rapport and the transmission of genuine concern and interest in the patient and the patient's outcome. This is the sole requirement to keep Evidence Based Medicine from an inevitable trajectory that leads to a dystopia as envisioned in Alan E. Nourse's science fiction classic 'The Blade Runner.' (http://www.sf-encyclopedia.com/entry/nourse_alan_e).

The recent recall of Xigris is only the most recent example of the unhappy result of having the science of medicine become tainted by the business of medicine. (http://saltycurrent.blogspot.com/2011/10/corporate-ethics-xigris-example.html) When an ever increasing proportion of medical research is funded by Pharmaceutical and Device companies, the objectivity of clinical scientists becomes more suspect. In particular Xigris, was explicitly and prominently recommended for use in patient's with Apache II scores of > 25. The fall out from this affair is only the latest in a series of scandals that periodically highlight the problems with mindlessly and diffidently accepting the evidence behind the evidence based medicine movement. Recall the outrage attendant to the revelation that some data used in the National Surgical Adjuvant Breast and Bowel Project was fabricated. (http://articles.latimes.com/1994-04-14/news/mn-45830_1_breast-cancer-research)

Along this line, a truly valuable and profound meta-analysis 'How Many Scientists Fabricate And Falsify Reserach? Systematic Review and Meta-Analysis of Survey Data' (http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0005738) suggests a lower limit of 14% for falsification of data and a 72% rate for 'questionable research practices.' Given these rates of self-admitted intellectual dishonesty as demonstrated by anonymous surveys, it behooves the artistic medical man to be relentless in questioning today's evidence based guidelines especially if they fly in the face of his practice experience or the grounded basis of well established scientific principles.

That is not to say that guidelines are not in their own right a useful intellectual exercise, a convenient way to summarize and encapsulate a broad body of relevant clinical research, and useful tools in the pursuit of superior outcomes. But they are tools and guides not an end in themselves.

High quality medicine and superior outcomes involves not slavish adherence to a possibly irrelevant guideline, but the intelligent and active elucidation of the patient's true problem(s) combined with a creative and artistic pursuit of an optimal individualized treatment plan for a unique and vulnerable human being. While perfection is never realized in medical practice, it is practice after all, there is never in this writers viewpoint ever a justification for giving less than your all for your patient. It is never justifiable ethically to argue that your human fallibility is a justification for an adverse outcome. Ultimately, the sense of responsibility for the individual outcome, is in my view the best way to assure a positive outcome.

This then, a sense of artistic integrity, the sense of being true to your own best impulses and the altruism that for millennia has characterized the profession of medicine is ultimately the engine for superior outcomes and a satisfying career in medicine.

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