Where is the art in medicine?

[officedepot]

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[MilkmanAl]

I think you're just not looking for the art very hard or can't recognize it when it slaps you in the face. Everyone I've worked with has preferred drugs and treatments and whatnot. That is especially true for surgeons of all kinds where everyone has his favorite instruments, antibiotics, techniques, etc. Go over to the other side of the curtain, and you'll see some improvisation on nearly every case.

 

[Mattchiavelli]

Plastics definitely- you get many consults that are general and it's really up to you to determine how to take care of them. You get stuff like "Coverage of lt hemithorax s/p thoracotamy" and "coverage of unstageable sacral ulcer" and the people I worked with on my plastics rotation all really liked the field for that reason. I think psychiatry has a lot of art to it as well. Each case really must be looked at as unique because diagnostic categories can be a little broad like the wide range of presentations on the autistic spectrum. Physical exams in all fields (including psychiatry's AIMS scoring) involve visual appreciation skills that can be improved by art appreciation Study from Academic Medicine --> http://bit.ly/rSe0YH

I think a lot of the art for medicine in general comes in the interaction with patients, like how do you get the patient to agree to let you perform the algorithm-driven workup and therapy that is considered standard of care? How do you work around comorbid diseases? Evidence based medicine is great but a lot of it involves diseases studied as controlled for as possible. When you have patients with multiple issues, you have to use clinical judgement that you will develop from experience to decide what gets the priority in treatment for the goal in mind.

 

[Valadi]

Plastics definitely- you get many consults that are general and it's really up to you to determine how to take care of them. You get stuff like "Coverage of lt hemithorax s/p thoracotamy" and "coverage of unstageable sacral ulcer" and the people I worked with on my plastics rotation all really liked the field for that reason. I think psychiatry has a lot of art to it as well. Each case really must be looked at as unique because diagnostic categories can be a little broad like the wide range of presentations on the autistic spectrum. Physical exams in all fields (including psychiatry's AIMS scoring) involve visual appreciation skills that can be improved by art appreciation Study from Academic Medicine --> http://bit.ly/rSe0YH

I think a lot of the art for medicine in general comes in the interaction with patients, like how do you get the patient to agree to let you perform the algorithm-driven workup and therapy that is considered standard of care? How do you work around comorbid diseases? Evidence based medicine is great but a lot of it involves diseases studied as controlled for as possible. When you have patients with multiple issues, you have to use clinical judgement that you will develop from experience to decide what gets the priority in treatment for the goal in mind.

Was going to suggest these 2 as well. Had a tough time deciding between psych and plastics for awhile. With the exception of microsurg, which is a lot more 'labor' than most plastics cases, it's a field that teaches techniques rather than an operation.

 

[surftheiop]

Surgery seems like an obvious place, also I feel like I've seen a fair amount of "art" in peds and psych.

In peds its an art just to get a physical exam done or to get consent from parents.

In psych the interview is so critical which seems to be a quite an art. (Granted im sure there are plenty of people in psych who get lazy and just whip out the prescription pad after 30 seconds, but if your going to do it right it seems like quite an art.)

 

[Barcu]

I think the lawyers stole the crayons

 

[El Dooderino]

you'll soon realize most of the "evidence" these algorithms are based on is complete garbage. Then you'll use a drug that the "evidence" loves for a couple of years and be a genious until a new study comes out to tell you you were an idiot for using that drug. Then two years later a new study will come out telling you, wait, nevermind, that drug is actually great. Then a year or two later it will get pulled off the market for some reason or another. The more you read medical literature the more you see how big a bunch of crap ebm is. I understand why the old docs laugh behind our backs about this stuff and how ridiculous med schools are to teach students how everything should be "evidence-based"

 

[PMPMD]

you'll soon realize most of the "evidence" these algorithms are based on is complete garbage. Then you'll use a drug that the "evidence" loves for a couple of years and be a genious until a new study comes out to tell you you were an idiot for using that drug. Then two years later a new study will come out telling you, wait, nevermind, that drug is actually great. Then a year or two later it will get pulled off the market for some reason or another. The more you read medical literature the more you see how big a bunch of crap ebm is. I understand why the old docs laugh behind our backs about this stuff and how ridiculous med schools are to teach students how everything should be "evidence-based"

e.g., Xigris

As stated above, there are holes in the algorithms big enough to drive a truck through.

 

[Mattchiavelli]

e.g., Xigris

As stated above, there are holes in the algorithms big enough to drive a truck through.

haha, you know they no longer make that- I am training in the city with Lilly's HQ and I've never seen it given in the ICU, only joked about.

Being able to joke about Xigris is also part of the art of medicine

 

[PMPMD]

haha, you know they no longer make that- I am training in the city with Lilly's HQ and I've never seen it given in the ICU, only joked about.

Being able to joke about Xigris is also part of the art of medicine

Yeah that's why I mentioned it, b/c when I was an intern it was the next big thing, then as a fellow it got dropped like it's hot.

 

[officedepot]

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[Aesculapius]

Almost no patient fits the clinical trials that evidence-based medicine is based on, and taking care of actual patients is far different from reading about them in textbooks. Remember also that much of the time, diagnosis is simply, at the end, what a very well educated person thinks is the most likely cause of a particular problem- not what a laboratory test (which, by the way, sometimes may also have subjective components) spits out. The art is in the gaps.

 

[MilkmanAl]

in my opinion slight deviations from a standard algorithm or just using slighly different instruments to do an operation are not "art"

I'm wondering where the uniqueness is. The small things that make a difference.

So...small things don't make a difference, but you can't find the small things that make a difference?

 

[Butler]

It is all about the small things that make a difference. A small PE finding that the attending missed. A certain depth and placement of stitches in an artery. A small nodule on a mammogram that the other radiologist missed. These seemingly small things could make a huge difference. Maybe that finding leads to the right diagnosis and life saving treatment or maybe that preference for stitch technique and depth keeps the artery from rupturing or maybe the breast cancer is caught early before it metastasis and kills the patient. Aren't the small details the most important part of reading a scan; as someone interested in Radiology, you tell me Depot . Devil is in the detail as they say. Just because every procedure isn't on the cutting edge of medicine and research anymore doesn't make it less "art" or exciting. Talk to retired docs that worked decades ago. They are amazed about the stuff that is commonplace in today's medicine and I am sure the same will be the case for us when we are all old retired docs.

 

[adaptation1]

ummm...milkman was simply pointing out an apparent contradiction in officepost's post. in fact he was the one suggesting that the small things were the ones that constituted the artistic side of medicine....

It is all about the small things that make a difference. A small PE finding that the attending missed. A certain depth and placement of stitches in an artery. A small nodule on a mammogram that the other radiologist missed. These seemingly small thing could make a huge difference. Maybe that finding leads to the right diagnosis and life saving treatment or maybe that preference for stitch technique and depth keeps the artery from rupturing or maybe the breast cancer is caught early before it metastasis and kills the patient. Aren't the small details the most important part of reading a scan; as someone interested in Radiology, you tell me Depot . Devil is in the detail as they say. Just because every procedure isn't on the cutting edge of medicine and research anymore doesn't make it less "art" or exciting. Talk to retired docs that worked decades ago. They are amazed about the stuff that is commonplace in today's medicine and I am sure the same will be the case for us when we are all old retired docs.

 

[Butler]

ummm...milkman was simply pointing out an apparent contradiction in officepost's post. in fact he was the one suggesting that the small things were the ones that constituted the artistic side of medicine....

I was refuting Depot's claims. I realized in hindsight it was confusing that I quoted milkman. I edited it .

 

[adaptation1]

o gotcha!

I was refuting Depot's claims. I realized in hindsight it was confusing that I quoted milkman. I edited it .

 

[Dharma]

Don't underestimate the art of diagnosis; it does go beyond ordering the correct tests, especially regarding the physical examination. Check out "Every Patient Tells a Story." Lots of interesting cases in that book.

 

[Telencephalon]

Even deciding which algorithm to use can be an art.

You may have an awesome algorithm for how to treat a a tumor based on its grade and stage. But grade and stage aren't handed down from on high. They are based on Pathologists practicing the art of comparing what they know about normal cellular features to those of your patient's tumor. Or radiologists practicing the art of identifying what radiographic changes represent likely metastasis.

 

[officedepot]

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[Spatula]

Do algorithms account for cost of procedures/medications and balancing various side effects? Where on the flow charts does it have "Is the patient an artist and would not be pleased with a hand tremor?".

 

[loveoforganic]

Patient education/counseling/behavior modification

 

[MilkmanAl]

well guess I didn't make it clear in the first post. What I meant by "small things that make a difference" I was implying that small deviations from an algorithm or using slightly different tools in an operation to achieve the exact same outcome is not what I would consider art. But hey that's just me. I'm glad people get a kick out of the "art of sewing", otherwise we would have no surgeons...

Again, I think the problem is that you're not recognizing the art when you see it. All of the things you listed as artful are "slight deviations from an algorithm." Do you really think transplant surgeons go in without a very definite plan of action that's predetermined by existing literature? Yeah, they troubleshoot like mad when things go wrong, but so does just about every other specialty.

 

[Evergrey]

Read this, officedepot. It explains where the art in medicine is.

http://ohiosurgery.blogspot.com/2010/02/jd-salinger-and-doctors-of-tomorrow.html