"Wherever the art of Medicine is loved, there is also a love of Humanity." -- Hippocrates
Medicine has always had a close relationship to the liberal arts. Many great thinkers have been physicians: Aristotle, Maimonides, Linnaeus, Darwin, Freud. And some great writers: Rabelais, Schiller, Keats, Chekhov, Conan Doyle. And there have been physicians who write with great eloquence about disease and medical practise: Hippocrates, Galen, Burton, Sydenham, Osler, Thomas.
Healing has until recently been mostly art, usually unaided by scientifically proven treatments that could actually heal. In fact, most of the treatments delivered during the thousands of years of medical history have been much more harmful than helpful. Think bleeding, emetics, cathartics, and heavy metals like arsenic and mercury. Doctors remained popular and prestigious even when they were engaged in activities that made their patients miserable and sometimes killed them.
The best doctors were those who followed the advice of Hippocrates to pay attention to the patient, not just the disease, and to render treatments that would first do no harm. They formed healing relationships with patients, understood their needs and psychology, and helped them mobilize natural resiliency to face and fight illness.
A physician was expected to cultivate wide knowledge of people and the world.
The relationship between medical art and science is changing rapidly, with the science now overwhelming the art. Doctors more and more function like technicians, not healers.
This would be fine if the advancing science were actually providing the technical tools to effect healing without a continuing need for medical art.
But sadly, this is usually not the case. Medical treatments are still often over sold and over bought -- technical fixes that don't really fix and too often have their own set of harms.
For most diseases, we have made little progress in the crucial translational step from basic science to clinical practice. We have learned a great deal about how the body works, but much less how to use this knowledge to promote cure.
Modern medicine is much more evidence-based than ancient medicine, but too often is not less dangerous- medical mistakes are the third leading cause of death in the US and usually arise because no one really knew the patient.
And as doctors gained in science they have lost in art; often they treat the lab tests, not the patient. The precious and powerful doctor/patient relationship is lost in the excessive application of unnecessary, even quite harmful, medical technology. Nicholas Capozzoli is the wisest doctor I know. A practising neurologist, he is also on the teaching faculty in the great books curriculum at St Johns College in Annapolis Maryland. He is well equipped to describe how the humanities can help us regain the human dimension in medicine. Dr Capozzoli writes:
"The ability to listen and empathize are crucial to the therapeutic doctor-patient relationship and yet these skills are undervalued and often ignored in traditional medical education.
Perhaps this is because these virtues are not easily taught, but rather are best acquired through life experience and through emulating those we admire.
Barely into their 20s, medical students have not had the life experiences and mentoring to give form to the barrage of scientific data, lab work and protocols which are thrown at them upon arrival to medical school.
The humanities can help substitute for the vacuum in lived experience. Great literature, philosophy, history, and movies are great precisely because they teach us about the meaning of life and how best to understand and respond to the needs of our fellow men and women.
Artistic depictions of human interaction, life and death, hope and despair, stand as ready resources for discussion and example as students try to sort out their role as healers in an increasingly technical milieu.
Of course, understanding the technical nature of illness will always be critical and not to be discounted. But illness is not something out there in a textbook- rather it is always happening to individuals, to persons not cohorts or study groups.
As physicians the person, not just the illness, should always remain our primary concern. Beyond diagnosing and treating symptoms, we must consider this person experiencing them. We can provide the best treatment and avoid mistakes only if we treat the whole patient, not just this or that symptom or lab test.
My love of the humanities has served me well in understanding those who come before me for help. Nuance and conversation, exploring questions together, and accepting that they may not always have a clear and certain answer are notions that are second nature to the student of liberal education. In our minds, uncertainty doesn't mean futility. Rather the process of working together is itself fulfilling and we will be better off accepting uncertainty than prematurely reaching false certainties.
Who better than Tolstoy, Joyce, Shakespeare and Homer to describe the human condition. Who better than Thucidydes to describe the alienation that comes with disease and death. Learning about life and death should be as integral to the student's medical education as Harrison's textbook of medicine.
The classes should be led by physicians, not professors in the humanities. Students should see the humanities teaching as integral to medical education, not an exotic add on."
Thanks, Nick. Medical schools seem finally to be catching on to the fact that illness does not occur in a vacuum and that its treatment is more than just a technical quandary.
The entrance exam used to select medical students is broadening its scope to include more questions on psychology and sociology. Hopefully, this will be just a first step in reversing the powerful technical trend that has transformed our flesh and blood patients into a set of laboratory report numbers.
Someday, perhaps all of medicine will be reducible (like most things) to a set of algorithms and doctors will be replaced by computers. But we are still far from achieving anything approaching this level of technical omniscience and certainty. For the far foreseeable future, we need doctors who understand life and people, not just lab test readouts and scientific papers.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.