MEDICINE, ART OF

In the art of medicine physicians themselves become the diagnostic and therapeutic instruments that apply the knowledge and skills of medicine. The art of medicine includes not only what is required for a physical diagnosis and for healing, but also the ability to apply the generalized knowledge of medicine and medical science to individual patients. This latter aspect includes knowing the particularity of the patient, knowing how to shape the doctor's knowledge of medicine to the particular patient, and developing the relationship between patient and doctor. Discrete skills serve these goals, among them understanding the behavior of patients and doctors, using the doctor-patient relationship for diagnostic and therapeutic ends, good judgment and decision making, and effective communication.

For bioethics, considering the art of medicine offers challenges because aspects of the art arise from the singular traits of sick persons and the special character of the doctor-patient relationship. These put in doubt the validity of some ideas about patients' independent self-representation and self-determination that have been important in the recent development of bioethics.

In this context art does not refer to the general meaning of aesthetics or the fine arts. Instead, it is derived from the Greek word techné, meaning craft or skill. This distinction is important because it is commonly said, in error, that the art of medicine cannot be taught. Crafts and skills are said to be learned from others. The ancient Greeks classified medicine as one of the original arts, along with weaving, carpentry, and geometry. On the other hand, mere skill is not all there is to this art, which must be served by a deeper practical understanding of its complex subject, as in Aristotle's phronesis (sound, considered judgment) or the Hippocratic phrase, "Life is short and the art is long." It was only with the rise of science in the seventeenth century that the term began to have its current meaning of the personal skills of physicians. In the twentieth century, the "art of medicine" has been sharply distinguished from the "science of medicine" and has come to have a somewhat pejorative connotation.

The Effects of Science on the Art of Medicine

The identification of the art of medicine with subjectivity and particularity is what has led to its recent loss of stature. It has been an article of faith of medical science in the twentieth century that objective scientific evidence would eventually replace the subjectivity of the transaction between an individual patient and physician. A further canon of medical science is that the knowledge and the science make the diagnosis and effect the treatment. The individuality of the physician is irrelevant; doctors are interchangeable. However, as Samuel Gorovitz and Alasdair MacIntyre have pointed out, generalizations of scientific medicine from systems that may not involve humans and by abstraction from observations of particular patients must be reparticularized to this patient, at this time, in this context, by this physician (Gorovitz and MacIntyre). In the care of sick persons, there are no sharp distinctions between medical science and the art of medicine, since both kinds of knowledge reside in the individual physician. It is his or her individuality that allows the physician to practice the art of medicine. An impersonal agency like a computer can deploy the science of medicine, but a particular doctor must adapt this knowledge to an individual patient. To do this appropriately requires both tacit and manifest knowledge within the doctor.

Patterning knowledge to the patient is generally known as medical judgment—acquiring and integrating both subjective and objective knowledge to make decisions in the best interests of the patient. Recent advances in studies of the theory and practice of medical decision-making do not fully encompass clinical judgment, because they have focused more on solving problems that arise from the uncertainties of medical information than on the consequences that follow from the relevance or meaning medical information may have for the particular patient.

The tendency of physicians and medicine to conflate the patient with the disease obscures the importance of the art of medicine. It is impossible, however, for physicians to confront or treat diseases. Because they can only treat the patient who has the disease, the art of medicine will always be essential.

How the Individuality of the Patient Makes a Difference

THE DISTINCTION BETWEEN DISEASE AND ILLNESS. Disease is the pathoanatomical or pathophysiological entity that manifests itself in symptoms that the patient experiences and the doctor discovers (Cassells, 1985a). Diseases are abstractions that have no concrete existence except as instantiated in particular patients. Illness is the patient's experience of the effects of the disease process; it includes not only the symptoms—alien sensations or perceptions of distorted function—but the interpretations and meanings of the symptoms. The illness also embraces the impact of altered function on behavior and social existence. It is the illness that the patient presents to the physician as reported symptoms and dysfunctions. While the physician may be primarily interested in the disease, the ethicist should be concerned with the illness because of its effects on the patient, his or her relationships, and the community that put in doubt the moral agency of the sick person.

THE EFFECTS OF THE INDIVIDUALITY OF THE PATIENT. Onset, course, treatment, and outcome of identical diseases vary from patient to patient because of individual variation from the molecular level to the whole person to the community. The contribution of the individual to differences in his or her illness is sometimes difficult to appreciate if one thinks only about the acute infectious diseases or trauma. Chronic diseases, which produce the greatest burden of illness in the U.S. population, provide better examples. For example, diabetes in adults is genetically determined, but its severity and manifestations are influenced by variation in diet and exercise pattern from person to person. In addition, the availability, type, and utilization of medical care play parts in the effects of diabetes. Because disease is a process that occurs over time, the responses of the patient to the disease manifestations become part of the illness itself, as they alter the patient's behavior and change the illness. For example, whether patients report symptoms, visit physicians, take prescribed medications, alter their lifestyle, accept illness as inevitable, or fight its every intrusion—each of these factors has an influence on the illness and expresses the individuality of the sick person. Each modification requires a change in the approach of the physician dictated, for the most part, not by medical science but rather arising from the doctor's art. The physician can affect the patient only through the doctor-patient relationship, which is central to the practice of medicine and its art, but differences among individuals—for example, their degrees of trust versus suspicion, openness versus shyness, or friendliness versus hostility—influence the kind of relationship formed.

The Different Perspectives of Patients and Physicians

The patient's perspective on his or her affliction is different from the physician's. In such crucial dimensions as time, space, and the meaning of specific medical objects (such as bodily organs, technological devices, and medications), patients' experience of their world diverges from that of the physician, whose scientific perspective on their disease includes objective measures of time and space and precise definitions of objects (Toombs). In the case of hypertension, for example, patients may feel threatened with a stroke by this moment's elevated blood pressure, even though the dangers of hypertension lie in its effects on the heart, kidneys, and blood vessels over long periods. To patients, the felt immediacies of other disease threats also seem more a result of their seriousness than of their actual temporal proximity.

A patient's focus on a particular symptom depends more on the patient's interpretation of the symptom than it does on the actual experienced events. For example, a patient who interprets his or her chest pain as signaling heart disease may not be aware of, pay attention to, or report associated shoulder or neck pain that would tell the doctor that the chest pain is secondary to an entrapped cervical nerve and not heart disease. Further, patients rarely understand the probabilistic nature of medical information—that the facts of a case are most often not simply true or false, but only true with degrees of confidence—and even when they do, it is difficult for them to understand the meaning of these probabilities for them. Objectivity, always difficult, is virtually impossible for the sick person because of the nature of illness. Important alterations in thought processes, such as the inability to see things from the perspective of others and a concreteness of thought usually characteristic of children, accompany only serious illness, but this is where the reflections generated by bioethics are most important (Cassell, 1985b).

More than just medical science determines the physician's perspective of the patient's illness. Besides diagnostic and treatment goals that draw heavily on medical science, physicians have other aims. Some, such as the desire to save or prolong life, relieve pain, avoid doing harm, and provide information, are patient-centered. Others, such as being trustworthy and truthful, relate to their relationships with patients. As physicians among other physicians they also want to maintain their knowledge, to be considered good doctors by their peers, and to uphold the standards of their profession. Many of these ends are professional in nature, are part of the socialization of doctors, and reach back to antiquity. They, too, distinguish the doctor's point of view from that of even informed patients.

Although doctors and patients may appear to speak the same language about the same subjects, their differing viewpoints ensure that a physician may remain within the medical-scientific worldview and not attend to the patient's concerns. The care of the terminally ill often exemplifies such dissonance. Here, one of the ends of medical practice—staving off death as long as possible—may be at odds with the patient's desire not to be in pain or suffer. A necessary aspect of the physician's art is to understand the patient's goals and adjust professional aims and medicine's tools to these ends. This is the meaning of sayings throughout medical history exemplified by that of Bela Schick, "First the patient, second the patient, third the patient, fourth the patient, fifth the patient, and then maybe comes the science." That this principle is often violated or ignored does not obviate its centrality for the art of medicine.

The Doctor-Patient Relationship

The special nature of the relationship between doctor and patient has been appreciated since antiquity (Laín Entralgo). As much a part of sickness and medicine as the diseases that make people ill, this relationship makes a sick person a patient and a medical person a doctor and a clinician. It is the vehicle through which physicians exercise their authority (not to be confused with authoritarianism), without which the practice of the art is impossible (Needleman). An examination of the way the relationship is formed and its potential for effectiveness suggests that this special bond is a basic part of the human condition with cultural and social dimensions (Cassell, 1991).

In emergencies, when doctor and patient have never previously met, the power of the relationship can become effective immediately. Within moments a doctor who is a stranger can ease pain, make panic subside, and improve breathing. (Physicians can also worsen symptoms and exacerbate panic by wrong actions.) The bond between doctor and patient is effective across cultural boundaries, even in the presence of antagonisms, and despite sometimes formidable social and environmental impediments.

Physicianhood is a role—a set of performances, duties, obligations, entitlements, and limitations connected to a function or status. The socialization of medical students includes learning about the doctor's role so that they emerge both as physicians and in the role of physicians. Given its sociocultural nature, it has its counterpart in the patient, who provides for the doctor's words and action access to the patient and the patient's body not available to ordinary relationships. Because the connection between doctor and patient is bilateral, the power of sickness to make patients susceptible to change at all levels of the human condition is matched ideally by the power of this benevolent relationship to induce physicians to extend themselves at all levels.

Physicians, because of the relationship, are enabled to see the authentic person through the mess of sickness, read the history of self-determined purposes in the life before illness, and understand the aesthetic whole that is the patient's life prior to the unwelcome intrusion of disease. In a modern extension of the art, they therefore have the opportunity and obligation to help the patient maintain autonomy, which, for the sickest, would be almost impossible outside the relationship. Clinical ethicists share in this opportunity when and if the patient extends this special bond to them (Zaner).

These aspects of the doctor-patient relationship are frequently obscured from view or even contravened in the high technology atmosphere of modern medical centers. The patient's trust is necessary for the most successful diagnosis and treatment, and therapeutic intimacy arising out of the relationship creates confidence. As part of their art, skilled practitioners actively nurture the relationship, not only encouraging its growth and promoting trust by the patient, but negotiating between empathic intimacy and objectivity. One skill in the art of clinicians lies in coming as close as ethically possible to intimacy while maintaining independence of action. A strong bond is essential in negotiating the difficulties and uncertainties of serious illness. It is equally important in supporting and teaching patients through the long trajectory of chronic illness.

The Behavior of Sick Persons and Doctors

THE BEHAVIOR OF SICK PERSONS. Even mild sickness alters behavior; profound sickness alters behavior profoundly. This is culturally acknowledged by what has come to be known as the sick role, the exemption from everyday duties and obligations granted to sick persons. Changes in functioning are not merely those associated with the disordered part—for example, the inability to move around because of back pain. Sickness induces changes in cognitive function and in relationships with self, body, and others. Patients who are sufficiently ill—for example, in life-threatening infectious diseases, congestive heart failure, for a few days after bypass surgery, or in long-term hospitalizations—although they are cognitively normal by conventional measures, have patterns of reasoning that Jean Piaget showed in children under six. For example, the sick frequently fail a classic test of reasoning about the conservation of volume. Two containers identical in size, shape, and the volume of water they contain are shown to the patient with the statement, "These two glasses have the same amount of water." The contents of one glass is then emptied into a tall thin cylinder and the patient is asked, "Which one of these has more water?" Sick persons will frequently indicate the tall thin cylinder. They may say, "I know that it shouldn't have more water, but it does" (Cassell, 1985b).

Sick persons usually are also unable to alter their perspective sufficiently to understand the viewpoint of another. A child's alphabet block shows this in its simplest form. Even if the block is rotated so that they have seen all of its sides, when looking at one face, they cannot report what is on the opposite face. One can routinely demonstrate many other similar changes in reasoning, of which the patient is almost always unaware. Because of the similarity of their reasoning (and other traits) to children, these characteristics have been considered regression. To avoid the error of treating the sick like children, it seems wiser to realize that this altered behavior is sickness expressing itself. Thus, in appropriate circumstances, patient self-determination will be enhanced by offering no more than two concretely worded alternatives at a time and avoiding choices couched in abstractions.

The sick are attached to their caregivers. How their attachment is expressed varies from love to anger or rebel-liousness. The skillful physician is aware that these emotions are not directed at the doctor as a particular person (about whom the patient usually knows very little) but at the doctor in the role (Landis). As such, they are not to be taken personally but should be used in diagnosis or treatment. Changes in the patient's relationship to the body are also a common characteristic of illness. The patient may become angry with the body because of what it has done to the patient, as though the disease was something the body "did" to the patient. Relationship to the body influences the patient's other illness behavior and reactions to the events of the sickness and its treatment.

Illness brings about dependency on others and often induces feelings of loss of control, helplessness, inadequacy, and failure. As a result, it may awaken unconscious conflicts and cause the patient to act toward the physician as if he or she were the patient's parent. The artful physician, aware of the problems that may follow reawakening of early childhood experiences or feelings and behavior brought on by illness, knows and acts in the knowledge that the sick person within the doctor-patient relationship may seem quite different in presentation and behavior from the same person when he or she is well.

THE BEHAVIOR OF DOCTORS. Physicians, too, may behave differently in the presence of the sick than they do outside the doctor-patient relationship. Physicians' interactions with their patients may evoke feelings of anger, sexual attraction, sadness, grief, failure, rejection, and omnipotence, among others (Maoz et al.). Many years ago a psychiatrist, Michael Balint, recognizing that physicians are not trained to deal with the feelings clinical events evoke in them, organized physician discussion groups (Balint). Although sometimes replicated, these so-called Balint groups have not been widely employed. Awareness of whether and how doctors' feelings and behavior interfere with their care of patients is important because physicians' experience of their patient's feelings is an essential source of information about the illness.

Physicians are powerful people who must employ their power judiciously if it is to do good and not harm (Brody). Yet, doctors are rarely trained in how to use their power or even to be aware that they have power, which may be abused perhaps more easily than it is used. An irreducible inequity of power between patient and doctor inheres in the clinical situation. Codes of medical ethics reaching back to antiquity and modern bioethics directly address this problem. It is widely recognized, however, that if physicians are not virtuous, all the precepts, principles, and regulations surrounding their conduct will be useless. Edmund Pellegrino and David Thomasma explain the virtues necessary to achieve the ends of the clinical encounter and the good of the patient, namely, to be made well again if possible, or to cope with sickness, pain, suffering, and impending death if necessary. These virtues include conscientious attention to technical knowledge and skill, compassion, beneficence, benevolence, honesty, fidelity to promises and to the patient's good, prudence, and wisdom (Pellegrino and Thomasma). Walsh McDermott believes that thoroughgoingness and self-discipline are also central virtues of the good clinician (McDermott). It requires a good person to be a good doctor—now, as in times past. As Paracelsus said, "The art of medicine is rooted in the heart. If your heart is false, you will also be a false physician; if your heart is just, you will also be a true physician."

It is difficult for a scientific (and cynical) era such as ours to accept the unavoidable necessity for virtue in doctors. As a consequence, the active training of doctors in the virtues of the good physician has largely been abandoned in the untested and probably wrong belief that medical virtue cannot be taught. During medical school and in postgraduate training, however, those who become doctors do learn, even if only through socialization, to restrain the employment of their skills in situations where more harm than good may follow, to be self-critical and admit error (at least to each other), to pursue the good of the patient, and to act benevolently (Bosk).

Medical Decision Making

Physicians are constantly making judgments, many of which are moral. The skill of exercising judgment, which has defied systematization, is the ability to apply the general to the particular; in medicine, this means to the particular patient, clinical situation, or context. To do this, physicians must obtain information of three distinct kinds—brute facts (also known in medicine as hard data); values; and aesthetics (patterns, relationships among the elements of a situation, and degrees of order or disorder). Often doctors are not aware of much of the information in the latter two categories that enters their judgments. Because of the necessity for such information, which is often neither obvious nor easily demonstrated, the art of medicine requires heightened skills of observation and synthesis. The art also requires that some systematic understanding be brought to judgment.

Alvan Feinstein was the first to closely examine the logic that underlies physicians' decisions; his work generated the field of clinical epidemiology (Feinstein, 1967, 1985). Feinstein's primary concern was the background evidence that the study of groups of people would provide for clinical decisions in patient care. Those who have followed him have elaborated his basic message and methods to assist physicians in judging the utility of a piece of evidence or information in the diagnosis or treatment of a particular patient (Wulff; Fletcher et al.; Sackett et al.). These writers have elaborated basic principles that determine the diagnostic meaning of a piece of clinical information, for example, a finding on physical examination, the result of a blood test, or a clinical measurement. The accuracy and validity of the test or measurement are important, as might be expected, but so is the likelihood that any similar patient would have the disease or state that is being tested for.

Put another way, to know how helpful a piece of information is diagnostically, one has to know the chance that any such patient truly has the disease. For example, even if a test for a rare disease is 99 percent accurate, when a large population of healthy people is tested and someone has a positive test, the chances are small that the person has the disease. The test will probably have been a false positive. Alternatively, in a population in a region where the disease is common, a positive test probably means the person has the disease. The test will have been a true positive. Because many conclusions of the clinical epidemiologists based on Bayesian mathematics are counterintuitive, their work has been extremely important in bringing objectivity and precision to decision making. (In the example given above, when the test is 99 percent accurate but the disease is rare, a patient who tests positive has only about a 10 percent chance of having the disease.) Terms such as specificity, sensitivity, and positive predictive value, which denote quantified measures of modern medical decision making, are now commonly heard in discussions about particular patients. Modern physicians must not only be conversant with these methods; they must also explain them to each patient so that the patient can participate effectively in the decision-making process.

Physicians rarely realize the degree to which each patient is different. Consequently, particularizing the generalizations of medical science to fit an individual patient requires great skill. The desires, needs, concerns, intentions, and purposes of patients are statements of values that must be elicited if they are to enter decision making. They are often faulted as hopelessly subjective and consequently not up to the standard of the hard data employed in the decisionmaking methods discussed above. A patient's desire for a certain outcome may be subjective, but the statement of that aspiration is objective and can be validated and given precision within degrees of confidence through discussion with the patient and attention to the pattern of the patient's previous actions and purposes. The artful physician is obligated to develop the mastery that gives these values decisionmaking weight—they are expressions of the patient's autonomy. Attempts to circumvent the need for such mastery by developing standardized methodologies, such as scales and questionnaires to assess individual values, have not proved clinically useful. It remains necessary, therefore, for the clinician to know the sick person to the greatest degree possible so that good clinical judgments can be made.

The clinical situation, like the disease and the illness, is always changing; therefore, decision making that integrates values and other clinical information constantly occurs in clinical medicine. Shifts occur not only because of the evolving process of the disease, but also because of the ongoing responses of both doctors and patients. In addition, the place care is given (home, doctor's office, hospital, etc.) and who else is involved (family, friends, medical students, etc.) influence the process of the illness. It is obvious why clinical judgments are not confined to the initial diagnosis or decisions about therapy.

The art of medicine requires that the physician be always mindful of changes in the circumstances, the illness, and the capacity of the patient. Although the formal principles of modern decision making may not always be applicable, newer ideas about the probabilistic nature of judgment and the need to integrate hard and soft data constantly inform the work of the artful physician.

Doctor-Patient Communication

The ability to employ the spoken language to obtain information from and about the sick person, gain the patient's cooperation, and provide information to the patient is a central element in the art of medicine. Doctor-patient communication is unlike many other verbal transactions, despite its use of ordinary language. The patient is in the conversation with the doctor for a specific purpose that is vital for the patient and diagnostically or therapeutically significant for the physician. The patient and the doctor have important joint purposes in the service of which the conversation is both necessary and crucial.

The patient wants the doctor to pay attention to his or her symptoms and concerns about the illness, and is worried lest these not be properly expressed or their importance not be appreciated. Doctors want to hear the clues to the diagnosis that only the patient's story can convey. Yet, some things that are important to the patient may not be of interest to the doctor and vice-versa. If the doctor attends solely to the evidence for disease, discarding everything else the patient says as irrelevant, then he or she may find the disease, but discard the sick person. A person's utterances convey not only the overt description of his or her actions and beliefs, but also the significance of the objects and events under discussion to the speaker. This other aspect of the speaker's message—the description of self of which the speaker is often unaware—lies in the specific choice of words, syntax, and paralanguage (Cassell, 1985c). The attentive, artful physician, listening to these specific aspects of the spoken language, has the opportunity to know more about the patient.

Conversation with the patient offers the doctor the opportunity to discover the patient's presuppositions and the beliefs according to which the patient assigns meanings. Similarly, doctors can inform their patients about the medical presuppositions and concepts that inform the doctors' actions. Such exchanges help avoid or correct the miscommunications that inevitably arise because of the differing perspectives of doctor and patient. Just as the patient's language informs the doctor about the patient, the doctor's utterances reveal himself or herself to the patient. The virtues of physicians are not abstractions, but are displayed in speech and actions. Trust is built by means of conversation as well as by action; compassion is communicated in words, in nonverbal communication, and in action. The constant flow of spoken (and unspoken) language provides a doctor the opportunity to build his or her knowledge of the patient and provides a patient evidence of the physician's skill and fidelity.

The doctor also has the specific responsibility of informing the patient about what is the matter, what it means, what actions might be taken, what options exist, and what choices the patient must make. The same is true, on occasion, of communication with the patient's family or significant others. Information, however, is also a therapeutic tool. Doctor-patient communication provides the physicians the opportunity to convey information that reduces the patients' uncertainties, enables the patient to act in his or her own best interests, and strengthens the relationship between the doctor and patient. On the other hand, poorly or inadequately communicated information can increase uncertainty, paralyze action, and destroy the relationship.

A specific aspect of doctor-patient communication is breaking bad news. When it is done poorly, it can destroy hope and leave a patient in shambles. As part of the art of medicine, doctors must learn to convey bad news so well that patients are enabled to make truly self-representative and self-determined choices (Buckman).

Patients, like everybody else, act and react because of what things mean to them. Meaning includes not merely denotative aspects of words, objects and events, but their connotative, or value-laden, content as well. With its cognitive and affective aspects, meaning has an impact on the physical and spiritual responses of the sick. By changing patients' meanings, physicians can alter, sometime profoundly, the patient's experience of illness (Cassell, 1985a). The effective use of spoken language, with its power of creating and altering the meaning of wellness and illness, is an important aspect of the art of medicine.

eric j. cassell (1995)

SEE ALSO: Compassionate Love; Emotions; Healing; Health and Illness; Information Disclosure, Ethical Issues of; Medicine, Profession of; Narrative; Pain and Suffering; Professional-Patient Relationship; Social Medicine; Trust; Value and Valuation; Virtue and Character

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