Ideas & Opinions

The Lost Art

Joseph Intile, M.D.

The author discusses the changes he has witnessed during his almost 50 year career as a practicing internist, military flight surgeon and health insurance administrator. He suggests that the art of medicine, as compared to the science of medicine, has been neglected. In his assessment, the vital art of medicine may not be lost but rather available through alternative systems.

Forty-six years ago, as a student of in medical school, I was indoctrinated with two related basic concepts. First, I was in training to be a “corking good physician” and second, “medicine was an art as well as a science.” Yes, we studied for difficult examinations in all the usual courses. While it is not likely that I can recall the exact mechanism of carbohydrate metabolism or expound on the various fossae of the human skull or describe in minute detail how and why the liver functions, I still remember the medical school philosophy that reflected the art of medicine, which was to treat the person in front of you, as well their diseases.

Medical school was followed by an internship, not a specialty residency. As interns we were again encouraged to master the art of medicine, all the while becoming better versed in the burgeoning science. We delivered babies, performed surgeries, dealt with tuberculosis and its ravages, looked for rheumatic fever, biopsied livers and kidneys, reduced and casted fractures, and took care of children as well as attending to the emotional needs of their concerned parents.

Residency in a chosen specialty was more of the same but of greater duration and more responsibility. It was about the professional maturation of the doctors who would soon be in the world, making decisions that dealt with life and death. With this responsibility came the obligation to be all things possible to “people” who sought our help and advice. We were diagnosticians. We were healers. We were researchers. We were counselors. We were advisors. We were listeners. We basked in glory when we succeeded and we cried when we failed. We did things like drive new widows and their children home from the hospital on Christmas Eve and encourage the elderly to enjoy the time they had left. We allowed people to die peacefully and out of pain when nothing else could be done. We went to funerals, baptisms and attended weddings of our patients’ children. We took time to explain, to people, what we thought was awry and how we might go about fixing it. We recognized that a “patient” was a “person” who had the added burden of an illness, real or imagined, which is always accompanied by some level of emotional stress. Sometimes, the most important thing we could do was to listen.

Yes, we were becoming “corking good physicians” and we were practicing the “art of medicine.” Somewhere over the years we became so overwhelmed with the onslaught of scientific developments that we lost sight of the art at which we were so good. We became involved in CT scans, and MRIs, arterial blood gases, endoscopies, superspecialization, referrals, credentials, prior-approvals, utilization review, plaintiff attorneys, rising insurance premiums, unrealistic requests, and nay demands by the same people we were trying to do the right thing for. Then there were the lay managers, CEOs, hospital administrators and third parties who considered themselves more knowledgeable than the doctors with whom they worked. Lest they feel ignored, the pharmaceutical manufacturers played a big role in this with direct-to-consumer advertising driving up the costs of care and the time it took to dissuade people from wanting “this year’s model of the antibiotic or antihistamine.” “Patients” became “subscribers”, “physicians” became “providers” and “nurses” became “case managers.” Many of us would chide those who used the new vocabulary with reminders that we did not attend a school of case management, but rather a school of nursing, and that provide was what we did for our families and not for our patients. And while all this was going on we surrendered the art of medicine. Perhaps surrendered is not the proper description of what happened. Perhaps we should admit that we, the physicians, gave it away.

Yes, we gave it away. The people who would come to us to get over an illness as well as for understanding and compassion, found that we no longer were providing that vital element of listening and empathizing. They were forced to look elsewhere. They encouraged the development of alternatives to the new religion of scientific medicine without the art. They sought those who would listen and who would consider other routes to wellness besides a hastily written prescription or another blood test or X-ray.

Many of us admit that we readily referred to chiropractic physicians, acupuncturists, nurse practitioners, and massage therapists, who had skills we didn’t have time for or never learned. Our goal was to reach a cure or at least adequate treatment of pain and illness, however we might arrive at that objective. We were not too proud to admit our shortcomings. We recognized that illnesses are not easily put into the computer and treated by printed algorhythm.

This is not to deride the amazing scientific advancements that have occurred in medicine in the last 46 years. But it is to bemoan today’s scenario in which the science is God and the art of medicine is considered unnecessary. To paraphrase John Donne: No illness is an island unto itself; no health care discipline is an island unto itself; the bell tolls for all of us, as well as for the lost art of medicine. Only by collegial and effective partnership and communication among all health care disciplines can we continue to provide our people with the care they need, deserve, and can afford. Together we can embody what the “corking good physician” was supposed be.

Joseph Intile, MD, FACP, is an internist certified by the American Board of Internal Medicine. He is a retired military flight surgeon, practiced for 25 years in Oregon City as a solo practitioner, was the first private practitioner in Oregon to work collegially with a nurse practitioner, and ended his career as the Medical Director for the Oregon Health Plan. He currently spends time flying, medicolegal consultation, enjoying friends and family in Portland and in the cattle country of Eastern Oregon. He can be reached by E-mail at: joeintile@juno.com