The Art of Medicine

Perhaps intuitive insights call upon tacit knowledge? Knowledge that is difficult to write down, visualise or transfer from one person to another. This sort of knowledge is easily overshadowed by knowledge that can be written down, visualised or transferred from one person to another.

Ferdinand Hodler: Valentine Godé-Darel on Her Sick bed, 1914, Oil on Canvas

        … What do we see?

 Ferdinand Hodler Valentine Godé-Darel on Her Sick bed 1914 oil on canvas

“Traditionally the practice of medicine has been divided into its science, concerned with disease, and its art, associated with the actual care of patients. As in many a tense marriage, arguments have been advanced about the differences, similarities, and mutual need of each of these aspects for the other. In these discussions, when the concern is that the needs of the sick are being overlooked in modern scientific medicine, the importance of empathy, compassion, communication, and other humane qualities of physicians are stressed. When its protagonists fear that science is getting short shrift, they point out the impossibility of understanding the processes of disease in the absence of science, and they demonstrate the superior precision of thought brought to clinical medicine by the biological and physical sciences….

I believe that to resolve the problem of art versus science in medicine, we must understand that the truly successful clinician must respect both aspects. Knowledge, whether of science or compassion, does not do things to patients – clinicians do. This is the corollary of the truism that doctors do not treat diseases, they treat patients. The disputation between art and science in medicine merely reflects a world that has been chopped up into artificial pieces. There are no diseases that exist outside of sick persons, there are no patients without doctors, and there are no clinicians without patients. The situation is like the story of King Solomon and the two women who claimed the same child. If the child had been divided in two, each woman would have had a piece – but there would be no child. Dividing up clinical medicine by reducing it to one or another of its aspects may satisfy the disputants, but then the thing that most people mean when they speak about medicine disappears.”
[from  Eric Cassell, The Nature of Suffering and the Goals of Medicine Oxford,OUP 1991 chapt 12]

Later in Chapter 12, Cassell discusses the way experience mediates between science and art. The crucial skill here is ‘attentive listening’ in which the physician hears what the patient says before beginning to interpret what they might mean. This entails hearing the actual words and phrases.

See Cassell interviewed on YouTube:

Cassell is emphasizing the relationship of subject to experience: the immediacy of experience which is often too overwhelming for us to cope with so we hang that experience in the old wardrobe of our mind and perhaps give it a medical label. So the richness is lost, or almost lost. Until perhaps it is awakened by a new experience that has resonance for something, somewhere in the past. This resonance is between one unique experience and another, a recognition without necessarily being able to recall the details of the past event. Some sort of essence remains. At its best, art celebrates this essence for its ability to touch the universal. It gives form to the formless through resonance.

A useful option for the practitioner to help with listening and retrieval is to jot down verbatim sentences as the patient speaks. Practising mindfulness should also help with this. Or if you are a poet you may be able to capture the power of direct experience. Cassell quotes (also in Chapt 12) from a poem by Rupert Brooke, The Great Lover.

Here is a slightly longer extract from The Great Lover:

These I have loved:
White plates and cups, clean-gleaming,
Ringed with blue lines; and feathery, faery dust;
Wet roofs, beneath the lamp-light; the strong crust
Of friendly bread; and many-tasting food;
Rainbows; and the blue bitter smoke of wood;
And radiant raindrops couching in cool flowers;
And flowers themselves, that sway through sunny hours,
Dreaming of moths that drink them under the moon;
Then, the cool kindliness of sheets, that soon
Smooth away trouble; and the rough male kiss
Of blankets; grainy wood; live hair that is
Shining and free; blue-massing clouds; the keen
Unpassioned beauty of a great machine;
The benison of hot water; furs to touch;
The good smell of old clothes; and others such –
The comfortable smell of friendly fingers,
Hair’s fragrance, and the musty reek that lingers
About dead leaves and last year’s ferns…
[The Poetical Works of Rupert Brooke Ed Geoffrey Keynes, London, Faber & Faber 1970]

 

Intuitive: listen, feel, be curious, reflect, imagine, play, resonate, respect the tacit, enjoy uncertainty, reframe, improvise, create, know what is health.

 

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