The Art of Medicine is the Foundation of Trust between Physicians and Patients

FigureFigureOur stature as emergency physicians, and, in fact, that of all physicians, is disintegrating in the eyes of society, driven by disruptive innovation, technology, knowledge doubling, society's loss of respect for authority figures, and the influences that affect medical practice. But one nagging question remains: Have we lost the revered art of practicing medicine? Centuries ago, physicians practiced medicine as an art. There was little, if any, scientific basis for what they did. The old-time doctor was a kindly old man everyone loved. He (always a he) sat by the bedside of the dying patient, unable to stay the process, holding the patient's hand, grieving with the family. Abraham Flexner, who was not a physician, was asked in 1908 by the Carnegie Foundation for the Advancement of Teaching to report on the status of medical education in the United States and Canada. There were 155 medical schools at the time and no standardized curriculum. (https://tinyurl.com/46cddb6u.) Many schools were focused on profit. There were no admission prerequisites and little interaction between students and teachers or between students and patients. Mr. Flexner recognized that there was an overproduction of undereducated, poorly trained practitioners and no state standards of credentials for practice. Medical graduates became aware of the limitations of their knowledge once they started to practice. They were, in short, unfit for practice, and many sought brief postgraduate courses to help them treat their patients. Mr. Flexner visited every medical school in the United States and Canada in the two years before the 1910 publication. He was particularly impressed with Johns Hopkins, which had a large hospital endowment and generous benefactors that afforded the institution a well-organized system of clinics, wards, dispensaries, and laboratories. Students assisted clinically and followed cases, seeing patients “from start to finish, now to recovery, again to autopsy.” (The Carnegie Foundation for the Advancement of Teaching. 1910; https://tinyurl.com/46cddb6u.) Mr. Flexner used Hopkins as the standard to evaluate other medical schools for academic rigor and the quality of the teaching faculty and hospitals. Mr. Flexner's scrutiny of education and the studies by the Carnegie Foundation that preceded his report led to consequences recognized to this day. A clear distinction emerged between secondary education and higher education. Rigorous standardization and regulation followed. Medical students in subsequent years received two years of thorough education in science and then spent two years in a teaching hospital. This template for medical education became the educational standard. “The report was so hard-hitting in its critique and recommendations that within a few years many schools had closed. Flexner reports that, in the thirty years after the publication of his report, the number of American medical schools had been reduced from 155 to about 60.” (Educating Physicians: A Call for Reform of Medical School and Residency. Jossey-Bass, New York City: The Carnegie Foundation for the Advancement of Teaching. 2010.) Mr. Flexner's recommendations had their critics. Most notably among them, Sir William Osler, often known as the father of modern medicine, who believed that student education and patient well-being were greater priorities than the advancement of scientific knowledge. Nevertheless, Mr. Flexner's model of education, with its initial focus on science followed by learning in a clinical setting, has been utilized by medical training programs for more than a hundred years. Puzzle Solving A medical knowledge base was built in the 20th century. These doctors knew more than their predecessors. Physicians practiced paternalistically. Everyone agreed the doctor knew what was best for patients and should make medical decisions for them. There were so many brilliant pioneers who emerged during the mid-1900s: Samuel Levine elucidated an understanding of coronary thrombosis; Proctor Harvey, Dr. Levine's first fellow, collaborated with him on describing the auscultation of the heart (they were pristine in their skill of diagnosis from auscultation); Harvey Cushing first described the Cushing reflex and Cushing's disease; and Bernie Loun developed the defibrillator and cardioverter. So many others also developed the understanding of pathophysiology, how it is expressed in the physical exam, and the basis for diagnosis in an individual patient. Honestly, I loved this as a student, learning physical diagnosis and piecing together what my patient's heart pathology was. Particularly with valvular heart disease, it was exciting to consider if a patient had aortic stenosis, for example, and to look for physical findings to confirm that diagnosis. The neurologic exam was equally as stimulating: What did the constellation of findings imply for a diagnosis? Where was the etiology of a patient's stroke? Which spinal cord syndrome did my patient have after trauma? Could it be Brown Sequard? A careful exam would reveal the answer. The thrill of medical practice for me has always been the puzzle solving, the diagnosis from history and physical exam. The imaging and tests were only for confirmation of the diagnosis. A Different World Fast forward to the practice of medicine today. More than a third of practicing physicians are women. Paternalism has been abolished. The loss of the doctor's authority may not be completely advantageous. Clinical decision-making has become extremely complex, and patients are sometimes left bewildered trying to make those decisions alone, confused by varying opinions and facing potentially dire results with the wrong choice. The world was changing dramatically and logarithmically while all this was happening (or possibly because of it). The concept of the doubling of knowledge is attributed to Buckminster Fuller, who noted that the sum of what people learned had doubled each century before 1900, but knowledge began doubling every 25 years after World War II. Since then, traditional linear rates of growth have been exponential depending upon the discipline. Clinical knowledge doubles every 18 months, nanotechnology every two years. Average human knowledge doubles every 13 months. IBM projected that that knowledge will eventually double every 12 hours because of the internet. (Industry Tap. April 19, 2013; https://tinyurl.com/bdesbdj9.) Learning communities with no walls or geographic locations—or ceilings—are now emerging. Anyone can look anything up. Information is not proprietary. Any knowledge we have is available online. Doctors were once held on a pedestal, revered and respected, but today are not accorded particular respect for their knowledge or opinion and little acknowledgement of their grueling training. What distinguishes today's physician? I would assert that it is the art of practicing medicine. But how many of us have the time to ponder a patient's symptoms and concerns in this era of burnout, emergency department crowding, and multifaceted demands? How many of us have time to thrill in the art of diagnosis? Have we lost the art of figuring out what's wrong with a patient based on history and physical exam or do we simply default to the much easier way of ordering tests and letting the results guide the diagnosis? Evidence-based medicine is important. Decision rules based on evidence help us not miss important findings or have blind spots. Artificial intelligence may well have a place in our practice. But should EBM and AI be our beginning, not our endpoint? Should we be satisfied with cookbook medicine constituting the entire practice of medicine? What will distinguish physicians in the future from everyone else? Does the fact that anyone can look up anything and acquire knowledge about a particular pathophysiology reduce our position as physicians? What do we have that cannot be researched on the internet? What do we possess that cannot be matched by nonphysician providers? I suggest to you that it is the art of medicine. The hours of practice, the many patients we've seen, the many experiences we have had, the greater we can excel as physicians. We have more to bring to the clinical scene than the many tools provided by others. Each of us has a singular experiential reservoir that no one else has. Using our unique past experience with patients can only enhance the success of our practice. This is why we have medical specialists. They have more experience with a particular malady than others. We rely on their unique expertise to help our patients. Some patients from my 30-plus years of practicing the art of medicine might never have been diagnosed through today's models of practice. You might call them zebras. Presentation: wrist fracture Diagnosis: subdural hematoma (and wrist fracture) Presentation: diarrhea Diagnosis: brain tumor (and viral gastroenteritis) Presentation: URI with mild headache Diagnosis: sentinel bleed (with URI) Presentation: febrile seizure Diagnosis: subdural hematoma, child abuse Presentation: flu Diagnosis: malaria There is no mystery how to practice medicine as an art. It is simply what we were taught. It involves taking a careful history and performing a thorough physical exam. The diagnosis should then be clear. If it is not, more history should be elicited. This would be the time for open-ended questions. Sometimes we just have to listen to the verbal meanderings of a patient to hear the ultimate clue. The patient will usually tell us the diagnosis. We simply need to conform rigorously to the process and wait for it. I believe that the art of practicing medicine lays the foundation of trust between the doctor and patient. It engages the doctor and benefits the patient. The art of medicine is where we find our joy in practice. I believe it is what distinguishes us from all other providers. Share this article on X and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]. DR. PARKHURST is a retired emergency physician who practiced in Florida, California, and Nevada. She is the former associate dean, professor, and program director at Barry University's Physician Assistant Program in Miami. She is currently practicing telemedicine.

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