Finding the art within the science of internal medicine
From the May ACP Observer, copyright © 2005 by the American College of Physicians.
By C. Anderson Hedberg, FACP
A fascinating essay appeared in the autumn 2004 issue of The Pharos published by Alpha Omega Alpha, the medical honor society. Authored by Hunter Groninger, ACP Associate, a resident at the University of Virginia in Charlottesville, the essay was titled "What do we mean by 'the art of medicine'?"
In his article, Dr. Groninger traced the evolution of that phrase from Hippocratic times to our own, finding that "the art of medicine" has taken on many different meanings. During numerous historical eras, physicians have defined the art of medicine as technical expertise, moral acumen and the ability of physicians to empathize with individual patients, not just solve clinical problems.
Dr. Groninger also quoted William Osler, MD, who said "[t]he practice of medicine is an art, based on science."
And he quoted the noted physician Francis Peabody, MD, who wrote, "[medicine] is an art, based to an increasing extent on the medical sciences, but comprising much that still remains outside the realm of any science." It was Dr. Peabody who, in 1927, authored one of the most quoted phrases in the history of medicine: "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."
These two great clinicians and teachers knew that the practice of medicine is both a science and a humanistic art. In our work, we use the scientific method to obtain a history, perform a physical examination and evaluate appropriate testing for our patients. With these data, we apply our knowledge, experience and judgment to form a diagnostic hypothesis and decide on treatment.
Clinical skill and strong compassion must merge to make up the art of medical practice.
Careful observation then reveals the outcome and may suggest further treatment. Throughout this process, we develop a compassionate understanding of the patient, and our expressions of concern and support help ease patients' fear and nurture their trust. Both of those aspects of care—our clinical skill and our strong compassion—must merge to make up the art of medical practice.
Art and rigor
When and where did the science and art of internal medicine begin? William Bean, MACP, an illustrious past chair of internal medicine at the University of Iowa in Iowa City and former ACP Governor for the Iowa Chapter, shed light on those origins in a brief article in the Jan. 21, 1982, New England Journal of Medicine.
The name "internal medicine" ("Innere Medizin") originated in Germany in the latter part of the l9th century. According to Dr. Bean, the discipline was differentiated from the body of clinical medicine being practiced at that time by being based on emerging experimental work in physiochemistry and physiology, rather than just the natural history of disease.
To quote Dr. Bean, "The emphasis on pathophysiology was repeatedly brought out in German textbooks dealing with internal medicine. The exclusion of surgical diseases and of dermatology implied a scientific point of view quite different from that of the general physician. In effect the term 'internal medicine' meant special training, knowledge, and skills."
At that time, Germany was the world center for medical research and study. American doctors training in Germany, who realized the potential for this approach, brought the developing specialty back to the United States where it was quickly adopted in the early 1900s by a new breed of scientifically-oriented teachers and medical school leaders.
Several of those early American converts accelerated the evolution of internal medicine in 1915 by founding the American College of Physicians, which today is the country's largest specialty organization. The American Board of Internal Medicine was formed in 1936, around the time when different internal medicine subspecialties began to develop.
This formal organization of internal medicine coincided with an explosion of medical research and knowledge, at the same time that academic departments of medicine were growing into powerhouses of research, teaching and clinical practice.
Early in this historic development, all internists practiced as generalists. Now, an ACP survey done in 2004 reveals that 52% of College members report their primary specialty as general internal medicine, while 39% list a subspecialty as their primary orientation. (At the same time, 41% of subspecialists indicate they do some general internal medicine.)
The growth of both the generalist and subspecialty areas of internal medicine has brought great depth and breadth to our specialty, as ACP has maintained its tradition of excellence as an umbrella organization, serving the whole of general and subspecialty internal medicine. As was clear from the Annual Session that was just held in San Francisco, the College continues to provide internists with ample educational materials, not only honing our clinical skills but addressing as well the humanistic issues that enhance the art of medicine.
Over the last 125 years, internal medicine has come a long way, and we continue to define our pivotal role in the world of medicine.
In the April l998 American Journal of Medicine, the Association of Professors of Medicine published an article titled "The Clinical Philosophy of Internal Medicine." Written by Robert L. Wortmann, FACP, the current chair of internal medicine at the University of Oklahoma in Tulsa, the article set out to define and differentiate the internist from other specialties to help students considering careers in our field.
Dr. Wortmann outlined four distinguishing characteristics of internists. Those were:
the ability to be a diagnostician, who can practice the deductive scientific process that leads to therapy;
the ability to provide care of complex problems for acute and chronic conditions in a patient-centered, comprehensive, continuous and compassionate manner;
the ability to be a consultant in our areas of interest for generalists, specialists and subspecialists; and
About curiosity, Dr. Wortmann wrote:
[I]nternists are typically people who are constantly asking the question what. All physicians share in the curiosity of what is the diagnosis and what is the treatment? The internist tends to carry these questions further. What caused the disease? What is the link between the disease and basic biology? What is the mechanism of therapeutic action? Some have termed the characteristic intellectual curiosity. Others feel it is a fascination with science. Regardless of how it is termed, the links between disease and pathophysiology as well as between the chosen therapy and its mechanism of action are prevalent in the thinking and practice of an internist …. Relating diseases and treatments to underlying science can make it easier to remain current and understand changes and progress in medicine.
Curiosity is a wonderful characteristic, one that has led to internal medicine's preeminent position in basic science research, clinical investigation and therapeutic trials.
Curiosity motivates excellent didactic and bedside teaching, and leads to a desire to understand patients in the whole context of their lives--their hopes, desires, fears and needs.
At the same time, curiosity fosters a humane understanding that nurtures patient-centered practice—a keystone of the art of medicine. And curiosity brings us professional growth, knowledge and gratification in the midst of busy and demanding lives.
As we all cope with increasing constraints on our time, we need to remind ourselves to keep that curiosity engaged. It is a necessary trait that all of us need as we each seek to answer what "the art of medicine" really means.
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