The Art of Medicine

I read an interesting post on Wachter's World about management and measurement. One of the commentators spoke about the "art of medicine."

I started thinking about art and medicine. I have heard medicine described as an "art that makes use of science." In my limited experience, I agree with that. I think, that as valuable as it is, evidence-based-medicine sometimes throws the baby out.

When learning to be an artist, there is a generally well-defined process; first we learn the technique, and then we learn to exist without it in our consciousness. As an opera singer, I spent the better part of a decade learning the technique. This included learning musical skills (learning the language and construction of music), and learning singing skills. I had to learn how to expand my ribcage and keep it expanded all the way through a phrase. I had to learn to allow my larynx to fall when I inhaled, and let it maintain its low position through the phrase. I had to learn to allow the soft palate to lift and stay lifted. I had to learn what it felt like to use too much vocalis muscle in the larynx, and how to relax that muscle, while maintaining thryoarytenoid muscle activity. I had to learn to relax my hip joints, and contract my quadraceps when singing, especially a high note. I had to learn how to sing in five languages without an accent; to learn which parts of the tongue to activate when singing an 'L' in Italian, compared to the same consonant sung in German. I had to learn music history; how to sing a trill if it was written in the 18th century vs. the 19th, and whether Mozart would have an appogiatura on this cadence vs. that. In short, I spent years working on details, struggling to get them right.

But as each carefully studied detail fell into place and my bag of tricks grew, I had to learn to forget about them. There is no way I can walk on stage and perform while thinking about the (definitely not exhaustive) list from the previous paragraph. Of course, there will be times I have to focus on something in a particularly tricky passage. When I'm singing a high C, for example (one of a tenor's highest and most difficult tasks), if I don't focus on my breath filling the extreme basolateral parts of my lungs and maintaining that expansion through the phrase, the note will splat. But if I have to think of that expansion for every phrase, I can't perform. I get tied into knots on stage, thinking about all the tiny little details that need to be in place to produce a good sound.

As artists, we obsess on details for years, until they are so ingrained, so much a part of who we are, that we forget they are even there or what it was like to not have done it this way. And therein lies artistic freedom. Once we have technical skill, we are free to let our inner voice out, because we now have a means to communicate our artistic message. Before we have technical mastery, we can't communicate our message effectively.

As experienced and liberated artists, the technical details that we spent so much time acquiring must underpin every note that we sing. But we must stop obsessing about them, because obsession will cripple us as performers, even though the obsession was once mandatory. We must make the detail we practice so much a part of who we are that it feels instinctive.

As a medical student, I see a similar journey ahead of me. I am close to the very beginning of my journey as a physician, and right now, all I am doing is obsessing about detail. Every fact I commit to memory, every painfully studied task I attempt, every idea and preconceived conviction I challenge is building my skill set; my medical technique if you will. And right now, it's nowhere near instinctive. It's still a carefully constructed house of cards.

As I continue through my medical education, however, I expect the detail to fall into place, and the tasks and protocols to become instinctive. I can foresee a day where I will be a medical artist; and the detail, while underpinning everything I do as a physician, will be only part of what it means to practice medicine. (I suspect that nurses and other health care workers have a similar process of mastery that moves from detail and protocol into instinctive care.)

It is interesting to me that in the larger discussion about evidence-based medicine (which I think is a good thing, btw), there is very little discussion about the art of medicine. I think perhaps because it is so undefinable and individual. The evidence-based portion of medicine is essential; it is the foundation of detail on which our practice lies. But it can't be the overriding focus of our practice. We must have such a good grasp of the details that we can move past them into instinct.

We've all seen instinctively good doctors who we don't trust, because their grasp of the details is second rate. And we've all seen doctors who have an incredible grasp of detail, but can't doctor their way out of a paper bag. Instinct is not enough, nor is a grasp of the details enough. To be a true medical artist, we need to marry the detail to the instinctive practice of medicine. The measurement that Wachter speaks about, while building part of the detail set upon which medicine is based, carries with it the danger of obsession. The risk to health care providers is that we can get stuck measuring things, and never find the freedom that is real performance.

For years, I was a really bad performer. My acting was awful, and my singing was tense and unpleasant to listen to. Every time I walked on stage, I would start to think about the details. My mind would be working so fast, the details spinning around with such clarity and confusion, that I really thought I was "in the moment." But I was really a deer-in-the-headlights; tense, and uncomfortable to watch. I knew I had an excellent voice and I knew I had the musical ideas and skills to really sing well, but I couldn't get them working for me when I walked on stage.

But over the years, as I worked on the details and got them to fall into place, as I worked on conquering my demons and learned to let go of my obsessions, and as I got up in front of audience after audience, I learned to trust my preparation. And I started to sing well.