Medicine as I.R.

McWhinney,

an

art forms

md, frcgp, ccfp

physician has two central tasks: Technology reached an advanced stage of understanding disease and understand¬ of development without benefit in¬ "The to science. Polanyi1 According ing patients. Although distinguishable from each other these tasks are indivi- dustrial revolution (was) achieved with¬ sible, for we cannot fully understand a out scientific aid. Except for the Morse patient's disease until we understand telegraph, the greatnoLondon Exhibition the patient as a person. The process of 1851 contained important devices pro¬ by which we understand the patient as or products based on the scientificMed¬ a person is the art of medicine. The gress of the previous fifty years." process by which we understand the ical technology was no exception. Technology is never inherently harm¬ patient's disease has been called the science of medicine. However, medi¬ ful. It only becomes so when the tech¬ cine has more in common with tech¬ nologist loses his sense of relationship and the world of which nology than with science, and the dis¬ to his machine both form a part. The physician's "ma¬ tinction is important. chine" is a human being. The physician-patient relationship (the art of The technology of medicine medicine) is therefore not a frill. Unless The physician, like other technol- the art flourishes, medicine, like any ogists, applies scientific knowledge to other technology, is potentially dan¬ human problems. Like other technol- gerous. It is not difficult to see why the art ogists he uses tools: material tools such of medicine has been neglected in our as the stethoscope and the microscope, the physician's drug and the surgeon's time. In medicine, as in other fields, knife; and intellectual tools such as the the application of scientific knowledge we diagnostic process. Scientists also use has given us so much powerthisthat is the tools, both material and conceptual. It have come to believe that is not in their activities that science and only kind of knowledge available to us. technology differ: it is in their ends. Only now, as we face the awesome The end of science is knowledge and problems of the modern world, do we truth; the end of technology is power. begin to see that science offers us a The scientists asks "Is it true?" The partial and limited view of the world, technologist asks "Does it work?" The and that technology without art upsets question "Does it work?" always im¬ the delicate .balance of nature and plies the further question "Work for lowers the quality of human existence. Scientific knowledge has been liwhat, to what end?" There is always, therefore, a potential conflict between kened by Toulmin2 to the map of a territory. The mapmaker reduces the technology and human values. The close relation between science features of a landscape to symbols. The and technology, which we take so much map guides the traveller and helps him for granted, is of recent origin. find his way but it is not a substitute for the experience of moving through ?Based lecture given to the faculty of the territory. A native who cannot read medicine, Dalhousie University, Halifax, a map probably knows his own terri¬ May 9, 1975 better than the mapmaker. We are tory Reprint requests to: Dr. I.R. McWhinney, here with two entirely different Faculty of medicine, Department of family dealing medicine, University of Western Ontario, types of knowledge. How many of us London, ON N6A 5B7

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on a

98 CMA JOURNAL/JANUARY 24, 1976/VOL. 114

have said, when we see our experience reduced to a set of statistics, "But that is not what practising medicine is like: it is only a shadow of the real experi¬ ence." Of course, such reductions are necessary and help us understand cer¬ tain aspects of experience. But they are only partial truths. The art of medicine

Like other arts, the art of medicine requires the use of imaginative powers: empathy, sympathy and projection. The physician as artist "feels with" the patient in his anxiety, suffering, despair or grief. The experience, like all artistic experience, is self-transcending and may be associated with feelings of truth and beauty. There are two per¬ sistent fallacies about the art of med¬ icine. One is that it is the equivalent of kindness. Of course, one expects phy¬ sicians to be kind and considerate to their patients, but we can be kind to patients without understanding them. Empathy and kindness are not equivalents. The other fallacy is that the art cannot be learned, that it depends on human qualities that are innate and therefore cannot be acquired. To dem¬ onstrate the fallaciousness of this belief we must turn to some of the other arts, for there is no reason to think that the art of medicine is different from all the arts of mankind. How does an artist learn? He learns in much the same way as anybody who is trying to acquire a new skill. First he learns the rules and techniques of his art, for every domain of art has its own

materials, methods, subject matter

and even theories. The process has been brilliantly analysed by Koestler.3 The time-honoured way of learning is for the pupil to follow one or several masters. But he will also learn by read-

ing, studying the manuals of his art emulating the great masters of the past. Of course, learning the rules of his art does not make the pupil a mature artist. Qualities of the imagination are also required. Like all human qualities these are to some extent innate, but this does not mean that they cannot be cultivated. As Medawar has written in his essay "Two conceptions of science",4 "... everyone who uses ima¬ gination knows that it can be trained and guided and deliberately stocked with things to be imaginative about." A study of the lives and writings of artists shows how consciously they strive to cultivate their imagination. In and

his book "Art and Illusion"5 Gombrich describes how Constable studied the series of schemata for clouds published by Alexander Cozens, the 18th-century landscape painter. What Cozens teaches Constable, says Gombrich, is "not. what clouds look like, but a series of possibilities, of schemata, which should increase his awareness through visual classification". At the same time, Constable's contemporary, Luke Howard, who was studying clouds as a naturalist, developed the classification of cloud formation into cumulus, cirrus and stratus. Constable and Howard were using identical methods to study the same phenomena, one in the interests of art, the other in the interests of science. It was Constable who re¬ marked that art is a branch of natural ..

philosophy. Learning the

art

master's books, submitted to his quizz- We analyse the patient's symptoms and ing or rode with him the countryside signs, the progress of the disease and in the enjoyment of valuable bedside the pathological findings, but how often do we discuss the patient as a person opportunities."6 In later life Flexner realized that his feelings, his values, his life story, medicine had both lost and gained by his relationships and the complex inter¬ .

the reforms that followed his report. In 1930 he wrote: "... the very in¬ tensity with which medicine is cul¬ tivated threatens to cost us at times the mellow judgement and broad cul¬ ture of the older generation at its best. Osler, Janeway and Halsted have not been replaced."7 Whether guided by a master or left to learn by himself, the student will learn by the empathetic study of his patients as people. He will be helped by reading in behavioural science and in imaginative literature. Behavioural science is to the art of medicine what mathematics is to architecture, and ana¬ tomy and optics to painting. It deepens our understanding of our subject and helps us to use our powers of imagina¬ tion. I do not share the view of Engel,8 however, that the art of med¬ icine will be replaced by behavioural science. Behavioural science provides us with a map; it is not a substitute for imagination and insight. Behavioural science can help us on two levels: on the theoretical level of writers like Freud and Erikson, and on the observational level of field workers like Kubler-Ross9 in her empathetic study of the dying. Her work is a beautiful example of how behavioural science can enhance the art of medicine without trying to ape the detachment and objectivity of physical science. It also helps us see how literature and behavioural science can complement each other in the education of the phy¬ sician as artist. The same insights into the experience of dying can be found in Tolstoy's story "The Death of Ivan Illych". What Kubler-Ross achieved by a systematic but empathetic study of her subjects Tolstoy achieved by the profoundest of personal insight. How can we remedy this defect in medical education? Some steps have already been taken. We are beginning to apply the methods developed by people like Michael Balint and Carl Rogers for deepening our understand¬ ing of human relationships and of our own selves. We have introduced the teaching of interviewing and we have added behavioural science to the curri¬ culum. But this is not enough. We have not yet taken the vital step of breaking down the dissociation that exists be¬ tween technology and art in clinical

When we ask how a medical student learn his art we encounter a miss¬ ing element in medical education. In our medical schools, as in our univer¬ sities generally, cultivation of the sensibilities and the imagination is almost entirely neglected. If he is lucky the student will find a master to follow, but such men have become rare in this technocratic age. The size and complexity of our med¬ ical schools has made it difficult to achieve this kind of master-student relationship. Moreover, the apprenticeship system has tended to fail into disrepute. This reputation is not deserved. Apprenticeship is bad in only two cir¬ cumstances: when the master is unworthy of his position, and when learn¬ ing by apprenticeship is not balanced by other modes of learning. It is often wrongly assumed that Flexner was critical of the apprentice¬ ship system. On the contrary, he criti¬ cized the medical schools of his day teaching. for having abandoned it. In his report The dissociation is exemplified by he wrote: "The student registered in the format of the clinicopathological the office of a physician whom he conference. This is a superb tool for never saw again. He no longer read his teaching the technology of medicine. can

action between these and his disease? It could, of course, be maintained that in a clinicopathological conference it is legitimate for a specialist to limit the discussion in this way, and that it does not imply any lack of interest in the patient as a person, or any lack of appreciation for the interaction between the disease and the patient's life. I challenge this point of view. I believe that we talk about, and devote time to, the matters we consider important. If we omit matters from our discussions, then we transmit unconsciously the message that we think them unimportant. And the first people to pick up the message will be our students.

The state of the art I sometimes think that the care of the dying is the best indicator we have of the state of the medical art because it reveals what medicine can do when all the technology has failed. The care of the dying has become a fashionable topic recently, but can we honestly be satisfied with what is being done? An¬ other indicator is the attitude to home visits. All kinds of technical and eco¬ nomic arguments have been used against home visiting. But how often do we hear of the home as an extension of the personality; of the personal knowledge that comes from seeing a patient in his own home; of the quality of the relationship that develops be¬ tween physician, patient and family in the home setting; of the warmth and comfort of being attended for a sick¬ ness in one's home? I fear we have made human values so subservient to technologic and economic values that they do not even count in our discus¬ sions.

Medical education for the new age I think that medical education will not be healthy until we have restored the balance between art and technol¬ ogy. I am sure it will be maintained that this is not the function of the medical school because the role of the university is to train the intellect, not the imagination and the sensibilities. Here we encounter another of those conceptual barriers created by Western man that really do not exist. The dis¬ sociation of intellect, feeling and imagination is a delusion, as the most perceptive people in our culture have known all along. "Deep thinking" said Coleridge "is attainable only by a man of deep feeling." And the same thought

CMA JOURNAL/JANUARY 24, 1976/VOL. 114 99

/\LEX1IiI.P\.4E"I7thyldopa,MSD

INDICATIONS: Sustained moderate through severe hypertension. DOSAGE SUMMARY: Start usually with 250 mg two or three times daily during the first 48 hours, thereafter adjust at intervals of not less than two days according to the patient's response. Maximal daily dosage is 3.0 g of methyldopa. In the presence of impaired renal function smaller doses may be needed. Syncope in older patients has been related to an increased sensitivity in those patients with advanced arteriosclerotic vascular disease and may be avoided by reducing the dose. Tolerance may occur occasionally between the second and third month after initiating therapy. Effectiveness can frequently be restored by increasing the dose or adding a thiazide. CONTRAINDICATIONS: Active hepatic disease such as acute hepatitis and active cirrhosis; known sensitivity to methyldopa; unsuitable in mild or labile hypertension responsive to mild sedation or thiazides alone; pheochromocytoma; pregnancy. Use cautiously if there is a history of liver disease or dysfunction. PRECAUTIONS: Acquired hemolytic anemia has occurred i'arely. Hemoglobin and/or hematocrit determinations should be performed when anemia is suspected. If anemia is present, determine if hemolysis is present. Discontinue methyldopa on evidence of hemolytic anemia. Prompt remission usually results on discontinuation alone or the initiation of adrenocortical steroids., Rarely, however, fatalities have occurred. A positive direct Coombs test has been reported in some patients on continued therapy with methyldopa, the exact mechanism and significance of which is not established. Incidence has varied from 10 to 20%. l.a positive test is to develop it usually does within 12 months following start of therapy. Reversal of positive test occurs within weeks to months after discontinuation of the drug. Prior knowledge of this reaction will aid in cross matching blood for transfusion. This may result in incompatible minor cross match. If the indirect Coombs test is negative, transfusion with otherwise compatible blood may be carried out. If positive, advisability of transfusion should be determined by a hematologist or expert in transfusion problems. Reversible leukopenia with primary effect on granulocytes has been seen rarely. Rare cases of clinical agranulocytosis have been reported. Granulocyte and leukocyte counts returned promptly to normal on discontinuance of drug. Occasionally fever has occurred within the first three weeks of therapy, sometimes associated with eosinophilia or abnormalities in one or more liver function tests. jaundice, with or without fever, may occur also, with onset usually within first 2 or 3 months of therapy. Rare cases of fatal hepatic necrosis have been reported. Liver biopsies in several patients with liver dysfunction showed a microscopic focal necrosis compatible with drug hypersensitivity. Determine liver function, leukocyte and differential blood counts at intervals during the first six to twelve weeks of therapy or whenever unexplained fever may occur. Discontinue if fever, abnormalities in liver function tests, or jaundice occur. Methyldopa may potentiate action of other antihypertensive drugs. Foldow patients carefully to detect side reactions or unusual manifestations of drug idiosyncrasy. Patients may require reduced doses of anesthetics when on ALDOMET*. If hypotension does occur during anesthesia, it usually can be controlled by vasopressors. The adrenergic receptors remain sensitive during treatment with methyldopa. Hypertension occasionally noted after dialysis in patients treated with ALDOMET* may occur because the drug is removed by this procedure. Rarely involuntary choreoathetotic movements have been observed during therapy with methyldopa in patients with severe bilateral cerebrovascular disease. Should these movements occur, discontinue therapy. Fluorescence in urine samples at same wave lengths as catecholamines may be reported as urinary catecholamines. This will interfere with the diagnosis of pheochromocytoma. Methyldopa will not serve as a diagnostic test for pheochromocytoma. Usage in Pregnancy: Because clinical experience and follow-up studies in pregnancy have been limited, the use of methyldopa when pregnancy is present or suspected requires that the benefits of the drug be weighed against the possible hazards to the fetus. ADVERSE REACTIONS: Cardiovascular: Angina pectoris may be aggravated; reduce dosage if symptoms of orthostatic hypotension occur; bradycardia occurs occasionally. Neurological: Symptoms associated with effective lowering of blood pressure occasionally seen include dizziness, lightheadedness, and symptoms of cerebrovascular insufficiency. Sedation, usually transient, seen during initial therapy or when dose is increased. Similarly, headache, asthenia, or weakness may be noted as early, but transient symptoms. Rarely reported: paresthesias, parkinsonism, psychic disturbances including nightmares, reversible mild psychoses or depression, and a single case of bilateral Bell's palsy. Gastrointestinal: Occasional reactions generally relieved by decrease in dosage: mild dryness of the mouth and gastrointestinal symptoms including distention, constipation, flatus, and diarrhea; rarely, nausea and vomiting. Hematological: Positive direct Coombs test, acquired hemolytic anemia, leukopenia and rare cases of thrombocytopenia. Toxic and Allergic: Occasional drug related fever and abnormal liver function studies with jaundice and hepatocellular damage (see PRECAUTIONS) and a rise in BUN. Rarely, skin rash, sore tongue or "black tongue", pancreatitis and inflammation of the salivary glands. Endocrine and Metabolic: Rarely, breast enlargement, lactation, impotence, decreased libido; weight gain and edema which may be relieved by administering a thiazide diuretic. If edema progresses or signs of pulmonary congestion appear, discontinue drug. Miscellaneous: Occasionally nasal stuffiness, mild arthralgia and myalgia; rarely, darkening of urine after voiding.

was expressed nearer to our own time in these lines of Yeats: God guard me from those thoughts men think In the mind alone; He that sings a fasting song Thinks in a marrow bone. Conversely, cultivation of the imagination and the sensibilities is an intellectual pursuit. Intellect and feeling are two inseparable aspects of a fully rounded personality. Our modern system of medical education, by developing only one part of the person, has produced a generation of physicians who are analytically brilliant but in other respects stunted and naive. Coleridge might have been thinking of medical education when he wrote: "I have known some who have been rationally educated as it is styled. They were marked by a microscopic acuteness, but when they looked at great things, all became blank and they saw nothing.. ." We practise medicine with our whole being, not with a single part of our personality. A system of medical education that recognizes this will foster the growth of the physician as a whole person. I thank Drs. C.W. Buck, B.K.E. Hennen, F.L. Holmes and P.A. Rechnitzer and the members of the department of family medicine, University of Western Ontario for reviewing and commenting on the manuscript. References 1. POLANY! M: Personal Knowledge Towards a Post-Critical Philosophy, London and Chicago, U of Chicago Pr, 1962

2. TOuLMIN S: The Philosophy of Science, London, Har-Row, 1967 3. KOESTLER A: The Act of Creation, London, Macmillan, 1964 4. MEDAWAR PB: The Art of the Soluble, London, Methuen, 1967 5. Goi.sasucss EH: Art and Illusion, New York, Pantheon, 1960 6. FLEXNER A: Medical education in the United States, Boston, Updike, 1910 7. FLEXNER A: Universities, American, English and German, Oxford U Pr, 1930 8. ENGEL GL: The nature of disease and the care of the patient: the challenge of humanism and science in medicine. Ri Med I 45: 245, 1962 9. KUBLER-ROSS E: On Death and Dying, London, Macmillan, 1969

Full prescribing information available on request.

How Supplied: Tablets ALDOMET* are yellow, film-coated, biconvex shaped

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Correction In the letter to the editor "Peritoneal dialysis in methaqualone overdose", by DeMarco, Bear and Kapur (Can Med Assoc J 113: 823, 1975), the diphenhydramine content of each Mandrax capsule was incorrectly given as 150 mg; it is actually 25 mg. CMA JOURNAL/JANUARY 24, 1976/VOL. 114 101

Medicine as an art form.

Medicine as I.R. McWhinney, an art forms md, frcgp, ccfp physician has two central tasks: Technology reached an advanced stage of understanding d...
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