The tension between the practice of science and art has been with us for a long time, but with every new technological advance, the tension ratchets tighter and anyone with an active imagination can see the piano wire is pulled so tight there is no longer any coil left. Art has simply been morphed into something else by the evidence-based mentality, all the better to peddle in some form that can be duly counted and priced.
The practice of medicine is much more than “evidence-based.” A very large part of any experienced physician’s expertise is based upon having seen similar symptoms in patients before—even one patient many years ago. This experience-based knowledge, like creativity, doesn’t comply with rulemaking in science. There’s no rule in an instance of one occurrence. Lewis Mehl-Madrona in Coyote Medicine provides examples of these kinds of dilemmas in medicine.
The “evidence” advocates want something that fits well inside a box, something palpable so a “market” can be created. The business of medicine can’t tolerate all those non-rule based behaviors that can’t be boxed up under a common term so everyone can be convinced to buy one. Never mind that what’s being sold isn’t what people need in health care. When it comes to health care, the expertise of the physicians has been dropped from the mix. The real expertise of physicians can’t be accurately described in any detail, much less fit into a box.
Many have tried to describe artistic thinking over the years. One of the more notable examples is the work of Dr. John Hayes and Dr. Linda Flower in the cognition of writing. They developed a method of trying to observe the creative process with protocol analysis, that is, assigning a writing task to research subjects and then having the research subjects verbalize what they were thinking as they wrote. Some very interesting information came out of these experiments, including the difference between the behavior patterns of expert and novice writers. However, there was always this “black box” in the room, the place where writers made decisions that were simply not verbalizable.
Some of the most valuable expert knowledge physicians have cannot be put in a check list or a box. But the bean counters have been quite successful in pushing, shoving, threatening, and getting rid of anything that can’t be isolated, boxed, and sold in the practice of medicine. The physician’s real art and expertise are lying on the cutting room floor. Unhappy with the state of medicine today? Take a look at the cutting room floor.
Linds Redding, a long-time creative idea person in advertising, blogged during his bout with esophageal cancer, and recently passed away. In his posts, he looks closely at what technology had done to his creative life, especially the headlong rush into doing everything faster and faster without the time to allow creative ideas to mature. He describes this tension between bean counters and artists well in his post “A Short Lesson in Perspective”:
This hybridization of the arts and business is nothing new of course – it’s been going on for centuries – but they have always been uncomfortable bed-fellows. But even artists have to eat, and the fuel of commerce and industry is innovation and novelty. Hey! Let’s trade. “Will work for food!” as the street-beggars sign says.
This Faustian pact has been the undoing of many great artists, many more journeymen and more than a few of my good friends. Add to this volatile mixture the powerful accelerant of emerging digital technology and all hell breaks loose. What I have witnessed happening in the last twenty years is the aesthetic equivalent of the Industrial Revolution in the 19th century. The wholesale industrialization and mechanization of the creative process. Our ad agencies, design groups, film and music studios have gone from being cottage industries and guilds of craftsmen and women, essentially unchanged from the middle-ages, to dark satanic mills of mass production. Ideas themselves have become just another disposable commodity to be supplied to order by the lowest bidder. As soon as they figure out a way of outsourcing thinking to China they won’t think twice. Believe me.
The correlations between what has happened to creativity in the artist’s world bears strong parallels to what has happened to the real expertise in the practice of medicine. A great part of a physician’s ability to recognize, diagnose, and treat illness depends upon experience—even the experience of one patient. Remembering one instance of something sort of similar seen 20 or 30 years ago makes physicians the experts they are. Physician expertise is grounded in the brain’s ability to remember pattern, and is as much art as a painter’s remembering a scene from 20 years ago and recreating it from memory.
Any attempts to reform health care in this country will require recognition and understanding of what constitutes the physician’s expert knowledge based upon experience, not book learning and checklists. It’s time to pick physician expertise up off the cutting room floor and put it back into the practice of medicine.
Anything less will leave us with more and more of the same dysfunction that plagues what we call health care today.