What stays constant at the heart of medicine
Authors: Harold J Cook
Journal: BMJ (2006)

The expression “the science and art of medicine” is much misunderstood. Too often the parts of medicine termed as its “art” seem to amount to no more than good communication skills or to what was once called a good bedside manner. No doubt patients feel better, and perhaps even do better, when they think their doctor cares about them. But stories also abound of well dressed doctors with smooth manners but little knowledge who have gained—and sometimes abused—the trust of their patients. 

While the historical record is replete with such examples, and almost every practitioner will be able to call others to mind, it is the fictional creations of writers such as Moliere, Shaw, and Cronin that have most amused and scandalised us. To provide a counterweight to such social frauds, all kinds of programmes and regulations have been introduced to make competence and knowledge more important to professional advancement than manners, social graces, and public regard. 

But to identify the art of medicine with “artfulness” is to fall into a set of modern confusions. It is now common to think of art as something done by artists and the arts as a different field of activity than science, sometimes even a field of activity opposed to science. But in the older uses of the English language art meant something else. The first entry for the word in the Oxford English Dictionary defines it as “skill in doing anything as the result of knowledge and practice,” citing uses from the medieval period to the 19th century. In other words, the art of medicine is not about appearance at the expense of substance, but rather the way in which knowledge is related to advice and treatment. It was in this sense that art was used in book titles of the 17th and 18th centuries; for example, The Art of Curing Diseases (Gideon Harvey, 1689) and A Plain Introduction to the Art of Physick (John Peachey, 1697). Such titles indicate that when dealing with patients doctors do not simply apply knowledge but also engage the art of medicine. 

The problem might be reformulated in this way: medicine requires knowledge of universals and of the application of them to particular instances, as embodied in individual patients. Or as it was put a millennium ago by the famed Avicenna, “When we say that practice proceeds from theory, we do not mean that there is one division of medicine by which we know, and another, distinct there from, by which we act—as many, examining this problem suppose. We mean instead that these two aspects are both sciences—but one dealing with the basic problems of knowledge, the other with the mode of operation of these principles.” The first aspect was called science proper, the second art.1

Medical art may be a form of knowledge that is more probabilistic than the demonstrative certainty of science, but it is crucially important knowledge nevertheless. Moreover, all commentators on this art emphasise that its exercise requires not only knowledge of content, but something called “judgment.” Philosophically speaking, the importance of judgment is today highlighted in phenomenology, aesthetics, “virtue ethics,” and “emotional intelligence.” Judgment is downplayed in instrumentalist and functionalist reasoning, where pride of place is given to the rationality of calculation, impartiality, and disinterestedness. On their own, attributes of disinterestedness can lead to coldly experimenting with cases; clinical judgment, on the other hand, requires attending to a patient. 

While the science of medicine continues to be advanced by laboratory research and the statistical investigations of evidence based medicine, the parts of it termed “the art” are developing too, and remain a source of resistance to bureaucratic assessment and benchmarking. For thousands of years, the question of how best to associate the universal and the particular has always been the real doctor's dilemma. No formulae, however good, can ever obscure the second part of medical knowledge, which comes from the exercise of clinical judgment.