The doctor said: Such-and such indicates that there is such-and-such inside you; but if that is not confirmed by the analysis of this-and-that, then it must be assumed that you have such-and-such. If we presume such-and-such, then…and so on. For Ivan Ilyich only one question mattered: was his condition dangerous or not? But the doctor ignored this inappropriate question.
-The Death of Ivan Ilyich by Tolstoy
Time present and time past
Are both perhaps present in time future,
And time future contained in time past.
-Four Quartets, Burnt Norton by T.S. Eliot
The full knowledge of the parts of a steam engine and the theory of its action may be possessed by a man who could not be trusted to pull the lever to its throttle.
-The Student Life, Sir William Osler
While in residency I spent a month working in the cardiac care unit during which I had the pleasure of meeting a woman of almost impossible strength and courage whom, for the purpose of this essay, I shall call Mrs. Green. Mrs. Green was quite young, in her late twenties, and had just delivered her third child about 2 months prior-a healthy baby girl. She had two other young children to care for but had been forced to spend almost the entirety of her post-partum period thus far in the hospital. Unfortunately, as I learned on day one of my month in the CCU, she had developed post-partum cardiomyopathy and was suffering from terminal congestive heart failure. Prior to my involvement in her case, she had received optimal care from her cardiologists. She was receiving a constant infusion of medications to improve her cardiac output (milrinone, dobutamine, etc.) through a PICC line in her arm and was hoping to receive a heart transplant. She had battled and battled against the odds and survived several episodes of cardiac arrest but her prognosis was extremely poor and there had already been, prior to my involvement in her case, multiple consultations with palliative care.
Mrs. Green, however, had an indomitable will. She had no desire to even discuss the possibility of life for her children without her in it and she made that abundantly clear to her ICU physicians as well as to the palliative care team. For a month, my team continued to work with her, trying to somehow provide her heart greater strength. She had some good days with her young family visiting at the bedside and some bad days where her blood pressure was barely registering while her heart was maxed out on medications designed to enhance whatever contractile force it could muster. There were nights while on call that I thought she must certainly die, or at least code, and yet inevitably we would round on her the following day. She undoubtedly suffered day in and day out because, as she told us so often, she could not leave her family, especially her newborn, to the world without her in it. She absolutely refused to be made do not resuscitate (DNR) status despite several codes she had already survived. So every fourth evening I found myself taking care of patients in the CCU overnight as the on-call resident physician, terrified that I would have to code Mrs. Green-a patient I had grown to respect and care for and whom I dreaded to have to perform CPR upon.
One morning, after another long night on call, she suddenly informed our team that she was ready to talk with the palliative care team again. Surrounded by beeping pumps, monitors, intravenous tubing and her loving family she had accepted that should her heart stop again it would be ok to let her pass away. She was exhausted. She had fought the good fight. About three hours later, after rounds were over, I sat at a computer station and wearily completed some last minute charts before heading home. The palliative care team had left her room about 15 minutes prior to that and she had been made DNR status. Her family had then departed about five minutes later with hugs and kisses, her newborn sleeping peacefully in her car seat, and with promises to return later in the day. Suddenly, her alarms went off and I looked up from the computer. Her blood pressure had plummeted again and the day team physician and nursing staff rushed in to do what they could.
From my position at the desk, I could peer into the room and see Mrs. Green through the glass barrier. She lay there prone on the bed with her head tilted just so and seemed to be gazing over in my direction as staff were fussing with the medication pumps and the wailing cardiac monitors. Given my sleep-deprived state, I cannot know now, nor could I be sure then, but I am almost certain that she looked directly at me through the glass and smiled. I was astonished and slowly lifted my hand, as if to wave or acknowledge that I saw her. Her heart gave out not ten seconds later and Mrs. Green slipped from this mortal coil and passed on into the undiscovered country.
Her death affected me as I still think of it now, thirteen years later, and often wonder about it. I believed then, and still believe, that we did not keep her alive for that entire month so much as she willed herself to live. It was not three hours after deciding that it would be ok to die that she did. Furthermore, she passed away after having the opportunity to say goodbye to her children and her family and yet seemed to wait until they were gone and would not have to bear witness to her departure. I often think of her now 13 year old child and how I hope that someone told her that her mother was an absolute champion. That she carried within her a spirit made of steel and that something of that remarkable spirit, built of love for her newborn daughter, must have been passed along to the succeeding generation. Her life and death was one of the most courageous I have had the honor of being a witness to and I wonder still-how did she do it? Our science helped but there was something else at play there. She lived for a while, I believe, on pure, flinty will. She was in effect a whole that was greater than the sum of her parts and there was nothing in our science to fully explain that phenomenon.
But what do I mean by “greater than the sum of her parts”? This idea lies in contrast to the positivistic ideas of Auguste Comte in which, as Will Durant concisely puts it in his masterful The Story of Philosophy, any field of thought could be “reduced to positive science by precise observation, hypothesis, and experiment, and its phenomena explained through the regularities of cause and effect.” By these lights, we could understand a motor vehicle by knowing every part of it, down to the last piston and lug nut, how they fit together and act upon each other and how the summation of this massive amount of information would give us perfect knowledge of the motor vehicle in question. Yet somehow, we look at a motor vehicle and most of us know almost nothing about how it’s built or how it runs and yet, we “know” what a motor vehicle is. We intuitively understand it without the scientific knowledge that a positivistic theory would demand of us.
The same applies with people, and perhaps even more so. To apply such purely mechanistic and dogmatic scientism to our patients must certainly lead to a short career in medicine, or at least one certainly would hope so. Luckily, there is a countervailing theory of knowledge in psychology that first formally came about in the late nineteenth century but that has been tacitly understood by good physicians since time immemorial. This is the epistemological theory of gestalt.
Gestalt, a term often bandied about in medical circles, is a German word that means something akin to a unified whole or a form or structure of something. Without getting too deep into the rhubarb patch, perhaps it is better understood as a tacit understanding of something that is immediately recognizable so long as it is not broken down into its individual elements. Put another way, the object under consideration is taken as a whole and intuited immediately without classic scientific investigation into its constitutive parts. In fact, one might argue that to try and break it down would be to lose the forest for the trees.
Somewhere hiding in these thick weeds lays the nebulous art of medicine-or at least a hint of it. If we think of understanding medicine in hierarchical fashion we might start with the basic science at the bottom. Everyone understands what this means and it is well taught in medical school. The average medical student will struggle for hours to obtain this critical fund of scientific knowledge that is a necessary prerequisite for understanding and practicing medicine. I do not dwell on this because we in the West have this down pat. It is all science, all day, and if you don’t understand the science well then you can’t practice medicine effectively. There is nothing controversial here but I will move on because this series of essays is about the art of medicine and therein lay the difficulties.
Assuming then, that all graduating medical students have a roughly equivocal fund of technical knowledge of the medical science, it will not be long before they set out into the world looking to gain experience. This takes time but, having acquired it over the course of fifty or sixty thousand patients, they can start to see trends and predict outcomes with far greater accuracy. This is the subtle whiff of gestalt and yet it isn’t perfect. Experience, as Hippocrates noted, is fallacious however stereotypes, as the Onion pointed out, are real time savers. The trick lies in recognizing the correct signs and symptoms in a given patient based upon well-earned experience without falling into the lazy tiger trap of stereotypes. This requires subtle discrimination and much practice. It requires a trusting of one’s instincts and, most importantly of all, listening to one’s patients-each one of them, individually. Sound reasoning requires excellent intuition and excellent intuition develops with sound reasoning-both of which are impossible without engaged listening.
So, there is the science, which is necessary but not sufficient. Then there is experience and gestalt, which is a higher plane of understanding but one must be careful not to fall into self-inflicted stereotypes (the letting of one’s guard down due to that experience). The third and final piece of the puzzle seems to be excellent clinical decision making which is applying the science and the experience to the individual patient in front of you each and every time. It is stepping back from the patient at the bedside to objectively apply the hard science set now within the framework of one’s overall gestalt of the case back upon the specific patient with his own fears, hopes and desires in mind. Thus, you find that good clinical decision-making requires an explicit foundation of basic science, an implicit medical intuition based on historical experience and the application of both to the patient laying presently in front of you.
The great late Medieval or perhaps early Renaissance (depending on one’s viewpoint) philosopher and theologian, Nicholas of Cusa, developed a similar hierarchy of knowledge, though he applied his epistemology in a more theological direction. Nicholas acknowledged sensory experience as the first and prime way in which we understand the world and develop knowledge of it. We then use reason to better understand the world and which we may affirm or deny our sensory input with. But the highest form of understanding for Nicholas of Cusa was the intellect; that for him was how we can approximate an understanding of God. He describes God as the coincidentia oppositorum, a coincidence of opposites in which two things that are considered opposite to each other by our reason are both true simultaneously within the Divine.
Certainly, one might be wondering by now what any of this has to do with the art of medicine. Consider a fictional patient: a Mr. Harris. He’s a sixty-eight year old man with hypertension who comes to the emergency department complaining of severe chest pressure. He is clutching his chest and hyperventilating. He is surrounded by staff attaching him to monitors, obtaining an ECG, removing his clothing, establishing an IV, asking him questions, etc. Is Mr. Harris merely a collection of cells, some working properly and others not, a human body filled with myriad simultaneous chemical reactions and electrical currents? Is he a set of vital signs or an ECG tracing? It seems certain that he is at least in part all of those things but perhaps he is also a bereaved father. One might realize this because of the tattoo on his left arm that carries his son’s name and the years of his birth and death. He smokes when he is anxious (his fingers have a faint yellow hue to them), and he is often anxious, especially this time of year as it is always about this time of year when he presents in a similar fashion. It is about the time of year his son passed away. He is of course all of this as well. He is in fact both these things at the same time and perhaps what I mean by intuition is an ability to step back and recognize this in a kind of mental or psychic tide that is both sought after and that also will arrive on its own to those who can pay attention in various ways, often simultaneously. In this sense, Mr. Harris really is greater than the sum of his parts and our ability to intuit all of this is a sort of synthesis of, not opposites necessarily, but definitely very different but equally important ways of attending to him. The art of medicine is a sort of diminished version of Nicholas of Cusa’s much grander coincidentia oppositorum- but instead of a synthesis of opposites it is a synthesis of different methods of understanding and attending to the patient. It might be akin to the way an electron can be both a particle and a wave, depending on how we are attempting to observe it, but in truth is both simultaneously and without contradiction.
And so perhaps Eliot had it correct all along. Time present (the patient in front of you) and time past (scientific knowledge and experience from previous patients) are contained in time future (the patient’s course dependent upon the proper application of both empirical and intuitive knowledge). And perhaps time future was always contained in time past. Perhaps Mrs. Green’s now teenaged daughter has buried deep within her an indomitable will-a will given to her by a stoic mother with a fierce and beautiful love and the soul of a warrior. For we are greater than the sum of our parts and it takes more than science, even more than simple experience, to understand this.
It would seem then that the art of medicine is elusive, and in a way perhaps it is difficult to put into prose because it is not the type of knowledge that is well-suited to that form of exposition. It seems to me to be more akin to wisdom-the kind of thing that is better understood and expressed in great art or poetry. It can be easily felt and understood but not easily explained. We catch it in rare little glimpses. We long for it all the time. I have often wondered if physicians of the past had a better understanding of the art of medicine because there was less science to grasp and more time for art, philosophy and poetry-subjects of at least equal importance if we are trying to understand what it is to be human.
Thank you for this wonderful essay, Andrew. It brings to mind a quote (Sir Thomas Browne, Religio Medici, 1643) which could be well applied to the Art of Medicine: “There is something in it of Divinity…it is a sensible fit of that harmony which intellectually sounds in the ears of God.” Such is Art.