Medicine: Science, Art, or Religion?


Part of my weekend plan was to finish re-reading Look Homeward Angel in time for book club, but despite the deliciousness of Wolfe’s writing, these particular characters are so irksome I have given up on them.  Instead, I could not resist diving back into The Republican Brain:  The Science of Why They Deny Science—and Reality by Chris Mooney.   

I’ve just finished the part where he suggests the higher prevalence of liberals in science stems from our comfort with change and uncertainty.  If medicine really is “art and science”, why don’t we have a bunch of creative types with funky Einstein hair who vote, if not always for socialists, at least for Yellow Dog Democrats?  I can’t find good stats for you with a breakdown by political party, but in my personal experience most Alabama physicians are at least moderately conservative.  They sure aren’t as well-represented at Democrat events as similarly educated professional groups. 

Understanding why might be important.  Organized medicine has traditionally fought against real healthcare reform, from the very beginning of Medicare until now.  I know the AMA and several specialty groups did support the Affordable Care Act, which ought to help clue you in that it isn’t really much of a reform.  I’m sure someone is saying right now “it’s because they’re greedy”.  I think the answer is more complicated. 

So what happens in medical school?  Is it more like engineering than other types of science (Mooney says engineers are the exception, less often liberal)?  Does medicine simply attract conservatives or does the training make us more that way?  Politics doesn’t seem to be like sexual orientation—we can be changed. 

 My guess is that something really does happen during medical training to nudge folks in a more conservative direction.  AMSA, the American Medical Student Association, is much more liberal than the AMA or MASA (The Medical Association of the State of Alabama).  Look at their website and notice they support single payer.  Over and over again, I’ve seen looks of disbelief on medical student faces when they hear about doctors that won’t take children with Medicaid—they just can’t imagine why people would behave so.  They would NEVER do that, they say, with sincere determination.  It’s just WRONG.  But later, they do. 

If openness to change and tolerating uncertainty are the most important elements in liberalism, I can see right away how our training might work against us.  Even with the recent limits on training hours, learning medicine is highly stressful and often frightening.  We realize quickly that a mistake could kill someone we are trying to help.  Can you imagine how hard it would be to stay comfortable with uncertainty, especially when new at the job?  No matter how much you hear docs talk about the fear of malpractice suits causing unnecessary procedures and tests, I think they are using a defense mechanism against their real fear, too overwhelming to even confront—the fear of not knowing or being wrong.

 I will never forget the first time, as a resident, I was the senior person running a code for a baby who died unexpectedly and not because of incurable illness like cancer.  Even thinking about it 17 years later makes my throat tight and my breathing shallow.  Afterwards, going over and over it in my mind, I did not really want to find out if there was something I could have done differently that would have saved him, even though that’s what we have to do to save the next person.  I only wanted to hear what I was actually told, that the infection was so far gone there was nothing to be done.  In fact, I wanted to hear that so badly that I told the whole story, crying, to four different teaching doctors that night just to be sure and just to hear it again.

The examinations we take reinforce an illusion of certainty—they are mainly multiple choice.  I hate taking these certification tests, even though I “test well”, because they never have my real answer exactly on there.  Often I’d like to ask a few more questions or maybe have the imaginary patient come back tomorrow before picking an answer—I’d like to see her facial expressions and ask her what she wants out of our encounter.  I’d love to be tested by essay instead or by having a group of experienced doctors watch me in action and ask me to explain myself. 

We have something called a “differential diagnosis”, DDx, that’s supposed to help us keep our minds open, and I often hear doctors saying we should “date, not marry” a diagnosis before we are sure about it.  There’s one thing I’ve never seen on a DDx:  “this patient might have A, B, C, or D, or maybe something we have totally forgotten to put on this list.” 

As for openness to change, after spending so much time learning the “facts” and practicing their correct application, I admit it is kind of annoying when those “facts” suddenly change. Progress in medicine is messy—it isn’t a steady layering of new knowledge on a base of other knowledge.  More often it’s like ripping out a chunk of floor or even the whole foundation and starting over.  I guess that should increase our openness—we know that sort of change will happen—but instead it can make us feel like digging our heels in and saying no, that can’t be right, it doesn’t fit with the rest of what we know.   We don’t want to think we’ve wasted a decade or more doing something that turns out to be ridiculous.

Liberals have our weaknesses too.  We can be too dithery, for one thing.  If your throat is closing up from an allergic reaction, I bet you don’t want me to meditate on the finer points of epinephrine.  You want me to grab the syringe and fix your problem.  That’s as it should be in emergencies, but it doesn’t always work that well in the rest of medicine.  Too much love of certainty and resistance to change can turn the practice of medicine into something far different from art or science.  The closest I can come?  Religion.  Not the spiritual/ artistic version but the type with lots of unassailable dogma, the antithesis to good science.

So here’s my question—would you be happy with a doctor who tolerated uncertainty?  By this I don’t mean a careless person.  I also don’t mean simply a doctor who admitted not knowing the answer to your problem right away—we do that all the time.  I mean someone who was willing to remain with you in a state of honest unknowing now and then, not always trying to pin down every diagnosis with every lab test and x-ray possible.   Would you be able tell your doctor “Hey, I’m ok with you not being sure about what I have?  Let’s talk about some reasonable options, and if you turn out to be wrong I will understand.”  How might things change, in medicine and medical politics, if you did?

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4 Comments

Filed under Physician Factors

4 responses to “Medicine: Science, Art, or Religion?

  1. Amazing. Right on the nail head. I like MD’s who tell the truth and admit they are not sure. After all “it is the ‘practice’ of medicine!”

  2. Barbara Power

    I witness MDs being placed under extreme pressure to be certain, and right. Also, I see a vast difference between the medical and surgical camps. An additional complexity is that the knowledge gap between medical professionals and the average patient is, at times, an unbridgeable chasm. Lay people often have misplaced expectations, as well as outright demands, for a “cure” or a perfect procedure that will fix a problem forever. This can be daunting. I so often try to explain to families that their 85 year old mother/grandmother’s medical problems often cannot be reduced or fixed. The march of time is inexorable and few seem to have the capacity to grasp this inevitable truth. MDs are reduced to reciting a list of tests and results to satisfy the oft repeated question from family members “what are you going to do to fix my loved one?” In the acute care setting patients and families are distraught and distracted. There is little time to communicate, and much is misunderstood by patients. Well intended MDs do not realize their entire dialogue with a patient or family is done in technical language, e.g.: “your husband has A-Fib. We are treating with a dilt bolus and then a drip. We’re also bolusing fluids to get that blood pressure up.” This happens while the MD’s pager goes off 4 times in 6 minutes. It’s a crushing load of pressure on docs.

    From a purely personal perspective, I would love a brief, but truthful, dialogue with my MD (or my children’s MD). Also, in assisting with, and advocating for, the care of many family members involving all sorts of physicians, I have had one single MD who was capable of this type of relationship.

    It’s a tall order. It’s a lot to expect in the midst of today’s medical machinery and the lack of time allowed for human contact.

    ~Disclosure: written by a non-physician ~

  3. Well said. I “came of age” during the 60’s. All of my life as a child and teenager having been taught that people of different color were not really people but some kind of inferior race, it slowly dawned upon me that people were real people regardless of color, religion, or whatever. Ever since then, I never took the conventional wisdom as being the gospel expecially when we had leaders like George Wallace, Ross Barnett, Richard Nixon, etc. I remember when Lyndon Johnson addressed Congress and the American people proposing Medicare. AMA went on television opposing it calling it “socialized medicine.” The establishment did not want change then and it does not want it now.
    I have practiced Pharmacy for better than 44 years. It has been very good to me and I have made a good living. Talk about change! When I was in school, 90% of all Rxs were filled at independant stores, now it is about 10%. Most of my colleagues are “conservatives” and do not believe that healthcare should be a right, but somehow should be earned. Healthcare for all might cost too much or affect our ability to make money,etc. As you said, too much love of certainty and resistance to change mixed in with religious dogma.
    By the way, I am working tomorrow, will work about a 10 to 11 hour shift and fill about 300 Rxs. Not bad for a 69 year old… At the end of day of the day, I will be so totally exausted but proud that I can still practice my craft. Might even have time to challenge somebody’s politics….

  4. Ezra Klein has an extraordinary article in the June 25 issue of the New Yorker. Titled “Unpopular Mandate”, he details how the individual mandate, a Republican proposal, developed in the Heritage Foundation, became the part of the ACA that Republicans universally consider unconstitutional. He begins with that issue and moves to a more generalized discussion of how people change the way they think in response to influences from groups of which they’re members.

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