Is Medicine an Art or a Science?

My oldest daughter was born with several health issues; a cleft palate, low muscle tone, windswept feet, and jaundice.  As new parents, my husband and I were beside ourselves on how to care for our new baby.  We were lucky to find a pediatrician who calmed our fears while offering great care to our daughter.  A piece of advice that he gave me is that he trusts a mother’s intuition regarding her children; in other words, if a mother thinks something is wrong with her child, she is usually right.  I have used that philosophy for the past 23 years in raising our daughter and two other children and it has always proven accurate. 

Health Day has recently reported on a study regarding intuition:

“Doctor’s intuition that something is seriously wrong may have more diagnostic value than many symptoms and signs, the report suggested.  Parental concern that a child's illness was differentthan normal was another strong influence on gut feeling, the study authorsnoted in a journal news release.  A gutfeeling should prompt doctors to conduct a full and careful examination, seekadvice from a more experienced doctor, and advise parents what to do if theirchild's condition worsens, the researchers concluded.”

Doctor’s use experience as well as education to treat patients.  Medicine has always been more of an art than a science.  Today, however, there is a push to make medicine a science, removing all subjective processes from t he experience.  It is a push under the title of “Medical Necessity”.  Medical Necessity has been pushed by the government for the past few years to have doctors use tests and past performances to treat a person.  Now private insurers are jumping on the bandwagon.  United Healthcare recently released a notice that it would implement Medical Necessity in inpatient care beginning Oct. 1:

“As a reminder, Medical Necessity is the process for determining benefit coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective for the individual member. The Medical Necessity process is based upon a foundation of evidence-based medicine and:

·  Provides an opportunity to address covered services at the individual level to support enhanced access to quality care for the member.

·  Utilizes generally accepted standards of good medical practice in the medical community.

·  Offers timely communication between health plans, members and providers to allow for prospective, concurrent and retrospective review as well as appeal rights for adverse determinations.

This foundation supports United Healthcare’s overall goals for providing enhanced access to quality care by raising performance standards and reducing variation in medical practice, and health care affordability by implementing a process that promotes efficient delivery of high-quality care in a cost-effective manner.”

What is important to note in this missive is the sentence: “The Medical Necessity process is based upon a foundation of evidence-based medicine.”  Evidence-based medicine is defined as "treatment based on tests, labs and best medical practices for the medical condition."  The problem is that diagnosing based on tests and labs is easy for the obvious conditions, such as a broken arm or an ulcer, but as a doctor once remarked to me “you cannot see pain on an x-ray”.  In other words, not all medical problems can be determined from a test or lab.  There are many anecdotal examples of doctor’s misdiagnosing or missing a serious problem, even with tests.  This was brought to attention recently in an article in the Daily Mail about a woman who died from undiagnosed cervical cancer.

If physicians will now only be paid for evidence based medicine, then many diagnoses that are being paid for today - such as chronic fatigue syndrome, depression, or low muscle tone, which cannot be determined by a test but instead by direct observation and physician expertise - will no longer be viable diagnoses.  At the end of the day, as much science as there is in medicine today, it is an art and art cannot be measured.