J Clin EpidemiolVol. 43, No. 5, pp. 527-531, 1990 Printed in Great Britain. All rights reserved
Copyright
0895-4356/90 $3.00 + 0.00 % 1990 Pergamon Press plc
Second Thoughts THE CLINICAL RICHARD Department
of Medicine,
PICTURE
V. LEE*
Children’s Hospital of Buffalo and State University Buffalo, NY 14222, U.S.A.
of New York
at
(Receiaed in revised form 26 June 1989)
modern physicians schooled in “hard science”. Van Gogh, I admit, does appear a bit removed from biostatistics, magnetic resonance imaging, coronary angioplasty, and DNA probes. Aesthetic sensibility, however, ought not to be excluded from clinical medicine. Indeed, how doctors perceive and appreciate art is not merely clinically significant. I maintain that a welldeveloped aesthetic sensitivity, an awareness of beauty and of ugliness, is clinically essential. Physicians are taught not to regard their patients as beautiful creatures, but as creatures to be dissected, poked, and observed with suspicion. The idea of the human body as a work of art smacks of religion; that the manifestations of illness might be considered aesthetic seems callous and disrespectful. Art can be trivialized. Medicine is too serious and too scientific for such antics. Medicine is too real to be contaminated or distracted by the ethereality of art. Still, the mythic “art of medicine” continues to circulate and to remind us of a more complete, perhaps humane, medicine. And, medicine without aesthetic sensibility and sensitivity is transformed into a kind of neutral tinkering: routine, colorless, boring. Viewing Van Gogh is more than a dissection: individual brush strokes, individual colors combine into a comprehensible whole. The painting reaches out, seizes my eye and captures my attention. There is immediate comprehension, instantaneous intuition, active awareness. Perhaps it is this intuitiveness that makes physician-scientists so suspicious about introducing notions of art in clinical activities. Yet my comprehension of the nature of a patient’s
An exquisite Van Gogh painting is displayed at the Albright-Knox Art Gallery in Buffalo. The Old Mill was completed in 1888, 2 years before the artist’s death and over a century before the composition of this essay. There is nothing medical about it: no earless, demented, bandaged, or sick people; no hint of plague fears, no angst. Rather, it is a welcoming, friendly landscape, full of warmth and color. It is about two feet square, a cozy painting, intense, arresting. I am unable to walk along the gallery corridor in which it hangs without stopping. For more than a decade on every gallery visit I have stopped to look: a bulky, rather disheveled academic, art history naive, enraptured by the vision of Van Gogh. What captures my attention? How is it that this small painting is a focal point? I even carry a coloured postcard of it as a bookmark for those long airplane rides that seem to be obligatory for academic status. Perhaps the attraction is, as doctors say, clinically significant. Is it this particular painting? Is it old mills? Or the blue hills and roof? Is it Van Gogh, the enigmatic Dutchman? Probably not. Breughel, Cimabue, El Greco, Turner, and Picasso created paintings that I go out of my way to reexamine as often as possible. Or is it me? Dissecting my affection for Van Gogh’s painting, or any painting for that matter, probably seems clinically obscure for young
*All correspondence should be addressed to: Richard V. Lee, M.D., Department of Medicine, Children’s Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222, U.S.A. 521
528
Second Thoughts
Fig. I. The Old MiN (Albright-Knox
misery is no less intuitive. Examining a patient, looking at a painting, listening to music share a sense of being possessed, totally engaged, intuitively immersed in the object and the act of observation. Practising clinical medicine has an extraordinary similarity with looking at paintings. A painting like a person is a palpable, visible fact. Each has a history. Each conveys, in its own way, a story, an image, a message or messages, a diagnosis or diagnoses. One is inanimate, created and composed by a living artist who
Art Gallery, Buffalo, New York).
suffuses the creation with memory, feeling and meaning. The other is animate often able to tell their own story; a story composed of memory, feeling and meaning. When I listen to and examine a patient I interpret the image and story, interpretations suffused with my memory, feeling and meaning. When I view a painting I do the same. Clinical medicine and looking at a painting unavoidably include my personal interpretation of symbols and symptoms. Both activities require a storyteller patient or storyteller artist, visual intimacy, time, and me.
Second Thoughts
Physicians often say that there is nothing creative about clinical medicine. The clinician is merely a well trained observer and recorder of human biology and a precise correlator of abnormalities and remedies. The increasing use of algorithms and “cookbooks” attest to growing support of clinical medicine as an automated, unimaginative activity. Much of medicine is craft; however, I suggest that the product of a patient’s clinical history and examination, the clinical picture, is a work of art. The clinical picture is a unique blend of the patient and the physician: both acting as artist, observer, and viewer. The patient’s description of the intensity of pain is colored by fear and anxiety, the hope that this is “just something minor”. The doctor’s relation of the description and clinical interpretation is colored by the “fit of the story”: does the pain match the events and the findings on examination, is the patient asking for relief of something other than pain? Clinical truth, like a Van Gogh painting, is a composite. Master physicians do more than master the craft of medicine. They use it in ways that inspire, that expand our knowledge and our vision. John Ruskin, the Victorian art critic and exegete, insisted that “art provides the visual vocabularies with which people confront the world around them” [I]. “Painting, or art generally, as such, with all its technicalities, difficulties, and particular ends, is nothing but a noble and expressive language, invaluable as the vehicle of thought, but by itself nothing. He who has learned what is commonly considered the whole art of painting, that is, the art of representing any natural object faithfully, has yet only learned the language by which his thoughts are to be expressed” [2].
The essence of the aesthetic experience, the artiness (if you will) in medicine, has to do with the conveyance of meaning. The patient who understands the human implications of their systemic lupus erythematosus and the students and peers that comprehend the biology of the disease and of the patient are the product of the medical art. “But I say that the art is greatest which conveys to the mind of the spectator, by any means whatsoever, the greatest number of the greatest ideas; and I call an idea great in proportion as it is received by a higher faculty of the mind, and as it more fully occupies, and in occupying, exercises and exalts, the faculty by which it is received” [2].
One connection between art and medicine is epistemologic. Both depend upon intuition, the
529
nonquantitative apprehension and comprehension of beauty and of ugliness. Art proclaims its intuitiveness; modern medicine attempts to camouflage it. Van Gogh uses blues, yellows and greens to make a verdant, fecund sensual image. A patient tells me of arthralgias, allergies, abortions, bruising and photosensitive skin that has malar telangiectasia and atrophy. Even before the confirmatory laboratory tests have been taken I can tell her 1 have her clinical picture, a diagnosis. Van Gogh’s Old Mill is stunning. My patient’s lupus erythematosus is stunning. But different artists, different patients, and different physicians can make different pictures of identical scenes and diseases. “Suppose, for instance, two men, equally honest, equally industrious, equally impressed with a humble desire to render some part of what they saw in nature faithfully; But one of them is quiet in temperament, has a feeble memory, no invention, and excessively keen sight. The other is impatient in temperament, has a memory which nothing escapes, an invention which never rests, and is comparatively nearsighted. Set them both free in the same field in a mountain valley. One see everything, small and large, with almost the same clearness; mountains and grasshoppers alike; the leaves on the branches, the veins in the pebbles, the bubbles in the stream; but he can remember nothing, and invent nothing. Patiently he sets himself to his mighty task: abandoning at once all thoughts of seizing transient effects, or giving general impressions of that which his eyes present to him in microscopical dissection, he chooses some small portion out of the infinite scene, and calculates with courage the number of weeks which must elapse before he can do justice to the intensity of his perceptions, or the fullness of matter in his subject. Meantime, the other has been watching the change of the clouds, and the march of the light along the mountain sides; he beholds the entire scene in broad, soft masses of true gradation, and the very feebleness of his sight is in some sort an advantage to him, in making him more sensible of the aerial mystery of distance, and hiding from him the multitudes of circumstances which it would have been impossible for him to represent. But there is not one change in the casting of the jagged shadows along the hollows of the hills, but it is fixed on his mind forever; not a flake of spray has broken from the sea of cloud about their bases, but he has watched it as it melts away, and could recall it to its lost place in heaven by the slightest effort of his thoughts. Not only so, but thousands and thousands of such images, of older scenes, remain congregated in his mind, each mingling in new associations with those now visibly passing before him, and these again confused with other images of his own ceaseless, sleepless imagination, flashing by in sudden troops. Fancy how his paper will be covered with stray symbols and blots, and undecipherable shorthand:-as for his sitting
530
Second Thoughts down to ‘draw from Nature,’ . there was not one of the things which he wished to represent, that stayed for so much as five seconds together: but none of them escaped for all that: they are sealed up in that strange storehouse of his; he may take one of them out perhaps, this day twenty years, and paint it in his dark room, far away” [3].
Art affirms and confirms the utility and intuitive existence of paradigmatic pathologies, of disease entities. Van Gogh’s Old Mill contains a fundamental image fixed for time, certainly for the life of the painting and for the life of its viewers. The viewers and viewing may change, the interpretation may change, but the painting and its image is constant. Our notion of disease and of health is the same. The clinical expression of lupus erythematosus varies from patient to patient, the clinical picture is shaped by the powers of description and observation by patient and doctor, but we do not doubt that there is a fundamental biologic disorder that generates the disease, the clinical picture. I have said before that medicine is not an art, that it is a craft [4]. I haven’t changed my mind. Art is the product of shared compassion and intuition among the participants. The creation of Van Gogh’s painting required craft: chemistry to make the pigments, physics to blend the pigments to refract the light entering the viewers’ eyes, and the deft touch of the brush. There is craft in art. There is art in the craft of medicine. “There are, I suppose, some similarities between physicians and calligraphers or painters and sculptors. We use our hands; we attempt to shape flesh and psyche; we have schools of theory, practice, and perspective; we cultivate philanthropic patrons. The dissimilarities are more striking. We do not put our living patients in museums for contemplating and viewing by the artistically curious, or on the auction block at Sotheby’s for sale to the highest bidding collector. We ought not to perform procedures and experiments on living things solely for the pleasure of observing elegant experimental design affecting the inherent symmetry of the live organism. Unlike the artist, we do our work for practical, vulgar reasons: so that the patient may defecate, urinate, breath, and sleep well. Our intent is to help, not to beautify. Our obligation is to the patient, not to the rich patron. No, medicine is not a fine art and physicians are not artists. Rather we are craftsmen, artisans-committed to the well-being of our patients regardless of their ugliness or beauty, and not for sale to the highest bidder” [4].
So, the affinity between me and Van Gogh, between my medicine and his art, has more to do with ways of knowing as opposed to ways of doing, with intuition not with technique, with
episteme, not praxis. The seemingly unbridge-
able contemporary gulf between medicine and the arts reflects a rather self-satisfied notion that medicine uses more accurate and more objective and reproducible ways of knowing and that the essence of medicine is practice: physicians don’t look at things, physicians do things. The modern medical armory is replete with things to do: surgeries, pharmaceuticals, diets, images, manipulations, exercises, and counselings. Good health has become a function of doing, not of knowing or sensing or feeling. We are guilty of paying more heed on rounds to what the machines attached to the patient are doing, than to what the patient tells us about their state of being. Which is to be acted upon these days: the cheerful patient saying what a beautiful day it is or her monitor which shows ventricular bigeminy? Contemporary health priorities are to do something or to have something done. Just being looked at is inadequate. People do or have done to themselves massage, liposuction, live-forever diets, holistic health, meditation. Good health implies an active not a passive voice. One must exude and proclaim their good health. People must do something so that their good health is recognized: dress, suntans (even those from tanning parlors), talk. Meditation has become a public cult, not a private practice. Just knowing or feeling without telling or displaying is somehow insufficient, old-fashioned. Health is no longer intuitive. Intuition is no longer healthy. Academic medicine devotes enormous amounts of energy, time and verbiage to the praxis of medicine: the design and statistical evaluation of experiments and experience, the performance of delicate surgery, obtaining and preserving anatomically precise, computer enhanced images, the definition and imposition of what is called “quality control”. The officiously objective burdens of utilization review and quality assurance ask only about technique and outcome. They do not ask about intuition or interpretation. Compassion and comfort, beauty and joy, are not concerns of “quality control”. More importantly those moments of exhilarating, humbling clinical intuition are not concerns of medical educators and administrators. Because it eludes measurement by standard scientific, statistical studies, clinical intuition is not taught, or even talked about. We assume that it is a gift, an endowment students bring to medicine, not something we teachers impart to them. We regard it suspiciously, as something
Second
unteachable, and therefore unreproducible, unreliable, and noncontrollable. Hermeneutics has not found a place in medical education. Despite my lamentations, contemporary medical education works. Perfectly adequate doctors are produced by medical schools and housestaff training programs, never having taken a course in art history, music appreciation or literary criticism, never having attended a symphony concert or strolled through an art gallery. Why bother about Van Gogh’s Old Mill or Lewis Thomas’s Late Night Thoughts on Mahler’s Ninth Symphony?
Thoughts
531
Because without them medicine is ugly. And, without intuition, and beauty and ugliness, without art, what I do wouldn’t be medicine at all. REFERENCES
l. 2. 3. 4,
Landow GP. Ruskin. Oxford: Oxford University Press; 1985. Ruskin J. In: Cook ET, Widderburn A, Eds. Modern Painters, Vol. 1, Library Edition. London: George Allen; 1903: 1903-1912. Ruskin J. In: Cook ET, Widderburn A, Eds. PreRaphaelitism Library Edition. London: George Allen; 191x: 1903-1912. Lee RV. The generalist: a jaundiced view XXIII. The art of medicine. Am J Med 1983; 75: 381.
Copyright
0895-4356/90 $3.00 + 0.00 % 1990 Pergamon Press plc
Second Thoughts THE CLINICAL RICHARD Department
of Medicine,
PICTURE
V. LEE*
Children’s Hospital of Buffalo and State University Buffalo, NY 14222, U.S.A.
of New York
at
(Receiaed in revised form 26 June 1989)
modern physicians schooled in “hard science”. Van Gogh, I admit, does appear a bit removed from biostatistics, magnetic resonance imaging, coronary angioplasty, and DNA probes. Aesthetic sensibility, however, ought not to be excluded from clinical medicine. Indeed, how doctors perceive and appreciate art is not merely clinically significant. I maintain that a welldeveloped aesthetic sensitivity, an awareness of beauty and of ugliness, is clinically essential. Physicians are taught not to regard their patients as beautiful creatures, but as creatures to be dissected, poked, and observed with suspicion. The idea of the human body as a work of art smacks of religion; that the manifestations of illness might be considered aesthetic seems callous and disrespectful. Art can be trivialized. Medicine is too serious and too scientific for such antics. Medicine is too real to be contaminated or distracted by the ethereality of art. Still, the mythic “art of medicine” continues to circulate and to remind us of a more complete, perhaps humane, medicine. And, medicine without aesthetic sensibility and sensitivity is transformed into a kind of neutral tinkering: routine, colorless, boring. Viewing Van Gogh is more than a dissection: individual brush strokes, individual colors combine into a comprehensible whole. The painting reaches out, seizes my eye and captures my attention. There is immediate comprehension, instantaneous intuition, active awareness. Perhaps it is this intuitiveness that makes physician-scientists so suspicious about introducing notions of art in clinical activities. Yet my comprehension of the nature of a patient’s
An exquisite Van Gogh painting is displayed at the Albright-Knox Art Gallery in Buffalo. The Old Mill was completed in 1888, 2 years before the artist’s death and over a century before the composition of this essay. There is nothing medical about it: no earless, demented, bandaged, or sick people; no hint of plague fears, no angst. Rather, it is a welcoming, friendly landscape, full of warmth and color. It is about two feet square, a cozy painting, intense, arresting. I am unable to walk along the gallery corridor in which it hangs without stopping. For more than a decade on every gallery visit I have stopped to look: a bulky, rather disheveled academic, art history naive, enraptured by the vision of Van Gogh. What captures my attention? How is it that this small painting is a focal point? I even carry a coloured postcard of it as a bookmark for those long airplane rides that seem to be obligatory for academic status. Perhaps the attraction is, as doctors say, clinically significant. Is it this particular painting? Is it old mills? Or the blue hills and roof? Is it Van Gogh, the enigmatic Dutchman? Probably not. Breughel, Cimabue, El Greco, Turner, and Picasso created paintings that I go out of my way to reexamine as often as possible. Or is it me? Dissecting my affection for Van Gogh’s painting, or any painting for that matter, probably seems clinically obscure for young
*All correspondence should be addressed to: Richard V. Lee, M.D., Department of Medicine, Children’s Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222, U.S.A. 521
528
Second Thoughts
Fig. I. The Old MiN (Albright-Knox
misery is no less intuitive. Examining a patient, looking at a painting, listening to music share a sense of being possessed, totally engaged, intuitively immersed in the object and the act of observation. Practising clinical medicine has an extraordinary similarity with looking at paintings. A painting like a person is a palpable, visible fact. Each has a history. Each conveys, in its own way, a story, an image, a message or messages, a diagnosis or diagnoses. One is inanimate, created and composed by a living artist who
Art Gallery, Buffalo, New York).
suffuses the creation with memory, feeling and meaning. The other is animate often able to tell their own story; a story composed of memory, feeling and meaning. When I listen to and examine a patient I interpret the image and story, interpretations suffused with my memory, feeling and meaning. When I view a painting I do the same. Clinical medicine and looking at a painting unavoidably include my personal interpretation of symbols and symptoms. Both activities require a storyteller patient or storyteller artist, visual intimacy, time, and me.
Second Thoughts
Physicians often say that there is nothing creative about clinical medicine. The clinician is merely a well trained observer and recorder of human biology and a precise correlator of abnormalities and remedies. The increasing use of algorithms and “cookbooks” attest to growing support of clinical medicine as an automated, unimaginative activity. Much of medicine is craft; however, I suggest that the product of a patient’s clinical history and examination, the clinical picture, is a work of art. The clinical picture is a unique blend of the patient and the physician: both acting as artist, observer, and viewer. The patient’s description of the intensity of pain is colored by fear and anxiety, the hope that this is “just something minor”. The doctor’s relation of the description and clinical interpretation is colored by the “fit of the story”: does the pain match the events and the findings on examination, is the patient asking for relief of something other than pain? Clinical truth, like a Van Gogh painting, is a composite. Master physicians do more than master the craft of medicine. They use it in ways that inspire, that expand our knowledge and our vision. John Ruskin, the Victorian art critic and exegete, insisted that “art provides the visual vocabularies with which people confront the world around them” [I]. “Painting, or art generally, as such, with all its technicalities, difficulties, and particular ends, is nothing but a noble and expressive language, invaluable as the vehicle of thought, but by itself nothing. He who has learned what is commonly considered the whole art of painting, that is, the art of representing any natural object faithfully, has yet only learned the language by which his thoughts are to be expressed” [2].
The essence of the aesthetic experience, the artiness (if you will) in medicine, has to do with the conveyance of meaning. The patient who understands the human implications of their systemic lupus erythematosus and the students and peers that comprehend the biology of the disease and of the patient are the product of the medical art. “But I say that the art is greatest which conveys to the mind of the spectator, by any means whatsoever, the greatest number of the greatest ideas; and I call an idea great in proportion as it is received by a higher faculty of the mind, and as it more fully occupies, and in occupying, exercises and exalts, the faculty by which it is received” [2].
One connection between art and medicine is epistemologic. Both depend upon intuition, the
529
nonquantitative apprehension and comprehension of beauty and of ugliness. Art proclaims its intuitiveness; modern medicine attempts to camouflage it. Van Gogh uses blues, yellows and greens to make a verdant, fecund sensual image. A patient tells me of arthralgias, allergies, abortions, bruising and photosensitive skin that has malar telangiectasia and atrophy. Even before the confirmatory laboratory tests have been taken I can tell her 1 have her clinical picture, a diagnosis. Van Gogh’s Old Mill is stunning. My patient’s lupus erythematosus is stunning. But different artists, different patients, and different physicians can make different pictures of identical scenes and diseases. “Suppose, for instance, two men, equally honest, equally industrious, equally impressed with a humble desire to render some part of what they saw in nature faithfully; But one of them is quiet in temperament, has a feeble memory, no invention, and excessively keen sight. The other is impatient in temperament, has a memory which nothing escapes, an invention which never rests, and is comparatively nearsighted. Set them both free in the same field in a mountain valley. One see everything, small and large, with almost the same clearness; mountains and grasshoppers alike; the leaves on the branches, the veins in the pebbles, the bubbles in the stream; but he can remember nothing, and invent nothing. Patiently he sets himself to his mighty task: abandoning at once all thoughts of seizing transient effects, or giving general impressions of that which his eyes present to him in microscopical dissection, he chooses some small portion out of the infinite scene, and calculates with courage the number of weeks which must elapse before he can do justice to the intensity of his perceptions, or the fullness of matter in his subject. Meantime, the other has been watching the change of the clouds, and the march of the light along the mountain sides; he beholds the entire scene in broad, soft masses of true gradation, and the very feebleness of his sight is in some sort an advantage to him, in making him more sensible of the aerial mystery of distance, and hiding from him the multitudes of circumstances which it would have been impossible for him to represent. But there is not one change in the casting of the jagged shadows along the hollows of the hills, but it is fixed on his mind forever; not a flake of spray has broken from the sea of cloud about their bases, but he has watched it as it melts away, and could recall it to its lost place in heaven by the slightest effort of his thoughts. Not only so, but thousands and thousands of such images, of older scenes, remain congregated in his mind, each mingling in new associations with those now visibly passing before him, and these again confused with other images of his own ceaseless, sleepless imagination, flashing by in sudden troops. Fancy how his paper will be covered with stray symbols and blots, and undecipherable shorthand:-as for his sitting
530
Second Thoughts down to ‘draw from Nature,’ . there was not one of the things which he wished to represent, that stayed for so much as five seconds together: but none of them escaped for all that: they are sealed up in that strange storehouse of his; he may take one of them out perhaps, this day twenty years, and paint it in his dark room, far away” [3].
Art affirms and confirms the utility and intuitive existence of paradigmatic pathologies, of disease entities. Van Gogh’s Old Mill contains a fundamental image fixed for time, certainly for the life of the painting and for the life of its viewers. The viewers and viewing may change, the interpretation may change, but the painting and its image is constant. Our notion of disease and of health is the same. The clinical expression of lupus erythematosus varies from patient to patient, the clinical picture is shaped by the powers of description and observation by patient and doctor, but we do not doubt that there is a fundamental biologic disorder that generates the disease, the clinical picture. I have said before that medicine is not an art, that it is a craft [4]. I haven’t changed my mind. Art is the product of shared compassion and intuition among the participants. The creation of Van Gogh’s painting required craft: chemistry to make the pigments, physics to blend the pigments to refract the light entering the viewers’ eyes, and the deft touch of the brush. There is craft in art. There is art in the craft of medicine. “There are, I suppose, some similarities between physicians and calligraphers or painters and sculptors. We use our hands; we attempt to shape flesh and psyche; we have schools of theory, practice, and perspective; we cultivate philanthropic patrons. The dissimilarities are more striking. We do not put our living patients in museums for contemplating and viewing by the artistically curious, or on the auction block at Sotheby’s for sale to the highest bidding collector. We ought not to perform procedures and experiments on living things solely for the pleasure of observing elegant experimental design affecting the inherent symmetry of the live organism. Unlike the artist, we do our work for practical, vulgar reasons: so that the patient may defecate, urinate, breath, and sleep well. Our intent is to help, not to beautify. Our obligation is to the patient, not to the rich patron. No, medicine is not a fine art and physicians are not artists. Rather we are craftsmen, artisans-committed to the well-being of our patients regardless of their ugliness or beauty, and not for sale to the highest bidder” [4].
So, the affinity between me and Van Gogh, between my medicine and his art, has more to do with ways of knowing as opposed to ways of doing, with intuition not with technique, with
episteme, not praxis. The seemingly unbridge-
able contemporary gulf between medicine and the arts reflects a rather self-satisfied notion that medicine uses more accurate and more objective and reproducible ways of knowing and that the essence of medicine is practice: physicians don’t look at things, physicians do things. The modern medical armory is replete with things to do: surgeries, pharmaceuticals, diets, images, manipulations, exercises, and counselings. Good health has become a function of doing, not of knowing or sensing or feeling. We are guilty of paying more heed on rounds to what the machines attached to the patient are doing, than to what the patient tells us about their state of being. Which is to be acted upon these days: the cheerful patient saying what a beautiful day it is or her monitor which shows ventricular bigeminy? Contemporary health priorities are to do something or to have something done. Just being looked at is inadequate. People do or have done to themselves massage, liposuction, live-forever diets, holistic health, meditation. Good health implies an active not a passive voice. One must exude and proclaim their good health. People must do something so that their good health is recognized: dress, suntans (even those from tanning parlors), talk. Meditation has become a public cult, not a private practice. Just knowing or feeling without telling or displaying is somehow insufficient, old-fashioned. Health is no longer intuitive. Intuition is no longer healthy. Academic medicine devotes enormous amounts of energy, time and verbiage to the praxis of medicine: the design and statistical evaluation of experiments and experience, the performance of delicate surgery, obtaining and preserving anatomically precise, computer enhanced images, the definition and imposition of what is called “quality control”. The officiously objective burdens of utilization review and quality assurance ask only about technique and outcome. They do not ask about intuition or interpretation. Compassion and comfort, beauty and joy, are not concerns of “quality control”. More importantly those moments of exhilarating, humbling clinical intuition are not concerns of medical educators and administrators. Because it eludes measurement by standard scientific, statistical studies, clinical intuition is not taught, or even talked about. We assume that it is a gift, an endowment students bring to medicine, not something we teachers impart to them. We regard it suspiciously, as something
Second
unteachable, and therefore unreproducible, unreliable, and noncontrollable. Hermeneutics has not found a place in medical education. Despite my lamentations, contemporary medical education works. Perfectly adequate doctors are produced by medical schools and housestaff training programs, never having taken a course in art history, music appreciation or literary criticism, never having attended a symphony concert or strolled through an art gallery. Why bother about Van Gogh’s Old Mill or Lewis Thomas’s Late Night Thoughts on Mahler’s Ninth Symphony?
Thoughts
531
Because without them medicine is ugly. And, without intuition, and beauty and ugliness, without art, what I do wouldn’t be medicine at all. REFERENCES
l. 2. 3. 4,
Landow GP. Ruskin. Oxford: Oxford University Press; 1985. Ruskin J. In: Cook ET, Widderburn A, Eds. Modern Painters, Vol. 1, Library Edition. London: George Allen; 1903: 1903-1912. Ruskin J. In: Cook ET, Widderburn A, Eds. PreRaphaelitism Library Edition. London: George Allen; 191x: 1903-1912. Lee RV. The generalist: a jaundiced view XXIII. The art of medicine. Am J Med 1983; 75: 381.
