The Doctor’s Art

Each July marks a special time for residency programs, heralding the transition of medical students into their new roles as interns, and of interns into their new roles as residents, leading teams of budding physicians. This dynamic, tumultuous and anxiety-filled period offers a unique opportunity for reflection, since residents like me are surrounded by perfect examples of who we were just one year ago—and of how we have grown and developed over that time.

For me, internship was an introduction to a wealth of knowledge about patient care, while second-year residency brought lessons about leadership and the importance of understanding the social context in which patients live. Now, as I transition into my third year of residency, an entirely new set of realizations has already significantly affected me.

Why Francis Peabody Called Medicine an “Art”

Harvard Medical School did a fantastic job emphasizing the intangible aspects of medicine in our patient–doctor courses, but the focus of our education fell resoundingly on anatomy, physiology and pathology. Further, the fact that we were students and not yet doctors made Dr. Francis Peabody’s storied 1927 essay, “The Care of the Patient,” seem more like words on a page than a living reality. Internship only solved part of the problem: we were finally primary caregivers, but so much work and stress filled our lives that we had little time to consider much else. Only during the second year of residency did we finally have enough free mental space to reflect deeply on our experiences.

For me, this reflection led to a new understanding of what Dr. Peabody meant. Our profession as physicians affords tremendous room for creativity, because after the “medical” part of patient care is complete, the rest of our experience is up to us. This includes everything from how we welcome patients into our offices to how comfortable we make them feel during the course of their treatment to how we explain a new diagnosis to how we organize our appointments. Each physician creates his own practice and is his own artist.

The Limitations of Medicine

We are all aware that doctors are limited in their ability to diagnose and treat illness, but to live within that reality is another thing entirely. Some of my most poignant memories are from family meetings in the intensive care unit, in which I have been painfully reminded of the boundaries of medicine. So often, I have found myself sitting in a room with a patient’s spouse, children and siblings, explaining to them why their loved one is sick, answering their questions and trying to convey that we are doing everything possible to keep him alive, but the future is entirely uncertain.

Their eyes are invariably intent and captive, they query an unknowable future and their faces carry a mix of fear, hope and doubt. When the prognosis is dire, I leave the meeting wishing deeply that we could do more, but knowing that we have nothing left to offer physically, mentally or technologically.

As physicians, we can do an enormous amount to cure illness and relieve suffering, yet there are many conditions whose understanding and treatment remain despairingly elusive. We are certainly fortunate for the many thoughtful minds that have helped us advance to our present technological level, but we still have much more work to do.

The Limitations of Data

This particular lesson has probably made an impression on me because of my background in research. All too frequently, I find myself ordering a test or starting a medication for a patient, with no confident knowledge of whether doing so will be of value to him or her. The reason is invariably a lack of clinical data to guide my decision-making. Even where data does exist, there are often reasons to worry that it may not apply to my patient.

After mentally struggling with this paradigm for two years, I have attained a little more understanding. Consider, for example, the most advanced tool we have to guide clinical decision-making: the randomized controlled trial. In its most basic form, such a study comprises a cohort of people of different ages, genders, ethnicities, comorbidities and socioeconomics who are lumped together to evaluate the effect of a single treatment. At the end of the study, their outcomes are aggregated in order to determine whether the treatment “worked,” while in reality, it worked for some people, did not work for others, and produced only a partial response for the rest. Indeed, the “average effect” is how we ultimately value the treatment, but there are no “average” patients.

Finally, as if to add insult to injury, we are then asked, as physicians, to translate this “average effect” to our patients, who happen to differ in some particular way from patients in the trial: older, younger, sicker, healthier. One day, I think we will look back and be amazed at the crudeness of the methods we once used to make decisions about our patients’ lives. Until that time, however, the randomized controlled trial remains the most powerful innovation we have to evaluate the effect of therapies. That is where the clinical science ends and the art of the doctor begins.

Joseph Ladapo, HMS ’08, is a resident in internal medicine at Beth Israel Deaconess Medical Center.

The names used in this column are pseudonyms, and the opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.