The journey inward

It is difficult at best to attempt to deconstruct the art of medicine — or even to define it. In my book the art of medicine includes the science of medicine; subsumes it, if you will; but there is so much more to it. While the science of medicine might take place in the confines of a sterile laboratory or in a pharmacologic interaction within the human body, the art of medicine always takes place between at least two individuals, the clinician and the patient. Practicing the art necessitates a skill set largely learned through experience, honed with compassionate practice. It is certainly more than mere technique.

Although Stephen Bartholomew was not writing specifically about the art of medicine in this passage from Physician Assistant: A Guide to Clinical Practice, he captures its sentiment beautifully for the practicing clinician.

“It is an adventure, the journey inward, to the center of our own being, where all the dragons and all the treasures they guard really reside. The destination of such a journey is well worth the price of the adventure. With humor, with honesty, with humility, we receive as much as or more than we give, remembering:” (here he quotes Joseph Campbell in a passage from Hero with a Thousand Faces)

We have not even to risk the adventure alone, for the heroes of all time have gone before us. The labyrinth is thoroughly known. We have only to follow the thread of the hero path. And where we had thought to find an abomination, we shall find God. And where we had thought to slay another, we shall slay ourselves. And where we had thought to travel outward, we shall come to the center of our own existence. And where we had thought to be alone, we shall be with all the world.

“Sahara” © Barry H. Penchansky, M.D.

Impressionistic Medicine

The Danish impressionistic artist Camille Pissarro lived most of his adult life in France. During his long tenure as a painter, Pissarro gleaned much from Corot, Courbet and Jean-François Millet, forerunners of the Impressionist school. Many other artists worked under his tutelage, Gauguin, Cezanne, and Seurat among them. Eventually, Pissarro came to be regarded as the father of French Impressionism, the only artist to exhibit his work in all seven Impressionistic salons over the last quarter of the 19th century.

More than a mere painter, Pissarro was an anarchist, whose radically egalitarian views found their way into his work. For his subjects Pissarro chose rural peasants, depicting them at work in the fields, as domestic servants, as buyers and sellers in the market place.

In the 1880s, Pissarro assembled a portfolio of 30 pen and ink sketches rendering the horrors of urban capitalism entitled “Turpitudes Sociales” (“Social Disgraces”). He used his art to draw public attention to the injustices inherent in what he saw as an unethical and immoral social order of his day.

Throughout his life Pissarro envisioned a kinder, gentler society, one where people have what they need in order to live a good life — and no more. He put his ethics into practice, opening his home to all visitors, including young hungry artists.

One could not wander through the recent Clark Institute’s Pissarro’s People exhibit without admiring the canvases depicting bucolic scenes peopled with peasants engaged in work and talk. Pissarro’s vision becomes contagious to a visitor immersed in such beauty and grace.

While standing in front of one of his portraits, I — as a practitioner of another form of art, the art of medicine — could not help but think that we clinicians are called to view those patients entrusted to our care as equals in the sense of their humanity, their needs and wants.

Osler summed it up when he wrote: “Dealing as we do with poor suffering humanity, we see the man unmasked, exposed to all the frailties and weaknesses, and you have to keep your heart soft and tender lest you have too great a contempt for your fellow creatures.”

I have learned much from looking at the world through Pissarro’s eyes. Collectively, his canvasses could be considered windows through which one glimpses the art of impressionistic medicine.

Minimal Medicine

Sometimes I wonder whether we as a society have not over-medicalized life. We spend so much of our time browsing health columns, monitoring vital signs, ruminating on our symptoms, consulting our doctors. Many of us have become so health conscious that we balk at deviating from the straight and narrow path. When it comes to our health, we have become risk averse.

Even those of us who spend their days in clinical practice recognize that medicine does not encompass all of life.

Perhaps we need to learn to practice minimal medicine.

These thoughts ran through my head as I read Mark Bittman’s final NYT Minimalist culinary column. Over a span of thirteen years Bittman authored nearly 700 weekly columns for the NYT Dining section. As it turns out, the culinary arts share a good deal with medical practice.

“I discovered that you never cook with someone else without learning something,” Bittman writes. “In every case, there’s a two-way transfer of knowledge. If they know less than you do, you grow from teaching. If more, of course, you grow from learning.”

Bittman’s words bring to mind Sir William Osler’s description of medical teacher and student: “the pupil and the teacher working together on the same lines, only one a little ahead of the other. This is the ideal toward which we should move.” After 25 years of practice, Osler observed, “I have learned … to be a better student, and to be ready to say to my fellow students, ‘I do not know’.”

Osler reckoned that “no man can teach successfully who is not at the same time a student.”

Here’s Bittman musing again: “Usually, I was either taught to make something or I modeled it myself, as best I could. I refused to buy into the notion that there was a ‘correct’ way to prepare a given dish; rather, I tried to understand its spirit and duplicate that, no matter where I was cooking.”

Osler advocated that “the practical shall take the place of didactic teaching.” To acquire the skills necessary to perform medical procedures, students are encouraged to “see one, do one, teach one.” In 1867 the physician Oliver Wendell Holmes argued that the “most essential part of a student’s instruction is obtained … not in the lecture-room, but at the bedside.”

Bittman maintains that, “as Jacques Pépin once said to me, you never cook a recipe the same way twice, even if you try.”

How true. And you never perform a physical examination or surgical procedure in exactly the same way. There are always confounding factors which necessitate workarounds and thinking outside the box.

Medical practice, like cooking, is always a compromise. Like their culinary counterparts, clinicians “almost never have the time, the ideal ingredients or equipment, or all of the skills we’d like.”

“Shop avidly, keep a full refrigerator and pantry,” Bittman advises; “pull things out and get to work.”

Where would the good clinician be without a well-stocked surgery?

“My growing conviction that the meat-heavy American diet and our increasing dependence on prepared and processed foods is detrimental not only to our personal health but to that of the planet has had an impact on my life.”

A nutshell of sound dietary advice, one every practicing clinician should take to heart.

Bittman concludes: “What I see as the continuing attack on good, sound eating and traditional farming in the United States is a political issue.”

What I see as the continuing attack on good sound traditional medical practice has lately become a political issue as well.

The Art of Medicine: Learning to capture the human figure

In his series of articles on the art of drawing, artist and author James McMullan speaks to that intuitive intelligence which the visual artist needs to cultivate in order to capture forces inherent in the human body:

Once we tune into these cooperative forces that animate the body, they seem obvious; yet opening up the kind of intuitive intelligence we need in order to see these forces is difficult when we are so used to relying mainly on the simple scanning operations of our eyes. As we draw, we need to record pressures and not just edges, and we need to see relationships between parts rather than just pieces of the body.

Reading these words, I was struck by the similarity between the art employed in drawing the human figure and the art of the practice of medicine. Both require the use of intuition to recognize the forces in play before the eyes of the observer.

In his approach to the patient, the medical student tends to dwell on organ systems—parts or pieces of the human body. This stance follows immediately from the way in which gathering the medical history is taught.

First, the patient’s chief complaint is identified. Many times it centers around pain. The student probes the patient to develop an understanding of the pain itself: its character, its location, its radiation, its severity, its timing—all necessary elements to round out a description that might fit a pattern consistent with a known clinical entity.

The physical examination serves to develop and substantiate the final diagnosis. Sometimes further testing—lab studies, imaging studies, tissue sampling—is deemed necessary to clarify the problem. Throughout this entire process, bits and pieces of data are gathered and assembled into an impression to describe the whole.

Although the master clinician gathers data in a similar fashion, at the same time he or she does more than just probe with questions and scan with the eyes. Intuition comes into play, albeit subtly, informing the clinician on a deeper plane, allowing him or her to discern the complex relationships between the pressures and forces that impact the functioning of the human being before his eyes.

In McMullan’s words, the clinician perceives that “significant energy relationships in the body are often not right next to one another.”

McMullan maintains that “You have to be alive to the possibilities of each pose as you encounter it, and be willing to be surprised and to surprise yourself.”

It is important “to identify the central aspects of a pose in order to give yourself a theme that helps you to organize your thoughts and the order in which you tackle the different parts of the body.”

“The best drawings of the human figure seize on its life force.”

In McMullan’s opinion, “all of these practices will lead you to empathic thinking,” a perspective which benefits both clinician and patient as well as the artist.

McMullan’s line echoes Tolstoy in his essay, What is Art? — “it is upon this capacity of man to receive another man’s expression of feeling and experience those feelings himself, that the activity of art is based.”

Historically, artists have studied anatomy to assist them in their understanding of the rendering of the human figure.

Perhaps clinicians need to consider the perspective of the artist to further an empathetic understanding of the patient.

A Pupil of Picasso

“I’m worried that my son might have a lazy eye.”

Seated in the chair by the exam table, this mother wears a concerned look as she produces a photograph from her purse.  “There—you see what I’m talking about?”

She points to the left eye in her son’s recent school picture.  By a narrow margin, it appears to be slightly smaller than the right one.  I study the color portrait and note that the light from the camera’s flash reflects off each cornea at the exact same spot.

The medical assistant has already checked the boy’s visual acuity on the Snellen chart:  20/20 vision in each eye.

“Anyone with lazy eye in the family?” I ask, reaching for a penlight to peer at the boy’s pupils.  “No?  Anyone in the family ever have eye muscle surgery?”

I ask the boy to follow the light: over, up, across, down, back to center.  I check for lid lag; I perform a cover test.  Finally, I use the ophthalmoscope to peer through the boy’s pupils to study his retinas.

The entire exam is normal.  I expected as much when I first glimpsed the photograph.

I find such encounters gratifying, because I’m able to reassure families that everything is fine purely on the basis of a thorough clinical exam.

“Then why does his one eye look smaller than the other?” his mother asks.

“It has to do with the distribution of the fatty tissue below the surface of the skin around the eyes,” I tell her.  “Have you ever studied Picasso’s works?  If so, you know that Picasso almost never rendered his subjects’ eyes as mirror images of one another.  They are usually of different size, location and proportion in his drawings and paintings.”

The mother seems pleased with my explanations.  She’s also happy that there is nothing wrong with her son’s vision.  All in all, it has turned out to be a good visit—for everyone.

In the Adventure of the Copper Beeches, Sherlock Holmes remarks: “To the man who loves art for its own sake, it is frequently in its least important and lowliest manifestations that the keenest pleasure is to be derived.”

Over the years I have taken keen pleasure in the art of medicine—and in the art of Picasso as well.