MANAGED CARE May 2001. ©MediMedia USA
At one time, I thought I understood how medicine could be an art. However, after hearing "art" invoked too often as an excuse for error, I wonder if we should reconsider the whole proposition.
The Russian poet Yevgeny Yevtushenko wrote some verse in the 1960s critical of the state of art in the Soviet Union. He chided his fellow artists for failing to keep up with the ideas of the modern world, creating obsolete, creaky "horse carts" in the age of "rockets." Today, I would ask some of my colleagues Yevtushenko's question: "How can you call that art?"
When a doctor keeps patient records on index cards, is that art? When prescriptions are illegible? When a surgeon attempts a procedure in a facility that isn't equipped to deal with its complications? When a new device, drug, or remedy erupts onto the market without adequate clinical trials? Are these examples of medical art? Or simply things unsupportable by science? Just because some activity is not science does not necessarily make it art. As every parent who has sat through a school concert knows, enthusiasm is not the same thing as art.
The theme song of the 20th century was "accelerated transition." This affected the arts as much as the sciences. Yevtushenko hadn't heard of a "webmaster" in 1960, but he anticipated that art would evolve new vehicles and forms constantly. His commentary on colleagues who were stuck with horse carts has a bearing on the ongoing revolution in health care.
Might it be misplaced affection for the traditional media that makes many medical "artists" slow to adopt new forms? Conversely, is the explosion of managed care partly due to a hunger for fresh approaches and fatigue with the old material? Indeed, some of the emotion that inflames managed care's advocates and critics reminds me of the passions evoked by the advent of impressionism, or cubism, or — heaven help us — rock 'n' roll. Some people say it's explained by the generation gap, but clearly this is wrong. This contest crosses generations. It involves the interpretation of art.
In medicine, as in other disciplines, we sometimes hear "art" used as a defense against critics. "I am an artiste!" laments the buffoon. "Don't blame me if you don't like what I do. Everything is merely taste." This is a serious misconception, even when applied to aesthetic arts, and an even greater error with regard to the practical arts. Good medicine is not a matter of taste (amoxicillin notwithstanding).
I don't claim to know the unifying principle that makes art what it is. However, nearly everyone would agree that some works labeled "art" are actually not. Granted, these creations sometimes look or sound or feel somewhat like art, and are usually aimed at the same audiences. Still, art they aren't.
You can sometimes identify things-that-are-not-art by their pretense, self-indulgence, and irrelevance. For me, the most distinctive odor that exudes from not-art is the stench of defensiveness. Not-art tends to be indignant — especially in the face of critique. It claims immunity from criticism on grounds that it might be art; or might almost be art; or at least it ought to be treated as art under some conditions; and thus should be impervious to reproach. This masquerade embarrasses real artists.
You've seen this in medicine. Like the spray paint vandal defacing a wall, an artless physician may bluster, "How dare you judge me? This is my medium of expression!" Well, maybe not in those exact words. Still, it sounds suspiciously similar when some crabby doctor protests, "Bah! I scoff at your guidelines, standards, and protocols. Medicine is art!"
"Art" is no excuse
This protest is wrong. Patients are not a medium of expression. Medicine is not vaudeville. There is art in medicine, but not to fill a vacuum left by the absence of discipline or accountability. "Art" should not be an acceptable excuse for misbehavior and error.
The art part of what doctors do involves motor skills, communication skills, intellectual and intuitive skills, and other virtues and talents that can be recognized, practiced, learned, and taught. These things are eminently subject to criticism, and the best artists profit from being criticized. The difference between Michaelangelo and a house painter — well, one difference — is that Michaelangelo had critics. All of us should learn to be better medical art critics.
This does not mean turning our backs on science. Science and art are siblings, not enemies. The violin maker must know the science of wood and varnish. The painter must understand paint, as well as painting. If a chemist blows up the lab because he gets creative with glycerin, the upstairs neighbor will not be consoled by some theory of art.
Likewise, the physician whose asthmatics all end up in the emergency room every time the weather changes can't be let off the hook on grounds of artistic license.
Surely, it is a pleasure to watch a gifted physician perform. There can be virtuosity in the practice of medicine, as in almost any other human activity. The possibility of excellence also makes it possible to recognize performances that fall short, like the mediocre, amateurish, and just plain awful. We all know this, including people who are not doctors. Critics need not all be experts.
One difficulty with criticizing medical virtuosity is that so many performances take place before an audience of one. Science usually produces a tangible product, but the artistry in medicine often evaporates when the patient leaves the examining room. This ephemeral and private quality of medical art makes the critic's task even more difficult.
Thus, we hear "art" sometimes invoked as a shield against peer review. As professionals, we should not allow each other up on that high horse. Art cannot be an excuse for inconsistency where consistency is needed. It mustn't excuse variation when variation is unjustified. It should never be acceptable to justify simple human vices like rudeness, brutishness, and callousness — that almost all of us have sometimes been guilty of. "Please excuse the doctor's tantrum today. She's so sensitive, you see."
Unfortunately, confronting one's critics is easier when they aren't suing you. Technical arts such as medicine, aircraft design, and architecture are held to a much higher standard than entertainment arts. Because the damages in medicine usually occur to individuals rather than masses, health care has avoided some of the technical accountability demanded in the manufacturing arts. This may be changing, however.
Another important distinction to make is between the artist and the art itself. One fallacy would have us accept every product of an "artist" as art by definition. We fall into this trap when we shrink from criticizing our best performers. Even more troublesome is our tendency to classify our colleagues routinely as either, "good docs" or "bad docs." This is really not constructive, and it severely inhibits the quality-improvement and error-trapping agendas essential to our profession. These global judgments make for ineffective criticism.
The better artists are more consistent, and recover from their errors better, and have more insight into their own performances than the lesser ones. They never fall back on the excuse of "art" when they give a bad showing.
So, let's try an experiment. Suppose we suspend the use of the word, "art" in conversations about medical quality for the next year. This does not mean rejecting what we know about medical art, just agreeing not to use it as an excuse for the things we have a hard time measuring.
Then let's compare notes about what tools, techniques, and protocols contribute to a great performance, without getting temperamental over them. Maybe a year from now we will know more about what works in health care. Without anybody having to chop his ear off.