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Is There a Role for the Art of Medicine in Science-Based Practice?

Bushpainting

The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.

The practice of medicine is an art, based on science.

-Sir William Osler, AEQUANIMITAS

The truth is that many of us have some kind of “extraordinary gift.” For a few of us, that gift is the ability to throw a ball at 90 miles per hour and hit a catcher’s glove. For others, that gift is a form of extraordinary perception. Medical intuitives “see” things that others don’t. Wendy Marks has been described as a “human CT scan.” What no one has been able to diagnose by conventional methods is often seen when Wendy scans a body.

-Boston Women’s Journal April/May 2002

The concept of an art to the practice of medicine comes up frequently and in a variety of contexts. Early on in our medical education, we are exposed to the phrase and what it supposedly means, which I will discuss in more detail shortly. But the art of medicine is always painted (pun intended) in a positive light. I will admit that I have a strong opinion, perhaps biased by my involvement with the science-based medicine movement and an equally early exposure during my medical training to champions of evidence-based practice and the use of critical thinking in the approach to patient care.

But first, imagine the following four scenarios:

  1. A patient seen by an emergency medicine physician for complaints of chronic mild and intermittent periumbilical abdominal pain has a normal physical exam. The physician establishes rapport with the patient while efficiently discussing her past medical, surgical, social and family history among other components of a thorough investigation. The patient is reassured that her normal exam, and a history absent any concerning red flags for organic illness, do not warrant additional laboratory or radiologic studies at this time. The physician discusses the potential role of stress in chronic abdominal pain and recommends that the need for outpatient mental health services be discussed with her primary care physician as well as implementation of lifestyle modifications such as increased exercise and a healthy diet with adequate intake of fiber. The patient is educated on possible concerning new signs or symptoms that would necessitate further work up.
  2. The same patient is seen by her primary care physician the following week. She has a normal physical exam. The physician establishes rapport with the patient while efficiently discussing her past medical, surgical, social and family history among other components of a thorough investigation. The patient is told that while her normal exam, and a history absent any concerning red flags for organic illness, are reassuring, in her experience some serious conditions can present without obvious findings in the early stages. The physician relates the story of a similar encounter during residency to one of her colleagues and sends the patient down the street for a number of metabolic studies and an abdominal CT to rule out inflammatory bowel disease. She is referred to a gastroenterologist.
  3. The patient is then seen by a local gastroenterologist one week later. She has a normal physical exam and no concerning red flags are discovered during brief questioning. The physician is in the room for about ten minutes when he abruptly recommends endoscopy to “see what’s going on in there” and shows her to the clerk for scheduling of the procedure. She is given a packet of information on the risks and benefits of the procedure and a prescription for medicine to clean out her bowels in preparation. She is reassured that biopsy findings will likely be normal and told that it is best to figure these things out so that she can quit worrying.
  4. The patient, having failed to show up for the endoscopy, is seen by a practitioner of Naturopathy recommended by a friend. The practitioner establishes rapport with the patient while discussing her past medical, surgical, social and family history along with a number of questions about potential exposures to chemicals and toxic substances in her environment and diet. The patient’s concerns are validated and she is warned that often problems like systemic yeast and various nutritional imbalances can present with vague symptoms but may become more debilitating. The practitioner orders a variety of metabolic studies as well as tests for heavy metals in the patient’s saliva, and he performs live blood cell analysis in the office. A number of supplements and a homeopathic remedy are prescribed, and acupuncture sessions are scheduled.

At first glance, especially to those who are familiar with and support the ideals of science-based medicine, it’s easy to see which of these scenarios is full of blatant pseudoscience and a good example of what goes on in the world of alternative medicine. Sadly, the practitioner of Naturopathy probably convinced our patient that she suffers from one of the many “one true causes” of all disease. You also probably realize, even without any specific medical training, that the physician in scenario 1 provided the most science-based approach to the patient’s symptoms, with excellent communication skills and an admirable level of comfort with a likely stress induced complaint.

In scenario 2, a well-meaning and competent personal physician perhaps placed too much importance on personal experience than was deserved, and I imagine this fictional doctor probably eschews what she perceives as excessive reliance on cookie cutter algorithms in “the real world.” The subspecialist in scenario 3 certainly didn’t demonstrate a good bedside manner, but probably meant well in his attempt to put his patient’s mind at ease with what is arguably an unnecessary invasive diagnostic procedure. All of these practitioners would almost certainly claim to be practicing the art of medicine, however, which should raise the question of just what the heck it means to do so.

What is the art of medicine?

This is a question I have often asked myself. When doing so I am frequently reminded of how politicians present themselves to the public in radio and television spots, which essentially amount to “Candidate Jenkins is for good things and against bad things!”, or for the bad and against the good if you happen to fall on the other side of the political spectrum. But they don’t really tell you anything about the candidate as a person. In a similar fashion, talk of the art of medicine is almost always focused on the positive aspects. Always a Rembrandt, never a Bush.

According to Sharon Bahrych, a Denver-based physician assistant, in her post on KevinMD, the art of medicine involves several components:

  1. Caring for patients, showing honest concern and compassion
  2. Giving patients time, not rushing in and out of the exam clinic room, being patient with them, having a great bedside manner
  3. Using the evidence based medicine algorithms as a guideline, as we apply them to each and every patient we see. Understanding that every patient is an individual who has individual circumstances that affect their lives.
  4. Helping every patient to acquire the best outcome they can for themselves by working with them, educating them, coming up with a mutually agreed upon plan of action

This is in keeping with most examples of how the art of medicine is defined. It’s about compassion, communication, professionalism, respecting patient autonomy, treating each individual as a beautiful and unique snowflake, and not being afraid to go off protocol when things get squirrelly. It all sounds very nice and hard to argue with.

It’s particularly hard to argue with the narrative when people start dropping quotes from Sir William Osler, like I did at the onset of the post. Osler, widely considered to be the father of modern medicine, accomplished many things during his career, not the least of which was the medical residency as an entity and the push to teach the practice of medicine at the bedside more so than in the classroom. An even-brief skimming of his biography should be sufficient to leave any physician feeling rather inadequate.

Osler’s legacy consisted of much more than this. A variety of medical conditions and specific findings bear his name, as do many buildings. He also left us with a seemingly endless supply of quotes, with several appropriate candidates to choose from for the title slide of almost any PowerPoint presentation. His notable quotes regarding the art of medicine speak volumes. Osler called for physicians to care for the patient, not the disease. To employ empathy, humanity and love, and accept that uncertainty and error are unavoidable in the practice of medicine. And to respect experience as a means of learning the art of medicine, but never forget that the art is subservient to the science.

The most compelling aspect of the art of medicine involves communication. While it really doesn’t matter all that much if you are an excellent communicator full of empathy and love for a patient who was diagnosed with an ear infection, the next patient may not be so simple. As Harriet Hall once wrote, “Medicine is not an art like painting. Neither is it a science like physics. It’s an applied science.” While I often, with tongue in cheek, make the claim that a robot could perform a lot of my job successfully, nobody wants to be told that they have cancer by a machine. The application of science to the patient will always need a human component.

Is there a dark side of the art of medicine?

If, like the Force in the Star Wars Universe, the art of medicine manifests itself as our “compassion, selflessness, self-knowledge and enlightenment, healing, mercy and benevolence”, then it seems fitting that there would also be a dark side. As water takes the shape of the vessel which contains it, the fluid nature of this aspect of medical practice allows misuse in the wrong hands. There is, after all, an “art” to more than just medical practice. Proponents of chiropractic, acupuncture and naturopathy, not to mention every other alternative medicine modality, incorporate similar language into their propaganda.

The dark art, so to speak, of medical practice is often employed as a rationalization when ignoring established evidence. Medicine can be very complicated, messy even, but a great deal of it is actually fairly straightforward. We have picked a lot of the low- and even high-hanging fruit in regards to both prevention and treatment of injury and illness. And when we can’t cure, we can often manage symptoms and improve the quality of a patient’s life. Of course there are gaps in our knowledge, but those gaps are steadily shrinking. The so-called art of medicine does often thrive in those gaps, and that can be a good thing, but the gaps are also where there is the greatest potential for harm when seen as a license to do whatever you want regardless of plausibility and basic science.

What many people think of as an art in medicine is the ability to make a diagnosis. Mark Crislip once referred to it as a craft rather than an art, but I just call it pattern recognition. Dr. Crislip went on to further elucidate his concept of the art of medicine:

The Art in medicine may occur as thinking about cases moves more and more over time from the conscious level of a third year medical student to the subconscious level of an experienced clinician. I recognize subtleties and important findings faster than newbies or the inexperienced.

Over the decades, as evidence has accumulated, we have learned a vast array of patterns and associations that are beyond the ability of most if not all individual physicians to maintain a complete working knowledge of. Hence we must increasingly rely on specialists who focus on specific areas of medicine and, when possible, the incorporation of the available evidence into algorithms that fit most patients most of the time. It is hard to deny the improved accuracy and outcomes that this approach has led to.

Certainly there will always be exceptions where patients don’t present in such a way that an applicable protocol is easily chosen or even available, and diagnosis does elude us at times. And patients will not always respond to treatment as we expect them to. But we must be wary of experience-based practice that focuses too much on individualization. Without due caution, and awareness of the many biases and errors in perception that plague us all, the difference between expert-level subconscious pattern recognition and the bogus concept of medical intuition may not always be clear.

In the world of alternative medicine, the complexity of medicine is exchanged for the simplicity of pure invention and excessive generalization (everybody has a spinal subluxation), even while attacking medicine for not being holistic enough. While we may quibble about how much of a role art plays in medicine, it is all that alternative practitioners have to offer really, with rare exception. And examples of our occasional difficulty applying what we know to the individual patient commonly serve as justification to ignore scientific progress entirely.

Physicians aren’t immune to this. The art of medicine is often described as how we apply the science to the individual, but taken too far it can serve as a shield against criticism, a place for quacks of all kinds to take shelter against evidence. The art of medicine is all-too-often used as a conversation-ending justification for what is simply bad medical practice.

Conclusion

In my opinion, the phrase “art of medicine” needs to be retired or at least restricted in use. Aside from being nebulous to the point of nearly losing all meaning, and serving as fertile ground for all manner of bogus approaches to healthcare, to me it almost implies that there should be some kind of innate ability to practice medicine that some people have and some don’t. I don’t believe that there are medical equivalents of Leonardo da Vinci or Yo Yo Ma, virtuosos with skill that can’t be acquired by practice alone.

But we shouldn’t throw the baby out with the bathwater. While I certainly understand the desire to have an all-encompassing ideal phrase, I believe that we would be better served to be more specific when talking about the important aspects of being an effective healthcare professional, and more honest about when we are making an educated guess secondary to a lack of evidence. When a legitimate healthcare professional chalks their action up to the art of medicine, it lends credence to when a quack does the same thing.

Good communication, in my opinion, stands out as the most legitimate aspect of the art of medicine. While it is true that some people do have a knack for it, and even that some physicians will probably never develop into excellent communicators, the vast majority of physicians can be taught how to speak to patients competently. And preternatural communication skills aren’t called for very often in medicine.

I don’t know if the net positive benefit of focusing on the art of medicine is worth the negative. It probably is. Think of this as a conversation starter and please let me know your thoughts in the comment section. I feel very comfortable saying though that we would certainly be a lot better off if we focused more on critical thinking during medical training. A strong foundation in scientific skepticism would very likely decrease the potential for abuse of the art of medicine.

Posted in: Science and Medicine

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72 thoughts on “Is There a Role for the Art of Medicine in Science-Based Practice?

  1. Windriven says:

    You should miss no opportunity to expose yourself to art.

  2. ChristineRose says:

    How about “The patient is frustrated, reports regular exercise and a good diet, denies the role of stress in her pain, goes home disappointed, tolerates the pain for several months, seeks urgent care when the pain becomes unbearable, is told again that no tests are warranted, tolerates more pain, goes to the ER when the pain becomes completely debilitating, is accused of malingering to obtain painkillers, goes to a second ER, has a twenty centimeter tumor removed in an emergency surgery that lasts four hours?”

    I guess I’m not living in the same health care world as Dr./Mr. Jones.

    1. Clay Jones says:

      No, it’s the same world. Obviously I can’t comment on your situation specifically, but trust me when I say that the art of medicine is secondary to the competence of medicine. Medicine isn’t perfect and there are some pretty weak physicians out there. My scenarios were not meant to be representative of all cases of chronic abdominal pain.

    2. qetzal says:

      If that’s what happened to you, then it sounds inexcusable, especially once you reached the “unbearable” point. But, with intending any disrespect to you and your experience, how does that contradict anything Dr. Jones wrote?

      1. qetzal says:

        Sorry, “without intending any disrespect….”

      2. ChristineRose says:

        The anecdote (which is a true story, yes) is meant to illustrate that doctors I’ve encountered are trained not to order tests when a cursory examination shows no obvious problem and the most likely explanation seems to be something benign and idiopathic. The situations in the article imply that overtesting is the norm.

        1. Clay Jones says:

          Depending on where you are, it is the norm. Different regions, different entry points (ED, urgent care, PCP, subspecialist) have different strengths and weaknesses. In my experience, over testing is rampant but often downplayed. “It’s just a CBC” or “We were sticking him anyway for the IV” for example are commonplace excuses. Sure most of what I see is the “nickel and dime” stuff like the unnecessary chest x-ray in an infant with bronchiolitis, but I also routinely see endoscopy, echocardiograms, CT scans and shotgun labs. Certainly medicine, with science at its core, is the best approach we have, but there is a lot of room for improvement. Attention any alt med proponents who have or will ever claim I only focus on their shenanigans.

        2. Windriven says:

          First off, we’re all happy the tumor was eventually found and excised.

          It seems to me (non-physician) that the problem centered on your PCP. EDs are great for trauma and acute conditions, maybe not so great for flare-ups of chronic ones.

          I preach the importance of selecting one’s PCP very carefully and then spending the time to build confidence in each other and a solid rapport. Your life can depend on it – as you very nearly found out.

          1. Harriet Hall says:

            I preach this: if you have a problem, go back to the same doctor and tell him ” the medicine isn’t helping” or I feel uncomfortable with the diagnosis” or ” I didn’t understand” or ” I forgot to mention”. The doctor has a head start, since he already knows something about you, and even Dr. House doesn’t get it right the first time. You are generally better off sticking with one doctor, following developments as the condition evolves, and improving communication than switching to a new one who has to start all over from scratch.

            1. Windriven says:

              I wouldn’t disagree – unless one is going back to someone like SSR.

              1. Harriet Hall says:

                I meant that as an afterthought to your advice about carefully choosing a good doctor. If you encounter one who thinks like SSR, you should run, not walk, to a doctor who understands the difference between anecdotes and evidence.

    3. oldebabe says:

      Good anecdote. Pretty much (except the part about `malingering’ for drugs) what I personally experienced w/a completely infected gallbladder (tho no tumor), and an emergency surgery in a far away place with an unknown doctor to remove. My regular physician (internal?) had, apparently, over a couple of years, had not noticed anything wrong… and upon being told of it after-the- fact, showed no concern – well, it was a fait accompli (sp?) of course, but…

    4. WilliamLawrenceUtridge says:

      Doctors aren’t perfect – the least satisfying answer anyone can ever receive. Do you have a regular physician? Sometimes because they know your history, they are more willing than “random” clinic or ER docs to take complaints seriously.

      But ultimately – everyone makes mistakes. When doctors make mistakes, stuff like this happens. Make a fuss, make a stink though – because it is through errors like this that doctors, and systems, learn and improve.

      1. Andrey Pavlov says:

        Doctors aren’t perfect…

        Speak for yourself, buddy :-P

        j/k (in case that wasn’t obvious)

  3. Ladyatheist says:

    In my experience, specialists can be real jerks, to the detriment of treatment. It’s no wonder so many people retreat to naturopaths.

    1. Jamie Gegerson says:

      … retreat to naturopaths.

      implies that naturopaths and your specialists are on the same path. I’d say naturopaths are more of a detour through a minefield. Instead, find a specialist who isn’t a jerk.

    2. Windriven says:

      Some can be. I’ve known a couple who deserved nothing more than a good thrashing. But a much larger portion of specialists I’ve known have been decent, caring, and polite.

      Something I’ve noticed is that those who behave like a-holes are usually not the ones of the highest competence. I always pay attention to the reputations of physicians among their peers. Who is in a better position to judge their competence?

      1. Egstra says:

        “Something I’ve noticed is that those who behave like a-holes are usually not the ones of the highest competence.”

        That’s been my experience, too.

  4. Andrey Pavlov says:

    This is in concordance with my own thoughts on the “art of medicine” which I have written about at some length in the comments here. It really boils down to acting with a lack of complete knowledge and relating what knowledge we do have in an effective manner to the patient. And yes, all too often it is used as a shield to protect doing whatever the clinician wants to do, evidence be damned. I’ve personally heard this rebuke from classmates and other colleagues.

    As for Osler – I’ve read his entire biography, a gift from one of my mentors. Dr. Jones is spot on in his assessment of how that would make a physician feel. Same goes for the autobiography of Gene Stollerman I am most of the way through.

  5. goodnightirene says:

    It’s important to acknowledge what comments #2 and #3 are telling us. I am no fan of sCAM, as regulars well know, but neither have I ever had an experience with a doctor even half as thorough as Dr. Jones describes in scenario #1. I can easily see how people are drawn to practitioners who actually DO listen to them. I have found some NP’s or PA’s to be far more personable than many physicians, and of course they are able to spend more time with patients, so that helps in itself.

    1. qetzal says:

      One pet peeve of mine is that I have rarely been spontaneously “educated on possible concerning new signs or symptoms that would necessitate further work up.” The majority of the time, I’ve had to specifically ask the MD about that. Obviously, I could take that as a sign to change MDs, but it’s been the case across several already, so I just make sure to ask on my own.

      MD students learn a standard “checklist” of things to do when evaluating a patient with a new complaint, right? Take the medical history, take vital signs, etc. Does that checklist include key things to communicate back to the patient (like what new signs they should watch for)?

      1. Andrey Pavlov says:

        Does that checklist include key things to communicate back to the patient (like what new signs they should watch for)?

        During my schooling there were a number of tests, most notably for my general practice rotation, where if I did not mention such things specifically I would have failed the entire rotation, regardless of all other performance throughout the course.

        1. Harriet Hall says:

          I’ve never heard of a doctor telling a patient NOT to come back if the symptoms became more severe or if new symptoms developed. I routinely told patients to return if those things happened, and even if I hadn’t said anything, surely the patient has some responsibility. The doctor can only work with what he knows; if new information becomes available, common sense should tell the patient to make that information available to the doctor in case it might change the diagnosis or management.

          1. Andrey Pavlov says:

            Indeed. I am in the habit of closing all my consultations with the blanket statement:

            “And if anything else you find worrying or concerning comes up, please don’t hesitate to come back in to be re-evaluated.”

            In some cases, where I can anticipate likely things that a patient my find to be concerning but really isn’t, I specifically address that and explain how to differentiate between scary and not-scary. Otherwise, I tell my patients to trust themselves and if something really seems concerning that discretion is the better part of valor and to return. I’d rather spend 5 additional minutes reassuring my patient than having him or her have something serious develop. It has the added benefit of reducing potential and actual mental anguish which in and of itself is (or at least should be) an active goal of medical care.

            There will inevitably be a portion of the population that abuses this – intentionally or not and for myriad reasons. However, they are a small percentage and will invariably present themselves as such in short order. At that point one must change tack to appropriately alter the advice, the patient-physician dynamic, and/or refer to specialists or other providers as the situation warrants.

            1. Clay Jones says:

              Right. A good doctor answers the questions a patient should ask as much as the ones they do. Is that part of the “art” of medicine?

              1. Andrey Pavlov says:

                An excellently succinct way of putting it Dr. Jones.

                I suppose that could be considered part of “the art” as well. To me it seems to fall under the general umbrella of good patient care. We should recognize that our patients can’t think to ask certain things because they have no reason to know to ask in the first place. As such, doing so would fit under my idea of “relating knowledge in an effective manner to the patient.” Sure, if I didn’t do it and it came up, the patient could come back in, be reassured and, for the most part, the overall outcome would be generally the same. But I think it is obviously more effective to pre-empt that if possible with myriad benefits to you, the patient, and your professional relationship with the patient.

  6. MTDoc says:

    Comment on #1: All that in 10 minutes?
    Comment on #2: Shouldn’t this have been the first encounter? The ER is certainly not the place to evaluate a chronic problem. I don’t mean to pick on your presentation, because your basic points are well taken and provoke considerable introspection. My observation is only to illustrate the need for more qualified primary care physicians. Instead we have a system where the emphasis is on specialty care and primary care is left to midlevel “providers”. As an example of the above scenario from my remote past, I had a very similar case. However, exams and several talks, as well as some collateral information available to a community doc, led me to consider her unhappy marriage and extramarital affair as a more likely cause for chronic pelvic pain. I declined to provide a surgical cure, so she self referred, and after a 20 minute consultation, was scheduled for the removal of a perfectly normal uterus. (Incidentally the GYN never even bothered to give me a call to see if I might have something to contribute to the patient’s wellfair). Eventual cure was achieved with a divorce and remarriage.

    Intuition vs (unconscious) pattern recognition. I like the latter, as I always found the former hard to reconcile with science. But it can be scarey when you somehow just know that kid with a runny nose and 102 temp has bacterial meningitis. So scarey, in fact, that I plan to stay retired.

    1. Clay Jones says:

      You are correct about everything. I presented an ideal case in the first scenario that may be somewhat if a pipe dream. In reality the 1st scenario would be more common at the PCP office but I just didn’t want to pick on an ED doc. They get piles on enough, often by me. Call it the art of blogging.

  7. Daniel Falcon says:

    Good read. I am a surgeon (hand surgeon), and see some similarities when patients (or doctors) claim their doctor/surgeon is “the best.” I agree there is no specific “gift” or talent, rather, there is a learned knowlege base and skill set applied correctly. To say one’s surgeon/doctor is the best makes no sense. Just give me a competent, caring, unhurried, licenced physician.

    1. NotADoc says:

      “Just give me a competent, caring, unhurried, licenced physician.”

      One problem with this- “pick any two of the above” is usually closer to what’s available.

  8. Gary says:

    Indeed, this is what our family doctor, later head of the state medical society, said decades ago to my father more than once, (speaking philosophically) “Medicine is an art, not a science”

  9. J. McCurdy says:

    Good observations, but in reading some of the comments, one thing that is overlooked is that things change and presentations develop over time, so that a tummy ache that appears very minor may become a rip-roaring appendicitis over the next 12 hours. The doc who sees the patient last may not be a genius, he/she may just see the disease in a more advanced state.

    1. Andrey Pavlov says:

      @McCurdy:

      As my surgery attendings used to say, sometimes we need the tissues to present themselves.

  10. PMoran says:

    Good stuff and the kind of thing that I hoped this blog would explore more. I agree that there is probably no such thing as an art to medicine in the sense that there are medical outcomes that cannot be, at least in theory, and at some point, and with the right technology, measured and explained.

    It does not follow that present technology has the ability to do that. It is thus an equivalent error to think that we have as yet been able to capture the entire essence of medical interactions with the placebo controlled trial.

    1. Harriet Hall says:

      There you go again with the straw men! “It is thus an equivalent error to think that we have as yet been able to capture the entire essence of medical interactions with the placebo controlled trial.” Yes that would be an error, but it is not an error anyone here has made or is capable of making. Are you spoiling for a fight so desperately that you have to make something up to fight about? Fight with SSR: put up or shut up.

      1. PMoran says:

        That is a childish and paranoid response to an innocent comment, Harriet.

        I did not have an attack on anyone here in mind when I made the comment. I was thinking of one-time views of my own and one that is in fact extremely prevalent within the scientific medical community and among sceptics generally.

        As it happens, though, at least two of the authors here do go out of their way to suggest that there is nothing worthwhile in the terms of the measurable patient outcomes I was specifying outside of the sham controlled trial. If you think otherwise you should be saying so.

        Childish and illogical also is the representation that I should not dare to comment on anything unless I first jump through hurdles of your making e.g. presenting a blog post (now happening), changing the mind of SS (never a claim of mine ).

        Or is it that any kind of plain speaking also only OK so long as it is flowing away from the SBM authorship?

        Have at me, if you like. I will not respond.

        1. David Gorski says:

          And, with that, Peter flounces away.

          http://www.urbandictionary.com/define.php?term=Flounce

          One wonders if that will be his MO now. However, I still can’t help but wonder over this remark from Peter:

          As it happens, though, at least two of the authors here do go out of their way to suggest that there is nothing worthwhile in the terms of the measurable patient outcomes I was specifying outside of the sham controlled trial. If you think otherwise you should be saying so.

          One wonders to whom he is referring. If I’m one, I have never, ever said such a thing. Of course, given Peter’s well-known antipathy towards me, I have little doubt that I am one of the two to whom he refers. My question is: Who is the other? Steve? Mark? Obviously it’s not Harriet.

        2. Andrey Pavlov says:

          I feel I should thank Peter. For finally making it easier for me to ignore his posts and save myself the bother of responding to their content. That actually takes some time, thought, and effort on my part.

          Now that he has unambiguously presented himself as unworthy of the effort, I needn’t waste my time any more.

          1. David Gorski says:

            Sadly, more and more, Peter is reminding me of this:

            http://www.flamewarriorsguide.com/warriorshtm/issues.htm

            His “issue” is civility, and he won’t rest until it’s everyone else’s issue, too.

            The Flame Warriors website, which dates back many years, is very wise and funny. In this case, it states:

            Her obsession, however, provides the key to defeating her in battle; she can’t tolerate indifference, so if her thrusts are simply ignored she will rage, accuse, condemn, plead and finally, go away.

            Of course, I don’t actually wish for Peter to go away completely. I realize he’ll never believe me when I say this, but I don’t. He’s actually quite awesome when it comes to analyzing cancer quackery. Unfortunately, his obsession with “civility” über alles undermines the great contributions he could make and leads to nothing more than threadjacking.

            1. Frederick says:

              WOW, that site is funny as hell. With also had ALLCAPS, the guy that left a long comment down below. lol

          2. Frederick says:

            You already do a good job answering a lot of posts already, and not all of them deserve a answer, I think you deserve to ignore some of them, take a break man!

        3. Harriet Hall says:

          Not such an innocent comment, in the context of your previous comments. You have repeatedly accused us of sins we have not committed, and have implied that there may be some kind of nebulous benefits to patients from CAM that we are not recognizing.

          The reason we asked for a guest blog post is to clarify your comments because they have continued to mystify us as to what you actually mean.

          As for my challenge to engage with SSR, your claim was that you “could probably help him understand better why his views are not having much impact.” This cuts to the essence of what you have been saying, and my challenge offered you the perfect opportunity to demonstrate your “kinder, gentler,” more understanding approach and show that it is more effective than ours. If you really believed that you could help him understand better, why would you not want to demonstrate that? If you succeeded where all the rest of us had failed, we would take your complaints more seriously and would amend our approach accordingly.

    2. MadisonMD says:

      It is thus an equivalent error to think that we have as yet been able to capture the entire essence of medical interactions with the placebo controlled trial.

      Perhaps this could be a critique of Cochrane. However, it is rather easy to demonstrate explicitly that this is not a view put forth at this blog. Here are some scientifically sound medical interventions without a placebo-controlled trial:
      (a) antibiotics for pneumonia
      (b) surgery for breast cancer
      (c) some childhood vaccines

      Many of these issues have been blogged about at SBM. The lack of equipoise of imagined RCTs is skewered in a well known BMJ article. In fact, the entire raison d’etre of SBM is that other lines of evidence bear on the present and provisional determination of known effective medical interventions. Plausibility is one such consideration, by which interventions such as acupuncture and liver flushes are rejected without RCT.

    3. Andrey Pavlov says:

      It does not follow that present technology has the ability to do that. It is thus an equivalent error to think that we have as yet been able to capture the entire essence of medical interactions with the placebo controlled trial.

      I think that it is even more fundamental than WLU states.

      What is dark matter? We don’t know. We have no idea how to actually characterize it. We don’t know how or even if it could prove useful to us. In fact, it isn’t even a thing. It is a place-holder for something that we know is there, but have not yet characterized.

      And so it goes for placebo effects, responses, and non-specific therapeutic interactions. Those are the “dark matter” of medicine. Except that we actually know more about our dark matter than the physicists know about theirs. But in either case, even though our current technology and understanding has not characterized what our “dark matter” is we can say what it is not and constrain where it can and cannot be. At least to a certain extent. And to the extent that we can we find that, unlike the physicist’s dark matter, it comprises a very small part of the medical landscape.

      Does that mean we shouldn’t investigate it, probe it, characterize it, and learn to exploit it to the fullest? No!

      What it means is that despite the fact that Peter is absolutely correct that “we have [not] as yet been able to capture the entire essence of medical interactions with the placebo controlled trial” we can say that we have captured enough to know it is not useful on its own, that the maximal effect sizes for conditions and situations in which it is best able to exert an effect is modest at best, and that we do not need to pretend that it could be something truly profound.

      In other words, we are not worried that someday we may find out that we could in fact exploit medical dark matter to the point of having a fellowship in it.

      1. Andrey Pavlov says:

        Derp. Not WLU. MadisonMD.

  11. Thor says:

    Great opening photo (and post), Dr. Jones! Looks like W’s artistic talent mirrors his presidential talent. Maybe he can start a line of Hallmark cards. I actually saw some of his work highlighted on the PBS Newshour a while back and couldn’t even believe my eyes. George the master painter!? Who wudda thunk? The portraits were fairly decent, and he does have the ability to capture the unique look of a person. But all in all, a bit
    cookie-cutterish. The works display a paucity of substance and depth.

    1. MTDoc says:

      Possibly he paints because he enjoys it. I did not hear any claims that he was an artist, only that he felt a need to express his thoughts on canvas. When you think about it, that is the motivation of many starving “artists”, including my granddaughter, and W doesn’t need the money.

  12. @BobbyGvegas says:

    Unfortunate choice of photograph.

  13. “critical thinking during medical training.” is vital! … But impossible without all possible treatment options and some continuity of care.

    You truly can not build a new medical paradigm without the wisdom of the past.

    In all the scenarios the patient was mismanaged, in the Traditional and complementary sense which is emblematic of our broken, chaotic, modern, dogmatic, mechanical, vending machine medical system.

    She needs an old school Marcus Welby MD he would address all of her needs

    1. WilliamLawrenceUtridge says:

      You truly can not build a new medical paradigm without the wisdom of the past.

      You can’t build a new medical paradigm without evidence. You shouldn’t offer “wisdom of the past” without empirically testing it first. You can’t ethically offer it without testing either. The wisdom of the past was generally quite wrong in nearly everything “the past” came up with. Violent purgatives, bloodletting, mustard plasters and herbs given for lung diseases “because it looks like a lung” were all ineffective upon testing. Medicine in the past, lacking a structured form of assessment, often led to quicker death, not longer life. And we can see very, very visible evidence of this in the average lifespans of humans from centuries past – far, far shorter than in contemporary times.

      The past simply wasn’t very wise. And anything devised in the prescientific mists of history that actually was effective will show up in controlled testing.

      In all the scenarios the patient was mismanaged, in the Traditional and complementary sense which is emblematic of our broken, chaotic, modern, dogmatic, mechanical, vending machine medical system.

      That’s a whole lot of adjectives that don’t acknowledge how much good modern medicine does, and how flawed and nonsensical complementary medicine is. Realistically, modern, real medicine cures the most common illnesses relatively quickly and easily. Cancers are eradicated. Wounds stitched shut. Broken bones set. Deadly diseases vaccinated.

      Meanwhile, complementary medicine offers you something expensive to do while you get better anyway, because they’re inert.

      And really – aside from acupuncture, what complementary modalities do you use? Why categorize real medicine as “all bad” and complementary as “all good” when the actual assessment should be made on a treatment-by-treatment basis?

      She needs an old school Marcus Welby MD he would address all of her needs

      She needs a fictional doctor? You’re an idiot. Marcus Welby didn’t exist, and the diseases he “treated” were imaginary and plot-driven. I can’t believe you invoked a TV doctor with a straight face.

      1. “You’re an idiot.”
        Gee man get a grip on your emotions, It’s difficult to think clearly if you are upset.
        That was a joke.

        The evidence is there to the opened minded individuals who know what to look or find.
        You my blogger, do not have the clinical expertise to discern what is valuable and what is not. You should default to one of your clinical colleagues.

        You keep using “Violent purgatives, bloodletting, mustard plasters and herbs” We still use these in practice today!! It’ difficult for you to understand since you do not practice medicine. Ask one of your practice blogging friends to educate you.

        Realistically, modern, real medicine cures the most common illnesses relatively quickly and easily.
        “Cure” is a tricky word that needs clarification. The body will cure itself of most common illnesses anyway! Medications in a actually “assist” the innate healing process.

        “Cancers are eradicated.” Eradicated from where to where?
        “Wounds stitched shut.” OK they knew this thousands of year ago…what is your point?
        “Broken bones set.” OK too they did this long ago also … what is your point?
        “Deadly diseases vaccinated.” This is true!! Thanks to a few humane scientist who were looking to help mankind and not the profit margins.

        You never invalidated any of my science comments.

        1. WilliamLawrenceUtridge says:

          Gee man get a grip on your emotions, It’s difficult to think clearly if you are upset. That was a joke.

          Poe much?

          The evidence is there to the opened minded individuals who know what to look or find.

          Is any of it on pubmed?

          You my blogger, do not have the clinical expertise to discern what is valuable and what is not. You should default to one of your clinical colleagues.

          I don’t have patients or clinical expertise (and I’m not a blogger, idiot). I do have a web connection and the web address for pubmed. Please provide me with evidence to support your claims. Clinical expertise deceives; clinical expertise supported two thousand years of bloodletting, and two decades of knee cartilage debriedement, and both were proven harmful through research. Where is the research supporting your clinical experience? How do you know your clinical experience isn’t deceptive, like it was for two thousand twenty years of bloodletting and knee surgery?

          You keep using “Violent purgatives, bloodletting, mustard plasters and herbs” We still use these in practice today!! It’ difficult for you to understand since you do not practice medicine. Ask one of your practice blogging friends to educate you.

          Where, outside of a CAM clinic, can you find violent purgatives, bloodletting, mustard plasters and herbs? Provide links please. Excepting the valid uses of each,
          acute poisoning, hemochromatosis and pharmacognosny respectively.

          The thing is – I don’t rely on my clinical experience for my health – I rely on the scientific literature. Why don’t you?

          Realistically, modern, real medicine cures the most common illnesses relatively quickly and easily.
          “Cure” is a tricky word that needs clarification. The body will cure itself of most common illnesses anyway! Medications in a actually “assist” the innate healing process.

          That’s a long line of bullshit that dodges the fact that real medicine treats many common illnesses quite well (type I diabetes for instance), and if its recommendations are followed (good diet, exercise, no smoking, sleep enough, reduce stress), health is preserved. The rest of your nonsense is a dodge to get around the fact that most CAM interventions are merely ways of wasting time (and money) until an illness gets better on it’s own anyway. Which is unethical, and unnecessarily prolongs the pain and discomfort (and sometimes endangers the life) of the patient.

          “Cancers are eradicated.” Eradicated from where to where?

          From blood, from bone, from breast, from brain. Real medicine can’t cure all cancers, but it’s a damned sight better than doing nothing – which is what CAM offers. Nothing but a painful, painful death.

          “Wounds stitched shut.” OK they knew this thousands of year ago…what is your point?
          “Broken bones set.” OK too they did this long ago also … what is your point?
          “Deadly diseases vaccinated.” This is true!! Thanks to a few humane scientist who were looking to help mankind and not the profit margins.

          My whole point here is that you claim real medicine does no good, that it’s mechanical and repetitive, and I’m pointing out there is an enormous amount of good done and that even the “vending machine” medicine you are so contemptuous of is a source of much of it. And beyond the stitches, broken bones and vaccinations that they could offer today, they can do far better jobs of it – none of which is due to CAM. Also, for all you hypocritically decry profits, do you provide your service for free, and do vaccines work, while costing very little?

          You never invalidated any of my science comments.

          What science comments? You provide almost no science – a long list of references you didn’t even read, and a single review article (that I would still like to get my hands on). But mostly you just shit on real medicine and pretend that’s all you need to do to justify charging your patients for unproven treatments.

  14. The art of medicine is actually what happens with you practice an all inclusive old and new school medicine … let it age into Wisdom and the Mastery of Medicine.

    1. George Tullington says:

      Mr Rodrigues: even though doctors & medical people care only about making money & maintaining the status quo, they actually produce positive net results to people, unlike liars & scammers such as yourself.

      The problem with the real medical profession is precisely that, like any dumb yet useful tool, they provide services to all people, the vast majority of whom don’t deserve them, which includes liars & scammers such as naturopaths & reiki & accupuncturists & physical therapists.

      In fact, maintaining the status quo & one’s HABITS – habits of every kind – of institutions, of business culture, etc – is 100x MORE important than money to doctors & lawyers & every single profession & job than research mathematicians.
      The habits & routines in business (not just medicine) of jerking people around. Of making garbage up on the spot. The most important thing to people their habits, not doing what is fair & optimal.

      Now, BY DUMB LUCK, professional culture & habits may just HAPPEN to be what is fair & optimal. Again, in ANY field, NOT just medicine – it is UNFAIR & UNJUST to single out the medical profession for your insulting attacks.

      1. @George Tullington
        Your comments are as if you known me for a long time but your have not!
        You do not seem to know all of my intentions!
        Dang all you had to do was ask!!

        You seem to be angry at everyone …. even yourself!

    2. WilliamLawrenceUtridge says:

      The art of medicine is actually what happens with you practice an all inclusive old and new school medicine … let it age into Wisdom and the Mastery of Medicine.

      What does that even mean?

  15. yogalady says:

    All the compassion and communication skills in the world are useless if the doctor can’t figure out a diagnosis and treatment plan. Of course patients deserve compassion, but they can get plenty of that from their dog. What we need from doctors is expertise.

    When medicine is called an art, I don’t think it means that compassion is central. I think it means that intuition is just as important as logic. If all a doctor can do is look up your symptoms in a book and write out a standard prescription, then he can be replaced by a robot.

    What makes a doctor an artist is not just years of experience, but having learned from that experience. An intuitive doctor will notice things that are not in the medical textbooks.

    And by the way, not many people realize this but scientific research is also an art. We use logic to reject false hypotheses, but we use intuition to generate new ones.

    1. WilliamLawrenceUtridge says:

      All the compassion and communication skills in the world are useless if the doctor can’t figure out a diagnosis and treatment plan. Of course patients deserve compassion, but they can get plenty of that from their dog. What we need from doctors is expertise.

      Yes, and that’s why currently medicine places emphasis on diagnostic algorithms, because in the greatest number of cases that leads to the greatest number of successful treatments.

      When medicine is called an art, I don’t think it means that compassion is central. I think it means that intuition is just as important as logic. If all a doctor can do is look up your symptoms in a book and write out a standard prescription, then he can be replaced by a robot.

      That’s a stunningly ignorant assessment. The reality is, as Dr. Jones says, much work can be done in a robot-like fashion, because in most cases the etiologies are common. Chasing zebras is a rarity. Perhaps because you get your assessment of medicine from television, where the unusual is highlighted because it is unusual, you get the impression that all doctors need to be master diagnosticians capable of diagnosing kuru in a hospital found in a flyoverstate servicing a population catchment of 40,000 rural inhabitants.

      What makes a doctor an artist is not just years of experience, but having learned from that experience. An intuitive doctor will notice things that are not in the medical textbooks.

      Um…rather the problem is that the textbooks cover everything, it takes years of residency to realize just how average the average complaint is. An intuitive doctor might just as easily be led down the path of some exotic disease merely because they don’t realize how easily intuition can lead one astray.

      And by the way, not many people realize this but scientific research is also an art. We use logic to reject false hypotheses, but we use intuition to generate new ones.

      Sure, but the real worth of science isn’t in those intuitions. Myth, natural history, theology, all the things that preceded science were based on intuitions and were worthless. It is the systematic testing and synthesis of science that allows it to be so tremendously powerful. Human intuition is adequate for social pattern analysis, but it’s horribly flawed for discovering things about an objective world indifferent to our preferences. Science is mostly about crushing intuition with a brick of data.

  16. George Tullington says:

    Just want to make this clear: just because medical doctors – i.e. REAL medical doctors – all really provably do cure people & really provably relieve pain does NOT mean that they either work hard nor care more about patients than money.

    The ONLY thing medical personnel care about is money.
    Just like all the lying scamming NDs & “nature” people & homeopathists.

    The SECOND a patient leaves a doctor’s office, the ONLY thing on that doctor’s mind is the billing department.

    Yes – they ALL go through medical school, they ALL earn their degrees, they are ALL equally good, because they do all PROVE that they can sufficiently pass their exams.
    And that PROVABLY saves people’s lives & reduces pain, far more than it kills them.

    CONTRARY to what all the lying scammer “naturopaths” claim.

    Medical school is just mindless brute force repetition & training. No creativity.

    I attended school with medical people & biology majors. I got As in biological sciences & biotechnology. Sure, I worked hard.

    But it is NO where near as hard as graduate school mathematics.

    Earning a PhD in math & working as a research mathematician is the SINGLE hardest job on the planet, by many many many orders of magnitude.
    I’m talking different galaxies harder.
    I am sick to death of POLITICALLY CORRECT commentators preaching their PERSONAL POLITICAL OPINION (NOT provable fact) that somehow being a soldier, a medical doctor, a nurse, or a parent is in ANY way harder than being a PhD-level math researcher. That is PURE ARROGANCE by those medical people.

    Do I have any respect or sympathy for medical people?
    No. None whatsoever.

    They are simply useful tools to be exploited. That’s it.
    That’s all that matters.

    1. If being a medical person (MD, nurse, etc) were hard, then THEY WOULD NEVER HAVE ANY CHILDREN. Why is it EVERY SINGLE MEDICAL PERSON ON THE PLANET
    has the time & money & LUXURY of PROCREATING?

    2. All medical people in the USA, at least, all vote, without a single exception for the 2 largest terrorist organizations on the planet: Republican or Democrat.
    Medical people simply are too stupid, lazy, & mentally inferior of conceiving of voting for someone else: Green Party, Socialist, Communist, Libertarian even.

    Why? Because medical people do not have the ability of doing hard abstract thought like mathematicians.

    2. If it were so “hard”, then quit. Find another job if you don’t like it.
    According to you medical people, according to the way you vote, according to the way you love & worship free-market anarchy, you can just get a job the next day for the same pay, say, working as a chef at McDonalds or as a WalMart greeter.
    Again, being mentally inferior to math PhDs, you are not mentally capable of QUANTIFYING how much a person gets paid., let alone quantifying the consequences of actions.

    3. It is you medical people’s worship of free-market anarchy (“capitalism”) that allows naturopaths, homeopaths, scammers, etc to flourish. You medical people have got NOTHING to complain about these scammers. You medical people complain & lie & pretend that your job is “so hard”. If it were so hard, then why do you complain about pseudoscience scammers helping to pick up the slack (or believing that they do, and making stupid patients believe that they do)?

    You allowed these scammers into your schools with this integrative medicine crap.
    So the real medical healers have got nothing to complain about.

    4. Again, if the real medical people’s jobs were so “hard” and so “busy”,
    then STOP GIVING MEDICAL CARE TO THOSE WHO DON’T DESERVE IT:
    christians, muslims, scientologists, anyone who votes Republican, Democrat, and meat-eaters.

    In the past 2 weeks, I had 2 visits to an orthopedic thumb surgeon, with no intention OTHER than to get surgery to fix my broken thumb. Only at the END of the 2nd visit this B**CH subhuman mentally inferior lazy nurse LIES to me, claiming that it’s
    “real important” that I get somebody to sit there the entire time at the surgical center the day of my surgery.

    BUUUUUUUUUUUUUUUUULLLLshit!

    That is COMPLETELY UNNECESSARY!I
    And IF IT WERE SO “important” THEN THIS WORTHLESS LAZY NURSE WOULD HAVE TOLD ME BEFORE I MADE THE 2 PRE-SURGICAL APPOINTMENTS.
    If they do not follow through with the surgery for me, they had BETTER not dare bill me.
    I have had at least TEN same-day surgeries over the past 15 years.
    NONE required that I WASTE somebody’s time, entire day, waiting with me.
    It is MORE than sufficient, and already enough BURDEN on me, to require that somebody drive me home after my surgery (a medical transport bus).
    I’ve already complied with THAT burdensome requirement at all my previous surgeries.

    It is PURE discimination against the poor & homeless, who have NO friends or family to waste a day waiting in a surgical center.

    Well, needless to say, I am NOT going to give a F**K about that.
    I played it cool. I didn’t spit in her face & call her a liar, like I should have.

    When my surgery date comes, if these mentally inferior shitheads try giving me a hard time, I’m telling them I REFUSE TO PAY FOR MY 2 PRE-SURGICAL OFFICE VISITS.

    I am so PROUD to have LIED to medical doctors, just to get drugs from them,
    and to have left surgery DRIVING HOME on my own.
    Because THAT’S what medical personnel do: they LIE. Because they got nothing to do.
    Because they have no-stress easy “jobs” getting free money.
    So the have NOTHING better to do than cause patients trouble.

    Because they deserve to be lied to, and done with a smug little smile on my face,
    just like this lying nurse did to me yesterday.

    I don’t ever want to hear MDs and nurses whine & cry about how “hard” their job is.
    BULLshit. Let’s see them prove the Twin Primes Conjecture.
    These conjectures lay unsolved for CENTURIES. But, medical schools churn out people who can pass their requirements every year.

    Medical people simply do not have the mental ability to compute the consequences of actions. They cannot mathematically model the world from the atoms on up like physicists, computer programmers & mathematicians do. So, medical people are simply not mentally capable of understanding abstract formal logic concepts such as the difference between “X” vs “not X”, such as, X = drank a whole bottle of alcohol before surgery.

    1. BillyJoe says:

      Geroge TULLINGTON, I am GLAD you got THAT off your chest.

      Now calm down and listen…
      Mathematics is hard, but not that hard. Really it’s not.
      You may not be able to solve the Twin Primes Conjecture, but there is at least no danger that you will KILL someone in the process. Wait…let me rephrase that…

      Any headache, even with no objective signs, could turn out to be caused by a brain aneurysm, but your doctor won’t scan you every time you have a headache, otherwise appointments would be booked out for such a long time that when you do have an aneurysm you will die because a scanner wasn’t available in time.

      On the other hand, if you don’t solve the Conjecture and all that happens is that you get to have a nice big fat rant on an internet blog.

      See the difference?

    2. Windriven says:

      “that somehow being a soldier, a medical doctor, a nurse, or a parent is in ANY way harder than being a PhD-level math researcher.”

      How much straw did it take to build that man?

      All that said, how does one judge the relative difficulty of a job? Abstract mathematical research takes a particular skill set, honed to a very sharp edge.

      So what? Every job has a skill set, a set of rewards and a set of negatives. And each has a set of consequences, some great, some small, when the job is done well or done poorly.

      This isn’t a contest of whose job requires the most brains, the most dedication, the most sleepless nights. People are drawn to their fields for a variety of reasons, some noble, some crass. Again, so what? How did this get to be such a prickly bug up your a$$?

      If you feel that your chosen profession doesn’t garner as much respect and adulation as you think befits it, that is your problem, not the problem of those around you. Are you so insecure that your sense of self-worth is dictated by people you barely know?

    3. WilliamLawrenceUtridge says:

      The ONLY thing medical personnel care about is money.

      If that’s the case, why did they go into medicine instead of bond trading?

      1. Harriet Hall says:

        And what about those who work on a fixed salary? Nothing they do has any effect on how much money they make. There was no “billing department” where I worked, in the military medical system.

        1. Eldric IV says:

          I find the accusation that doctors only care about money to be exceptionally stupid. I work in the VA system, which is salaried and, overall, less money than a physician could make outside. And even when I have to argue with the most arrogant, bone-headed physicians we have, I have no doubt that they care about their patients.

          We are told early and often in pharmacy school that if your only draw to the profession is the paycheck, you will not last. Health care is a demanding field and no amount of money is worth the crap you have to endure day in and day out. You need to find satisfaction in selflessly serving others.

        2. Sawyer says:

          Those hundreds of thousands of people do not exist in George’s mind, therefore they do not exist. He’d try to explain it to you but you wouldn’t understand the math. Because YOUR TOO DUMB DOCTOR PERSON!

          In all seriousness I think it should be fairly obvious to anyone with an inkling of medical training what’s going on here, and I trust we will all respond appropriately (ie not bother responding).

      2. Frederick says:

        And why Some of them, like one of my best, chose the specialty with the lower salary? and why she have the same car for years, and why she also invested so much time in non-profit organization to help people with drug problems? that made her go to medical school, and choose a path to help those person?

        Wow talk about a crazy totally single sided view of world, WITH all those caps, so totally sure of himself. One of the worst rant ever, could not even finish reading it, the emptiness of the word were giving me a headache.

    4. This is a place to get a few of your questions answered.

      https://www.healthtap.com/

  17. JD says:

    As someone who is getting a PhD in a field based on mathematics (statistics) that spends about half my day with MDs, I could not disagree more with this nonsensical screed. One could argue the level of difficulty associated with a career devoted to mathematics, but the number of hoops needing to be jumped through seems to be never-ending. Really, not much of this deserves a response.

    The SECOND a patient leaves a doctor’s office, the ONLY thing on that doctor’s mind is the billing department

    Because it, unfortunately, has to be. An egregious amount of a physician’s time is spent dealing with bureaucracy, including hours spent on such personally enriching (without ANY compensation) activities as obtaining authorization from an insurer for patient x to use drug y instead of drug z. I do not envy that aspect of the field one bit.

    I feel like the underlying problem here is the belief that physicians have not earned the level of respect that they are given. I tend to disagree with that assertion. With the amount of training needed, the time spent away from family and friends (of which you seem ignorantly unappreciative), and the sheer amount of bs dealt with on a daily basis, I think this has been earned. Taking into account the time and effort devoted to the profession, if these individuals were solely interested in money, it would be easily within their abilities to become investment bankers and make millions of dollars per year. Instead, they are doing something they are passionate about for a good salary that has job security. There are far more lucrative career options that are far less taxing on an individual.

    1. Missmolly says:

      Don’t worry, JD, the dude up there is clearly just trollin’ and deserves to be utterly ignored. Sane people know medicine is not the career for the pathologically fiscally enthusiastic :)

  18. Discussant says:

    Interesting post! Here’s a related one on the “art of psychotherapy”: http://forbiddenpsychology.wordpress.com/2014/05/04/the-art-of-psychotherapy/

    If you give yourself creative license to take a risk to create something original and good, then you can expect to have some failed attempts on your way to a masterpiece, and to be unable to predict when the inspiration and skill will hit the right note. If it’s canvases that are redesigned or discarded along the way, then that’s just fine. But if it’s human lives at stake, then this level of collateral damage is too much.

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