Medicine: both art AND science

I have just returned from two days at the Faculty of Old Age Psychiatry conference in Glasgow: good company, a good programme and a comfortable, though maybe pricy, venue. What sticks in my mind is the debate on the motion: “Science has little place in the practice of old age psychiatry”. Could that possibly be true? My initial thought was no: we strive to be scientific with standardised cognitive testing and brain scans for dementia, evidence based pharmacological treatments and non-pharmacological treatments, and an expanding knowledge base.

But medicine is not just science – it’s also art and “craftsmanship” (not my word but I can’t easily think of a gender neutral alternative). Craftsmanship in establishing a relationship with patient and family, in working out a treatment plan that accommodates the peculiarities and preferences of that particular person, in harnessing compassion in the interests of care, in knowing when to go with the science and when not to go with the science. Discussing cognitive testing in an earlier session, a senior Faculty officer talked about making a diagnosis of dementia in a person who scored 30/30 on a test of cognition – yes I’ve done that too (maybe we all have), and I’ve also made a diagnosis of no dementia (is that a diagnosis?) in people who scored well below 20/30 on the same test. That’s part of the art of old age psychiatry (and of medicine), and, without that maybe robots that are programmed with NICE guidelines and complex algorithms could replace us.

So old age psychiatry is art AND science, but is science little or large? Is one more important than the other? What makes the diagnosis of dementia: the clever cognitive testing results repeated at intervals; the results of the scan? Or the skill of the clinician in teasing out a detailed history in relationship with patient and family, putting it in the context of that person’s daily life, and bringing it together with the results of tests and investigations? The art grows larger and the science grows smaller as I think about it. And I worry that the science is easier to teach and learn than the art, and that we (professionals) value the science more. I suspect that’s not true for our patients and their families. I suspect too that the same is pretty much true throughout medicine, even though it’s psychiatry that attracts criticism for not being “scientific”. Maybe we should take that intended criticism as a compliment.

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