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Lazarus is an adjunct professor of psychiatry.
Once, I agreed to be an expert witness. Never again! Not because I was grilled on the witness stand for several hours. Not because my qualifications were questioned. And certainly not because I was compensated poorly for my time. Rather, I don’t ever want to have to defend our profession’s great tradition steeped in the “art” of medicine.
A little over a decade ago, I was hired on behalf of a patient’s attorney who was suing an insurance company for “bad faith” decision-making for denying the patient what I and other physicians believed was medically necessary treatment. The lawyer representing the insurance company confronted me on the stand.
“Dr. Lazarus,” he belted out, “are you familiar with this textbook?” The lawyer practically heaved Harrison’s Principles of Internal Medicine at me, further questioning whether I was familiar with the tenets of evidenced-based medicine. I have lived by those principles my entire career, I told him, but I remained silent about the real truth: the fact that “textbooks tell lies.”
“Textbooks tell lies” is a phrase I’ve never forgotten after reading Viktor Frankl’s Man’s Search For Meaning. Frankl and other physicians at Auschwitz concentration camp quickly learned that the information contained in medical textbooks was irrelevant to their plight, i.e., the brutal conditions their bodies and minds were required to endure. Who could have predicted the need for treatments for the myriad illnesses resulting from the unimaginable inhumanity prisoners were subjected to? And conversely, no medical textbooks of that era anticipated the surprising resiliency of some prisoners in the face of famine, torture, and disease. “Resiliency” wasn’t even a concept in the early to mid-1940s.
As someone who embraced and practiced evidenced-based medicine long before the term was coined, testifying about the sanctity of the art of medicine was an interesting turn of events because I had to find it within myself to tell the lawyer how compassion and caring should have factored into the insurance company’s decision. I had to channel Viktor Frankl.
My opening pitch involved telling the insurance company’s lawyer that there’s much more to practice than what textbooks and journal articles teach us. However, the attorney tried to shut me down, implying I was not familiar with the concept of evidenced-based medicine. He actually asked the judge to excuse me, claiming that I did not qualify as an “expert.”
The judge had the good sense to let me testify, and testify I did! I explained that the art of medicine entails understanding patients’ histories — where they’ve been and how they got here — and listening to their stories, in many instances stories of grief and destitution. To practice the art of medicine means that you know your patients inside-out, including social and psychological issues impacting their health. You know their occupation, who they are close to, and what their living situation is like. When you’re a psychiatrist, you know them even more deeply. Who do they love? Who do they argue with? Who do they hold a grudge against and regret not making amends? Textbooks and journal articles do not steer you in that direction, I said to the attorney.
The lawyer objected to my testimony as being “non-responsive,” but I was on a roll, and the judge held up his hand like a stop sign to the attorney and let me proceed. The art of medicine goes beyond mere knowledge obtained from double-blinded placebo-controlled studies, I continued. It requires treating the patient as a whole person, not just their illness. This includes taking into consideration their mental and emotional health, lifestyle, and personal circumstances. It demands treating patients with empathy and concern. Understanding and acknowledging a patient’s feelings can greatly improve their healthcare experience and can positively influence their health outcomes. Doctors have to discover the essence of their patients’ existence on their own and not through some textbook, I concluded.
The insurance company doctors who denied care to this patient knew nothing about him other than that he had condition “X” and his physician was requesting treatment “Y,” which the insurance doctors considered “not medically necessary.” They did not even weigh the fact that, despite the patient’s current therapy, he was not responding to it and was becoming progressively blind.
Such callous decision making and patient neglect, I argued, was tantamount to practicing medicine in bad faith. My argument was a stretch because legally “bad faith” generally refers to intentional dishonest behavior or misleading actions that result in harm or potential harm, and that was not entirely evident here since the insurance company physicians were simply relying on a set of guidelines, misguided though they were. Nevertheless, the judge was sympathetic and he essentially forced the insurance company into a settlement.
The art of medicine and the science of medicine are two fundamental aspects of healthcare. They represent different but complementary approaches to patient care. The science of medicine aims to provide objective, evidence-based solutions to health problems. It provides the tools and knowledge necessary to diagnose and treat diseases.
The art of medicine, on the other hand, refers to the more subjective and personal aspect of healthcare. It involves understanding the patient as an individual, empathizing with their experiences, and building a therapeutic relationship. The art of medicine ensures that broad knowledge of the patient is applied in a compassionate and culturally competent manner. Both the art and science of medicine are necessary for effective medical practice.
I don’t have anything against lawyers. I just wish more of them would read Man’s Search For Meaning.
Arthur Lazarus, MD, MBA, is a member of the editorial board of the American Association for Physician Leadership, an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, and a former Doximity fellow. His forthcoming book is titled Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.
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