Older Mind Matters

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.

1 comment (Add your own)

1. Dave Jolley wrote:
You are wise as ever. It is wonderful that you and quite a lot of experienced (dare I say ‘old’) colleagues and friends were there to contribute to discussions formal and informal. I am proud to be part of this movement that has kept its humanity longer than many others.
There is, indeed, a worry that we are being displaced by robot-like successors who are cowed to rehearse and believe only what is handed down by management-controlled algorithms. When you know what you are doing you have a responsibility to be fearless and to use your skills and experience to provide the most honest, effective and efficient advice, treatment and care to individuals and to their families and to the population you are privileged to serve. Formal guidelines are part of the wealth of knowledge you will bring to bear on the challenges and conundrums.
I would say, however, that the use and interpretation of a careful/caring history, examination of physical and mental state, including special investigations and neuropsychological tests, and gathering of understanding of social and spiritual dimensions are all science. Good science uses them well. Bad science can lead to tram-lined, inflexible thought and action which is heedless of the full picture: where we came from and where we can go.
Perhaps there is art in spinning together these threads which science has provided. But there is art too in producing and providing a service from the resources available, in meeting every individual – patient, family, colleagues – in their world and communicating in terms which mean something to them. Art and love in ensuring continuity in the care.
Further still – we appreciate that art contributes so much to what makes life worth living, so that the contributions of our medicines and the science behind them are dwarfed in the measure of what will bring people peace and enjoyment. For the most part, people and their families chose and provide their own art menu and milieu but when they are placed within a care home or similar closed environment we need to make sure that art is given a place in the routines of the day. When people are changed by dementia the sort of art which will get through to them is often changed – But maybe that takes us back to science.

Sun, March 29, 2015 @ 7:07 PM

Add a New Comment


Comment Guidelines: No HTML is allowed. Off-topic or inappropriate comments will be edited or deleted. Thanks.