October 2015 | Issue 20
LKCMedicine Dean delivers 22nd Gordon Arthur Ransome Oration on the art of medicine

More than 300 members of the healthcare fraternity from Singapore and around the region attended the 49th Singapore-Malaysia Congress of Medicine and the Academy of Medical Sciences' second Induction Comitia of 2015 held at the Academia on SGH Campus on 31 July.

The highlight of the evening's packed programme was the 22nd Gordon Arthur Ransome Oration delivered by LKCMedicine Dean Professor James Best.

LKCMedicine Dean Prof James Best delivers his Gordon Arthur Ransome Oration on the art of medicine at the 49th Singapore-Malaysia Congress of Medicine and the Academy of Medical Sciences' second Induction Comitia 
Courtesy of the Academy of Medical Sciences 

Focusing on the art of medicine, Prof Best spoke about the need to remember that medicine is an art as well as a science, a truth that risks being forgotten by the advances in technology and scientific knowledge.

Here is an abridged version:

Sixty-two years after Watson and Crick reported the structure of DNA and 12 years after the first human genome was sequenced – we stand on the threshold of an era named precision medicine. In this proposed model of medical care, diagnosis, prognosis and treatment will be based on genome analysis (genomics), protein analysis (proteomics) and metabolite analysis (metabolomics), from each individual. This mega-data or big data will be collated to predict response and so to individualise therapy. Of course, this approach relies on high level computing, which is also changing the nature of medical practice.

But what are the consequences of this explosion of technology and scientific discovery for the practice of medicine and the role of the doctor? Science and technology of medicine is at its most advanced in the US and so perhaps we should look there for the answer to what lies ahead. Dr Abraham Verghese, physician-author and Professor for the Theory and Practice of Medicine at Stanford University Medical School says, 'I joke, but only half joke, that if you show up in an American hospital missing a finger, no one will believe you until they get a CAT scan, MRI and orthopaedic consult.' So using one's judgment and common sense is still part of the art of medicine, in both diagnosis and treatment. Much of medicine continues to involve complexity and uncertainty, so there remains a place for clinical reasoning despite the ubiquity of clinical guidelines and decision support systems.

What constitutes the art of medicine and is it still required?

But what other elements of medical practice remain relevant and constitute the art of medicine? They are contained in the many strands that make up the bond between doctor and patient. The basis of the doctor-patient relationship is trust - and trust is engendered in ways that include active listening, empathy, compassion and physical contact.

Even with the scientific advances over the past 40 to 50 years, I would contend that this kind of relationship with our patients is just as important as it ever was. With more chronic disease and in Singapore an ageing population, complex illnesses such as diabetes require a strong bond between doctor and patient to achieve good outcomes. We are far from curative treatments for kidney, liver, lung or heart failure, despite the advances in stem cell research. Neurodegenerative diseases and musculoskeletal disorders are major burdens with only modest advances in most areas. Mental illness remains a major cause of morbidity and progress in the therapeutic management of major psychiatric disorders over the past 40 to 50 years has been incremental but not dramatic.

In cancer treatment, there have been significant advances in some areas, but cancers of lung, pancreas, breast, ovary and prostate are still major causes of mortality and the promise of precise therapies based on the genetic and molecular analysis of individual cancers remains just a promise.

I do, of course, share the excitement at the discoveries that have enhanced our knowledge of the pathophysiological basis of human disease and I can envision the amazing progress likely to occur over the next 50 years in the treatment, and hopefully in the prevention, of many diseases. But I do not foresee medicine becoming totally mechanised and even if there are effective treatments for all illnesses, they will still need to be managed by caring clinicians with empathy and compassion. Just as insulin was expected to be a cure for diabetes 94 years ago, I expect that many of the so-called cures that will be discovered in the future will in fact be imperfect and complex therapies.

Management of patients with terminal illness in the era of precision medicine

One concern about the advent of precision medicine is that we could, as a profession, focus almost entirely on technical treatment of the disease process and lose our view of the whole person – our patient. This danger of applying scientifically sound therapies in circumstances which are futile already occurs frequently in the management of patients with cancer.

In the precision medicine age, we will undoubtedly see major advances in cancer therapy with dramatic and worthwhile outcomes. At the same time, there will be many other therapies that have only incremental benefit, extending life by a few months at great cost to all concerned. Helping our patients and their families to choose wisely in this situation will require great art.

Sir Murray Brennan, a New Zealand born and educated surgical oncologist, who was Chairman of the Department of Surgery at Memorial Sloan Kettering Cancer Centre in New York for more than 20 years, contrasted the ways that doctors can care for their patients when the decision is made that aggressive treatment of the disease is no longer warranted. An all too common approach is to say 'There is nothing more I can do for you' and to pass the patient on for palliative care management. His recommended approach is to say 'I do not think there is any further benefit to be gained from more surgery. But I will continue to care for you and make sure you receive the best possible treatment.' I believe that is the kind of doctor you and I would like to have caring for us.

So let us make sure that use of the new treatments that will become available as the precision medicine wave rolls in, is matched by a renewed focus on patient-centred care, balancing the science with the art of medicine. Let us afford our patients a good death when the time comes, with all the care that modern medicine can provide, but avoiding futile and invasive treatments that rob them of dignity and precious last moments with their loved ones.

The rewards from medicine as a caring profession and its teaching

If it is important for doctors to practise the art of medicine well into the future, how should we be equipping our medical students to learn the art? Again, Dr Verghese from Stanford says, 'What we need in medical schools is not to teach empathy, as much as to preserve it - the process of learning huge volumes of information about disease, of learning a specialised language, can ironically make one lose sight of the patient one came to serve; empathy can be replaced by cynicism.'

Of course, we do attempt now to select students in part on the basis of their empathic skills, but that is a very inexact science. At least we demonstrate that we think it is important. Encouraging our students to learn from their patients and from other health professionals is part of the modern curriculum for instilling a sense of empathy and compassion. We can also teach about professionalism and ethical responsibility. The development of professional identity is aided in many medical schools by white coat ceremonies and recitation of the Hippocratic Oath on entry to medical school. More than 100 years ago, William Osler urged us to treat medical students as our junior colleagues, surely an important way for them to develop that sense of belonging to our profession.

Innovative programmes in the humanities and medicine use art, literature and poetry to explain the human condition and to help our students come to an understanding of human nature and the effect of illness on the individual. In fact, it is not just students who can benefit from a study of the humanities. William Osler read non-medical classics from 10 to 11 every evening - and just as we keep ourselves up to date with medical literature, we can refresh our commitment to the art of medicine in this way.

With all of these efforts to develop our students as caring professionals, it is the role model that doctors provide to our students that probably has the most impact. Learning by example, just as children tend to emulate their parents' behaviour, is called the hidden curriculum. That means we all have a responsibility to demonstrate the art of medicine when we are being observed and to practise it even when we are not being observed. Because genuine empathy and compassion are not qualities that can be turned on and off like a tap.

What can we learn and emulate from Gordon Arthur Ransome?

So what can we learn from that master of medicine and first master of the Academy, Gordon Arthur Ransome, that will stimulate our ambition to practise the art of medicine?

I draw on his entry in Munk's Roll of the lives of members of the College of Physicians, which in turn derives from the writings of his students and colleagues, some of whom have spoken of him at earlier orations in his honour. He is described as kind and softly spoken. He was always ready to answer any cry for help from patients, staff or colleagues. When he was with a patient, he was transported into a world where only the patient mattered – and his patients knew that. He believed that a doctor is placed in a special position to gain the patient's trust and that a doctor needs to be a student of human nature.  He was a master of clinical diagnosis and an enthusiastic and effective teacher, fondly remembered by his students.

Gordon Arthur Ransome epitomised the art of medicine and we can learn much from his example of selflessness and devotion to his patients. Of course, the world and its ways have changed since he practised medicine here in Singapore. The gender balance of the medical profession has changed and the importance of family and other commitments outside of medicine are acknowledged more readily. We are also challenged by changes that can distance us from our patients, like the computer terminal, the mask and gloves that are now part of the medical uniform in many settings. But it is the ethos, the spirit of his legacy that we want to emulate and pass on in turn to the future members of the medical profession.

Gordon Arthur Ransome valued medical history and medical books and was a devotee of the works of William Osler. So it is fitting to conclude the oration in his honour with an aphorism from Aequanimitas, '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.'