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EDITORIALS: Harold J Cook What stays constant at the heart of medicine BMJ 2006; 333: 1281-1282 [Full text]

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Clinical judgment is not enough

Stephen M. Taylor   (24 December 2006)

Context

Stephen J Redmond   (3 January 2007)

beside science and art

Andre Crismer   (23 January 2007)

Clinical judgment is not enough 24 December 2006
Stephen M. Taylor, Retired, 103 Easterner Place Rockwall, Texas 75032 Send response to journal: Re: Clinical judgment is not enough	Although at first reading of Professor Cook’s essay I thought I agreed with him, after several more reads I became uncomfortable with both his hypothesis and his final definition equating clinical judgment with the art of medicine. His vapid dismissal of communication skills is regrettable given recent research into the placebo effect. Kaptchuk[1-3] and others have shown that the placebo effect has a measurable impact on pain, that it's effects occur over time and using fMRI, that these effects are configured through multiple brain pathways and mechanisms. He also reports that the placebo effect, adverse reactions and the nocebo effects are linked to the instructions given to the patient. With this line of evidence I do not propose that physicians become good liars, but rather that the expectations of patients are in large part determined by those conveyed to them by their physicians. Also, I believe the rubric of clinical judgment is too undefined in the essay. I have known a number of physicians whose penchant for rudeness contaminated every patient encounter. It was then left to the rest of us to apologize for their behavior and calm patients down. These offensive actions by the few are frequently justified as "being honest about my clinical judgment". Over the years I have grown tired of these rude and obviously unhappy colleagues. They may have great clinical judgment but no one wants to hear it because of the harshness and insensitivity with which it is conveyed. Sincerely, Stephen M. Taylor, D.O. Clinical Associate Professor of Manipulative Medicine University of North Texas Health Science Center Fort Worth Retired 1. Kaptchuk, T.J., et al., Do medical devices have enhanced placebo effects? J Clin Epidemiol, 2000. 53(8): p. 786-92. 2. Kaptchuk, T.J., et al., Sham device v inert pill: randomised controlled trial of two placebo treatments. Bmj, 2006. 332(7538): p. 391-7. 3. Kong, J., et al., Brain Activity Associated with Expectancy-Enhanced Placebo Analgesia as Measured by Functional Magnetic Resonance Imaging. J. Neurosci., 2006. 26(2): p. 381-388. Competing interests: None declared
Context 3 January 2007
Stephen J Redmond, GP principal Ellergreen Medical Centre, 24, Carr Lane, Liverpool L11 2YA Send response to journal: Re: Context	I did not think that the author dismissed communication skills out of hand but wished to emphasise that the art of medicine consists in more than this. I think this is easier to appreciate in general practice where we are much more dependent on raw clinical skills and freer of the easy recourse to further investigations. To me the essential difference between the art and the science of medicine is that the former deals with the unique individual suffering from a dis-ease and the science deals with the clearly delineated cause, such as diabetes mellitus. What the latter lacks is the context in which the person meets the condition and it is clear that the art is in the application of the scientific knowledge to a unique set of circumstances rather than thinking that the same response will be right in all situations because science says so. The same set of problems will elicit massively different responses from different patients and hopefully this will also be reflected in the actions taken by their medical attendants Competing interests: None declared
beside science and art 23 January 2007
Andre Crismer, family practice 4100, Seraing, Belgium Send response to journal: Re: beside science and art	Just to add one comment to Harold J Cook, What stays constant at the heart of medicine, BMJ 2006; 333: 1281-1282 [Full text]. Beside science and art, there is an other way to think, to find and to act, which has given birth to many discoveries and progresses for mankind. This way, practised by people using their knowledges, their abilities and their beliefs has been dominant in human history and in most traditional groups, described by anthropologist Claude Levy Strauss, and is still in the heart of daily work of general practice: that's odd jobs. In front of an original and specific patient, with his suffering, his problems and questions, and with him, the doctor has to find a way to move on: in this situation, it's no question of art even if creativity is essential and most of the time, there is no help to find in science: by essais et erreurs (tests and errors), with their logic and the material they find around, the doctor and his patient try to find the way to manage. Competing interests: None declared