by Danielle Ofri
New York Times
What are you doing creatively these days?
It’s not a question you hear commonly, and certainly not in a medical journal. But that was the title of a commentary in a recent issue of Academic Medicine. It caught my eye, because medicine is a field with a strong history of creativity, but its daily practice feels less and less so. Health care is being pushed steadily toward standardization, insisting on an algorithmic approach to diagnosis and treatment. Some ramifications of this trend have been beneficial, but many of these algorithms have been mechanized to the point where there is little need for human beings and their intricately personal neural networks.
Part of this stems from the way in which we are taught to think about clinical medicine. Medical school can seem like an ongoing exercise of committing lists to memory, the only creativity being the mnemonics for memorizing branches of the facial nerve or diseases with anion-gap metabolic acidosis. When students present cases, there is a sense of roteness. A patient with chest pain, for example, becomes, “Rule-out M.I. (myocardial infarction). Get an EKG, serial troponin levels, stress test, cardiology consult….”
Some of this roteness, of course, is thoroughness. You need to cover all your bases to ensure you are not missing anything serious. But rote recitation inhibits the ability to think beyond diagnostic straightjackets.
In one of my recent clinic sessions, I saw four patients with diabetes over the course of a morning. One was a young man whose glucose, weight and early-onset heart disease resist control, despite jogging 10 miles a day and eating like a rabbit. Another was an elderly woman with fragile bones, congestive heart failure and a medication list longer than my arm. A third was a middle-aged man unable to compromise a single French fry in his diet. And the fourth was a middle-aged woman whose depression snowplows all of her other salutary efforts.
Other than insulin dysregulation, these patients have nothing in common. Yet our medical approach is expected to be “standardized.”
Dr. Niamh Kelly, the author of the creativity essay, wonders what it would take “to bring the notion of creativity into the everyday delivery of health care.” It is a question we, as a profession, should take seriously. Patients and diseases do not come as prepackaged widgets. A slavish approach to standardized treatments without any creativity can do more harm than good. “It is much more important to know what sort of a patient has a disease,” the famous Sir William Osler is reputed to have said, “than what sort of a disease a patient has.”
When I talk to medical students about how creativity can fit into the medical world, I often cite the case of Witty Ticcy Ray, profiled by Dr. Oliver Sacks in his now-classic book, “The Man Who Mistook His Wife for a Hat.” Ray had a severe case of Tourette’s syndrome. The unpredictable bouts of facial grimaces and grunts — often laced with expletives — interfered with many aspects of his life. When Dr. Sacks prescribed Haldol, the tics were eliminated, and Ray’s job and family life were markedly stabilized as a result.
But in addition to removing the tics, the Haldol had a “side effect” of flattening out Ray’s ability to improvise as a jazz drummer. Typically, the medical profession would not have done much at this point beyond nodding sympathetically about having to take the bad with the good.
But Ray and his doctor came up with a plan: Ray would take his medication Monday to Friday, and be the “sober, solid” person that his job required. On weekends, however, he’d ditch the Haldol and be the “witty ticcy Ray,” reveling in the frenetic, free-wheeling music that he so loved.
This solution was quite simple, but it was also remarkably creative because it looked beyond the standard definitions of “treatment success” and “medication side-effects.” It is unlikely that this arrangement would have come about in the algorithmic approach to medicine that is insisted upon today.
How do we teach creativity in medicine? For one thing, Dr. Kelly suggests, people’s creative sides should be brought to the forefront. She imagines water-cooler conversations and medical conferences that start by asking, “What are you doing creatively lately?” There is likely more creative talent lurking in medical professionals, and in patients, than we suspect. Bringing it forward could have a salutary effect on the medical interactions that follow.
Explicitly focusing on the creative process is the important next step. Many medical schools are beginning to incorporate arts, literature and humanities into the curricula. Critics deride this as fluff, but I think it is crucial in medical education.
Poetry is one of my favorite tools because of its unselfconscious focus on metaphor. By definition, metaphor requires the stringing together of parts of the mind that don’t normally work together. Master diagnosticians and scientists cogitate in the same way, actively considering ideas that don’t normally sit together.
If all patients and their diseases presented in exactly the manner of the textbooks, then the algorithms would be sufficient. Computers could surely do our job much more efficiently. Lord knows, they certainly wouldn’t keep misplacing their reading glasses.
But the human condition is far messier — in health and even more so in illness. Complex biology and the many overlays of social, psychological and economic issues make medicine a complicated, and nuanced, affair. The serpentine logic often seems closer to literary metaphor than to the orderly taxonomy of knowledge that we cut our teeth on.
It is our job as clinicians to work with patients to untangle these metaphors. For this, solid medical knowledge is necessary but not nearly sufficient. We need to flex the oddball neurons that connect the disparate corners of our consciousness. They need to be honed in the same manner as muscles at the gym, with ongoing stretches and workouts.
The next time you see your doctor, you might want to ask what he or she is doing creatively these days.