Is Medicine Creative?

Hint: it depends...

© Photo by Dani Bregman

I recently spoke with an artist who is considering going into medicine as a second career. Tired of the financial instability and monastic loneliness (her words) of artistic life, she wanted to transition to a job where she could help people and be part of a team - not to mention pay the rent.

Meanwhile, she had one major hesitation. “I’m a very creative person,” she said. “I would hate for that to go to waste. Is medicine creative?”

“That’s an easy one,” I said. “I’ll give you a definitive answer: yes and no.”

In college, where I was liberal arts major, creativity was prized. The whole point of speaking up in class or writing a paper was to say something new, to make some insight, connection, or interpretation that had not been said before - at least not in that way as far as you knew. 

Of course, you were expected to know the lay of the academic land - to research the relevant sources, and cite them - but if all you did was survey the field without adding a creative twist, then it would not be reasonable to expect an “A”. 

Incidentally, it occurs to me that one way to understand the pride of place creativity holds in the college mindset is through the corresponding gravity of plagiarism.

Plagiarism - the act of stealing someone’s original work or idea and passing it off as one’s own, is the worst academic crime a student can commit. The penalty for plagiarism is likewise severe. I had a friend who was expelled for lifting several paragraphs from a book and putting them in his senior thesis word for word. In his particular case, we all viewed it more as a stupidity tax than a criminal penalty: it turned out that the author of the book was none other than his thesis advisor (true story)!

In any case, to view plagiarism as a sin implies the sanctity of originality. Conversely, think how highly originality must be valued for stealing it to carry such a heavy price.

Like my plagiarizing friend, every Princeton student has to write a senior thesis. I still have my bound copy on the bookshelf, eighty-two pages of sweat and tears that represents my most demanding and satisfying accomplishment in four years of college.

My topic was how Albert Camus’ inner conflict over the Algerian War of Independence was reflected in his fiction. I can’t rightly claim that my ideas were so creative in the grand scheme of things, but they sure seemed that way to me at the time.

I tried my best to say something new and by the time I was done, I felt that I had grasped something about the intersection of politics, morality, and literature in the life of Albert Camus (and by extension my own) that no one else had understood in quite the same way.

When I got to medical school, I was surprised to find that creativity was at best irrelevant. In med school, nobody cared how original you were. In fact, the opposite was true. The secret to success in medical school was to be as unoriginal as possible - to swallow vast mountains of facts and regurgitate them on demand and without adulteration.

In med school, there were right answers and wrong answers, and the only thing creativity got you was the latter. 

Consider the anatomy exam. Imagine that you are standing around a flayed cadaver with four other medical students in gowns and gloves, clipboards in hand. See that strip of flesh with a pin stuck in it that looks like beef jerky? That is, and only ever will be, the piriformis muscle and any more original answer will also be wrong. 

The same holds true for residency training. 

My first job as an attending was as the inpatient director of the Columbia University Family Medicine residency program. When I would teach a team of residents how to approach a case of hyponatremia, analyze an EKG, or work up a sick, hospitalized patient, my goal was for them all to do it in the exact same way. I tried to teach them to think about clinical problems clearly, systematically, and algorithmically, without skipping any steps.

“Don’t overthink it,” I remember saying, “you will only confuse yourself. Trust the process.” 

I remember one resident who ordered the wrong type of intravenous fluids for a post-op patient while on call in the middle of the night. When I pointed this out to him on rounds the next morning, he launched into a convoluted justification based on the patient’s body habitus and the physiology of fluid shifts. 

It was all very creative and totally wrong. 

That’s when I realized that the most dangerous type of resident is one clever enough to come up with a plan based solely on first principles followed by a chain of creative reasoning.  Such an approach might make for a great English paper but it’s not the way that medicine works. In the practice of medicine, if no one else has thought of it that way before, it’s probably wrong (exceptions only prove the rule).

“Let me give you a pearl,” I told the resident (in medicine everyone loves a good pearl). “Start by learning the standard of care. Then reason away to your heart’s content. If your conclusion coincides, great. If not, stop - red flag! Do not pass go and collect $200! Call for help before you make another move.” 

Sometimes in medicine - as I’m sure is true in most fields - the easiest person to outsmart is yourself.

After a few years of clinical practice, however, I began to notice something interesting. My work was starting to feel more creative.

I used to think that a medical case was like a jigsaw puzzle: if you put the pieces together in just the right way, the full picture - the correct diagnosis - would predictably emerge. 

I still do love that feeling.

But over time, as the puzzle-solving became routine, the challenging cases have come to feel like problems with more than one solution, potential paths through the undergrowth to be hacked into actuality.

The reason is simple: while diseases and treatments may arguably be the same, it turns out that patients, being people, are very different. A given disease may present with the same set of symptoms, signs, and data over a diverse group of patients; but each of those patients will experience it in their own unique way.

After the process of making the diagnosis - call it the craft of medicine, where your toolbox includes textbook knowledge, the physical exam, diagnostic studies, and clinical algorithms - comes the task of treating the patient. And effective treatment includes considering the patient’s personal, economic, cultural, and even existential condition - trying to put yourself in their shoes and see the world through their eyes - shifting your point of view in an act of imagination that is perhaps most akin to reading or writing fiction. 

Call it the art of medicine.

There comes a stage where the craft is the easy part while the art is the hard part, the part that requires actively enlisting the patient as a partner and an ally. The part without which, I might add, it gets hard to see the point of the whole endeavor.

After all, doctors are not there to help themselves.

Last week a patient wrote a very nice comment, which I will immodestly and faithfully quote (no plagiarism here) because it encapsulates what I am trying to say:

“I find your office visits begin with the bedside, goes to the listening, and then the chart reading. At this point the conclusion; which I observe comes after a quiet moment where you decide on the type of sentence that would have maximum impact-- a nudge, a request, an acknowledgment that the patient will not listen but what the heck he might surprise me or an admonishment that takes the patient by surprise. I have received all of those and they work for me…”

Thank you! And that’s exactly the thing that feels creative to me - figuring out the ideal route from the intervention you know the patient needs, to the change the patient is able and willing to make.

So, is medicine creative? Yes and no.

For my part - and this is what I told the artist - it feels like I’ve come full circle: starting from the liberal arts where creativity rules, passing through the craft of medicine where creativity has no purchase, and emerging into the art of medicine where creativity reclaims center stage.