Doctors debate art vs. science in medicine

Dr. David Goodman, left, a professor of medicine

Dr. David Goodman, left, a professor of medicine at Dartmouth, argues that health care is a science. But Dr. Marc Siegel, right, a physician at NYU Langone Medical Center, says medicine is more of an art because every patient is different. (Credit: Dartmouth School of Medicine, Handout)

For six years, Erica Shur, a longtime resident of Manhasset Hills, has been taking a 2,000-milligram capsule filled with a substance many in the culinary industry would add as the final touch to casseroles or stews.

Shur, however, has taken the deep-amber colored spice called turmeric not only as a treatment, which she and her doctor say effectively beat back advanced thyroid cancer, but continues to take it years after completing the therapy. It's insurance, she said, to keep the malignancy from coming back.

"I feel wonderful -- and grateful for having found a doctor who was willing to think outside the box," said Shur, 64, a retired fourth-grade teacher.


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Shur's doctor wanted to cure her based on his knowledge of Western and Eastern medicine. While some advocates call this style of practice integrative or alternative medicine, an increasing number of doctors -- including Shur's -- refer to it as the art of medicine, which they say relies on a doctor's knowledge -- and instincts.

"There is a poetics to medicine," said Dr. Marc Siegel, an internal medicine physician at NYU Langone Medical Center in Manhattan. He was not involved in Shur's case.

"Medicine is an art because every patient is different. I want the ability to choose what's best for my patients based on what I learn about them as individuals," he said.

Medicine as a healing art, some doctors say, is under threat from an increasingly more regimented form of care.

Siegel and a growing number of physicians have voiced opposition to medicine's growing reliance on protocols from insurance companies and guideline-driven care.

Dr. David Goodman, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire, defended the guidelines, saying they are founded on evidence-based medicine.

Evidence-based medicine means the treatments and recommendations provided to patients have a foundation in years of documented scientific research, Goodman said.

"Medicine is becoming more guideline-based and some primary care physicians feel hamstrung by that," Goodman said. "What we aim for in medicine is scientifically based care that is highly personalized.

"I don't think most patients would trade science for art."

Yet many doctors make that exchange, especially with the practice of off-label drug prescribing, which involves using a medication approved for one purpose but prescribing it for one for which it has not been scientifically vetted.

About 20 percent of all medications prescribed for adults are for off-label purposes, according to research from Stanford University and the Institute of Medicine, a federally chartered nonprofit organization that provides advice to government agencies, lawmakers and the public.

About 46 percent of medications, particularly heart-disease drugs, are prescribed off-label and 50 percent to 75 percent of medicines prescribed to children are off-label because so few are developed for the pediatric population.

The practice is legal and strongly defended by the American Medical Association and the FDA.

Shur's doctor goes a step further, seeking treatments from the spice rack or the vitamin shelf as well as blending Eastern medicine with Western science.

Shur strongly believes the approach helped her become cancer-free.

 

Doctors had given up

Diagnosed with late-stage thyroid cancer in 2007, Shur underwent 33 radiation treatments as well as chemotherapy. Then doctors told her there was nothing more they could do, she said.

Thyroid cancer is rare and can prove tough to fight in some patients, as was Shur's case. Six years ago, the cancer had not only infiltrated her thyroid -- it had also spread to her right lung.

It was at that point she and her husband, Rudy, a Garden City book publisher, decided to search for a physician capable of taking a different approach.

They found one who customizes treatments to each patient.

"What may be a food or spice in one culture is medicine in another," said Dr. Raymond Chang, the cancer specialist the Shurs chose. Chang recommended conventional cancer therapy and the addition of a daily turmeric dosage.

Turmeric is believed to be a cancer preventive because it's a potent anti-inflammatory agent. Many types of cancer are believed to have roots in the body's inflammatory processes.

The spice also has antioxidants, compounds common to plants that guard healthy cells from destruction.

Shur, who taught at a Garden City elementary school, said Chang refers to the combination therapy as a medication cocktail. She has been free of the malignancy for five years. The cancer began disappearing shortly after treatment began, she said.

The American Cancer Society refers extensively to turmeric on its website, indicating that anecdotal evidence suggests "tumors of the esophagus, mouth, intestines, stomach, breast, and skin" have been treated with the spice.

But the cancer society cautions that more study is needed to confirm turmeric's efficacy in cancer therapy.

Trained in oncology at Memorial Sloan-Kettering Cancer Center, Chang has a private oncology practice in which he incorporates ancient Chinese medicine into patients' therapies.

He also uses other compounds known to have anti-cancer properties that are not routinely used in either Western or Eastern cancer therapy, such as aspirin and similar compounds.

These medications, known as nonsteroidal anti-inflammatory drugs -- NSAIDs -- theoretically can damage tumor blood vessels, short-circuiting their access to nutrients in a patients' blood supply.

Chang said he spends an hour or more with each patient trying to learn as much as possible, asking about preferences and habits -- such as whether the patient is a day person or night owl.

Cancer therapy differs based on the time of day, Chang said, so it's important to know how patients go about their lives.

During Shur's therapy, Chang additionally recommended a regimen of vitamins and green tea to further fortify her ability to battle the cancer. Vitamins, he said, replace those lost to chemotherapy and green tea serves an extra source of antioxidants and anti-inflammatories.

He said if more doctors took such an approach patients would be stronger and healthier as they fought cancer.

 

Key aspects of care

"The reality we are facing today is the opposite of personalized medicine, it's protocolized medicine, which is dictated by insurance companies," Chang said. "The insurance companies tell you what they will pay for and that's that."

The incursion of insurance companies into patient care, he said, has helped damage the doctor-patient relationship and siphoned the art out of the practice of medicine.

But precisely what constitutes art in medicine is open to wide interpretation. And some practices, critics say, can be dangerous.

An off-label usage of a dangerous diabetes medication had been routinely prescribed to children with autism by a few doctors around the country in recent years who call themselves specialists in the condition. They claimed the drug improved brain function. Neither the FDA nor the makers of Avandia had such evidence.

The drug causes a 43 percent increase in heart disease in adult diabetics and also is linked to blindness in some patients. Avandia carries the FDA's strictest caution, a so-called "black box" warning because of the severe side effects.

Ethicists and policy experts say the potential for harm is the reason modern medicine is grounded in the principles of scientific investigation.

Medical ethicist Rosamond Rhodes of the Mount Sinai School of Medicine in Manhattan said the art of medicine is emphasized during medical students' course of study helps to create compassionate physicians. But the key emphasis in any U.S. medical school, Rhodes added, is on science.

Goodman, the Dartmouth health policy expert, sees too great a danger when practitioners rely more on art than science.

"When I was a medical student," he said of an era more than 20 years ago, "physicians varied a lot in their style of practice. Their reason? There is this so-called art of medicine and that term became an excuse that allowed physicians to practice in any way they wanted.

"If I were a patient and wanted art I would go to an art museum," Goodman said. "Focusing on the art of medicine is romanticizing the past and doesn't help us understand the problems of the present."

Shur disagrees: "I have four grandchildren and I am just grateful for every single day."

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