Tuesday, November 14, 2023

Science or Art

Medicine is a science. But there is art involved. I was asked recently to deliver a lecture on credibility in opinion evidence, and there is a great deal to unpack there. There is much that contributes to credibility, and much that may detract from it. See The Chair of Truth (February 2018); Credibility - a Conversation (December 2019); Magic Words (February 2021), and Credibility from Vulgarity (October 2021);

But, this presentation was about the science of medical opinions. There is an increasing tendency to strive for scientific foundation in the expression of opinions. That has been likely driven in part by Florida's adoption of the Daubert standard. Daubert's New Day (May 2019); Daubert Better Explained (May 2016). Science is about reasoning, experimentation, and reliability. Unfortunately, as similar as you and I may be, there are likely differences in the way our bodies may react to insult, injury, and illness. 

There is scientific foundation, but sometimes notable distinction in how patients present, perceive, and express. It makes the job of the physicians challenging at best. Thus, while there is science in the diagnosis and treatment of disease or dysfunction, there is art in the treatment of the patient. There will likely be both involved in the overall effort to remediate injury or illness.

In preparing for the presentation on credibility, I was driven to the idea of science and art. It occurred to me that these two could actually go together. Perhaps they would not be the best of roommates (The Odd Couple, Paramount 1968). However, might they co-exist in the world of today, the constraints of Daubert, and the "objective medical evidence" standard to which we are directed?

The question of medicine, art, and science is not new. An excellent monograph in 2006 tried to tackle the question by defining the "meaning of Art and Science in terms of Medicine." The author, S.C. Panda, strives to explain that both exist and can be "complementary." See Medicine: Science or Art?, Mens Sana Monogr. 2006 Jan-Dec; 4(1): 127–138. This is an excellent starting point for understanding the perspective of combining science and art. 

The reading reminded me of a corollary that is perhaps instructive. There was a ridiculous "troupe" of comedians that I watched in the good old days. They cooperatively produced some of the most ridiculous and hilarious material of our age - Monty Python's Flying Circus. A memorable skit in 1969 regarded the "Funniest Joke in the World," and the theme was weaponizing this joke for use in wartime. Absurd, irreverent, and yet too funny. Their perspective was driven by another time and different social mores. 

They posited that this joke was
“Wenn ist das Nunstück git und Slotermeyer? Ja! Beiherhund das Oder die Flipperwaldt gersput!“
For those who speak German, there was the added humor from the fact that some of the words are mere nonsense. As a side note, it is a bit different in that regard from the disgusting restaurant name in The Anchorman (Dreamworks 2004), which all Spanish speakers noted. However, Google Translate says this somewhat German phrase means
"When is the now piece git and slotermeyer? Yes! At hand the Oder die Flipperwaldt gersput!"
And so, we have humor that is not. Is this funny? Whether from this Python foundation or from other inspiration, another intrepid group set out to study the science of humor and to determine why it is that we laugh. We might concede at the outset that humor is in the ear of the beholder, and what I find amusing may not appeal to you at all. In that regard, perhaps not so different from our personal perceptions, descriptions, and expressions of medical complaints?

The resulting article "Telling the world’s least funny jokes: On the quantification of humor as entropy" concludes that humor may be predictable and replicable (science). The authors believe that perceptions of humor are "a quantifiable function," and that "Shannon entropy does predict human judgments of non-word humor." By that "non-word," it is presumed we mean the old slapstick slap to the head from the Stooges or Lucy stuffing chocolates into her shirt on the assembly line. Their conclusion seems to be that we have reactive similarities and we are somewhat predictable.

But, there is art in comedy. As Jack Lemmon related, someone striving to entertain us might well say "dying is easy, comedy is hard." I have told many a joke that flopped, and have gotten many a laugh from phrases I never expected to land so well. In fairness, I never rehearse. And, as importantly, as Ferris Beuller famously noted while screeching on a clarinet: I "never had one lesson" in humor. So as I may not understand the science, nor even the definition of entropy, perhaps I can have some chance in comedy periodically, sporadically, or even empirically. But, I am no scientist (or humorist).

I am suggesting, that there are others out there who consistently deliver punch lines with aplomb. Their appreciation for, and talent for, humor is unparalleled by the rest of us. It is likely that they have studied humor, practiced, repeatedly failed, and persistently continued to refine and rewrite. Their experience is part of the package, and they bring with them an expertise in humor that is worthy of consideration. That does make it labor-intensive, but not science. But, what of the science or lack of science?

Perhaps we might as readily admit that medicine is science. As different as we are individually, the systems in the body are similar and tend to reasonably consistent reactions to insult, injury, and treatment. But, due to our differences, might we expect some distinction in our reactions to treatment? Might there be room beside the science for the art of delivering care, explaining expectation, empathy, sympathy, encouragement, and more?

In the end, we could perhaps agree that neither humor nor medicine is wholly are or science. That is likely why our workers' compensation statute says that decisions have to be "based on objective relevant medical findings," but not exclusively so. There is no prohibition on the inclusion of experience, education, and training in the analyzing and quantifying of medical data and evidence. There is the foundational requirement, but no expression of exclusivity. 

With that conclusion, we return to the question of credibility above. How can a witness be credible? Particularly, how can the expert witness? The key, if there is one, is likely reduceable to a few key points:
  1. Be prepared.
  2. Be sincere.
  3. Be concise.
  4. Be clear.
  5. Be consistent.
  6. Be patient.
  7. Be instructive.
  8. Be informative.
  9. Use examples.
  10. Use comparisons.
  11. Show your work.
  12. Explain your conclusions.
In these regards, it is critical to remember that who you are speaking to is not known. The judge may decide this case, but for that to be so, the case must travel far along an expensive byway. Along the way, patients, risk managers, adjusters, and various others may weigh in on, or make, decisions regarding resolution. Any of them may be your key audience. Which of these is most critical to that decision maker? You cannot tell, because the audience is not certain at the outset. One cannot always predict who will make the decisions. 

In the end, each of those suggestions may matter, whether you are an expert witness or a fact witness. Each has the potential to make your conclusions, suggestions, and opinions more or less credible. Certainly, the science itself is of value (but only if the decision maker understands you (7 - 12). The conclusions are more likely to be accepted if the listener has faith in you (1 - 6). It is not a recipe. There is no golden rule. There are these factors to consider.

Credibility comes down, similarly to humor, to the eye of the beholder. Do you, as an expert or other witness, inspire faith, confidence, and trust? Is your conclusion logical, have you explained not just the what (your conclusion), but the how (what process led there, and why do those elements support the what). 

In the end, medicine is a mixture of science and art. The witness who would succeed is the one that accepts this, refines this, brings the data to the table and effectively presents it in a comprehensible and clear manner.