Is O&P Science, Art, or Neither?

During my prosthetics residency a colleague described an interaction with a patient who was frustrated after experiencing ongoing discomfort despite multiple adjustments to his prosthesis. The patient expressed confusion about how it was possible to put a man on the moon but not make a comfortable socket. The clinician responded that unlike prosthetics, space flight involves a lot of math. The clinician’s succinct description of a key difference between science and clinical practice made an impression on me early in my career, and I’ve appreciated it even more in the years since. Orthotists and prosthetists frequently encounter patients whose expectations about their care are influenced by the assumption that it is based on absolutes and guarantees regarding functional abilities supported by the devices, outcomes of treatment, and other aspects of their experience. Clinicians recognize the disconnect between the certitude expected by many patients and the uncertainty we navigate daily. At the core of clinical practice lies a complex decision-making process based more on experience and judgement than scientific absolutes. The common way of acknowledging this complexity is to describe medicine as both an art and a science. In 1951, well into the era of significant scientific advancements in medicine, clinical pathologist Lionel Whitby, MD, described it this way, writing that medicine “can never become an exact science unless all variables can be estimated and allowed for, unless the personal element can be eliminated, and unless each patient can be reduced to a standard form.” 1 He went on to state that “the frequently ridiculed ‘bedside manner,’ which secures the confidence of the patient, is of fundamental importance in medicine. It is an art…which develops with practice.” 1 Whitby considered the art of bedside manner “more often inborn than acquired.” 1 Behavioral skills are often described as crucial to providing care but something that cannot be taught. However, the scientific method has been applied to this area of practice, meaning that there is research evidence to support skill development. In that way, even the relational dynamics between a provider and patient can be understood as at least a blend of art and science. Perhaps more importantly, exercising the judgement that is the core of clinical decision-making involves more than scientific evidence. The line between art and science is not as clear as those labels make it appear. Problems With Terminology Kathryn Montgomery, PhD, author of How Doctors Think , describes the use of the terms art and science in descriptions of medicine as “slippery and almost entirely unexamined.” 2 Art is used to describe “behavioral attributes such as bedside manner or the display of professional etiquette” and “moral values or virtues manifested in demeanor or habits of communication” that “are recognizably different from the knowledge of biology.” 2 She concludes that “‘art’ stands for the relatively subjective skills of physical diagnosis, or more precisely, for tacit knowledge, the hunches that experienced physicians have without quite knowing how.” 2 Of science she writes, “The word promises the unambiguous regularities of Newtonian physics.” 2 People “assume that science is the replicable, invariant, universalizable description of material reality.” 2 She concludes, however, that “‘science,’ especially in its limited, old-fashioned physics-based sense is neither an adequate description of what physicians do nor a good characterization of how they think.” 2 Clinical Judgement Montgomery makes a convincing case for describing medicine as neither an art nor a science, but instead, as “an interpretive practice. Medicine’s success relies on the physician’s capacity for clinical judgement. It is neither a science nor a technical skill (although it puts both to use) but the ability to work out how general rules—scientific principles, clinical guidelines—apply to one particular patient.” 2 John Saunders, MD, expresses a similar perspective: “Good doctors use their personal judgment to affirm what they believe to be true in a particular situation. Their knowledge is not purely subjective, for they cannot believe just anything ; and their judgment is made responsibly and with universal intent, i.e., they take it that anyone in the same position should concur. It is practical wisdom. Medical practice demands such judgments on a daily basis. The good doctor is able to reflect on diverse evidence and to apply it in a particular context. No computer could replace him, for the judgment cannot be reached by logic alone. Here medical practice as art and science merge.” 3 Scientific Claims in O&P I once attended a presentation by a clinician with extensive experience that included a slide with the phrase “The Art and Science of Prosthetics.” The words “art and” were crossed out, and the speaker emphasized that his presentation would focus on science. Over the course of the next hour, he described his approach to clinical practice, stating multiple times that “this is just the way I do it,” assuring the audience that different methods and approaches may be equally effective. It struck me that this statement is something that an artist, not a scientist, would make. A physicist describing gravity or the shape of the earth would never reassure an audience that different understandings of those two realities would be equally effective when travelling to the moon. The presenter’s statement, however, accurately reflects the ambiguities of clinical practice. What is commonly referred to as “art” involves clinicians’ use of clinical judgement in evaluation and diagnosis, as well as tailoring the treatment for each patient. I found it disheartening that the presenter appeared to believe that his experience and clinical judgement constituted science, or (equally concerning) that they only had value to the extent that they were considered science. In doing so, he denigrated what I consider to be the most valuable thing he had to offer the audience, and that we have to offer our patients. Experience and judgement matter, and all of us have much to learn from those like that presenter who have spent decades practicing at a high level. Practitioners who aspire to provide the best care and improve their clinical skills diligently attend to detail, carefully observe cause and effect, document outcomes, and adjust their technique based on results. This approach shares characteristics with the scientific method, which, according to the Oxford English Dictionary’s definition, involves “systematic observation, measurement, and experiment, and the formulation, testing, and modification of hypotheses.” Despite overlap between the two, clinical exploration of this type differs significantly from the scientific method in several ways. Science is more methodologically rigorous and its findings more definitive. For example, a practitioner’s experience with the ways specific modifications influence patients’ comfort and function can become guiding principles that inform other cases, but they lack the absoluteness and universal applicability of scientific truths. We can recognize purposeful skill development and the generalizability of knowledge and skills, without mislabeling clinical practice as a science. Why Is Science Appealing? The contributions science has made to medicine, O&P care, and life in general are undeniable, and the replacement of nonscientific ways of knowing is responsible for much of the progress in these areas. The understanding that medicine is more than a science is also common among contemporary medical professionals whose practice benefits from scientific breakthroughs. However, the perception of medicine as scientific at its core, with “art” used to describe its intangible, nonbiologic, and less significant aspects, remains. In part, this is due to the belief that science represents the pinnacle of understanding. Montgomery points out that “medicine’s status in society depends in large part on the scientific character of much of its information. To claim to be a scientist in our culture is to stake out authority and power.” 2 Additionally, practicing medicine involves a “need for certainty when taking action on behalf of another human being.” 2 This can be a heavy burden, and one that may appear lighter if we define clinical decision-making as a scientific process. Science, after all, promises “reliability, replicability, and objectivity,” which are valued highly when seeking medical care. 2 In general, we (and patients) prefer absolutes to ambiguity, and believing that medical decisions and recommendations are science, rather than the judgement of an informed practitioner, can at least give the appearance of certainty. Evidence-Based Practice, Algorithms, and Practice Guidelines Randomized controlled trials, considered the gold standard of research, are much more common in medicine than O&P, due in part to the variation inherent in rehabilitation. In most areas of O&P practice, the significant contributions of science have resulted in insufficient evidence for deciding between treatment options in specific cases. Even in practice areas where science has clarified much about the condition and treatment, decisions about timing and specific design features remain within the realm of clinical judgement. This is not because science has failed, but because science is limited in the types of questions it can answer. Answering clinical questions requires judgement when applying scientific evidence to the case. Even in medical disciplines with more high-level research to support decision-making, “neither evidence from randomized controlled trials nor observational methods can dictate action in particular circumstances. Their conclusions are applied by value judgments that may be impossible to specify in ‘focal particulars.’” 3 Montgomery expresses it this way: “Clinical reasoning is far more situated and flexible than even the most complex clinical algorithm can express.” 2 Jerome Groopman, MD, writes that algorithms “quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact…in such cases…algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they can constrain it.” 4 Clinical practice guidelines (CPGs) are often developed to influence decision-making. However, a 2018 scoping review found “no previous studies designed to directly quantify the effects of implementing standards and guidelines on service delivery” within O&P. 5 In my judgement and that of guideline authors, CPGs can provide valuable insight, particularly for novice or less skilled clinicians. They can also help confirm the extent to which the decisions of experienced clinicians align with those of their peers and may provide an impetus to improve. (Montgomery refers to this as “teaching the young and reminding the old.” 2 ) Clinicians of every level of experience should be mindful of potential risks associated with ceding responsibility to an algorithm and continue to develop the judgement to use it appropriately. Considerations for O&P Ethical clinical practice involves accepting responsibility for decision-making and a commitment to developing the skills it requires. This includes accessing, understanding, and appropriately applying research. It includes humility and confidence in recognizing the essentialness and limits of our judgement. After years of practice, many decisions and techniques become routine. Challenging ourselves to learn and try new things helps us avoid the trap of assuming that the technique we’re most familiar with is the most appropriate. Qualitative research on clinical judgement and decision-making can deepen our understanding of these indispensable skills (see Anderson, et al.). 6 Making our tacit decision processes explicit by developing algorithms and practice guidelines allows us to evaluate our practice and make improvements. Improvement requires a transparent and thoughtful approach when things go wrong, including if and how mistakes in thinking may have contributed to a negative outcome. These cognitive distortions include availability (“the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind”), anchoring (only one possibility is considered), and confirmation bias (finding “what you expect to find by selectively accepting or ignoring information.”). 6 Dichotomizing science and art does not accurately reflect clinical practice. We must embrace the responsibility to develop and exercise our clinical judgement. This includes recognizing how it differs from and applies science. We must avoid attributing our decisions and recommendations to science and present our judgements with humility and confidence. This approach may help us partner more effectively with patients in defining expectations and making decisions. John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education. References Whitby, L. 1951. The science and art of medicine. The Lancet 2589(6674):131-3. Montgomery, K, 2006. How Doctors Think: Clinical Judgment and the Practice of Medicine, Oxford University Press, New York. Saunders, J. 2000. The practice of clinical medicine as an art and as a science. Medical Humanities 26(1):18-22. Groopman, J. E., and M. Prichard. 2007. How Doctors Think . Vol. 82. Boston: Houghton Mifflin. Sadeghi-Demneh, E., S. Forghany, P. Onmanee, U. Trinler, M. P. Dillon, and R. Baker. 2018. The influence of standards and clinical guidelines on prosthetic and orthotic service quality: A scoping review. Disability and Rehabilitation 40(20):2458-65. Anderson, C. B., A. J. Kittelson, and S. R. Wurdeman, et al. 2023. Understanding decision-making in prosthetic rehabilitation by prosthetists and people with lower limb amputation: A qualitative study. Disability and Rehabilitation 45(4):723-32.

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