Medical Informatics - The Debate of Art vs. Science Is Over

The envelope please... and the winner is ... (drum roll)... Art.

Back in 1976, the year the Apple I was released, computer “user groups” (UGs) were popular. Enthusiasts could meet in friendly surroundings and swap war stories. Common topics included extolling a great new piece of hardware or software. Members would describe some wonderful thing they just discovered that “you” can do with it, "you" meaning them. They would recount their experiences with WidgetX - the greatest thing since sliced bread (or what a disaster!) You should start using it immediately (or avoid it like the plague.) There were UGs of all kinds with names like HUG, BUG, PUG, SCUG, and MUG.

By 1976, about 10 years had elapsed since the first deployments of computer applications in healthcare and more people who had caught the bug, and the UG bug. Being early adopters of practically everything, many of these folks wanted to spread the word and formed medically-related UGs. Thus it was that in 1977 the first annual Symposium on Computer Applications in Medicine (SCAMC) was held in Washington, D.C., not an UG in name but an UG none the less.

Most of the early work on medical computing was done at academic centers by physicians with faculty appointments. A bit was of a theoretical nature but most involved tinkering with hardware and software in attempts to implement applications. Unfortunately, this kind of work is rarely of interest to the main-line medical journals. Nevertheless, academics must publish to get promoted; if they don't, they don't get tenure. If they don't get tenure they either get shown the door or (for the computer geeks) asked to resign their appointment and work in computer operations. The situation is no different in any other medical specialty. There are great practitioners that don't do scientific research or publish. They get the title of “clinical” professor, not the “real” academic positions.

The inability to garner the academic recognition had been frustrating. The response, spearheaded by some of the graybeards in the field, was a strategy that today would be called re-branding. They coined the name Medical Informatics. Evoking an analogy to mathematics, it was undoubtedly intended to imply the scientific study of information in a medical context.

SCAMC merged with several other groups in 1989 to become the American Medical Informatics Association. The annual meetings continue, much as before, and have continued to have little impact on either basic science or the EHR products that are offered for sale. Most institutions, even research institutions, could care less about scientific research into EHR. They are satisfied to get their medical computer systems from vendors and are not dependent on (and often not interested in) having physicians on the payroll acting as what they consider to be glorified computer technicians. If they need “clinical” input, they promote a nurse. Larger institutions may have a physician as chief medical information officer, reporting to the CIO, assigned the task of getting physician “buy-in” to whatever the management has decided to do. An occasional large independent organization has a physician CIO.

The name change from SCAMC to AMIA has not fundamentally altered how medical informatics is perceived. Doctors that practice the computer trade can be very knowledgeable and technically proficient but they have not, for the most part, succeeded in convincing universities that they are scientists, and frankly, most aren't. Scientists get Nobel Prizes, practitioners get board certified. In retrospect, even those that lamented the lack of academic recognition have fostered the view that it is not science. After 20 years of effort, they have convinced the American Board of Medical Specialties to recognize that practicing the medical computer trade is a medical specialty, which it certainly is. Next year the first examination will be administered for board certification in medical informatics. Soon it will be another one of those specialties, like internal medicine and pediatrics, except that medicine has an extensive theoretical foundation with which the applicant is presumably conversant.

So the answer to the question of whether medical informatics is science or art is settled - it's an art. The only tiny, remaining problem is that today's EHRs still lack a sound scientific foundation and there is still a lot of science that needs to be done if we are to get better systems in the future. The practitioners will be busy configuring EHRs, training users, and writing rules for knowledge bases for years to come. Who will do the scientific research and what will we call the discipline in which those researchers (if there are any) are engaged?

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