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A Season for Everything
Perhaps it is the approach of the winter solstice and the start of the end-of-the-year rituals, but I am reminded of Ecclesiastes 3 that for everything there is a season. I have seen three articles recently suggesting thought leaders are recognizing the need to recapture the human element in medical practice lest we produce a service no one wants. Chang and Lee argue we need to go beyond evidence-based medicine.[1] “Guidelines are based on clinical research are being hard-wired into our operational norms, incentive programs, and information systems…But even when physicians prescribed medications that have been proved beneficial in randomized trials, the chances that patients are taking them a year later are akin, at best, to a coin toss…EBM placed new emphasis on the relationship between clinical research and clinicians’ practice patterns, but shifted medicine’s “center of gravity” away from the space between clinician and patient to somewhere between research and clinician.” The authors propose “interpersonal medicine,” which recognizes “clinicians’ influence on patients and informal caregivers and the relationships among them.” They insist this is not a rejection of EBM, but a next step. They note most care today is for chronic illness, many of which include not only physical, but social and behavioral components, and dealing with this requires more than just a pill. They also note compliance with medications, for instance, is improved by an empathetic treatment relationship between the physician and the patient. They caution not to assume physicians know how to provide empathetic, patient-centered care—rather it must be taught. Metrics need to be developed but note “soft” metrics have been found important in EBM approaches, so it is technically possible to develop them. Lastly, they point out a change from fee-for-service care to population care changes the emphasis from “production” to “effectiveness.” One of the drivers for the EBM enterprise is the desire on the part of the payers to standardize both the service and the cost of what they are buying. Uncertainty and variation are negative factors when looking at medical care from this perspective. But Schiff and colleagues lay out ten principles for more conservative, care-full diagnosis, which attacks this challenge head on.[2] Among other items, they argue for developing a new science of uncertainty, which acknowledges that up to half of all patient symptoms defy diagnosis, and 75-80% of those go away within three months without any attempt at management. They also note many positive test results are not clinically important. To deal with this uncertainty, patients need trusting relationships with their physicians, and must be willing to take some time for issues to clarify. And, of course, some symptoms need immediate attention. Knowing which is which is not easy for either patients or providers. Having started medical school and clinical training just as chemistry autoanalyzers were just becoming widely available, I was trained by a generation for whom specific tests had to be ordered. A serum calcium, for instance, had to be requested when the possibility of malignant hypercalcemia was entertained. They decried the SMA-18 as corrupting medical reasoning, but the truth is now we have “SMA-120” approaches both in the Emergency Room and in the doctor’s office. This creates a great deal of work (and expense), but it is not clear that it does much to improve health status. The third article was a panel discussion conducted last summer on the topic “Changing the Culture of Medicine: A Starting Point.”[3] “Swenson’s Mayo Clinic colleagues have studied physician camaraderie and commensality or sharing a meal together. “Basically, if doctors get together and talk about professionalism—what’s your best patient story ever—their cortisol levels go down, joy goes up, emotional exhaustion goes down, social isolation goes down, positive feelings about the organization goes up, all from spending time over a meal talking with colleagues about life as a professional. We’ve lost track of that.” When I entered practice, the doctors in the group had a Monday lunch in the basement, but attendance dwindled as the older members retired, and the practice stopped more than 20 years ago. Now we have trouble even getting the group together to talk about what is going on, and there is no question that esprit d’corps has been much reduced. For a generation for whom “joining” is not a common activity, it has proven difficult to figure out a way to break through the isolation. A related symptom is direct conversation about patient problems. When I needed a consultation, I thought it helpful to let my consultant know what was going on, what the issue was, and what I needed them to help with. Then it became common to have the ward clerk call and give you a patient name and room number, eventually replaced by an electronic notice in the computer. When some of the specialists complained, the response was an encrypted text message. I have even seen ads on medical websites arguing if you are still using the telephone you are hopelessly out of date and wasting time. But more than just data transmission takes place during a phone conversation—relationships are built. I remember calling one of my consultants late on a Sunday evening, during which I reported new lab results to him. His comment: “Boy, he must be sick for you to order lab. I’m on my way.” Perhaps it is just the season of the year, but it strikes me that all three articles are a return to the past—a recognition that medicine is as much art as science. Yes, we need the science and our patients have benefitted from scientific advances. And the days when “medical necessity” was defined by individual physicians is gone forever. But the art of medicine has been given short shrift, and now “data scientists” are beginning to realize it is important, too. Dr. Hallenbeck, who was chief of general surgery when I was a medical student, used to say he could train a monkey to do the operation—it took a surgeon to decide if the operation was necessary or helpful. Nowadays we would probably say a robot programed with artificial intelligence rather than a monkey, but the idea persists. Unfortunately, far too many physicians have been programmed to believe the technically correct answer, being a pre-programmed robot if you will, is the “right” answer, independently of patient context. To do otherwise is to be too subjective. Except that it isn’t. Scientific advances may change the boundary for uncertainty, but we will not eliminate it. Trying to eliminate the human element hasn’t reduced costs and won’t. To everything there is a season. Maybe this is the time to recapture the art of medicine to complement the science. 25 November 2018 [1] Chang S, Lee TH. Beyond Evidence-Based Medicine. N Engl J Med 2018;379(21):1983-1985. doi: 10.1056/NEJMp1806984. [2] Schiff GD, Martin SA, Eidelman DH, et. al. Ten Principles for Conservative, Care-Full Diagnosis. Ann Intern Med 2018;169(9):643-645. doi. 10.7326/M18-1468. [3] Swenson S, O’Connor M, Lee TH. Changing the Culture of Medicine: A Starting Point. 25 July 2018. Accessed online at https://catalyst.nejm.org/videos/changing-culture-of-medicine/?utm_cam. |
Further Reading
Choosing Wisely Communications Messaging is replacing dialogue in clinical practice to the detriment of all. Empathy Is empathy the value we have tossed out as part of "improving" health care? Equipoise Equipoise can be defined as a state of equilibrium or counterbalance. We would do well to seek it both personally and as institutions. Performance Measurement An expert panel has concluded less than half of current measures used by CMS to assess value for primary care services are valid. What does this tell us about current pay-for-performance efforts? The One Best Way Variation in Health Care Is variation in health care good, bad, or inevitable? The answer may determine future medical practice. |