On Training the Medical Mind
scholars-stage.blogspot.com
scholars-stage.blogspot.com
Could it be that medicine was more individually "caring" before the introduction of highly-codified procedural standards and allopathic/evidence-based medicine?
A personal anecdote: I've had a tremendously hard time finding an ophthalmologist to treat a chronic and very annoying type of allergic conjunctivitis. I finally just found a great doctor — an "Osler type." She actually took the time to try to diagnose the issue, walk through my medical history with me, and focus on figuring out the root cause. All the other ophthalmologists I've been to have just put me on steroidal eye drops after running through a checklist.
I've seen this same thing in other parts of my life too. I had a period of about two years when I was a (younger) teenager where 3 psychiatrists and one GP diagnosed me with depression, anxiety, ADHD, narcissistic personality disorder, Bipolar I disorder, Bipolar II disorder, and more.
I finally got off the treadmill of medications and completely unfounded diagnoses, took a few psychedelic trips, and left home to travel alone for a month. On a follow-up visit my psychiatrist was stunned to learn I was leading a successful life without medication. (He had previously told me that "people with your kind of depression almost always need SSRIs for life.")
If only more doctors had the empathy and courage to wean themselves from the checklist style of medicine and practice medicine in the way Osler emphasizes here — by preparing their souls to do so.
I think there are "House, M.D."-style situations where the checklist will kill your patient and a quick hunch will save it. But the usual doctor's visit because of an itchy eye isn't.
As an IT professional, just think of the number of times where it really was one of point 1, 2 or 3 on the checklist: "is it switched on?" "is it plugged in?" "have you tried turning it off and on again?". Of course those are often useless. But when they are not they do waste far more time than just quickly checking...
Yes, but from a systemic standpoint, it's considered a non-issue, unfortunately.
https://en.wikipedia.org/wiki/The_Checklist_Manifesto
I think Atul Gawande is a talented surgeon, but an even more talented writer. He makes talking about the hard questions in medicine and health a lot more approachable.
My discontent comes more from the robotic tenor that checklists can engender. And, moreover, that checklists don't seem to be very good for preventative medicine. If a doctor takes no care for the patient's holistic situation (soul and psyche included), the steps and procedures advised by checklists can be hard to follow through on.
Consider obesity, for example. It's obvious our medical system is doing a horrible job at preventing the root causes of obesity. Yes, physicians often recommend the AHA guidelines on diet and exercise, and can provide some intervention like bariatric surgery if absolutely necessary. But for the most part, obesity is an untreated epidemic.
I think this has a lot to do with the cold and robotic feeling of checklist-style medicine. A doctor who is willing to engage with their patient to provide cures and remedies at the "level of the soul" is invaluable. Because everyone's situation is so idiosyncratic and peculiar, finding and fixing the root cause of someone's chronic ailments is much harder than running through a checklist.
To take obesity: any number of things could be the root cause, but they're hard to discover through a checklist, just because the realm of possibility is so large. Interacting with the patient on a human level might be the only way to really understand and solve these sorts of wicked problems.
Perhaps this type of thing (lifestyle issues) is more in the wheelhouse of a dietician or a lifestyle coach who has a different type of training.
If you have sepsis, a dietician probably wouldn't be the safest bet. If you have lifestyle issues with diet and exercise, maybe a physician wouldn't be the safest bet.
This article is interesting to me because it portrays a version of medicine which treats the patient as an integrated unit.
I think a physician who can interrogate issues more deeply in addition to treating symptoms is invaluable. Maybe someone’s weight is not just a function of their lifestyle or diet, but is also due to undiagnosed, low-level hypothyroidism, for example. I don’t know that a dietician can be expected to have the knowledge and expertise to treat issues like this. Who knows, with the rise of smart medicine we might be able to replicate such a care team through technology.
Also, unfortunately, quality of treatment is in large part a function of time. And in most countries, the level of medical attention one gets is very dependent on how much they can afford. I mean, even in places like Germany that have socialized medicine, the privately insured get better care, more time with their doctors, less time to schedule an appointment, etc.
Knowing that, this might be an insoluble problem until we automate the checklist-style medicine with chatbots and ML, and then reserve doctors for the tricky cases where DDx falters.
You used this phrase, and I like it.
I see this as the core of the problem, and I might just be re-phrasing what you are saying.
I risk veering off into politics here, and I don't really want to, but I do think that the profit-centered healthcare system in the United States creates this separation of people who should really be consolidated into a single team. There should be a team of people working together: Dieticians, physicians, etc.
But, in my experience, everything is siloed pretty bad. Physicians work for one company, the dieticians work for another. Everybody is divorced from one-another. Nobody is part of a consolidated team.
Ideally, you would have both a PCP, and a dietician that you could consult, both of whom are part of a team, share the same medical records system, talk to each other over lunch, etc.
Let the doctors do the doctor part. Let the dieticians do the dietician part. Let them both work together for the benefit of the patient. But, integrate them into the same system.
I work in a hospital setting and I would say 90+% of the time the issue is diagnosed following a checklist for a particular problem. In the medical field we are taught to think of a 'Differential Diagnosis', or DDx for short, and sort by probability based on the history, age, sex, etc of the patient. Of course in the hospital setting you would also think of 'which of these issues can possibly kill my patient in the next 24hrs' and look for those as well.
So you go down your DDx list and if you run out of diagnoses, go back to the history/patient and think about it some more or consult with your peers.
As far as the "House MD" situations, i haven't run into any of those so i can't comment on that part.
But — and I don't say this to provoke — I think this view is myopic. It somehow misses the humanity at the core of the doctor/patient interaction. What is the ultimate purpose of medical care, really? Is it not to treat the patient, and not simply cure the disease?
A lot of times the checklist-style of medicine forces patients into a loop of patchwork solutions which don't address the root cause. To an extent, this is even true in emergency medicine. If someone comes in with their third heart attack, and they're clearly obese and in bad health and spirits, the problem that needs to be fixed goes beyond the immediate danger of the heart attack. There's something much more systemic, much more basic, which lies at the core of this person's suffering.
And I think the same is true for many chronic diseases and ailments, which are hard and time-intensive to solve in a holistic way, but which are easy to treat with patchwork solutions.
Take also the recent advent in hospice care, which I find wonderful. Hospice kind of rethinks the concept of "curative" medicine and treats the patient as a human being. How many people spend their last days in a miserable state, burdening themselves and their families by forcing themselves to stay alive? The "treatments" justified in the name of life-saving care can be incredibly diabolical and torturous. Doctors know this, and they often spare themselves that gruesome fate: https://www.rd.com/article/how-doctors-choose-to-die/.
Point being — treating the patient is not as simple as it sounds. The proper treatment is not only to fix the immediate disease.
But again, I am not against checklists. Doctors who use checklists and can care for the patient at the deeper level of soul and psyche are golden.
Also just in case you are ever sick, you NEVER want to hear the words ‘oh that’s interesting’ or ‘you are an interesting case’... there are a lot of rare diseases of which there are maybe 10 cases reported in the medicine books, and sure your doc can diagnose it but there may be no good treatment options ( since there is so little data all the accepted treatments are just guesses ).
In any case, if I’M ever sick i hope i fit the checklist, at least i know the diagnosis and treatment is well known and defined.
Edited to add: regarding hospice care, i wish this was more widely understood by non-medical people. I see so many people suffer unnecessarily because they don’t understand or their families refuse to understand. I cant speak about specific cases but I can say that some doctors have a gift of guiding their patients and some dont, and even the good one sometimes cant get through.
This is as you say a systemic problem and I dont have a good answer as to how to address it.
Or the checklist was tried and didn't work. It seems like the problem the OP faced was doctor after doctor just re-executing the same procedure to arrive at the same result as the previous doctor who failed to effectively treat the illness.