Medicine

I miss the relative simplicity and patient-centeredness that characterized the early years of my medical career.

Decades of behavioral economics research and management science predict that framing quality of medical care as something that can be captured effectively by a simple metric, and then incentivized by financial rewards or punishment based on that metric, would misfire.

I find it disheartening that those who push for QI and P4P programs based on evidence do not understand the most basic principles of the scientific method.

Patient-centered shared decision-making is one of the toughest tasks in clinical medicine. It involves a collaborative effort to collect and assess evidence, leavened with clinician experience, and framed within the context and values of the individual patient. 

The world of medicine is quite properly focused on finding and applying the best available evidence to processes of care. Unfortunately, too often this results in the use of inappropriate hard targets and mis-applied guidelines.

The deluge of clinical information I face every day is littered with clinical junk mail.

All day long I work with patients who want answers and certainty. My awareness of how few questions have proven answers, and how unpredictable human health and disease can be, is a heavy burden.  This discordance may be why I enjoyed Stuart Firestein’s excellent book, Ignorance,  so much.

I did my family practice residency in a Catholic hospital in the mid west. The strong presence of nuns in leadership and the quiet influence of the attached order and Catholic school lent an unmistakably religious atmosphere to the hospital. Mostly, as residents, we were too busy and too tired to either notice or care, but occasionally the interface between the hospital’s spiritual context and the world of patient care was uncomfortable. Even jarring.

Throughout our medical training we are told again and again that the most important task is an accurate diagnosis. And we hear it at CME lectures and read it in journals. An accurate diagnosis is certainly essential if one wants to offer successful and safe treatment.  But it is not enough to ask and answer: “What is the diagnosis?”

There are several other questions that every experienced clinician asks - and answers - with every visit. Or should ask. We skip these questions at considerable risk to our patients.

She called in tears. Beyond tears, actually. She was so upset that it was impossible to get a coherent history and the triage nurse was only able to ascertain that her psychiatrist was no longer willing to prescribe her long-term clonazepam, she couldn’t function, and that she couldn’t afford the urine drug test. She insisted she wasn’t suicidal and didn’t need to go to the ED Crisis Unit, but begged me to prescribe the clonazepam that her psychiatrist had discontinued. With considerable misgivings, I found a way to see her for an extended appointment later that week.