The Dangers of Practicing Medicine Without Context

We once had a locum provider who spent a great deal of time reviewing each patient’s record before each visit. He would then enter the room and proceed to “clean up” medication and problem lists. Everything he did was done without eliciting the back story from the patient or the record. All he looked at was the data, never the narrative. Patients were often bewildered, saying “he changed my medicines without even talking to me”.

It may sound great to only act on the facts, but real medicine is a lot messier than that.

Sometimes we prescribe medications for more than one purpose: Amitriptyline may not be the theoretically best drug for neuropathy, but if the patient also has trouble sleeping and a history of migraines, it could solve three problems at once.

And propranolol could be used for migraines, tremors, palpitations and stage fright. It may not be the best beta blocker for the average 70 kg male, but there aren’t many of those around.

A high potassium could be a life threatening emergency or a simple case of hemolysis. Without seeing previous values, a provider could easily overreact.

Or, in the case of the previously stable warfarin patient I recently described, her critical INR seemed out of the blue and there was no vitamin K to be had, so I did nothing except hold the blood thinner. The next value was 1.0 and the home health nurse confessed that her device wasn’t calibrated properly.

Again and again I find that asking why before reacting has saved me and my patient all kinds of trouble, even though it takes time. But it is time well spent.

To quote myself (2014):

Context is crucial when deciding what to do with abnormal test results. But doctors are often pressed for time, and finding the story behind the results takes time. Even when all the data is in our electronic medical records, it takes time to see the patterns: The test results are usually in one place, the prescriptions in another, the office notes in a third, and the phone messages in a fourth. My own EMR (up north) can produce flowsheets with lab results, but each test is identified by the date it was ordered instead of the date it was performed, so correlating lab values with prescription dates becomes confusing, for example when following thyroid cases.

In times past, when solo practice physicians cared for their patients in the office, hospital and nursing home, they kept the threads of context and continuity together more easily. Today, with more providers sharing the care, and with other office staff also interacting with patients and their families, there is more room for errors, gaps and confusion. The tools we have right now are not always as effective as we would like, and they certainly can be cumbersome and slow to use. Reading each other’s notes can take a while, as the EMR format is primarily built for coding and not for ease of following the clinical “story”.

A few words doctor to doctor, doctor to nurse or doctor to patient can sometimes do what half an hour on the computer might not. Treatment without context is essentially just random reflex actions: Killing the innocent bacteria, lowering the falsely elevated potassium, treating the lab value and not the patient – none of it does anybody any good, and probably will cause harm to some unfortunate patients.

Our temptation to view test results as obvious facts in a predictable process instead of possibly misleading clues in a complex mystery reminds me of these words from a Sherlock Holmes novel:

There is nothing more deceptive than an obvious fact.”

5 Responses to “The Dangers of Practicing Medicine Without Context”

  1. 1 Liz Champeon February 7, 2019 at 10:02 am

    As a practicing geologist, I often ran into reports of “pollution” where only the downstream values were measured and recorded. Since groundwater is not “pure or distilled”, but reflects rainfall, snowmelt and soil environment, measurement of upstream values is essential. Shortly after the Mt. St. Helen’s eruption, a sudden decrease in pH was recorded at two Maine landfills. Volcanic ash can be very acidic. These values were observed both in the groundwater ENTERING and leaving the sites. After some time, the values returned to what had been normal for the sites. Just a related science observation…

  2. 2 Ralph Allen February 7, 2019 at 3:45 pm

    Thanks for helping understanding! Excellent advice and timely for those of us in the long-term care side. I am an administrator who can speak more convincingly to residents and families now. Ralph Allen Nine Mile Falls, Washington

    Sent from my iPhone


  3. 3 Nancy Merle February 16, 2019 at 11:57 pm

    Today’s day way too frequent the patients are relegated to the latest position and the pre-fabricated patient care will be at the beginning and at the end of the “patient visit”. The “airplane visits” look good for the administrator because is quick and fall well in the “assembly” lines that produce more revenues.
    Family practitioners in the most part put patients first, but are in the risk of the New Era.

  4. 4 Paul Dunn February 17, 2019 at 1:56 pm

    This story is so true. After 35 years in practice, I see younger providers change medications to be “efficient and cost-conscious only to confuse the situation and challenge the trust I have spend so long to build with my patients. That’s certainly not to say that I could always use a good consult but consultation takes time, doesn’t it. Unfortunately, time is the enemy of schedules and money. I have so much respect for primary care colleagues and the complexities of their jobs. If you read this PLEASE take a few moments of your precious time to consult with the patient’s caregiver before you make changes to the plan.

  5. 5 Grace Ogas Todd February 18, 2019 at 4:29 pm

    Yes yes yes I have found from my good old country mentors- you treat the Patient and not the access code or medications- the listed medications can give you good clues but not a total picture- I listen to the patient and find 90% have a good grasp on their condition. After all they Live in that body and if they can describe the context of when something started and what they were doing – you can get a Good picture of what is going on and how to use your detective skills. They may be taking that medication for a good reason- or not- if they complain of the side effects the medication can be changed and maybe find one medication that does the work of two? I enjoy treating my patients- in family medicine 9 years after 25? Years of hospital and home health nursing

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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