Medicine is Not Like Math

We do a lot of things in our head in this business. Once a patient reports a symptom, we mentally run down lists of related followup questions, possible diagnoses, similar cases we have seen. All this happens faster than we could ever describe in words (let alone type).

And, just like in math class, we are constantly reminded that it doesn’t matter if we have the right answer if we can’t describe how we got there.

So the ninth doctor who observes a little girl with deteriorating neurologic functioning and after less than ten minutes says “your child has Rett Syndrome” could theoretically get paid less than the previous eight doctors whose explorations meandered for over an hour before they admitted they didn’t know what was going on.

Does anybody care how Mozart or Beethoven created their music? Or do we mostly care about how it makes us feel when we listen to it?

We know that stress, meditation and Thai Chi can alter metabolism, immune response and neurotransmission. But do we endorse them based on how many minutes, elements, movements or postures they involve over what their results are?

Of course not!

We also know that physician demeanor can affect treatment efficacy a whole lot more than the number of minutes spent or boxes checked in the EMR. So why are we so fixated with proving the monetary value of our process, instead of the value of our results?

Medicine, at least in the non-procedural specialties, is a relationship based business. If a hostile stranger spends fifteen minutes trying to change your behavior, is that more effective or more valuable than if a trusted doctor, friend or admired mentor mentions the same thing almost in passing?

Of course not!

So why is medicine viewed as an easily quantifiable and standardized endeavor? The manufacturing analogy is outdated; we are more like old-house renovators or art restorers most days, and, on perhaps rare but inspiring and memorable occasions, like composers. We sometimes find ourselves creating something new in the lives we touch and interact with. In those instances we should take little credit for anything except how we were able to awaken the healing potential within our patient.

Health care professes to value outcomes, but we are a long way from doing that. We are stuck in a thick soup of surrogate endpoints and ignorant overemphasis on standardized processes in an era where we are only beginning to understand how genetically different we all are.

Or, are we really suggesting our patients are all 70 kg white males with only one, typical and standardized, medical problem?

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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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