A Country Doctor Writes:

“It appears to me a most excellent thing for the physician to cultivate Prognosis: for by foreseeing and foretelling … the present, the past and the future, he will be more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician.”

Hippocrates: “The Book of Prognostics”, 400 B.C.

This time of year, many of my patients make public announcements, at least to me, of their intentions to quit smoking, eat less of certain kinds of food, exercise more and so on. In many cases, this year’s New Year’s resolutions are the same as last year’s.

Physicians sometimes also walk around making promises that are more optimistic than realistic. Sometimes we do it as a way to invoke the placebo effect, for example when we prescribe a new antidepressant for someone who has “failed” on several others. Other times we do it because neither the patient nor the doctor is ready to admit that the disease seems to have the upper hand.

We need to be careful with our promises. Those of us who treat children know that “This won’t hurt a bit” makes for unhappy and mistrusting patients for years to come. Honest predictions like “This will hurt for just a couple of seconds, and then you won’t feel any pain at all” makes young patients more trusting and courageous the next time.

Promising recovery in a case that proves fatal is a far more serious error than to be proven wrong when predicting a patient’s death from their disease. Still, many doctors make vague promises in the name of hope and encouragement.

Little Amy Ruggles’ family doctor and consultant pediatrician more or less promised she would catch up in her development when she, in fact, had Rett syndrome (“Amy Laughs with The Angels”).

William Sykes’ pulmonologist predicted his alpha-1-antitrypsin deficiency would claim his life within 18 months (“Adverse Effects”), but Bill lived another ten years, haunted by his carelessly delivered death sentence.

One physician I know has made an art form of preparing his patients and their families for the worst possible outcome. Andy Spoerri is a brilliant infectious disease specialist, who was one of my teachers in residency. Every time he admitted or consulted on a patient with pneumonia, he called a meeting with the family. In his animated style of speaking as if time was running out, he would explain the mortality rate of pneumonia. Even in the most routine case, Andy would explain that the patient had a one-in-ten chance of dying from their condition. When the patient recovered without complications, the family would praise Andy as a genius and a lifesaver.

I have never been totally comfortable with Andy’s approach. I sometimes struggle with finding the right level of caution, of under-promise and over-delivery, without making the situation seem more serious than it is.

As physicians, we need to be aware of the power of our words in giving hope and encouragement. We need to be judicious and never promise what we cannot deliver or predict what we cannot know. We need to cultivate the skills of clinical observation and prognostication in the tradition of the old masters. And we need to be humble.

Hippocrates also wrote:

“Medicine is of all the Arts the most noble; but, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgement of them, it is at present far behind all the other arts.”

Those words were penned over 2,000 years ago, and the body of medical knowledge has grown exponentially since then. Are we perhaps so focused on keeping up with new technical information, statistical averages and Kaplan-Meier curves that we sometimes forget the tremendous variability among individual patients? Are we sometimes neglecting the value of our own experiences as clinicians when trying to deliver a prognosis?

(An earlier version of this post was published in January 2011)

Doctors tend to speed read. We are often in a hurry to extract the salient points from the large amount of information we receive every day in the form of journal articles, discharge summaries, imaging and consultation reports – and we often bring the same trait to our verbal history taking in the office or at the bedside.

In the past, before Electronic Medical Records, people argued over how many seconds the average doctor listened before interrupting the patient, but the point was clear – we often prefer to receive information on our terms, when we want it and in the order we want it. In part this is because we often imagine that this is faster than letting the patient speak uninterrupted. In part it is because it helps our pattern recognition, which can be a useful way of making a diagnosis but it may also be a counterproductive way of pigeonholing our patients without trying to see the uniqueness of their condition.

Osler said, “Listen to your patient, he is telling you the diagnosis”. But there is more to listening than making a diagnosis. All communication requires listening. Physicians today are not asked to diagnose patients as often as Osler’s contemporaries were. Our patients come to us looking for relief from anxiety, insomnia, overweight or depression. They sometimes ask our help in obtaining disability benefits instead of diagnosis and treatment. Those situations are not at all like making a diagnosis of myxedema or an infectious disease. In those situations we need to understand what motivates our patients.

The concept of Narrative Medicine has been around for a dozen years. It is not only the patient with a psychological or psychiatric complaint who needs to tell the story that goes with the symptoms. Many patients cannot reduce their experience of any illness to clear-cut, easily catalogued clinical factoids.

In the days of dictated office notes, many of us put the patient’s chart somewhere within reach but then gave all our attention to the patient. We would use eye contact and body language to encourage continued communication and we would listen for the untold parts of the story that unfolded. Not until after the visit was over and the patient gone from the clinic would we reach for the microphone or digital recorder and create our office note, which would summarize both the clinical details and the narrative.

Today, with real-time documentation into medical records built around structured data entry, doctors who used to sit back and listen are leaning over keyboards and mouse pads. Instead of savoring and contemplating their patient’s unique words, doctors are now choosing between adjectives in drop-down menus, as in a reverse paint-by-numbers process.

With fewer nuances and less detail in the digital narrative, there is greater risk that we may never understand what a symptom or disease means to a patient: Hermeneutics, mostly thought of in the context of Bible interpretation or philosophy, is an emerging area of exploration in medicine, just when our electronic clinical notes are starting to look more and more similar from one patient to the next. At the same time the revolution of modern genetics is creating the potential for what some call Precision Medicine, referenced in a recent issue of The New England Journal of Medicine. This is the science that lets doctors know in advance which patient will respond to what treatment. It has even been suggested that one could pick antidepressant medications based on biochemical testing.

It is ironic that the medicine of the future promises to be exquisitely personalized in the biochemical sense, but more and more depersonalized from a humanistic, hermeneutic point of view:

Picking antidepressants based on genetics – instead of listening to the patient? Maybe if we listen more, we might prescribe less.

Hitting machine with hammer:         1.00

Knowing where to hit machine:    999.00

Total:                                      1,000.00

There are many versions of the story with this punch line. One is about a plumber, another about Thomas Edison and a third is said to be translated from Arabic. There are even claims that it is an old Norwegian anecdote.

My subject is not physician fees or salaries, but physician skill and experience. Just like painting or gourmet cooking, the practice of medicine can seem deceptively easy to the observer, but it can seldom be done well the first time.

Few people would question the value of experience in the surgical specialties, but medication prescribing isn’t always viewed as an equally complex medical service.

In medical school we memorize which drugs are preferred for which conditions, but our training gives us limited practical experience with these medications. That experience comes with use and over time.

A medical school professor of mine said: “Choose a few drugs from a class, get familiar with them, and stick with them. Add new ones only if they offer a clear advantage over the ones you know.” Today, there are often more similar members of many drug classes than most physicians can become thoroughly familiar with. An unfamiliar drug, even if it has a theoretical advantage, can be harmful to the patient if it is less than expertly prescribed.

When I worked in Sweden, we wrote “In Manu Medici” on prescriptions for medications actually administered by the physician. The words mean “In the physician’s hand”. Strictly speaking, though, I think even medications administered by the patient, including most pills and topicals, are used in the physician’ hand, since the same medication can have widely different results depending on how it is dosed, when and how it is administered and how it is suggested and explained to the patient.

I have reflected before on the art of dosing antidepressants and on giving injections. Choosing the right medication in the first place is often complicated and not easily done without experience.

Probably the two most “artful” areas of prescribing I get involved with are heart failure and depression. The placebo effect in depression treatment is almost as big as the proven benefit of antidepressants, and each member of the antidepressant class seems to have a different set of effects and side effects: Fluoxetine is energizing but often not tolerated by very anxious patients, paroxetine can be mind-numbing and may insulate patients from even appropriate degrees of emotional pain, sertraline is quieting but can break down the defenses of tenderhearted, gentle men, and citalopram turned out to have more side effects even though it was marketed as better tolerated. Bupropione is sometimes particularly helpful in depressed patients with anger issues, and duloxetine brings out aggression in those who harbor potential for it.

I once heard of an overworked psychiatrist who told a primary care provider that a consultation wasn’t necessary because both clinicians had the same number of medications to consider for the patient. That reminds me of an amateur Iron Chef contest I saw, where one contestant couldn’t get the skin off a salmon. Having something at your disposal doesn’t guarantee you can do the right thing with it.

Recently a colleague switched a patient with Parkinson’s disease from pramipexole to ropinirole because the patient’s new insurance wouldn’t cover the first drug. Within a week, the patient became psychotic. After stopping ropinirole, the patient recovered. It was then easy to get a Prior Authorization from the insurance company for pramipexole, which in practice has fewer side effects than ropinirole. Reading the official drug information, you would never know one drug was a little safer than the other, yet this type of substitution is now becoming automatic in many hospitals and nursing homes, and may soon take effect also at the pharmacy. In our Parkinson-patient the doctor was the one who switched drugs because of the insurance – what would have happened if the pharmacist had made the switch? When would the doctor have found out about the substitution? Before or after the patient became psychotic?

“In Manu Medici” is not how today’s health care system views prescribing. When insurance companies and pharmacists want a say in the choice and dosing of medications, the artfulness of the physician may have to be partly utilized to navigate the system and to minimize the damage caused by outside influences on the therapeutic relationship and the treatment plan.

Our clinic has an advanced computer scheduling system. It gives overviews of available appointments, makes statistical reports and shows several providers’ schedules in one view. But it can’t even begin to compare with Doreen and her paper and pencil system.

Doreen was our master scheduler more than ten years ago. She moved on to become the office manager in a specialist’s office, but then got tired of modern medicine and opened a country store.

Without any formal medical training, Doreen instinctively knew who needed to be squeezed into their provider’s schedule urgently and who could wait, and how long each type of visit would take for each of our differently tempered medical providers. At the same time she was able to keep track of the future appointments each patient had without the benefit of a computer.

Doreen knew our patients well enough to know who needed an extra long appointment no matter what ailed them. She also knew which patients were straightforward enough to be squeezed in for acute illnesses. She knew that “double books” really weren’t physically possible as no doctor is good enough or fast enough to be in two exam rooms with two different patients at the same time. She was able to look at her paper and pencil schedule and see that Mrs. Smith’s blood pressure check on Tuesday morning was just a quick visit to check her blood pressure, review her potassium level and write one or two prescriptions whereas Mrs. Brown’s blood pressure visit Tuesday afternoon was likely to be an outdrawn affair because of her husband’s dementia and her daughter’s recent breast cancer diagnosis. A child with an earache could have five minutes of Mrs. Smith’s 15 minutes, but nobody could be squeezed into Mrs. Brown’s timeslot.

With the precision of an air traffic controller, Doreen would schedule the straightforward Mrs. Smith’s blood pressure visit for 10:00, little Danny Swan’s earache for 10:10 and the next regular visit at 10:15. When Doreen scheduled, everything ran on time, just like a Swiss train.

She once told me: “If I can’t tell on the phone what sort of problem they’re having, not even you can figure it out and take care of it in a double booked 5-minute visit, but if they know what they need, I’ll squeeze them in”.

Doreen constantly scanned the wide lined double page spread of her appointment book and kept an eye out for potential office bottlenecks. She would make sure several providers weren’t doing pap smears at the same time, since too many nurses would then be tied up and not available for telephone triage. She watched out for room or equipment conflicts – two cryosurgeries at the same time and needing the same equipment never happened while Doreen was in charge. Our fancy computer schedule can be used to schedule the procedure room, but doesn’t spot for the little conflicts Doreen was always on the lookout for.

Doreen effortlessly and intuitively mixed fast and slow visits throughout the day, so that two patients with the potential for running over were never scheduled back to back. If a visit ran over a little, chances were good that the next visit would allow me to catch up. Thanks to her wisdom, I seldom felt rushed, even though I regularly saw record numbers of patients during her reign at the front desk.

No amount of color-coding or drop-down menus could match Doreen and her old-fashioned system. Her compassionate dedication and the simple flexibility of her paper and pencil appointment book kept our clinic humming.