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The Parallel Realities of Health Care: Ratio and Intellectus

Every patient is unique, with some common basic and measurable features and parameters. For a couple of decades now, healthcare has professed to be patient centered. But the prevailing culture of “quality” (and the reality of getting paid for what you do) has us spending at least half our time documenting for outsiders, who are non-clinicians, the substance and value of our patient interactions. That means our patients get half of our attention and others get half.

But of course, if you really wanted to be patient centered, you’d have to ask what patients actually care about, like their blood pressure or their cholesterol, their anxiety or their sore knees. Their answers may not align with the payers’ priorities. And then what…

Parents raise their children and never have to file any reports on how they do it. I believe clergy can still counsel their parishioners without filing reports. But doctors, nurses, nurses aides and physical therapists are trapped in the tyrannical dichotomy of “If you didn’t document it, it didn’t happen”, which actually forces us to do less for our patients just so we will have time to document what we did do. We are, to varying degree, robotniks in a big, inhumane corporate and federal healthcare billing machine these days.

Perhaps the most striking example of the micromanaging and patient-uncentered mandates we are subjected to is the Medicare Annual Wellness Visit: Miss one thing, like offering HIV screening to 80 year old devout French speaking, monogamous Catholics in Van Buren, Maine and risk getting your payment retracted. But we are not mandated to ask about personal life goals or how to balance seniors’ independence with reliance on their children.

Which is more real? The work we do, face to face or even screen to screen, behind closed doors with our patients, or the EMR documentation we produce as a result of those encounters? I know many providers generate voluminous notes that don’t reflect in any way what happened in the visit. That is where the money is.

Right now I am reading a Swedish book by philosopher Jonna Bornemark, titled (my translation) RENAISSANCE OF THE UNMEASURABLE – battling the pedants’ world domination. Much of it is about how the professions of caring for others have been reduced to protocols and reporting systems that make it harder to do what we were trained and developed a passion for. It talks about how checklists and workflows devalue and discourage the powerful creativity that arises when professionals interact with their unique clients and with each other. She anchors all this in the writings of philosophers Cusanus, Bruno and Descartes. It talks about the unknowable, which is something pedants usually don’t want to think about.

Basically, according to Cusanus, there are two models of knowledge, Ratio and Intellectus. Ratio is the possession of measurable and definable information, which basically fits with generalizations we humans make. Beyond that is what is not known. Our modern way of thinking is perhaps that this is simply what we don’t know yet, but eventually can learn or understand. Intellectus is a form of curiosity that scans the horizon of the known or knowable. It asks “what is” and can thereby sometimes make classification and counting possible, but far from always.

People who have Ratio but completely lack Intellectus, Bornemark describes as pedants.

Pedant is a common word in the Swedish language, but not so common here. It means someone with superficial knowledge, focused on perfection of form rather than substance. Words like stickler, nitpicking and OCD reverberate with the notion of the pedant. The Intellectus archetype is what professionals have always strived to emulate.

(Bornemark has a few books available in English that I know of. She is the editor of one with a title that really intrigued me, EQUINE CULTURES IN TRANSITION – Ethical Questions.)

Henrik Sjövall, professor emeritus at Gothenburg’s department of molecular and clinical medicine (that sounds like the title of a man who knows both Ratio and Intellectus) writes:

Bornemark’s discussion of Cusanus’s concept of Intellectus centers on the distinction between the unknown and that which is not yet known. She notes that Ratio accepts only the latter, because according to Ratio, everything can be measured and weighed provided you have sufficiently good methods, which in principle can replace the “flummery” of Intellectus. Intellectus responds with the circle metaphor: a polygon will never be the same as a circle. Oh yes, it can be, provided there are enough of sectors, Ratio responds… Then tell me what a patient’s narrative weighs, says Intellectus. It simply consists of the answer to a lot of yes and no questions, Ratio retorts, and it is dead easy to measure.

He continues:

Bornemark writes that Ratio has, in principle, already won that battle and Intellectus is in retreat, as most people consider him difficult. A manifestation of this is all these algorithms and patient care plans with checklists that inundate us. Triaging in the emergency room is part of the same way of thinking, a rough sorting based on the outcome of a number of objectively measured vital parameters. The next step in that chain is, of course, the introduction of artificial intelligence as interrogator and information sorter, and maybe eventually as a decision-maker without the patient having to meet a doctor at all…

It would be cheap and good, right?

What are the counterforces to this development? I am active in the Swedish Association for Narrative Medicine (anyone interested is welcome to join), an association that wants to focus on something that cannot be measured and weighed, namely the patient’s story. We are making an effort to stop or ideally reverse this development. In other words, to train Intellectus doctors.

I read in the Wall Street Journal about a forthcoming book about living with autism – not being able to fully understand the nuances of facial expressions and intonation, for example. It seems to me that those things are exactly what good clinicians excel in. Such things make them Intellectus practitioners and elevate their work to a level beyond Ratio, the territory some hope will ultimately be the domain of Artificial Intelligence. I, for one, don’t think AI will ever move beyond Intelligence to Intellectus.

The Art of Diagnosis: Teasing Out the Timeline

When we take a medical history, there is a modern tendency to concentrate on simply listing symptoms. This is evident in many EMR notes, since the number of items in a medical history or review of systems for many years has driven reimbursement.

This, and clinician compulsion to quickly get to the diagnosis in a time pressured visit, has kept us from letting the patient tell their story.

The order in which symptoms appeared is an important part of solving a diagnostic dilemma.

A simple example is the mysterious rash I read a case description of a while ago. Someone had an itch that turned into a severe rash on one leg and later developed a similar rash on the other leg. The timeline (if I remember correctly) revealed that a harmless itch was first treated with a cortisone cream to no avail and later treated with topical neosporin. This worsened the itch and caused a local allergic reaction. Rubbing one leg against the other during sleep exposed the other leg to neosporin, which the patient was by now allergic to. This case made it all the way to the medical journals. A simple question, like “tell me what happened, from beginning to end” would have solved this case very quickly.

When a patient is on multiple medications and has a new symptom that could be a side effect or interaction, the timelines of symptoms and treatments can sort things out. In my experience, patients aren’t usually able to recall which drug was started exactly when. Modern EMRs don’t display a graphic medication timeline the way our old paper charts used to. For this reason it takes more work than our patients would expect to correlate medication stops and starts with symptoms.

My 2011 post, A Deadly Interaction, illustrates how the stopping and starting of statin drugs can severely affect INRs in patients on warfarin, sometimes to the point of causing death. In the case I saw, the patient fared better, but it took the timeline to understand what had happened.

Speaking of statin drugs, I’ve lost count of the many times patients ignore their own timeline. People will say, “I think the medicine is causing my legs to hurt”. I then often get a positive answer when I ask, “did they hurt before you started the medicine?”

A dry cough from lisinopril and other ACE inhibitors is another case where I try to tease out the timeline. But if a patient with a preexisting cough still blames the medicine, I don’t argue the point; I just move on.

Twice so far this year I have seen a diabetic suddenly present with dramatically increased blood sugars. In both cases they had decided to eat healthier on the advice of helpful relatives and increased their fruit consumption. These patients had been diabetics for a long time, and somehow had forgotten that if something tastes sweet, it probably raises your blood sugar.

The detailed timeline is time-tested tool in making a correct diagnosis, just like the broad view of asking “what else is going on”.

A Dozen Years of Writing About Doctoring

On April 28, 2008 I hit the “Publish” button for the first time on “A Country Doctor Writes”. That post, “Cholesterol Guidelines and the Bachelor With Platform Shoes” is featured in the sidebar (or below, reading on a smartphone).

In the twelve years since then I have hit the Publish button 654 more times. Thinking back over all those words and the years that have passed, I especially value my clinical vignettes and glimpses into other people’s way of dealing with their illnesses and circumstances. I also notice how much I have written about what it means to be a physician and how I have evolved in my profession over the last 40 years (41 this summer).

As medicine has changed, I have also seen physicians change. I have seen distractions from our old focus of patients and their diseases multiply, and I have seen more and more burnout and disillusionment around me.

I have worked on my own feelings and attitudes because of the distractions in my own life. I love medicine and I have felt that this was my purpose in life since I was a very young child. When I don’t take time to reconnect with this sense of purpose I can feel my mental focus dragging my emotions away from the profound joy and satisfaction doctoring usually brings me.

For my twelve year anniversary, I decided to gather a sampling of pieces that illustrate the many aspects of doctoring I keep thinking about: The Fixer, The Hippocratic Apostle and The Guide through Life and Death.

Rather than reposting the pieces in their entirety, I decided to include a good size quote and a link to the original post, hoping this will give the essence of my observations without having to read too many words, for those with other things to spend their time on.

(Each title is a link to the original post)

Doctor Fix-It (2008)

Today I visited Ginny Leach. She lives by herself in an old trailer not far from our house. She is an ageless more or less shut-in woman.

A mild chaos erupted the moment I walked through Ginny’s front door. She was on the phone with her sister; I think they must call each other at least three times a day. Her only other contact seems to be the nuns from a nearby order; they help her out with chores and hand-me-downs. As I walked through the door, Ginny gestured to me, stretched the phone cord, and somehow her Slimline telephone fell to the floor and went dead on her. Ginny worried that her sister would assume something bad had happened.

Before I knew it, I was on my knees on the floor, examining the jack and the telephone…

The Apostolic Nature of Our Profession (2009)

I twice had a priest for a patient and I have been the personal physician of a handful of protestant ministers of various denominations. In each of these doctor-patient relationships I have found myself entering a ministerial role vis-à-vis my pastoral patient.

I have had reason to temper the hypochondriachal tendencies of one man of the cloth, and I have cautioned another that taking care of one’s body is a form of stewardship, and as such, just as important as taking care of one’s spiritual health. I have urged a minister to quit smoking and a priest to temper his sweet tooth.

Each time I have done one of those things I have been reminded of the apostolic nature of both our professions. People come to each of us, clergy or physician, with hearts and minds that are at least to some degree more open to hear what we have to say because of the office we hold, the cloaks we wear, that make our words somehow carry more weight than those of friends, relatives or family members.

Thank You, Father (2009)

I checked his heart and lungs without finding anything unusual, and then Mrs. McCann proceeded to expertly change his dressings, so I could inspect his diabetic ulcers.

“They’re coming along great”, I said, and added, “You are doing a superb job”.

“I do my best”, she answered, beaming.

I wrote some new prescriptions and we agreed on the timing of my next house call. She followed me to the door.

“Thank you, Father”, she said, and then quickly corrected herself.

“I mean, thank you, Doctor. Father Harris was here yesterday to see him.”

It struck me that Father Harris and I had come on similar errands, giving our blessing to the care and commitment we see in that house, neither one of us delivering much more than reassurance that the McCanns are doing their part and whatever happens next is in God’s hands.

The Counterintuitive Concept of Burnout Skills (2011)

“Burnout skills are the actions at which you excel, that people identify as your strong points but which drain you of motivation. They are unable to energise you and therefore deplete you without refueling you.” (Clair Burge)

The other night I suddenly realized I have always had the wrong perspective on how burnout occurs. It doesn’t happen to us, we bring it on ourselves.

One of our [reading] choices the other night was provocatively titled “Not Every Skill Is Profitable”. The subtitle was even more provocative: “In fact, some will just burn you out.” The writer referred to a South African blogger and businesswoman, Claire Burge, whose words in one instant changed my understanding of burnout:

“Burnout skills are the actions at which you excel, that people identify as your strong points but which drain you of motivation. They are unable to energise you and therefore deplete you without refueling you.”

I realize now that my strength as a tenacious problem-solver can be a burnout skill if I choose to take on problems that are ultimately unsolvable or go beyond my scope or authority as an employed primary care physician. When I can’t fix such problems, I feel frustrated and drained. My strengths as a diagnostician, communicator and motivator are my energizing skills. I need to use and cultivate them more in order not to risk burnout in my career.

A Samurai Physician’s Teachings (2013)

The images of a samurai – a self-disciplined warrior, somehow both noble master and devoted servant – juxtaposed with the idea of “physician” were a novel constellation to me. I can’t say I was able to predict exactly what the book contained, but I had an idea, and found the book in many ways inspiring.

Ekiken’s own words, in 1714, really describe Disease Prevention the way we now see it:

“The first principle of the Way of Nurturing Life is avoiding overexposure to things that can damage your body. These can be divided into two categories: inner desires and negative external influences.

Inner desires encompass the desires for food, drink, sex, sleep, and excessive talking as well as the desires of the seven emotions – joy, anger, anxiety, yearning, sorrow, fear and astonishment. (I see in this a reference to archetypal or somatic medicine.)

The negative external influences comprise the four dispositions of Nature: wind, cold, heat and humidity.

If you restrain the inner desires, they will diminish.

If you are aware of the negative external influences and their effects, you can keep them at bay.

Following both of these rules of thumb, you will avoid damaging your health, be free from disease, and be able to maintain and even increase your natural life span.”

On the topic of Restraint, the Yellow Emperor text states:

In the remote past, those who understood the Way followed the patterns of yin and yang, harmonized these with nurturing practices, put limits on their eating and drinking, and did not recklessly overexert themselves. Thus, body and spirit interacted well, they lived out their naturally given years, and only left this world after a hundred years or more.

During the Ming dynasty, a prominent physician wrote:

“Premature death due to the hundred diseases is mostly connected to eating and drinking.” 

That quote still carries relevance today.

Something Extra (2016)

The pressures of time, the complexity of our patients’ needs and today’s documentation requirements can easily make a medical provider feel less than generous these days. We must counteract that in order to carry on as healers.

All day long, I am conscious of the time as I work my way through my long list of fifteen minute encounters. But I am also conscious of the fact that the more pressure I feel, the less empathic I can become, and the less effective I am in building and maintaining the relationships that lie at the root of my ability to care for my patients.

It is only because of those relationships that I am in any way able to tell a fellow human being what to do; it is that relationship that allows me to reassure someone in just a few words with only my demeanor and the tone in my voice.

I can only cover so many issues and help solve so many problems in fifteen minutes, and I have long been aware that some of those minutes need to be time spent nurturing the relationship that allows me to be my patient’s doctor, not just any doctor.

Be the Guide, Not the Hero (2018)

The dominating narratives present a flawed, insecure hero, who faces challenges while also reaching a higher level of insight, and he or she is supported by a guide who is older or wiser (Obi-Wan Kenobi or Yoda) but in no way competing with the fledging hero. These characters have been there, done that, and have nothing to prove. They are portrayed in ways that indicate they are supremely competent and yet almost self effacing. It is not their turn to shine.

That is a useful way for doctors to think of themselves. We must support our patients in their own pursuit of health and happiness. They must find out or choose for themselves. We can not make them do things that they don’t see or feel by themselves. And we have no right to expect that they will always follow our advice.

Our quality metrics can make us feel as if we are the main characters, or heroes in the story analogy, in our interactions with our patients. The results of our efforts can make us feel as if we are experiencing success or failure. This in turn can create job stress and burnout.

By adopting and staying in the role of Guide, physicians can preserve their stamina and enthusiasm for each and every patient encounter. We offer guidance, but every hero is free to choose whether or not to accept our words of wisdom.

Curiosity, Antidote to Burnout (2019)

I read an article on the BBC website that made me think again of my patient’s observation and how it fired up my curiosity. Titled “The secrets of the ‘high-potential’ personality”, it described curiosity as an antidote to burnout and one of several predictors of professional success that the authors claim to be better predictors than the Myers-Briggs Personality Types.

“Compared to our other mental traits, curiosity has been somewhat neglected by psychologists. Yet recent research shows that an inherent interest in new ideas brings many advantages to the workplace: it may mean that you are more creative and flexible in the procedures you use, help you to learn more easily, increases your overall job satisfaction and protects you from burnout.”

At the beginning of my day, my mind had been wandering back to New Year’s Eves away from the office, trudging through the snow in the Swedish countryside or dancing at Chateau Frontenac in Quebec.

As my workday ended, I wished my Suboxone group Happy New Year and thought about the literature search I wanted to do on my day off.

May I never lose my curiosity…

The Stages of a Man’s Life (2019)

Jungian psychologist Robert A. Johnson explains the difference between mood and feeling. Feeling is the ability to value and mood is being overtaken or possessed by a man’s inner feminine.

I am still working on reining in my tendency for moodiness on some levels, and I am working on letting go of my Americanized idea of “the pursuit of happiness”.

Johnson, as many other thinkers says that happiness is, linguistically and philosophically, living in the present, with “what happens”.

He references Alexis de Tocqueville:

“One cannot pursue happiness; if he does he obscures it. If he will proceed with the human task of life, the relocation of the center of gravity of the personality to something greater outside itself, happiness will be the outcome.”

Here I am, unpacking boxes, mending fences, cleaning stalls, reorganizing closets and cupboards; life is happening in a humble red farmhouse with peeling paint and a sagging front porch. It feels a lot like moving out to camp every summer when I was a young boy, before I started to think I had to be a knight and a dragon slayer…

To quote James Taylor, not for the first time:

“The secret of life is enjoying the passage of time. Any fool can do it. There ain’t nothing to it.”

A Country Doctor Reads: Job Crafting for Character – Harvard Business Review

Every once in a while something in the business literature catches my attention. Last week I found an article in the Harvard Business Review daily newsletter about Job Crafting. I had never heard the term, and I had not paid any attention to the possibility that how we view and approach our career can affect our personality and our morality instead of the other way around.

Business professors Smith and Kouchaki write:

“As originally presented by scholars Amy Wrzesniewski (Yale University) and Jane Dutton (University of Michigan), people can craft their jobs by first altering the way they think about their work (cognitive crafting), second, changing the scope and type of tasks they engage in (task crafting) and, third, changing the nature of their relationships and interactions with others at work (relational crafting). To date, most scholars and practitioners have explored job crafting as a means to make work more meaningful and satisfying, and potentially increase individual performance. But we suggest that you can also engage in job crafting to become your best moral self.”

I don’t often see articles about morality and business, and not often about health care and morality either, for that matter. But last week’s reading gave me reason to think about how our work can elevate us to a higher plane if we view it the right way. We often think that we bring some of our own selves into our work, but we don’t talk nearly enough about how our work shapes us and how we make daily choices in exactly how and in what direction we allow that to happen.

“Whether you view your job as merely a paycheck, as a step up the career ladder, or even as a calling, we encourage you to also approach your job as an avenue for becoming a better person — as a laboratory for refining your character. Doing so will not only help you become virtuous, but it can help others as well. Psychology research on elevation (the moral emotion experienced upon witnessing the virtuous acts of others that leads to a desire to become a better person yourself) suggests that morality can be contagious. Crafting your job in a way that leads to exemplary behaviors might just result in a moral contagion that benefits others in your organization as well. Like a tiny pebble tossed into a vast pond, your simple job crafting efforts might ripple throughout your entire workplace. Try job crafting to make the world a better place — one life at a time, starting with your own.”

I guess we and the journals that cater to us need to claim some of our attention and reading time to consider not just drugs and diseases, patients and third parties but us, the healers, the physicians and other clinicians who are at constant risk of burning out if we don’t see the moral value in and resonate with the moral implications of how we do our work, of our behavior and of our attitudes.

More and More Pills for 25-30% Better Odds of This, That and The Other – Some Patients Want That, and Some Will Run the Other Way

I scribbled my signature on a pharmaceutical rep’s iPad today for some samples of Jardiance, a diabetes drug that now has expanded indications according to the Food and Drug Administration. This drug lowers blood sugar (reduces HbA1c by less than 1 point) but also reduces diabetes related kidney damage, heart attacks, strokes and now also admission rates for heart failure (from 4.1% to 2.7% if I remember correctly – a significant relative risk reduction but not a big absolute one; the Number Needed to Treat is about 70, so 69 out of 70 patients would take it in vain for the heart failure indication. The NNT for cardiovascular death is around 38 over a three year period – over a hundred patient years for one patient saved). There are already other diabetes drugs that can reduce cardiovascular risk and I see cardiologists prescribing them for non-diabetics.

It’s a bit of a head scratcher and it makes me think of the recently re-emerged interest in the notion of a “Polypill” with several ingredients that together reduce heat attack risk. The tested Polypill formulations are all very inexpensive, which is a big part of their attraction. Jardiance, on the other hand, costs about $400 per month.

The “rep” asked whether this medication would be something I’d be likely to discuss with my diabetic patients.

“Well, you know I’ve only got fifteen minutes…” dampened his expectations. But I told him about the Polypill studies. I think patients are still not ready to make the distinction between on the one hand medications that treat a more or less quantifiable problem like blood sugar levels, blood pressure or the much less straightforward lipid levels and on the other hand ones that only change statistical outcomes. Most of my patients have trouble wrapping their head around taking a $400 a month pill that doesn’t make them feel better or score a whole lot better on their lab test but only changes the odds of something most people think will never happen to them anyway.

I’m a simple minded person in some ways, I guess, but it helps me in my patient interactions to distinguish between what we know with decent certainty and what we think is a good probability and also between what tangible benefit a treatment can be expected to offer as opposed to just some statistical advantage that means nothing if you draw the shorter straw.

It almost makes sense to think of a two tiered approach to healthcare: some people truly want every statistical advantage and pharmaceutical intervention possible while others just want to treat what they can see or measure, and I think we have to figure out where each patient falls on the spectrum between those opposites, or we will overwhelm and lose patients and see them give up on everything we might have to offer.

Whichever approach patients take requires their commitment and determination and we need to listen carefully for clues about their beliefs and willingness to treat. There’s no point in prescribing anything in a half hearted way, because treatment adherence isn’t likely to be very good then. And doing a hard sell to a disinclined patient in fifteen minutes along with many other things we need to cover is a pipe dream and a guaranteed turnoff.

So, and this is a thought I’ve developed working with horses: Doctors shouldn’t be horse whisperers, nor should horse people. People have looked at this from the wrong vantage point. You don’t whisper to the horse so it will do what you want – you must first listen to the horse, and then, once you know how the horse feels about things, you can whisper your suggestion. And because the horse trusts you and knows you’d never suggest anything that is completely against its nature, the horse is likely to follow your low key, “whispered” suggestion better than a harsh command.

But listening comes before whispering, in horsemanship and in healthcare.

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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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