January 29, 2014 | 1
Even as I write this, my iPhone tells me by sound and motion I have a new message. Given my e-mail preferences chances are it is some information about a new “best practice” or “evidence-based” treatment guideline. And that’s marvelous.
But with all the instantaneous, up-to-the-minute communication these days there is a tendency, and risk, of failing to balance the urgent with the important in our practices and scientific professional lives. And much of the “important,” I would suggest, lies in the wisdom passed down through the ages from practitioners of old who have provided us with important, basic tenets, like: “to cure sometimes, to help often, to comfort always,” attributed by most to Hippocrates centuries ago. I submit that such advice should guide our dealings with patients, whatever our role in the scientific community in this present century.
Perhaps I am getting old and crotchety, but I prefer being called a physician rather than a “provider.” Provider has a sterile, commercial connotation to it with little “comfort” included for difficult cases where we can’t cure. And while the electronic medical record holds promise of providing me instant medical information on a patient, frankly, I prefer looking at the patient rather than my handheld screen, and prefer conversing with the patient instead of making sure I am entering information properly on a keyboard. There is so much one can gain from facial expression and eye contact by careful observation. I don’t think the electronic medical record makes up for that loss.
But then, I guess all of us are looking at our iPhone and iPad screens much more these days than at each other, even at the dinner table whether at home or at a very nice restaurant.
Maybe it is heresy, but I find that “best practice” doesn’t necessarily fit each patient on an individual, personalized basis. And “evidence-based” protocols, which were supposed to be guidelines only, have become entrenched practice rules especially liked by insurance carriers and government coders. I don’t mind being advised on what seems to work best for many patients, and I don’t mind being provided evidence from double-blind and large-scale collaborative studies regarding treatment efficacy. But I’ve seen enough patients to know that all treatment “guidelines” need to be adapted to each and every patient individually, and unyielding “cookbooks” simply don’t fit each patient. Perhaps that’s why I have always enjoyed as much the art of practicing medicine as the science of it.
Looking back in time, and even at present, some of the most gigantic gains in diagnosis and treatment have some from “anecdotal,” or even accidental findings, like the discovery of antibiotics and antidepressants. Some of the most accurate, classic descriptions of certain disorders were made by clinicians so observant, so tuned in and so able to verbally describe the condition. Dr. Leo Kanner’s description of Early Infantile Autism in 1944, for example, has never been improved upon but it is hard to find even remnants of that in DSM-V. In fairness, if you read the preamble to DSM-V you will find it is meant to be used only as a consensus, guideline document. But in the coding and insurance industry, in litigation and even in the media DSM-V, in my field, is treated as if it were a legal statute-book or a peek at the holy grail.
I am not complaining about where medicine is these days in terms of progress and cutting edge. Even though physicians of my vintage often refer longingly to the bygone ‘golden years’ of practice without insurance, government and litigious interference, those years lacked many of today’s remarkable advances. There were no heart transplants, neonatal intensive care units, certain new life-saving drugs and procedures. So I appreciate some advice on “best practice” and like to review “evidence-based” material for treatment as helpful information if left at that.
All I am suggesting is first, that “best practice” and “evidence based” data remain guidelines, rather than having the power of a “rule” so that I can continue to individualize the diagnosis and treatment to fit the patient, rather than requiring the patient to fit the rule. Second, I suggest that physicians spend as much time looking at the patient as they do looking at the screen or keyboard of their handheld device. And third, I suggest that while I still answer my iPhone and read my e-mails, which do provide valuable up to-the-minute information for my particular role or specialty, I should also find some time to look back and reflect on some of the advice and pearls of wisdom about my practice that have endured through the years. That sage advice risks getting buried in this avalanche of information age.