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Will the art of medicine be lost in the sea of guidelines?

| Physician | May 1, 2012

I don’t like doctors!

It was always the same with Ronald. After years of absence, he would appear at my doorstep with some particular problem that had progressed to alarming proportions. Once, it was the abscess that seemed to swallow up his whole back. The next time, it was a hernia that had grown to the size of a grapefruit hanging out of his undergarments. But today was different. In fact, when I asked what was wrong, he told me that he was feeling fine.

Doc, I had a funny dream last night. At least I think it was a dream.

The night before, Ronald woke up to a gentle nudging on his left arm. When his eyes opened, he almost fell to the floor. His teenage daughter, who died decades earlier, was standing above him. She called out to him like she had when she was alive.

Papa … Papa, you’re not breathing right. Go to the doctor.

***

Ronald tried to convince himself that it was just a dream. He tried to ignore his daughter’s words, but her voice paralyzed him. He walked in to my office cautiously as if embarrassed by an urge that he couldn’t explain.

While I was skeptical to say the least, there was something about Ronald’s story that moved me. There is a time when clinicians drop algorithms and guidelines and work from the gut.

I felt it would be reasonable to obtain basic lab tests and a chest x-ray. I also informed him that given the lack of indications, Medicare wouldn’t pay for any of it. He took my referrals and left the office. I suspected that he would eventually think better, and decide not to go for testing.

I was wrong.

***

Three years later Ronald is disease free. The lung cancer found coincidentally on x-ray was early stage, and was surgically cured. The thoracic surgeon marvels that if Ronald had waited any longer, he wouldn’t be alive today.

Ronald did end up paying a few extra hundred dollars for the tests, but he now feels it was money well worth spending.

And I am left to wonder about the future of medicine. As guideline based care pervades health care reform, I fear that something will be inexplicably lost.

You may call it divine intervention. It might be described as having a hunch. Or one could lay this gift on the doorstep of lady luck.

But if you ask me, I call it something completely different.

The art of medicine.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • http://twitter.com/DoctorPullen Edward Pullen

    I fear that the need to make our EMR use meaningful has been the last straw at pushing us past patient focused care.  It is an art just to get all the data entered and still have time to greet and dismiss the patient.  

    • MarcGarfield_DPM

       Amen Dr Pullen. EMR with MU is like buying our own choke collar and handing the leash to the government.  They may thow us a bone, but if we want to eat we will go where they pull us.

  • sFord48

    I don’t trust my doctor to make a decision about my health.  Too many conflicts of interest.  I like guidelines and know when a doctor deviates from those guidelines, it’s time to do research.

    And of course, Ronald’s gut was the one that lead to the diagnosis…and the fact he avoided medical care.  I doubt the same consideration would have been given to someone who came in regularly for simple things.

    • http://www.facebook.com/brianpcurry Brian Curry

       Or, it just might have been the X-ray that the doc ordered as a reasonable workup.

  • karen3

    I gotta say, for all of my family members, we all would have fared better if doctors had stuck to the guidelines. I have actually never witnessed a doctor do something that was “more” than the guidelines as related by the story.  I have only seen doctors chose to do shortcuts, sometimes with catestrophic consequences.  For one every doctor in a 100 who does better than the guidelines, there are 99 who do worse. Overall, patients would be better with docs who aren’t so creative.

  • http://twitter.com/Hootsbudy John Ballard

    The future of effective medicine lies with evidence-based outcomes and best practice protocols that will vary among specialties. It is important to remember two points. First, the protocols are recommendations, not prohibitions or mandates. Doctors remain free to follow or ignore all or any of them. Second, there is an important distinction between diagnostic testing and routine testing.

    Too many tests are simply trolling for business, either for hospitals, small clinics or the pharmaceutical industry. And the downside of mass screening includes false positives resulting in unnecessary anxiety, costs to both patients and providers and invasive procedures, sometimes with bad outcomes.

    Even the suspicions of someone’s family member qualify for diagnostic testing. That is very different from the mass screenings at which the guidelines are aimed.

  • http://www.facebook.com/people/Tom-Fitzsimmons/1405121136 Tom Fitzsimmons

    I’m a skeptic but I have heard similar stories like this where someone is visited by a dead relative and told they were sick. Betty Bethards founded a spiritual group after her experience of her dead husband (a guy she had problems with, BTW) appearing and telling her that her illness would be fatal if not treated. She had sepsis from an ovarian infection, it turned out. She barely survived. Makes me scratch my head and say “huh?”.

  • Sam23345

    The art of medicine is indeed lost to a sea of guidelines.  Guidelines are great when the patient is text-book example, or near text-book example, especially for common conditions.  But what if the patient doesn’t seem to fit in that box?  What if the patient has a condition for which lab tests are not accurate?  

    Guidelines are simply that – guidelines.  Unfortunately, I have found that some doctors treat guidelines as the law, and forget being a healer, to practice the art of medicine, that not all patients present and react the same way even when they have the same condition.  I have found older doctors to be better at treating the patient rather than treating the lab results.  I certainly hope treating the patient and the art of medicine doesn’t get lost in future physician generations.

  • http://twitter.com/DRSALWITZ James C Salwitz, MD

    I do not see this story as being inconsistent in any way with guidelines.  A physician’s job is to interface with the complexity and vagueness which is a human life.  Then, after collecting data to assemble that information and use research based medical decision making (i.e. guidelines) to test and diagnose.  Then go back to the patient and interface to give treatment.  The art of medicine is our interaction with the patient. The art should not include making up our own treatments.  That is the role of guidelines.  This story demonstrates beautifully why we will always need doctors and the true role of their art.  jcs

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I don’t think anybody can object to guidelines as long as they are truly guidelines. The problems arise when guidelines for treatment turn into hard rules for reimbursement or lack thereof.
    And somehow they always do, and somehow it always starts with Medicaid and “managed care”.  If Ronald didn’t have “a few extra hundred dollars” laying around, and too many people don’t, he would be dead now.

  • John_C_Henderson

    As a producer of guidelines, I would always say that the physician is the one seeing the clinical presentation and that they should have the right and responsibility to act in what they consider to be clinically correct and in the patient’s interests. There is an Art and a Science to medicine, guidelines focus more on the latter but even then, the right to override a guideline (suitably noted) must be respected.

    Its a pity that Medicare did not recognize the value of the preventative action of the patient!!

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