There was a time, before treatment algorithms, when physicians would rely on the detailed bedside and/or office observations of their patients in conjunction with the most recent published peer-reviewed studies.
Time spent with each patient was considered essential and appropriate to reach a proper diagnosis and treatment plan. Now, due to corporate mandates to produce higher RVUs, time is regarded as an unnecessary luxury, to be controlled and curtailed. Yet recent patient surveys have indicated that decreasing patient interaction time is one of the greatest patient dissatisfiers.
Furthermore, anecdotal cases, once considered interesting findings to be further discussed, are now automatically dismissed as voodoo medicine. Sadly, the inner gestalt physicians once had, described as an intuitive, sixth-sense about any given disease process, is no longer considered important to groom in newer physicians.
What has caused our profession to throw away the importance of experience garnered over the years? Why has this experience been so devalued? I believe there are many reasons for this.
The first time experience is pitted against evidence occurs during medical school, where students are taught that “measured” data is the gold-standard. Time spent with patients, reviewing their history, and performing a thorough physical exam, though still considered important, is not as critical as it once was. Instead, lab reports and imaging results are prioritized over the patient’s symptoms and/or how they are clinically responding to treatment modalities. Nor does it appear that common-sense is valued as much as it once was, or as it still should be.
In fact, a person who is considered book smart is more widely venerated, leaving behind those who use a more analytical, practical, common-sense approach to the medical problems that patients present with as antiquated.
Unfortunately, this trade-off continues into residency.
Although there are limits placed on the number of patients residents can see, the extra time made available to them is usually spent doing research projects and presenting case reports to their peers. Patients do not reap the benefits of that extra time.
By the time these residents finish their post-graduate work and begin their careers as attendings, they are left to fend for themselves. These newly minted attendings are rarely paired with mentors, i.e., older physicians who have “pearls of wisdom” to impart. If, in fact, the practice to mentor these younger physicians were encouraged, these “pearls” would enhance the evidence-based medicine already well-known to the younger physicians.
How do I know this to be true?
Throughout my career and my husband’s (as a pediatric endocrinologist), we have witnessed young attendings making decisions mostly using evidence-based medicine. More often than not, we would see these decisions result in knee-jerk reactions to a lab value rather than how the patient is clinically responding.
When I have brought this observation to the attention of other physicians, I have been quickly shot down and labeled old-fashioned. I was reminded that I should, instead, rally around newer, evidence-based data and treatment algorithms, considered to be the true harbinger of appropriate patient care.
This has led me to question how I practice. Is it indeed outdated and, therefore, dangerous to my patients? Yet, every time I have second-guessed my approach towards any given patient’s care, I have found myself returning to my experience, not instead of but in conjunction with evidence-based data.
By utilizing both methods of practice rather than relying solely on one or the other, I found I have been able to provide better patient care and, in general, improve their outcomes.
The first question to ask, then, is how do we prove to these younger, more technologically advanced physicians, that there is better patient satisfaction and outcomes when both methods are used to treat their patients?
Unfortunately, attempting to study experience-based medicine proves difficult because quantifying the validity of a “sixth sense” is not measurable.
The “experience” that each physician acquires throughout the years, through detailed patient interactions, creates a repertoire or library stored and cataloged in the cerebral cortex.
When this “library” is activated, it releases a cascade of medical responses to a patient’s clinical presentation. Statistically studying the results of treating patients this way is close to impossible.
Furthermore, in today’s marketplace, the secondary value of patients appreciating the extra time taken with them is simply not enough to justify the increased cost to health care.
Instead, we should attempt to hypothesize and prove, that integrating both modalities in our practice of medicine would result in a decrease of erroneous and possibly costly diagnoses. It would also dissuade us from ordering unnecessary tests in order to arrive at diagnoses. This integrated approach would then prove to be a fiscally efficient system since it would decrease the overall health care costs incurred by both the system as well as the patient. Demonstrating improved patient outcomes, together with overall positive patient interactions would be the final sought-after result.
Once we prove its value, how do we begin to integrate experience-based medical practice with the present-day universal use of evidence-based medicine?
Re-introducing experience-based medical practice will require that mentors be valued, thereby assigning them to residents as well as new attendings. It will require that the various specialty boards recognize the importance of experience-based practice and integrate this type of critical thinking within the training programs as well as the tests given to certify these physicians.
Finally, it will require a paradigm shift in the medical world, where neither evidence nor experience trumps the other to ensure excellent patient care. Instead, by utilizing them in tandem, we can achieve the best possible outcomes for our patients while demonstrating a culture of expertise and caring.
This “holy grail” of health care is, after all, what patients demand and rightfully deserve. The time has come to challenge our health care system to allow us to practice medicine appropriately. Let us lobby to use both experience together with evidence, so we may finally give our patients what they are entitled to: the best care possible.
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