Going with our gut, not guidelines

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His voice was gruff and his expression surly.

“I don’t want any more medications.”

His face was indented by deep clefts, remnants of eight decades of life hard lived. His tone was commanding and certain. I knew that he was fond of me, but I could feel his patience slipping. He neither asked about nor accepted his diagnosis of heart failure. I could tell him till I was blue (or he was for that matter) in the face that his low ejection fraction portended a poor prognosis, and national guidelines suggested both a beta blocker and defibrillator placement.

He wouldn’t budge. And before the age of electronic medical records, evidence-based medicine and quality scores, no one really cared. Before all of that, we would have taken the patient’s wishes into account and noted that he couldn’t afford the new med, nor was particularly compliant with his other medications. We would have considered that his wife had died a few years back, and he had no interest in extending his life. Then we’d weigh the positives and negatives from the patient’s perspective, and come to a tailored decision for this particular human being.

But now the guideline-ification of American medicine has turned this proud and aged skill into a humdrum maze of algorithms.

Algorithms that are more expert opinion and less evidence based. Algorithms that rely on evidence collected from typical white male patients with isolated disease processes and may not be generalizable. Algorithms that will change often and probably contradict themselves in the decades to come.

The true art of medicine, expertly meshing the known with the unknown. Factoring in human variability and preference to develop a unique plan has been lost, ridiculed, chewed and spit into the trash.

We pray to the ever-eroding altar of longevity even as our patients have abandoned such false deities.

They want quality of life. They want control over their own decisions. And they want to go with their gut sometimes.

And I think we should support them.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion. Watch his talk at dotMED 2013, Caring 2.0: Social Media and the Rise Of The Empathic Physician. He is the author of Five Moments: Short Works of Fiction and I Am Your Doctor: and This Is My Humble Opinion.

Image credit: Shutterstock.com

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