Re: how doctors handle the human element

[Michael Simpson <mikie.simpson () gmail com>]

On 26/04/2009, Larry Seltzer <larry () larryseltzer com> wrote:
> Have you ever watched the TV show House?
>
> Larry Seltzer
> eWEEK.com Security Center Editor
> http://security.eweek.com/
> http://blogs.pcmag.com/securitywatch/
> Contributing Editor, PC Magazine
> larry.seltzer () ziffdavisenterprise com

When i was at medical school a couple of decades ago we were told the
following methodology

1) introduce yourself to the patient - the best docs tend to use their
first name and not their title in a "one human to another human" kinda
way
2) ask open question like what has been going on
3) listen to patient!
4) proceed to elucidate further information - time lines, associated
symptoms, family history, social history, contact with others, foreign
travel, allergies, etc

known locally as the biconicoid theory of history taking (open to
closed questioning)

5) ask standard barrage of general questions known as systemic review

At this point you should have managed to form a differential diagnosis
with a 95% surety that that your top choice is the correct one

You then proceed to examine the patient looking for signs to prove or
disprove your theory
Once you have your working diagnosis you then order the correct tests
to back up your hypothesis or delineate the severity of the diseases.

Using tests or treatments as a "Hail Mary" is particularly frowned
upon and is seen as 1) exposing patients to unnecessary risk and 2)
bad medical practice by an incompetent doctor.

Whilst i enjoy House it has very little in common with good practice.

As A. Conan-Doyle would have told you disease is highly logical and
that if you manage to elicit the correct clues and put them together
then you will achieve the correct diagnosis and the best possible
outcome for your patients.

Therein lies the problem though.

case example:

45 year old patient presents with gastric irritation.
He has previously presented with nasal polyps as a child, asthma as a
teenager and developed a dropped foot 10 years ago, given a diagnosis
of mononeuritis monoplex which has proven to be resistant to
treatment.

His GP and all  the consultants that have been treating him for 20 odd
years are unable to think of anything further.

He is referred to a local gastro guy to have an endoscopy.
This consultant does the biopsy of his stomach wall but as he is a
*very* thorough type, who also is renowned for his poor social
function and his "interesting" quirks, he sits down with all the
volumes of this patient's case notes and reads them from cover to
cover. By the time that the biopsy pathology report comes back it
merely confirms his theory that this patient has Churg-Strauss
syndrome.

<http://en.wikipedia.org/wiki/Churg-Strauss_syndrome>

It is not simply a question of medics knowing about debugging.

The main problem in medicine is that the manual for the human is
fscking huge and pride can often get in the way of asking for help
from those doctors with the required "mind the size of a planet"
needed to understand it, several of whom i have had the enormous
pleasure and privilege to work for/with in the past.

Hear hooves and think horses but if you see stripes and can't tell a
zebu from a zebra then refer. There are no stupid questions, only
stupid mistakes.

> What of trends of illnesses in recent history?

And the current crop of active doctors have real problems in the west
for identifying diphtheria or TB (the great mimic) or more recently
measles.
Again, if your doctor cannot admit that she/he doesn't know what is
going on then they are either brilliant (very rare) or arrogant (much
more common) and you need a new doctor.


> It does, but what of emergencies? Say the patient reaches the
> hospital near death. The doctor may need to "fire in all directions" and
> hope for the best.

The only time i have ever come across this concept was at the Glasgow
Royal Infirmary ER where i was a registrar (middle grade doctor) and a
patient would come in with a coma score of 3 and no signs of visible
injury (and a normal blood glucose and no smell of alcohol, methanol,
ethylene glycol) and we would use a narcan/flumazenil/glucagon
combination to reverse heroin/benzodiazepines/beta_blocker toxicity in
one handy syringe. Use of this was an incredibly rare occurrence as
even when patients arrive "near death" there are still *very well
researched* protocols for use to identify the cause and correct
treatments.

<www.resus.org.uk>
and
<http://en.wikipedia.org/wiki/Advanced_Trauma_Life_Support>


And wrt the guy that got 6 treatment from his doctor, please tell him
never to go back to that hack but rather to seek professional help.

moving on

> There is not much we can do about many doctors being elitist snobs,

There is a surgeon that i worked for who was best described as a total
pr*ck yet was so very good at what he did that if i had to have
someone remove bowel cancer from me it would be him. On the other hand
there are a fair few doctors who are unpleasant to have contact with
but don't have excellent skills. There are also docs with talent who
are real nice to deal with.

It seems that there are lots of w*nkers within the human race and i
don't think that medicine has the market cornered on elitist snobs, it
just seems that way because most people will have to be in contact
with medics at some point, whereas most folk won't be exposed to
higher echelons of tech-support, banks, civil service, etc.

> Medical doctors are technicians--granted, very smart and able technicians--but >technicians non-the-less.

Many orthopaedic surgeons would gladly shake your hand for that
statement, indeed many medics are technicians. There are (usually at
least one in each hospital normally the haematologist) still outposts
of wonderfully intelligent puzzle-solvers, gentlemen and gentlewomen
with the ability to cut to the heart of a problem and solve it through
application of their raw intellect and acquired knowledge. These are
also technicians to a degree.
You are forgetting though that medicine is the oldest art as well as
the oldest science

<http://www.dcmsonline.org/jax-medicine/1999journals/december99/presmess.htm>

and whilst compassion is a actually a useful tool at the bedside it is
not that useful at the CLI

> Teach doctors proper debugging.

Teach them medicine, not EE or CS.
Learn from the mistakes that medicine has made over the centuries wrt
professionalism!

mike
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