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Friday, October 22, 2010

Magical vs. Methodical

I am an optimist, perhaps bordering on being delusional at time. I am methodical and systematic in how I approach problems and I assume that this is a characteristic shared by my colleagues and even my patients. I am constantly reminded that this assumption is simply wrong. Nevertheless, I hold on to this belief system. I am not sure why.

Today, I was pulled in to see a patient by one of the PA's I was supervising. This patient was undergoing chronic outpatient treatment for a distinct condition under the supervision of another physician. The patient was actually visiting from well out of town. He was a very sophisticated professional who had achieved much and was highly regarding within his own field (non-medical - he was a chef). He was availing himself of treatment not available in his home community thousands of miles away.

Here is the bizarre part of the story. He was referred to our office for a distinct difficult and chronic problem which ad already been exhaustively evaluated and treated at one of the most famous integrated health care entities in the world. He had undergone literally months of diagnostic evaluations and countless treatment approaches at the hands of some of the most intelligent and diligent physicians anywhere. So, when he comes to visit our fair city, someone has the brilliant idea of garnering a 15 minute slot with my PA for a second opinion. He comes with no records and basically no recollection of what had been done, diagnostically or therapeutically.  We briefly played a variant of medical 20 questions... Did the medicine sound like??? Did the test sound like??? until I realized that this was going to go no where.

I guess I assume that patients and referring physicians have some conception of what it takes to evaluate and treat people with complicated medical problems. I have to say I was tempted to ask this patient how he would react if I came to him saying that I had this great meal and I would like for him to recreate it immediately. However, I remembered only that it had a main course, it contained meat, and involved a sauce.

I perhaps should expect such lack of insight from the patient but what about the referring physician? Shouldn't someone with medical school and residency training in almost anything understand that referring a patient under these circumstances is crazy. Perhaps they thought we would be able to cast a spell upon this gentleman and purge the evil spirits. Perhaps it did not occur to whomever initiated the endeavor that medical problems are best solved by methodically analyzing the data, creating a differential diagnosis, and weighing options. Most likely no one gave it a moments thought beyond the impulse to call and secure an appointment even if it was not with anyone who was in a position solve their problem.

The magical thinking perspective is the default mode. When we ask patients to secure records from previous evaluations, they view it as an imposition. At least part of the reason for this attitude is some realize many of the records contain little or no actual information. When we ask them to provide information in the form of questionnaires, they follow the principle of opening the door wide enough only to get through. They appear to have a hard time conceiving that the information provided might actually be useful. To some degree the medical profession historically has fostered the belief that physicians power over disease bordered on the magical. Current TV drama tends to underscore very short time lines and ad hoc functioning of the medical profession. Heroes in this world require little time or data to solve issues, relying instead on intuition, gut, and impulsive decision making skills. It may make great TV but it is not the best way to deal with most medical problems.

1 comment:

  1. Yes, as you point out many patients leave rationality behind when they come to see us.