Mea sententia

The deluge of clinical information I face every day is littered with clinical junk mail.

All day long I work with patients who want answers and certainty. My awareness of how few questions have proven answers, and how unpredictable human health and disease can be, is a heavy burden.  This discordance may be why I enjoyed Stuart Firestein’s excellent book, Ignorance,  so much.

I did my family practice residency in a Catholic hospital in the mid west. The strong presence of nuns in leadership and the quiet influence of the attached order and Catholic school lent an unmistakably religious atmosphere to the hospital. Mostly, as residents, we were too busy and too tired to either notice or care, but occasionally the interface between the hospital’s spiritual context and the world of patient care was uncomfortable. Even jarring.

Throughout our medical training we are told again and again that the most important task is an accurate diagnosis. And we hear it at CME lectures and read it in journals. An accurate diagnosis is certainly essential if one wants to offer successful and safe treatment.  But it is not enough to ask and answer: “What is the diagnosis?”

There are several other questions that every experienced clinician asks - and answers - with every visit. Or should ask. We skip these questions at considerable risk to our patients.

She called in tears. Beyond tears, actually. She was so upset that it was impossible to get a coherent history and the triage nurse was only able to ascertain that her psychiatrist was no longer willing to prescribe her long-term clonazepam, she couldn’t function, and that she couldn’t afford the urine drug test. She insisted she wasn’t suicidal and didn’t need to go to the ED Crisis Unit, but begged me to prescribe the clonazepam that her psychiatrist had discontinued. With considerable misgivings, I found a way to see her for an extended appointment later that week.

Alone we go faster, but together we go further. Alone things are simpler, but together things are better. Alone we control the process and perhaps the product, but it is together that we learn and grow. 

Sidney Dekker is a world recognized researcher, successful author, speaker and consultant on safety, error, and complex systems.

My institution is striving to become more patient-centered, and is making good progress, but has an odd way of showing it sometimes.

The primary care providers (PCPs) I work with all love what we do. Partnering with patients to improve their lives is challenging but rewarding work, and I almost never hear regrets about going into primary care. But we do complain. And one of the things we like to complain about is that we often feel abused by our better paid limited-specialty colleagues. It doesn’t happen often, but when it happens, the bad feelings may linger for a long time.

George Bernard Shaw said: “The single biggest problem in communication is the illusion that it has taken place.”