Medicine is an Art and Science

Medicine is an art, not a science.  We’ve all heard that maxim before, but what does it actually mean for living, breathing patients?

Physicians rely upon knowledge and experience when we advise patients.   We try to stay current on relevant medical studies to guide us, knowing that the latest medical ‘breakthrough’ may be debunked in a few years.  Seasoned physicians resist the temptation to abruptly change their medical advice based on a single study, even if published in a prestigious journal.

Knowledge and experience are important, but judgment trumps them both, in my view.   The best clinicians are those who consistently exercise excellent medical judgment.

A knowledgeable physician may be able to recite a dozen explanations for your high calcium level.

An experienced doctor can expertly perform a colonoscopy having mastered the technique.

A physician with a high level of medical judgment knows that surgery is wrong for a particular patient, even though medical textbooks and journals recommend an operation. 

Judgement Outweighs Knowledge

Keep in mind that medical judgments are not right or wrong.  Physicians on the same case may have differing judgments and recommendations.  This is a typical scenario in the medical universe which can be vexing to patients and their family.

Consider a few typical patient vignettes which call for medical judgment.

A cardiologist recommends Coumadin , a blood thinner, to start today to treat a patient’s heart condition.  The gastroenterologist wants to delay this for a few weeks as the patient has a duodenal ulcer that could start bleeding once the blood thinner begins.   When should the Coumadin be started?

A man undergoes a CAT scan of the chest which shows a 1 cm nodule in the lung.  The nodule is slightly larger than it was 6 months ago.  The patient is a smoker.   The location of the nodule is at high risk for a serious complication if a biopsy is done.    Should the biopsy be done to determine if a cancer is present?  Considering the risk of the biopsy, should the lesion be watched with a repeat CAT scan done in 3 months to see if it is enlarging or remaining stable? 

A patient is seen by a surgeon after a severe attack of abdominal pain, which resolved.  The patient was immobilized during the pain and was seen in an emergency room where he was found to have a gallbladder full of gallstones.   The surgeon is not certain that the gallstones were responsible for the pain.  The patient is very frightened that if nothing is done, that the pain might return.  Should the surgeon remove the gallbladder, which might have nothing to do with the pain, or advise watchful waiting?

Medicine is art and science.  If I’m sick, I’ll skip the scientist.  Give me the artist.

Money Back Guarantee on Medical Care?

How many times each week do we hear the phrase, 'if you're not completely satisfied, we'll refund the purchase price - no questions asked."

This is more often a marketing ploy than a true money-back guarantee.  I have a sense that trying to obtain a promised refund on an item that dissatisfied us is about as easy and carefree as changing an airline ticket reservation or reaching a live human when our home internet service is down.   So, when the weight loss pills don't really melt the pounds off, don't be shocked if the check isn't in the mail when you mail back the placebo pills to a post office box several states away.  And, of course, you won't recover the shipping and handling costs.

Send Stuff to P.O Box in Southeast Asia

Photo Credit

This is my opportunity to ask for help from my erudite readership.  What exactly is shipping and handling?  Doesn't postage already cover the 'shipping'?  $8.95 seems pricey for a 'handling' charge for anti-wrinkle cream or a set of steak knives endorsed by make-believe chefs.  I don't really want strangers handling my stuff anyway.  Are they wearing gloves, I hope?

I hear a commercial often for a zinc product that promises a full refund if the product does not shorten the course of the common cold.  I do have some medical training, as readers know.  Readers who are smart enough to understand'shipping and handling' are asked now to explain how an individual can assert that the zinc product was not effective.

The Complaint

"Please give me a full refund.  My cold lasted 6 days. Usually, I feel better by the 5th day.  Your zinc stinks."

The Response

"Thank you so much for your input.  All of us at Zinc Jinx, Inc.welcome customer feedback.  Please send urine samples for days 4,5 and 6 packed in dry ice at your own expense so we can verify that you were taking the product as directed.  Include all packaging including the shrink wrap around the bottle that you should have retained had you consulted our customer service web site prior to opening.  Expect a response in 6 weeks.  Even if your urine drug content is deemed to be sufficient, our on site cold and flu experts may conclude after impartial study that your cold would have lasted 9 days without our product."

I'm not offering an opinion on zinc's effectiveness in fighting the common cold.  I'm suggesting that it is not possible for a zinc swallower to really know if zinc expedited his recovery.  Belief is not evidence.  If we recover on day 6, perhaps, zinc was an innocent bystander receiving credit for a favorable outcome that it did not contribute to.

Sometimes, we physicians are lucky in the same way.  Our patients get better, as they usually do, and we get the credit. As we know, the converse is sometimes true.  We get blamed when we don't deserve it.

Should doctors offer a money back guarantee if our patients are not fully satisfied?  The zinc scenario illustrates how difficult it can be in medicine to assign credit or the blame for the outcome.  The only secure guarantee in medicine is that there are no guarantees. 

If any reader is not fully satisfied with this post, the full purchase price will be promptly refunded - no questions asked.  

The Doctor-Patient Relationship, Is There an App for That?

I just deposited a check into my bank account by photographing the check with my iPhone and zapping it through cyberspace.  I realize this is ho hum to the under 35 crowd.  Soon, there won’t be any paper checks as the entire transaction will occur electronically.  As a member of the over 35 crowd (plus 20 years), I am wowed by this process.  I remember being astonished when my kids told me how they performed this same process months ago.   It’s the same amazement I experience when I first read about a new piece of technology called a ‘fax machine’.

You mean you slide a document into a machine and an exact copy emerges elsewhere?

In my younger days, depositing a check into a bank account meant waiting in line with my bank book in hand waiting for a living, breathing human to count and record my allowance and snow shoveling earnings.   The bank that my kids use has no physical offices.  It is entirely in the Twilight Zone.

Medicine will not be left behind here.  The manner in which medical care will be administered will be beyond what we can imagine.  We are seeing glimpses of it already, but our vision of its trajectory is limited.  There will be huge advances, but as with all technology, there will be a cost.  The traditional doctor-patient relationship will fade out as this will not be the bedrock of medical care.  There will be nostalgia for it from those who experienced it, much as I have warm memories of bank books, rotary phones, ice cream sodas and playing basketball after school in the school yard.

I’m sure there is technomedicine going on today that I’m not aware of and would be amazed by.  Smart phones will become medical diagnostic tools.

Easy Stuff

• Tell Siri your history and send a photo of your rash to DERM APP and prescription will arrive at your door in 1 hour.
• Place phone on your chest and cardiopulmonary data will be forwarded to your cardiologist who will transmit medication adjustments to you electronically.
• Shine beam of light through a urine specimen which will confirm if urinary tract infection present.

Hard Stuff

• Coronary bypass surgery performed robotically by a surgeon in New York City on a patient in Abu Dhabi.
• Artificial organs created in 3-D printers.
• Miniature cameras journeying through the digestive tract, circulatory system and major organs delivering customized treatment for various diseases.
• Smart phone analysis of saliva sample which will screen for risk factors for 20 common chronic diseases that will have effective preventive strategies.
• Satellite delivery of yet to be discovered form of radiation to the developing world which will decimate food borne illness.
• Patient will place his palm on a glass and an electronic signal will be transmitted to internal organs whose function needs adjustment to treat disease or preserve health.

I worry about the collision of technology against the doctor-patient relationship, which is an ongoing conflict. For example, most patients and physicians do not feel that electronic medical records have nurtured the doctor-patient relationship.  I think it's been a wedge separating physicians from patients. Generally, the tidal wave of technology forges ahead with no true regard or attention to the ethical costs incurred.    Doing stuff just because we can doesn’t make it right.  Smart phones won't be smart enough.. Will there be an app for empathy, compassion, facial expression and listenng?  Perhaps, AppMD will be tomorrow's health care provider and physicians will join the ranks of typewriter repairmen and encyclopedia salesmen..  

Rolling Stone Magazine Rolls the Truth

 Recently, I was with a group of good friends whom I have known for 20 years.  They are a spirited group of unabashed liberals.  I doubt any of them have ever voted for a Republican, or ever would.  Of course, we have a secret ballot in this country so we never know for sure.  Publicly, at least, they profess unwavering fealty to the Democratic Party.

I regard myself as a political independent, although I tend to vote Republican.  However, when I am amid this group of left-leaners, they look to me for the ‘far right’ view on the issues of the day. 

Yes, we have different views on the proper role of government and the judiciary, but I don’t look to Ted Cruz or Sarah Palin for political inspiration.

During our conversation, the recent Rolling Stone journalistic debacle that detailed an alleged rape at University of Virginia came up.  Immediately, the prevailing liberal talking point was offered up to the group, expecting acclamation.  

“This Rolling Stone retraction is terrible.   It is a huge setback for women who are victims of sexual assault on college campuses.”

Lots of heads were nodding in agreement, except for mine.

The issue for me is one of journalistic failure, not the overhanging issue of sexual assault on college campuses.  If an account by an alleged rape victim has become problematic and inconsistent, then we should acknowledge this, as Rolling Stone was forced to do, and not automatically rehabilitate the victim to serve a larger cause.   If the press fails its readers and its profession, then that is the issue.   Our focus should be on what went wrong, not how a misdeed might negatively influence a larger agenda.  

Rolling Stone Needs Honest Weights

I’m a physician.   If one of my colleagues is convicted of Medicare fraud, should my initial response be, “Oh, this will be very bad for doctors”?   Shouldn’t I clearly condemn the criminal act without any qualifications?   Apply this example to your own profession. 

When we try too hard to downplay an individual’s action that we think might harm our cause, it detracts from our credibility.   In my view, an organization or an individual that speaks and seeks the truth will only strengthen the currency of its voice for its own cause. 

I understand that sexual assault is a serious issue that demands our full attention and response.  Let me state boldly; I am against sexual assault.  But those who advocate for this important cause need to acknowledge the injustice of a false allegation, such as occurred with the Duke lacrosse case in 2006, a very public example of how lives can be unfairly ruined.  A false or questionable allegation should be identified as such, not lamented as a setback for another agenda.  Many commentators on the Rolling Stone retraction have expressed regret, but not at the possibility of a false charge or reckless reporting.  They are sorry that their cause may have been negatively impacted.

We don’t know for sure whether ‘Jackie’, the protagonist in the Rolling Stone article was truly a victim.  I am not denying the possibility that she was, but I am expressing uncertainty.  We do know that important details of her narrative have not been corroborated.  We also know that inexplicably Rolling Stone acquiesced to Jackie’s request to refrain from interviewing the alleged perpetrators, a professional lapse that made the Rolling Stone piece one of advocacy, not journalism. 

Rolling Stone has requested that the Columbia Journalism School perform a post mortem on the story, which I trust will be an independent and objective review of what appears to be journalistic malpractice.  

Should our reaction to the Rolling Stone’s lapse be that “this will be bad for the journalism profession?”  Or, would a better reaction be that “this will be bad for Rolling Stone?”  

Ready for the Silent Treatment?

When moved to do so, I wander off the medical commentary pedestal to share thoughts with readers.  This is one of those occasions.   I had a singular experience last weekend that impacted me.

Most of us can agree that there is a paucity of silence in our world.  There is noise and static everywhere filling our time and space with cacophony.  Television news shows have become performances where we watch panels of pundits who appear as clucking hens.  Try to find a coffee shop that isn’t blaring music.  Even sports games on television have every nanosecond filled with barkings from commentators.  Can’t we just enjoy the play?

Last Sunday, I went to a Quaker Meeting House for the first time, accompanied by my daughter Ariella, representing our family.  There was no speaker, ushers, music or program of events.  The room was set up with chairs in each half that faced each other.  Folks took their seats and remained quiet.  At first, I was disquieted by the quiet, impatient for some action to commence, as I would be at a theater, sports arena or musical performance.  Not here.  Several minutes passed and not a syllable was uttered.   Were we all just wasting our time?   On the contrary, I was being offered a rare gift – the opportunity to contemplate in silence.   

I enjoy spending time alone, and I am known to duck out to various undisclosed hideaways where I read and write.  I have not made silent meditation, however, a part of my life.  The Quakers are onto something here.  For them, silence is not the absence of activity, but an opportunity for thought and reflection.   Silence is the event, the music in between the notes.

We were assembled together to recall the life of a remarkable human being, Betty Lake.  Betty had been part of our lives for over 20 years.  We took her on as nanny to what became a house of entropy with 2 working parents, 5 children, a dog or two and an occasional boarder.  We remained actively connected to her for the rest of her life.   She exuded warmth, generosity, good cheer and love with infectious enthusiasm.   She created a Sea of Tranquility in our Cauldron of Chaos.   She loved us all and we returned that love to her in full measure. 

A few years ago, she gifted me a small rocking chair that she had sat in as young girl in Cincinnati.   I treasure it.  I have moved twice since I received it and still display it where I see it every day.

At the Quaker Meeting, after a silent overture, folks stood and offered reflections when they were moved to do so.  By the end, nearly everyone had shared a memory or a vignette about Betty, each contributing a few stitches to the tapestry of her life.  When the meeting ended, we all felt good that we had collectively captured her essence and had honored a woman of such great worth.   Photos of her were scattered on a table and guests were invited to take one home. 

Grab a few minutes of silence today.   Turn the volume down and cherish a transient oasis of calmness and peace.

Thanks, Betty, for all you have given us.   You gave without ever expecting anything back, a lesson that I try to use to become better than I am.

What's the Cause of Chronic Abdominal Pain?

I see patients with abdominal pain every day.  Over my career, I’ve sat across the desk facing thousands of folks with every variety of stomach ache imaginable.   I’ve listened to them, palpated them, scanned them, scoped them and at times referred them elsewhere for another opinion.  With this level of experience, one would suspect that I have become a virtual sleuth at determining the obvious and stealth causes of abdominal distress.  

I wish it were the case.

Some Cases Defy Sleuthing

The majority of cases of chronic abdominal pain that I – and every gastroenterologist – see will not be explained by a concrete diagnosis.   Sure, I’ve seen my share of sick gall bladders, stomach ulcers, diverticulitis, bowel obstructions, appendicitis and abdominal infections, but these represent a minority of my afflicted patients. 

Patients with acute abdominal pain are more likely to receive a specific diagnosis, such as those listed above.  However, patients who have abdominal distress for years, which constitute most of my stomach pain patients, usually will not have a specific, explanatory diagnosis even though these patients often feel otherwise.

Many of these patients come to the office advising me that “their diverticulitis is acting up” or that “their ulcer is back again”.  Usually, this is not the case and they may never have had diverticulitis or an ulcer in the first place.

Physicians often assign these patients a diagnosis of irritable bowel disease or functional bowel disease, which is a rather amorphous entity that cannot be detected on available diagnostic testing.  The labs and scans and scopes are all normal in these folks.  I believe that the condition is real, but it is a frustrating condition that is difficult to define.   It often coexists with other chronic painful conditions, such as fibromyalgia, chronic pelvic pain and migraine headaches. 

This is tough for patients and a medical profession that strive to label every symptom numerically and quantitatively.  The body does not work this way. 

Of course, I may be missing true diagnoses in some of my chronic pain patients.  Medical science isn’t perfect and neither am I.   How many celiac disease patients have I overlooked?  Should I test every individual who has a cramp now and then for celiac disease so I don’t miss a single case?  If every physician adopted this approach for celiac disease – and a hundred other conditions – we would elevate our current practice of overdiagnosis and overtreatment beyond the stratosphere. 

So, how much testing should a patient with chronic nausea or abdominal pain receive?   Patients and physicians don’t always agree here.   How much cost and care are patients, physicians and society willing to expend to approach 100% chance of not missing a diagnosis?   Is your answer the same if you or a loved one is the patient?

Whistleblower Holiday Cheer 2015!

T’was the week before Christmas

And all through the House,

Boehner was stirring

No longer a mouse

The Senate as well

In GOP hands

Girding for battle

With toothless demands.

No government shutdown

That never played well.

Impeachment would surely

Damn them to hell.

Executive orders,

No self-deport.

Why diss the Congress?

He does it for sport!

In 2016,

Are Repubs aware,

That they need a candidate

With Romney’s hair?

GOP are no saints

They carp and complain,

Blaming Obama

With dripping disdain.

“He’s a king or a czar.

It’s all been a ruse.”

We know this is true

It was on Fox News.

So will there be progress?
Will they join hands?

Can we have hope?

As we watch from the stands?

Or can we expect,

More of the same,

Bickering, sniping

And pointing the blame?

Will Jeb give the nod?

Can Hillary lose?

Or Dancer or Prancer,

Or maybe Ted Cruz?

Sit back and relax,

For the start of the show,

It’s a rerun of sorts,

Gridlock 2.0!

Wishing you joy and peace.