Monday, June 16, 2014

Medical Myths and Asking the Right Questions

Last week, I started my blog post with the statement that “Doctors are people.”    There are many medical myths and the one I was addressing in that post was the myth that physicians have some supernatural power that makes them more than just people.  Dr. Robert Pearl, the CEO of the Permanente Medical Group, in the latest installment of his “medical myth” series of blog post in Forbes attempts to prove  that the statement “medicine is an art, not a science” is a myth.  The fact is that medicine when practiced optimally must be both. 

He starts by asking the question whether medicine as an art or a science saved more lives.  His answer is that science has saved more lives and therefore medicine as an art must be considered a myth.  Whenever you have the opportunity to ask the question in the way you want, you can always produce the result you want.  Just ask any pollster.  The question he asks is written from a population health management point of view, not an individual patient care point of view.  The answer becomes more nuanced when the question is changed.  Let’s look at the three examples he gives. 

His first example is treating people with stroke and he rightly points out that when guidelines developed by the American Heart Association in conjunction with the American Stroke Association are used by hospitals to standardize admitting orders, then the outcomes are better.  Science therefore triumphs.  However a major factor in the use of those guidelines calls for patients to get to a center that can effectively treat them in a very short time.  Delay, in this case, kills.  Quick action demands faith in one’s doctor and in the health system and also demands that the access to care is simple and perceived by the patient as helpful.   A different question to ask in this case is whether art or science will help people access care at the right time and at the right place in order to take advantage of the best practice protocol.  The art of medicine requires that patients know their doctors and other health professionals, trust them, and therefore reach out in a timely manner when care is needed.  That is a precursor in this instance to using the right protocol once someone is in the hospital.  Unless physicians pay attention to the art of medicine, gain people’s trust, and give them the confidence to reach the right facility soon enough, the scientific efforts are worthless.   

The second example he talks about is the use of beta-blockers, ACE-inhibitors, aspirin and statins after a heart attack to reduce the risk of future heart attacks.  He cites the fact that “the best doctors prescribe these medications 98 percent of the time.”   However he neglects to mention, that when a physician prescribes a medication, that is only the start of the challenge of ensuring that the patient takes the medication.  A different question therefore is whether the art or science will help the patient take the medication as prescribed.  The patient may hate taking any medication and may not believe that the beta-blocker will help.  A friend may have told them of a bad experience with the same medication and they may be afraid to take it.  The patient may have a benefits plan which requires a co-payment that they cannot afford.   The art of medicine requires that the doctor know the context of the person’s life, their values and beliefs towards the therapy, and the potential barriers that are present that may affect the patient carrying out the doctor’s instructions.  It requires the doctor to think past the protocol and help address the life issues in a way that respects the patient’s beliefs and values. 

His last example is the setting of protocols for the operating room.  Again those protocols are necessary and the science behind them is compelling.  However an experienced, knowledgeable surgeon, who is able to react to the changing situation in the operating room, using experience and the art of medicine, is often necessary.   A different question therefore in this case is whether the art or science will help in assessing any surprises in the OR.  In his editorial in the WSJ entitled, “The Bureaucrat Sitting on Your Doctor’s Shoulder”, Dr. Zane Pollard from Scottish Rite Children’s Hospital in Atlanta tells of a case in which in the operating room, he had to change his surgery due to findings that were unexpected.  He was not paid and was cited for performing a surgery that was not part of the protocol that was approved even though he clearly did what was right for the patient.

The best medical care never makes a choice between the art and science of medicine but rather uses both to benefit the patient. Dr. William Osler, considered to be the father of modern scientific medicine said, “The good physician treats the disease; the great physician treats the patient who has the disease.”  He also said, “Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under that abnormal conditions we know as disease.” 

Dr. Pearl’s examples and questions to prove his point are all about populations and disease.   If the questions we ask, and the metrics we use, are only about the populations and about disease and not about the “patient who has the disease” in Osler’s words, we will miss major aspects of care.  If they are only about what goes on in the doctor’s office and in the hospital and not what happens before someone arrives at the hospital and after they leave, we may actually cause harm to the patient even if we improve our population numbers.  We must practice both science and art: we must follow scientific protocols diligently and use the communication skills, the assessment skills and the trust building skills that are all part of the art of medicine.  We must partner with people and understand how the disease impacts their lives, and how their lives impact the treatment of the disease.  The real myth is the belief that medicine is either art or science when it must be both.