Being “Certain” in an Uncertain Medical World

The art of medicine is managing uncertainty. Yet, be honest: Have you ever met a more certain group of people than physicians? As a physician, I am no different. This past week, a close friend of three of my sons called me, as he was having severe abdominal pain. I spoke to him and his wife and quickly determined he needed to go to an emergency room. I told them that while I could not diagnose over the phone and without examining him, I did think this was most likely a kidney stone attack and not appendicitis. The next morning -- when he was out of surgery for his appendicitis -- I thought about how my relative certainty about it being a kidney stone was so wrong. I actually thought about asking to see the pathology report to make sure it was really an inflamed appendix, and not a kidney stone.  I was certain even in the face of uncertainty and conflicting data. 

That incident got me thinking about another time when I was wrong in a very similar situation. At that time, more than 35 years ago, I was an intern in internal medicine and I developed severe abdominal pain. My wife -- the smartest physician I know and at that time an intern in pediatrics -- took me across the street to the emergency room where I gave a perfect story to the surgical resident for appendicitis (this was in an era before we did CT scans to rule out appendicitis), and they started to get me ready for the operating room. The surgeon, my wife and I were all positive this was an acute appendicitis, but then I gave a pre-operative urine sample that was filled with blood.  My wife and I were surprised, as was the surgeon, but we all realized that while we were certain it was appendicitis, we were wrong. It was really a kidney stone. 

Even in this day of advanced technologies, much of medicine is still mysterious, and the practice of medicine is all about understanding that diagnostics and therapeutics are based in science, but are only rarely in concrete isolated fact.  More often, there are competing facts and multiple complicating factors; physiologic, sociological and psychological -- as well as different communication styles and contextual issues that make truly good doctors understand and learn to cope with a fundamental level of uncertainty in all that they do.  Perhaps coping with that uncertainty is why physicians often seem so sure.  Perhaps that is one way people survive as physicians. 

The secret behind the physician’s bravado is that caring doctors have to also manage their own anxiety and their own uncertainty while they manage the patient. They deal with this influenced by their own communication style and their own life context. The idea of a physician being perfect is a myth, and many excellent physicians struggle internally with carrying that myth. So doctors manage this internal uncertainly in various ways. Here, I offer my own characterization of doctors’ techniques for managing the uncertainty inherent in medical care -- and their own anxiety that occurs as a result. These techniques can be very adaptive, helpful – and, at the same time, dangerous to the patient and the physician:

When most uncertain, appear most certain:  Early in my career, a very prominent leader in academic gastroenterology told me his rule for handling patients with chronic irritable bowel syndrome:  “The less specific the treatment, the more specific the instructions should be.”  He told me of prescribing tincture of opium for these patients in the 1950s and telling them to place 11 drops -- not 10 or 12 -- in one-quarter of a glass of water, not half a glass, and drink it quickly. While he knew the efficacy of the treatment he was giving was uncertain, he believed that showing certainty as a physician would make it more likely the treatment would help than if he wavered.  This maximizes a placebo effect, which is real and effective; however, in the long run, this also carries the risk of harming the patient’s trust in the physician. 

Use specialist consultants generously:  This is the other extreme of the first technique. Instead of appearing to be totally confident in all pronouncements, the physician is quick to send a person with any illness to a specialist. In my previous life as a gastroenterologist and nutritionist, I was often frustrated by consultations that appeared more related to the referring physician’s lack of knowledge than the patient’s need.  The really skilled physician knows when to use the specialists in terms of both timing and condition. A consultation made too early creates risk for the patient, as the specialist may feel the need to “do something” -- when doing nothing and waiting for a self-limited illness to run its course may minimize harm and maximize benefit for a patient. The doctor who farms everything out due to his or her own internal uncertainty does the patient no favors while the doctor who never uses specialists may create risk by delaying needed care that only a specialist can give. 

Order every test to rule out the less likely diseases:  In this case, the fear of missing a disease drives over-testing.  While the good physician is compulsive and complete, the advances in medical technology and the ability to order newer and newer tests often lead physicians to downplay the harms that can come from over-ordering.  Every test has false positives and false negatives. I have seen people saved from devastating illness from a test they didn't really need (the cancer found on a CT of the abdomen for pain that was “incidental” and not related to the pain), but I have also seen people die as a result (the person who has surgery when a finding on a similar CT scan is thought to be a tumor, and who dies during the surgery in which no mass is seen).  The risk of harm from over-testing is higher than the likelihood of benefit however if the physician treats everything as routine and not needing investigation, that too can be harmful. 

Follow the algorithm: In this era, the more we learn, the more important standards and guidelines are.  However, the doctor who only relies on the algorithm and does not “see” the person behind the disease will miss important opportunities for diagnosis and treatment.  It is often easier for physicians to take solace in following an algorithm than to understand that algorithms are limited and cannot take the place of the decisions a good physician needs to make in managing uncertainty.  Dr. Saul Weiner’s research on the context of medical care shows the need to understand the patient’s life in order to maximize the benefit of the algorithm and minimize the risk of blind obedience to it. 

Go to the academic medical studies: I usually believe that this is the most useful technique, yet the doctor who needs to look everything up is neither efficient nor maximally effective.  You need to know enough and, at the same time, know what you don’t know and what you need to investigate. You need to understand that facts change and that the latest pronouncement of a breakthrough in the medical literature may be followed by later reports showing the breakthrough to create harm as well as benefit.  At the same time, I always will trust a doctor who says “I am not sure” and “I want to look up more information” more than a doctor who tries to show he or she has mastery over everything. 

The good doctor manages uncertainty. The great doctor also effectively communicates that uncertainty to the patient while still maintaining the patient’s trust.  That is the high form of the art called medicine.  

Ted Med Great Challenges Discussion

This week I was honored to join a distinguished group of participants in the Ted Med Great Challenges program underwritten by the Robert Wood Johnson Foundation on a panel moderated by Dr. Kavita Patel.  Here is the panel discussion (broken into two parts, due to a technical difficulty during the program).

https://www.youtube.com/watch?v=KjB8MZuzL1c


https://www.youtube.com/watch?v=52-2hG3AKaY#t=1692 

Thanksgiving, Kate Penny and the Medical Advisory Board

In my last blog post, I spoke about Accolade’s new Medical Advisory Board and the caring smart people who serve on that Board.  I also described two cases, including one of helping a patient who had end stage cancer, that Accolade nurses presented for discussion at the meeting.  Kate Penny is one of the talented nurse who presented and this is her reflection on that meeting:

"I wanted to thank you all for the privilege of presenting at our very first Medical Advisory Board. It was both a great learning opportunity and a tremendous experience.  I found the Advisory Board to be both kind, and thoughtful with their questions. 

In retrospect, I believe I did a less than a stellar job in representing M_____ and differentiating Accolade’s mission and values (Alan editorial comment – a stellar job was done).  Working with M_____, we added value. We dealt with claims, appeals, pain control, prevented unnecessary procedures and educated and supported the family. M______ gave me much more than I gave her. She let me share in her grief so that I was able to share in her love. We were together in wondrous times and witnessed the miracle of life and death together. We shared joy, sorrow, courage and tenderness. It was real. Kindness, tears and laughter are the currency of the heart, and meant to be exchanged.

M______ lived in constant terror of dying. She viewed her life as if it were a past event, and for many months defined herself solely by her terminal disease. M_____ had forgotten that she was a soul with a body, not a body with a soul. “Operation Love” helped her remember that for a short time. M_____ died peacefully and with grace. How do you communicate this in terms of metrics and statically project these measurements? Active love and listening goes beyond engagement and feelings of connected moments. It is looking for what is needed and providing it. It’s realizing that what needs to be done, is for you to do.

I have the privilege to witness this daily in the Health Assistance Center on so many levels with my co-workers, often unrecognized by others. It humbles me. My team mates and leadership are acutely aware of my strengths and weaknesses and they continue to educate, support and encourage with love. There are days when you feel like there is not one microgram left to give. I look around me and hear the passion to serve or just get it right and am inspired by my colleague’s devotion.

One of the Medical Advisory Board participants asked the “what’s the secret sauce?” question. People, stop over thinking it…it’s the people! We’ve learned and employed our beautiful model. We work hard to engage and build relationships. Once that has been achieved, the real work begins. We take the journey with the client and often share some of the most intimate moments of their lives. Health Assistants and Clinical Health Assistants have been empowered to do this and share the dream. The dream to change health care in the most unique way I have ever witnessed in a corporate setting. Just do the right thing!

In past years my family had a tradition at Thanksgiving of writing short letters of gratitude. I would like to continue that tradition with my Accolade family. I am most blessed because of each of you.

I am grateful for the sense of community I experience daily.

I am grateful to simply be accepted here as me. You have allowed me to combine both the art and science of nursing, a dream come true.

In short, each one of you at Accolade has given me purpose and enriched my life. For that, I will always be grateful."

Smart, Caring People Changing the World

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has. – Margaret Mead

These days, the news is filled with stories about the political strife surrounding the Affordable Care Act rollout. As I listen and read, I worry that individuals in need--who are dealing with their own and their family members’ illnesses--are being given short shrift in a debate driven by poll numbers, congressional races, and ideology. Yet I still have hope about the future of healthcare.  That’s because I spent two days last week with Accolade’s newly formed Medical Advisory Board. These renowned healthcare professionals came together to discuss ways to improve the care we provide and, despite their national prominence and expertise in health policy, were totally focused on how these policies and programs affect individuals and their families.

I admit to being a bit awestruck by the people who sat together to discuss ways that we at Accolade could better help people in need.  

• Dr. Joseph Betancourt, the director of the Disparities Solutions Center, director of Multicultural Education for Massachusetts General Hospital, associate professor of medicine at Harvard Medical School, and an expert in quality of care, disparities, and cross-cultural care and communication talked about ways to better help people by understanding their unique cultures
• Dr. Samuel (Buddy) Hammerman,  senior vice president and chief medical officer for Select Medical—where he oversees the company's division of 110 long-term acute care hospitals—uses his expertise in pulmonary medicine and critical care to ensure that every single patient in these facilities receives excellent care.
• Dr. Larry Kaiser, the CEO of the Temple University Health System, senior executive vice president for the Health Sciences, and dean of Temple University School of Medicine, is a world-renowned chest surgeon and the co-author of more than 13 books and 250 papers, but he is as deeply concerned about the high-needs population his health system serves as he is about the academic responsibilities of research and training new dedicated health professionals.
• Dr. Bruce Korf, chair of the Department of Genetics, and director of the Heflin Center for Genomic Sciences at the University of Alabama at Birmingham, is focused on children and families who deal every day with the challenges of complex genetic diseases, including neurofibromatosis; he spoke of the need to better address families with these challenges.
• Dr. Andrew Lasher, chief medical officer of Aspire Healthcare, is one of the nation’s bright lights in palliative care and a physician totally dedicated to using compassion when caring for the dying.
• Dr. Adam Perlman, associate vice president for Health and Wellness for the Duke University Health System, and executive director of Duke Integrative Medicine, is working to meld alternative medicine and the best of academic medicine into results for the most difficult patient problems.
• Dr. Saul Weiner, professor of medicine, pediatrics and medical education and vice provost of planning and programs at the University of Illinois at Chicago as well as deputy director of the Veterans Affairs (VA) Center of Innovation for Complex Chronic Healthcare is conducting cutting-edge research on how the context of life issues impacts the delivery of care; he has begun to change the conversations about what “best care” really is. 

We were also joined by Dr. Tanya Benenson, the corporate medical director for Comcast NBCUniversal; she worries about the health of the Comcast call center worker while at the same time she worries about the talented individuals NBC has working around the world. 

Throughout the time together, these smart caring people talked about individual patient cases and how to better help them. 

We discussed the 50-year-old man, originally from Cuba, whose wife had recently died of cancer; he had a history of drug abuse, was on anticoagulation for heart disease, and had diabetes.  This man was having trouble communicating with his doctors and was therefore not taking his medications as he should, but was too proud to admit his difficulties.  The Accolade nurse who helped him got to know him, talking with him in both English and Spanish, gaining his trust and changing his life as his medical illnesses and his behavioral illnesses came under closer control.  Our Medical Advisory Board sat listening and shared their insights on how to improve his care even more.

We discussed the woman dying of ovarian cancer, and the need to incorporate her large family in the discussion as she moved into hospice care.  The Accolade nurse talked about the trust she formed with this woman as she helped the person accept her diagnosis and prognosis and how her last days were made better by being open with her family.  She discussed the work done to help this woman move to hospice care in order to have more quality time with her son.  The national leaders around the table were as energetic and thoughtful about those individuals as they were about how to improve a nation’s healthcare system.

Over and over, I see the best and the brightest people in healthcare sharing the perspective of the individual and the family in need.  This week I was again reminded that healthcare is not about politics, but about people’s lives, and the real leaders in health understand this and incorporate that compassion and focus on families into everything they do.   

Health Professionalism: More than Following Algorithms

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” Sir William Osler (1849 – 1919)

I use--and perhaps overuse--this quote by William Osler, who is considered to be one of the fathers of modern medicine.  As a physician, I have always believed that understanding the patient, and not only the illness, is the key to effective therapeutics. However, today there are many who believe that the future of effective therapeutics lies in use of standardized approaches and in computerized systems --rather than in the ability to understand the person who has the disease. 

There are those who even believe that we are approaching the point at which doctors, nurses and other health professionals may be unnecessary.   The belief is that as evidence-based algorithms get more sophisticated--and computers and apps provide the platforms for their use--the need for a professional disappears.  Yet I worry about the loss of professionals and the loss of professionalism.  I am not the only one to worry.  A recent article in The Journal of the American Medical Association (JAMA) and a recent blog from the American Journal of Nursing suggest that I am not alone in my concern that blind faith in technology and algorithms may not provide a panacea. 

In the JAMA article “The Optimal Practice of Evidence- Based Medicine,” three physicians from the Mayo Clinic state that “research evidence is necessary but insufficient for making patient care decisions.” They go on to say that “careful attention to the bio-psychosocial context of patients and to their informed preferences when crafting treatments requires expertise and practical wisdom.”  Their article focuses on incorporating patient preferences into guidelines, however they also argue for a certain expertise and judgment that is part of professionalism.  They make the point that “guideline panels should rarely formulate strong recommendations.  Panels should become much more comfortable with ambiguity, both in the tradeoffs involved and in the recommendations given, and explicitly report how patient preferences and context were considered in formulating the panels’ recommendations.”  Presumably, if the guidelines are partially based in ambiguity and patient preferences--which vary from patient to patient and are part of the puzzle--an experienced professional who can customize those guidelines is a critical element of good care. 

In a blog post from the American Journal of Nursing, Karen Roush, a nurse practitioner, discusses her experience working in a retail clinic. She ultimately left that position because, she says, “the computer was in control. From the moment the patient checked in at the kiosk outside my door, every action was determined by the computer…The organization I worked for prided itself on following evidence-based practice, but someone forgot to tell them that the patient’s history, presentation, and personal experience, as well as a clinician’s expert knowledge, are also part of the evidence.”  She spoke of her slavery to the computer leading to bad medicine:  “It interferes with two really important skills – critical thinking and intuition based on experience.” 

Ms. Roush, in speaking about critical thinking and intuition based on experience, is talking about elements of healthcare professionalism.  Professionalism implies a certain moral commitment and an ethical approach that is individualized and transcends any particular job a professional may hold.  Lynne Kirk, in a 2007 article in the Proceedings of the Baylor University Medical School, gives a variety of definitions of medical professionalism and notes that all the definitions share a focus on patient welfare, altruism and trust:  “Market forces, societal pressures and administrative exigencies must not compromise this principle.”  Definitions of medical professionalism also share a commitment to patient autonomy, which implies being honest with patients and empowering them to make their own appropriate medical decisions.  

Tom Lee from Harvard and Partners Health System in Boston makes this point, as well, in a Health Affairs  blog post-- “Patient Experience Will Drive a Renewal of Professionalism”--in which he advocates for more robust measurement of true patient preferences and patient experience.  He writes: “My strong belief is the emerging focus on measurement of the patient experience takes health care in the right direction, one that will restore and give new pride to physicians and other clinicians.”  Notice he uses the word “restore” in acknowledging that in our present medical world, professional pride may be lost.  He goes on to say that we have to understand patients’ needs.  “Measuring patient needs is the right focus for physicians and other clinicians. It is the essence of professionalism.  What is not the core of professionalism is performing high volumes of services that are reimbursed under the fee for service system.  Nor is reducing spending on populations of patients under capitated contracts.  Neither of these business objectives are inherently wrong, but these financial strategies are of limited relevance to any thoughtful sense of professionalism for clinicians.”

Accolade Health Assistants®, when helping clients with needs that are clinical and social and psychological and financial, have to maintain professionalism at all times.  We are professionals helping people and to be effective, we will always use and communicate best practice, evidence-based protocols.  At the same time, we will always customize those protocols so that the autonomy and unique aspects of every person is respected.  We will, as an organization, work to better develop our own algorithms and evidence-based protocols that address our clients’ social, emotional and financial needs in relation to their clinical needs.  At the end of the day, we will also use our own critical thinking--and even intuition based on experience--as Karen Roush says, to help meet the needs of those people we help every day. 

Victories

There are victories of the soul and spirit.  Sometimes even if you lose you win.

                Elie Wiesel

It is amazing how victories can be small – even invisible to others – and can manifest in the darkest of situations and times, and yet still have a major impact.  This past week, that truth was brought home to me yet again, as I shared a stage with a number of very prominent women leaders in health.  I was fortunate enough to be part of a panel discussion at the Women’s Healthcare Innovation and Leadership Showcase sponsored by the Metro (NY/NJ/CT) chapter of the Healthcare Businesswomen’s Association .

On that panel were very smart women who are passionate about changing the world of healthcare. Two, in particular, spoke forcefully and eloquently about the seemingly small, individual efforts that—when multiplied—can change the world. 

Dr. Julie Gerberding, President of Merck Vaccines and the former Director of the Centers for Disease Control, spoke of scrubbing toilets in a small African village and realizing that clean water and empowered mothers in this village could change the world.  She talked about women who had nothing finding ways to fight cervical cancer by working together with community support.  In the midst of the poverty and squalor of a small village in Africa, Dr. Gerberding saw hope and strength in the women she met and worked with. 

Dr. Anne Beal, Deputy Executive Director and Chief Operating Officer for the Patient-Centered Outcomes Research Institute, remembered a poor single woman, who—upon discovering she was pregnant—spent weeks and weeks fighting her way through the system to obtain Medicaid coverage so she could receive the right prenatal care. Finally, at 24 weeks of pregnancy, she saw the doctor for the first time—and discovered she was carrying triplets. Dr. Beal spoke of that woman’s great strength, and of her ability to obtain care for herself and for her new family when she delivered prematurely. In a situation that some would find hopeless, Dr. Beal and that brave mother saw triumph. 

In both of these leaders’ stories, I could hear the satisfaction and joy each had in helping these women in the worst situations achieve small victories.  We were not talking about dramatic lifesaving surgery, but rather about the commonplace issues of clean toilets, routine exams, and Medicaid coverage. 

And the entire meeting was energized by their work and their words.  These moving stories made me think about my own personal journey and the fact that I was most inspired by playing a small role in helping someone find the “victories of the soul” as described by that great writer, Elie Wiesel.   While I was in college, I taught guitar to children with brain injuries. My talent at guitar was such that I could only teach someone who had physical disorders of coordination (which is why I am not playing guitar on stage these days, but talking instead).  When I saw a child’s satisfaction at mastering a note, I did not know that I was working to change the world, but helping those young people master motor control and gain confidence was earth- shaking. 

My sister has recounted her own experience as a special education teacher, helping a small child in a wheelchair at Halloween.  That little boy—dressed in his costume—came to her class in his wheelchair for their Halloween party.  He was so excited about the costume! When my sister greeted him and told him what a great costume it was, he asked, “How did you know it was me?”  He was not, at that moment, a sick child confined to a wheelchair; he was just a kid in a costume acting like any other kid. 

When I was in practice, I often treated patients who were terminally ill.  I was given the privilege of being with people at their time of greatest need, sharing their fears and their hopes, helping them communicate with their families, and helping them feel valued and heard by those they cared about in their last days and hours.  The victories I saw as they spent their last days with those they loved were inspiring. 

My wife (a specialist in clinical genetics) helps parents every day whose baby is born with a severe genetic illness, often terminal, as they struggle to accept that reality and create new hopes for their child—if that child survives—and for future children.  When she sees an older child with severe disabilities and greets the child playfully—as a child and not as a “specimen” with severe impairments—parents understand that she sees their son or daughter as a unique person.  Those are huge victories for the entire family. 

Good, experienced clinicians —and health policy leaders like Drs. Gerberding and Dr. Beal--know this secret almost instinctively: When you help people achieve small triumphs, victories of the soul and spirit, you help them achieve higher quality care—and you also save money for the entire healthcare system.  When that villager is able to help her community get clean water, the entire health of the community improves.  When the mother of triplets can advocate for herself in the confusing and difficult systems of healthcare and health benefits, the care her children will receive is better, and the chance of those triplets ending up in the hospital for prolonged stays drops dramatically.  When the family of a terminally ill child is able to avoid unnecessary, often uncomfortable tests and procedures--and the parents can hold their baby for those last precious hours instead, it is better for the parents, the child and the healthcare system.

At Accolade, I am privileged to have helped build a system that helps people every day in small ways. We help people get those small victories every single day—the victories that allow them to improve their health, live their lives, and maintain autonomy over their own bodies and their own decisions.  I get to play a part of the interactions our Health Assistants have daily. I know that as we help each of those people in small ways, we are changing their individual worlds and helping the broader health system and community, as well.   

 

 

Bad Habits or Critical Thinking?

Danielle Ofri, a physician at NYU Medical Center (in New York City) and a New York Times contributor, is one of my favorite medical commentators. Her insights and judgment into issues such as the use of the medical narrative are impeccable. However, I wonder if in this recent opinion piece she might have missed the mark a bit.

In this article, she takes herself to task for a “bad habit” of not following the ‘Choosing Wisely’ guideline from the Society of General Internal Medicine (SGIM) concerning routine visits. She still sees her patients routinely for health checks, even though this particular SGIM guideline states “Don’t perform routine general health checks for asymptomatic adults.” The guideline then goes on to explain:

 “Routine general health checks are office visits between a health professional and a patient exclusively for preventive counseling and screening tests. In contrast to office visits for acute illness, specific evidence-based preventive strategies, or chronic care management, such as treatment of high blood pressure, regularly scheduled general health checks without a specific cause including the ‘health maintenance’ annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing.”

And yet, while Ofri considers her own actions to be bad habits, I consider them good critical thinking—and good instincts. I believe this “bad habit” is really related to a deep understanding she has of the doctor-patient relationship—an understanding not reflected in the guideline.

While this guideline (and the many others that accompany it) is well-intentioned and an important step toward making us all wiser doctors and patients, it’s also important to think critically about it.

The guideline is based on scientific studies of populations and the population effect on reducing morbidity, mortality and hospitalization, but it doesn’t take into consideration other studies that have documented the eroding trust in physicians, as well as the studies that document the morbidity increases resulting from lifestyle diseases.

I find it difficult to separate these two issues. Patients must trust their doctors if they are to follow doctors’ advice concerning lifestyle, as well as the more immediate advice doctors give suggesting diagnostics and therapeutics. If patients are going to take medications as they were meant to be taken or undergo a diagnostic test that will ultimately help them better, they must have a relationship with the physician built on trust. That kind of relationship only happens when the doctor gets to know the patient as a person—not just his or her physiology and health risks—and that requires regular contact between a doctor and an individual.    

In today’s world, it is more important than ever to think about what happens outside of the doctor’s office as well as what happens inside it. Before the person ever sees the doctor, how does he or she decide whether to go in the first place? It often depends on how much trust a person has in that doctor—and how much value he or she thinks the visit will offer. In an absence of trust, a person may not even go to the visit—and miss an opportunity for early treatment.  Or, when that person leaves the office, will he or she act on the physician’s advice?  What if the physician wants to try “watchful waiting,” which requires a great deal of patience and confidence in that guidance?

We should ask ourselves if the guideline’s goal should also be related to trust. Shouldn’t trust be at least as important as the epidemiology of a borderline cholesterol level? Perhaps the real benefit is not just in treating that borderline cholesterol, but comes home to roost 1 or 2 years later, when—in an urgent situation—the person actually calls the doctor he or she trusts.

Many years ago, I ran a nutritional support service and made regular home visits to the patients we treated. I found I learned the truth about what patients were really doing when I went to their homes. I learned about the real-life barriers that prevented them from following the advice I gave. I formed a bond with them that was related to my willingness to meet them where they were, not just emotionally, but physically.

In healthcare, we are beginning to recognize the importance of shared decision- making—in which the doctor and the patient jointly decide the best course of action. This can only occur with trust. It only occurs when the doctor knows the person, and not only the patient. It only occurs when the patient believes the doctor has his or her best interest at heart--and not the best interest of the health system they work for, the government, or even society as a whole--no matter how “noble” that may seem from a population perspective.  

Perhaps we could modify the Choosing Wisely guideline so that we avoid lab tests at those yearly visits, but maintain the yearly visit itself to help maintain the bond? Perhaps it should even be a yearly home visit (although I suspect that would not be warmly received by most doctors or health policy people) to really see all that the patient and the family unit has to deal with in order to try and stay healthy?  A modification in the guideline that fostered trust and relationship building could result in better care and even more cost savings.

I applaud Dr. Ofri’s instinct to follow her own path, rather than following the guideline in this case. Her voice will help SGIM and all those involved in setting guidelines better understand that healthcare needs trusting relationships as much as it needs science and epidemiology. I hope that she continues to use the critical thinking skills that are reflected in so much of her writing to build trust and motivate patients so they call when they are in need--and follow the sage advice I am sure Dr. Ofri gives.