Tuesday, 18 September 2012

Letter to my nieces

A letter to my nieces

Sam (USA)
– who has just joined med school this year


Mayank (India)
- who completes med school this year

Dear Sam and Mayank

Congratulations. Sam you have done well to get to med school. Mayank you have done great and will finish med school later this year. You are in the top 2% of the academic performers and you will continue to remain there at least till you begin independent clinical practice, hopefully many decades into your clinical practice.
I write this in joy but more relevantly to provide you another window for your intellect and for your practical development.

I did Anatomy, Physiology and Biochemistry in my first year at med school. There are not many more accurate and fact based subjects than these in medical education. Fact after fact, learnt day after day. We realised that these facts were the foundations of our future careers, we took it really seriously. We demonstrated our mastery (okay, personally I just demonstrated my mere competence) by passing tests and exams. It was tough. It was worth it. I was satisfied that my foundations were good.

These fact based subjects left an indelible impression in my mind that medicine and its practice was based on accuracy and facts. When the facts varied, such as when the cystic artery was double or it was low lying and so on, they were grouped into sub-facts to be remembered for future reference and practice. Some facts were actually a range of facts as in the normal range of plasma sodium values and so on. Later on while attending physiology classes at the Royal College of Surgeons at Edinburgh, the tutor would squeal in dominant delight ‘either you know it or you don’t’; no more powerful, explicit message for post-graduate doctors about the need to be precise and accurate. A message that I heard many years earlier in first year med school and repeatedly thereafter.

As we moved along we recognised that subjects like pathology and microbiology begin to interfere with subjects like anatomy and physiology and gives rise to trouble in real people. Help was at hand for us to understand that. Pathology text books showed clear microscopic slides on how every pathology looked, again where there were variations they were classified as yet another group of facts.  I got the impression at that time that if that’s how it looked, that is what it must be. That kind of thinking was compatible with the fact based approach of anatomy and physiology. All this knowledge was then put to practical use by learning even more glamorous and glorious subjects such as surgery, internal medicine, gynaecology, et al. Those were exciting days.

We continued to learn from revered text books on the one hand and from revered teachers on the other. Patients had clinical problems, we used our knowledge to diagnose them (CT scans were extremely rare when we were medical students and ultrasound scans were just taking off and x-rays in general provided basic support) and applied our knowledge to treat them. Of course things did not always go well for patients, we still call them complications or morbidity, sometimes patients died, we classify that as mortality.

As we gained experience often as post-graduate doctors we began to realise that all of our revered teachers did stuff very differently from each other while they were dealing with similar problems. The cleverer of the lot justified their different styles of practice by references to science, the rest told us that their experience suggested that their practises were valid. Our professors and consultants told us that they acquired their wealth of knowledge so that they can give their opinions. One sudden day we recognise that we learn medicine on the basis of knowledge and practise it on the basis of opinion. On the basis of very very widely varying opinion.

We begin to wonder. If the learning in undergraduate medicine was based on accurate facts, why is the practice of real world medicine on the basis of hugely varied opinion? We brush aside these discomforting thoughts. We have not only made a huge investment in our knowledge but also in our method of acquiring and practising that knowledge.

Pathology text books did not tell us that two pathologists looking at the same slide could give you two different opinions, not often but certainly possible in the definition of complex cases. We were never told that the text books that we read were by definition about five years out of date or that at worse some of the editors edited those books while travelling in their ultra-luxury cars between various locations of their private practices or at best after a couple premium alcoholic drinks in their study. We were realised that when our teachers said the words ‘in my experience’ it did not mean objectively measured operational experience but meant their personal subjective understanding of how they thought they performed.

In medical practice there is evidence for everything and there is evidence for nothing. This provoked David Eddy, the American father of evidence based practice (oh, by the way evidence based practice has two fathers one American and one British) I believe to say something like that you can find two physicians to testify in court to the exact opposite views.

Nobody will tell you yet that

Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence
Substantial activity in clinical medicine cannot after care delivery find evidence to back it
Substantial clinical care is delivered incompletely
Substantial amount of errors are found in the delivery of care
Substantial numbers of clinicians are either unable or unwilling to accept the above

These issues are not just academic, they have great direct impact on patients and their lives. We did not know at med school that there was an entity called avoidable mortality; when we first heard about it we found it unbelievable for the reason that if it was avoidable us clever and experienced doctors would have already avoided it. We did not know at med school that practice of healthcare is highly error prone and extremely unsafe; when we came to know about it we did not believe it. Despite this we and the public, trust ourselves - the medical profession; we trust our high intelligence, our extreme hard work or proven record of success for ourselves and for our profession. We are brilliant and we have faith in ourselves.  The brilliance of the medical profession is also blinding itself.

The lack of evidence and the opinion based practice results in hierarchical power games. Those who are unable to play become bad apples initially and ‘poor performers’ later. Now, imagine that, top scores at school graduation, long mind numbing hours of hard work for years, proven success in exams and other challenges, then eventually being called incompetent or poor performer or some other derogatory term by people who practice the art of medicine while imagining it to be based on facts and evidence. Worse still these phenomena perpetuate the wide clinician generated variations in practice. Doctors are intelligent and learned enough to be able to justify their individual practices as evidence based; that is of course true. What is important to understand is that their justification is based on the evidence they choose to base it upon. My evidence is the truth and nothing but the truth but not the whole truth. Simply because firstly the whole truth probably is not already known, secondly the whole truth is too vast to know and thirdly in healthcare the whole truth often has a tendency to contradict itself.

I write this not in despair, not to distract you, but to give you hope. Because the solutions for embracing a world of wrongness and still do good to the maximum number of your patients are already out there. I want to briefly introduce you to that world and I want you to be aware of it. These are the shades that you wear when you are out in the bright sun, it will also make you look cool. It might make you comfortable in a world of contradictory evidence.

In conventional science based research oriented world there is probably nothing that is absolutely true; there is a current hypothesis which we attempt to validate or reject and the hypothesis stands till it is rejected. You will find that most hypothesis in medicine are rejected over a period of time, this gives rise to problems in clinical practise as the research that is good today becomes ‘false’ very soon. However, that is how research and science works. That is how it should work. However, in our routine clinical practice we do not work as researchers, we work as operational practitioners. My suggestion therefore is to look at operational methods for a good clinical practise and use to them to the best benefit for your patients. These derive from the shared baseline approaches devised by Brent James and his team at Utah.

At a basic level, a good shared baseline method looks like this

-         - You agree with your immediate and local colleagues on a protocol for most common problems that are seen in your clinical practise
-         - You track the outcomes over time of some of the process and outcome parameters of the protocol that you have agree
      - You amend your protocol based on the outcome tracking
-         - You show deep and genuine respect for everyone who works with you
-         - You share and learn operational clinical day-to-day practise first and primarily with/from your immediate and local colleagues before you do so with the rest of the world

Intermountain Healthcare does this, they probably discovered this method. IHI recommends it (I suggest you become members of IHI open school), people at Mayo, Virginia Mason, Jonkoping and a few others have their own versions of this. The method though, is not one of a pick and mix buffet, one has to do them all or get no benefits from them.

I suggest that you start exploring this kind of thinking in parallel with your conventional learning, not for fact based subjects but for the rest of them. We are all creatures of habit, attitude and cultures. It will be very difficult to change once certain mindsets are established. The energy and effort required to do it now in parallel is much less than to do it later. Your patients will get remarkably far better results and your systems (your patients, insurance, hospital, yourself) will spend far less on a like for like basis.

Many doctors will understandably be either uncomfortable or unwilling to accept or follow this kind of practice. They will deride it as cook-book medicine run by technical managers interfering in clinical work. Obviously the ignorant will be prone to say what they want, that will be a reason to work to remove the ignorance not to forget the observed truth, unlike conventional healthcare practices and religion with its believed truth, this method is really the observed and demonstrated truth. Of course if you decide to choose conventional scientific research as a career then these methods are not suitable for you but if your life is that of a normal operational clinician then these are entirely relevant. I do not expect you to understand the new method fully, it will be a reason to learn it in due course. Enough for now to be aware that there are plenty of problems and there are proven solutions – just a matter of putting them together at the right time.

The wrongness that exists in medicine will not go away, that can only be solved by scientific research and one day you may in your lifetime find that medicine is based purely on scientific evidence. Till that time, awareness of, learning and practising the shared baseline method will give you superior results despite the wrongness around you.

As you stand on the threshold of entering into a new world, I wish you every success and great happiness in the practise of your profession. There can of course be no greater professional joy for a doctor than to see more of their patients get better.

August 2012

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