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 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.
Affectionately
HEMADRI
August
2012
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