Changing the doctor-patient relationship

OPENING THE BLACKBOX OF CLINICAL JUDGEMENT

A 15 year old girl went to her doctor with excessive fatigue, shortness of breath, weight loss, and amenorrhoea. On examination she was found to be mildly hypotensive and to have numerous moles. Initial laboratory findings proved borderline or normal. Subsequent diagnostic and treatment efforts focused initially on common conditions. Despite a number of admissions to hospital, and many more tests, the diagnosis remained elusive. After several months and serious deterioration in the girl's condition, Addison's disease was finally diagnosed. She began hormone replacement therapy and rapidly recovered.

This case history from the New England Journal of Medicine in 1996 shows just how difficult it can be to diagnose rare conditions when doctors initially focus on general knowledge about large populations. But, according to Lawrence and Lincoln Weed, this approach is backwards. What is needed is to focus on the individual combination of symptoms and signs, and to then work out what such a combination suggests. In this case it would have become obvious that Addison's disease was likely for this girl, and it seems that the only barrier to an earlier diagnosis was the physicians' lack of ability to couple the readily available findings with medical knowledge.

In Hippocrates Revisited, a 1973 collection of essays by some of medicine's elder statesmen, Herrman L Blumgart described the physician's role: "The art of medicine consists of the skilful application of scientific knowledge to a particular person for the maintenance of health or the amelioration of disease. For the individual physician, the meeting place of the science of medicine and the art of medicine is the patient.... But scientific knowledge is more readily taught, whereas the application of knowledge at the bedside is largely the function of the sagacity inherent in or personally developed by the individual physician."

Yet scientific knowledge is too vast to be "readily taught," and the personal "sagacity" of doctors is too fallible to assure the unfailing application of medical knowledge at the bedside of every patient. Both the knowledge and the hands-on skills of physicians too often fall short of what their patients need. Thus, medical error, random variation, and waste on a large scale have been documented in medicine for decades.

The doctor-patient relationship needs new tools and approaches for practising medicine, so that each patient can have some assurance that the best medical knowledge and high levels of skill are always brought to bear. To accomplish this goal, healthcare institutions must, before measuring outcomes of care, focus on controlling inputs from doctors and other clinical workers.

The way we make medical decisions, for example, can be improved dramatically with the use of simple software tools for guiding the collection of patients' data and linking that data with an enormous medical knowledge base. This is a task that is too complex and time consuming for the unaided human mind to accomplish reliably. But new information tools and software can free doctors and their patients from such cognitive limitations.

Practitioners who have made systematic use of such information tools find that they acquire a new view of both medicine and the doctor-patient relationship at many levels. Not only do they escape their own cognitive limitations, but they gain new insight into the limitations of medical knowledge itself. The tools that permit such comprehension not only advance the science of medicine but also enable patients themselves to comprehend and participate intelligently in medical decision making. It then becomes apparent to all that the personal knowledge and commitment patients bring to their own care is frequently no less important than any expertise the doctor can bring.

Before we expend yet more resources in medicine, we must first employ new tools to better use the resources we have. Resources will continue to go to waste as long as we persist in false ideals of physicians' competence and authority.

Competing interests: LLW is president and shareholder at PKC Corporation, which develops and markets software described in this article. LLW is the father of LW.
 
 
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Relevant Article

The changing doctor-patient relationship

Vincent McAulay, Lawrence L Weed, and Lincoln Weed
BMJ 2000 320: 873. [Extract] [Full Text]

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Rapid Responses:

Read all Rapid Responses

Physicians'' competence

Vincent McAulay
bmj.com, 17 Nov 1999 [Full text]

Re: Physicians'' competence

Lawrence L Weed
bmj.com, 25 Nov 1999 [Full text]