> There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though. It’s all shooting in the dark, and most of the time I felt like I could have done just as good a job on these longterm issues...
This articulates very well what I've usually felt when dealing with doctors. It's like the story of a programmer finding that his code outputs 5 when it should be 4, and then adding...
if(return_value == 5):
return_value = 4
...to fix it, and being satisfied. What I want is something like in the television show House. The main character is unhinged and anti-social and takes extreme risks, but at least he demonstrates curiosity to really figure out and understand the root of what's going on. To be fair, I don't actually think that doctors lack curiosity or are incapable of doing this, the medical system as it's set up just doesn't allow it. For chronic issues, I've usually figured them out for myself, as a layperson, by persistently keeping track of things, searching the web, reading, and experimenting over months and years.
The main thing that House MD has, that no other doctor in the world has, is not so much his superior intellect. It's that he and five other doctors spend 100% of their time on a single case, and can sit around all day discussing it, trying different things. If real world doctors had even a fraction of that luxury, you would see a lot more of what you describe.
Yeah, that's what I mean by the medical system just not being set up to allow this. I generally see a different doctor every time I make an appointment, because I'm assigned to a team in a clinic with constant turnover, the appointments are 20 minutes long, and the doctor easily spends more time on boiler plate stuff in the computer system than examining and listening to me. I don't even think they have time to look over the basic medical history, let alone have a whiteboard session to consider all the pieces of the puzzle and brainstorm possible explanations.
Jeez, no kidding. I imagine if they made a realistic doctor show they'd be constantly showing the doctor at the bar (on days off) trying to make money on side gigs like health startups.
Stumbling in a hangover to appointments on "work days" and giving everyone the same diagnosis as the last (and likely whatever sickness they themselves had recently). Also giving everyone fluids and an ativan so the patient says - "i feel much better doc".
It's kind of an open secret that the ER just gives a diagnosis of dehydration, provides fluids and ativan to get the pipe rolling and charge $4k a pop. Sure they might catch a case of undiagnosed covid, rsv or something else from time to time.
Also I'm not kidding but I would LOVE such a show.
You should check out The Resident. The first several seasons are about the doctor invested in a device that is a fraud, a private equity group buying the hospital, it eventually failing.
Chicago MD has some of the aspects you mention, especially overloaded, drug abuse, blame, police interactions.
New Amsterdam attacks it by the main character trying to solve the problems and running into bureaucracy.
I rank New Amsterdam and the Resident better for the hospital politics; Chicago MD is more short episode drama (though does touch on mental health and social services more.
Back when ER was a hit show, there was survey among medical professionals and hospital staff asking for their favorite medical drama series and the reasons for it. Grey's Anatomy, and similar series, constantly beat ER. The reason was that medical staff considered ER way too realistic. Makes sense, why would I entertain myself during my off hours with what is basically a documentary about my on-duty hours.
You would not. 5 doctors talking about your case wouldn't help much.
People really don't understand the dire and primitive state of current medicine.
We are in the dark ages. We don't know why most drugs work; we have some notional idea but it's often an after-the-fact fiction that we tell. We don't know what causes the majority of diseases. In many cases we don't have treatments for the underlying problems, we only have treatments for symptoms.
If you want to see House MD, then tell your congresspeople and senators to invest in funding medical research so we can one day maybe leave the dark ages.
I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers.
What you should want is curious and creative _researchers_, but precise and totally unimaginative clinical staff. Those are often the same person. See the problem? You want protocols applied down to the last detail. You want nothing left out of standard operating procedure. That's what kills patients in practice.
You might mean creativity in the sense of "let's have guys who think about the right things, and search for rare diagnoses and analyze stuff to see what could work, like Dr House". But that simply can't be done in practice. You can't be testing for every rare thing, because the tail of low probability diagnoses is much too long! And believe me, you _really_ don't want creative doctors around...
Maybe you don’t want creativity in the ICU, but as a patient with chronic health issues, I do want creative clinicians. Over and over my entire life, I’ve gone to doctors with health issuesand watched as they mentally plug my symptoms into a flowchart that they learned in medical school, then they find that the symptoms don’t match anything that a standard protocol can treat, then they shrug their shoulders and say they can’t do anything. The latest case of this has been severe blood glucose drops in the middle of the night that wake me up with a pounding heartbeat. I waited four months for an appointment with an endocrinologist, then was told I don’t have “true hypoglycemia” because it’s not corrected by eating. End of story. No curiosity. No help. Goodbye. Again.
Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably.
I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.
Completely agree. Any educated layperson can figure out and follow a clinical decision tree. I mean it can work in your favor if you know you need something and know how to get the decision tree to give you what you want, but otherwise clinicians should definitely be actual experts and not just meat following something a computer could do
You still have the problem of writing a sufficiently detailed tree. I had a blood test last year and when I discussed the result with the doc, he asked me the clinic location where the blood was taken, because then he could estimate time between blood draw and lab test and interpret the result accordingly.
It might be different where you live, but where I am, the vast majority of blood tests are not done at the hospital.
Family doctors and lab test centres do it.
What I meant is that I can follow it for myself, not do it for others. I don't have the training to know every medical decision tree by heart, but I can look up ones for problems I have and apply them.
I am a bit biased because I have several medical professionals in my family, but a common refrain is definitely that most doctors/nurses aren't going to be that engaged and helpful, and are more of a input/output device to navigate rather than someone you want to completely defer to.
Are all doctors working these hours? I thought these were the hours for residency, not the average general practitioner or specialist working outside of a hospital. If they’re working 15 hours a day, why are they only open 8?
Yes, it's so tiresome and frustrating. I once had a period of a few months where my sleep was down to around 5 hours/night (normally I would get 8-9), I was exhausted and my body just wouldn't sleep more than that. Went to a doctor who offered a couple of thoughts "some people only need that much sleep" and "there's only one thing it could be, but that's not what it is". He wasn't even going to test the "one thing" until I asked if he would. Turns out he was correct that that wasn't what it was, but obviously there was at least one other thing. My sleep ended up returning to normal though I still have similar periods where I can't get enough sleep.
The only medical practitioners I've found willing to be more curious and to take a more holistic approach are naturopaths. I have had some notable improvements in my chronic health issues working with them, though I am a little uncomfortable with them given their general openness to things that seem pretty questionable to me (like homeopathy).
I think when dealing with chronic issues, it might be better to optimize for luck. [0] A little ridiculousness like homeopathy might be worth it to find the thing that actually works.
Thank you for this link. Well written and mirrors a lot of my experiences though I am still looking for my 'miracle cure'. I think this could be helpful for sharing with other people in my life who don't understand why someone would stray from an empirically/scientifically sanctioned approach.
Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`.
For less fancy options, “#” and “number ” would both be better choices and easier to read than “n°”.
I was not familiar with keyboard layouts including DEGREE SIGN handily, so I though there was at least a decent chance you had deliberately gone fancy. (I double-checked that it was ° and not º U+00BA MASCULINE ORDINAL INDICATOR, which I would expect to see on some keyboards, and “Nº” is incidentally distinctly better than “N°”, since it’s the shape of an o rather than a circle.)
To the best of my knowledge, I have never come across “n°” before. “№” plenty, “#” plenty, “No. ” plenty, “no. ” a few times, but not “n°” with a lowercase n.
I think another aspect that made it harder for me to recognise immediately was the lack of a full stop; I’d probably have recognised “n° 1” a bit faster. (I’d write “№ 1” rather than “№1”, though personally I’d go fancy with NARROW NO-BREAK SPACE, but that’s ’cos I enjoy doing crazy things like that.)
P.S. I live in Australia. Similar Anglocentrism to the USA in language, though less pronounced in matters of culture.
I appreciate your perspective as a professional in this area.
Yeah, I'm not really looking for doctors to demonstrate creativity (although House does), so I don't think I'm asking for anything at odds with evidence-based medicine. What I'm saying is that I think you need to get to the bottom of what's actually happening (i.e. why is the program outputting 5 when it should be 4) before you can know what evidence-based medicine to apply in a "precise and totally unimaginative clinical" way to actually fix the problem. As a patient, it just feels like the system, and therefore the doctors in the system, lack the curiosity to figure out what's actually happening. We often get the treatment for the most common issue even though it doesn't quite fit the real issue, or the common issue seems to just be a downstream effect of the real issue.
Curiosity is essential. Eg guy with chest pain and trop rise gets sold by ED as a NSTEMI. But why is the pulse pressure so high? Hang on what is that scar on his back? Oh he had an aortic root repair 20 years ago after a car accident... Ok I’m calling in the radiologist at 2am to do a CT angiogram. Sure enough, his aortic root repair is failing, and he has new onset AR. Curiosity saved that guy’s ass, following the protocol would have probably killed him.
Creativity also has a role for non-critical conditions when standard treatments aren’t working.
So curiosity as a remedy for systemic failure to perform a full exam and actually do the job correctly in the first place? Not a very convincing argument.
Not really, the clinical signs were subtle, I couldn’t hear the AR. If you had a ‘protocol’ to pick up these edge cases, you would be doing a CT and echo on every chest pain that walks in the door. The workup was perfectly evidenced based and standardised.
I don’t think it is ideal to operate this way though, to be clear. Obviously this could have easily been missed by me or anyone else. But you aren’t arguing that point. You are approaching it from the perspective of minimising the variance in clinical quality. I don’t agree with you that this requires standardising how clinicians are, not just what they do.
If medical treatment was actually as formulaic and fully-solved as you imply, we wouldn't take the best students of every generation and make them spend ten years training to become doctors. We'd just have nurses, checklists, and diagnosis flowcharts.
Medical treatment is obviously not fully-solved, or anywhere close.
But it is just as formulaic as described above. The doctors aren't trying to solve your issue. They're following a flowchart, and if that doesn't work for you, that's your problem, not theirs. Next time, be a better patient.
I've had doctors tell me "Good news! You don't have a problem!" when they were testing me to see if they could explain the problem I have. It's good news for them, because their next step is to tell me to fuck off. It's not good news for me, but apparently they can't tell the difference.
I'm precisely not implying that medicine is currently "fully solved". I'm implying that we should strive to gather more information, synthesize it better and study how to make it useful.
As a clinician, I'd say yes to a bicycle for the mind. But currently, my job is already plenty full with worrying about applying what's known in a correct manner without seeking to break new ground while treating patients, which would be very dangerous and given the odds of success, very stupid. What I'm implying is that the general public has a completely skewed view about what really kills patients in the ICU: mundane infections and "medical errors", which are not really errors at all but in a large majority of cases failures and complications of usual procedures.
General Practice medicine seems to come close enough. No differences in patient outcomes between physicians and nurse practitioners.
> Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care
> Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).
House is not real, it falls under "arguing from fictional evidence"; House's patients are written by a writing team to have obscure and surprising - yet easy to fix - ailments. They are generally young with acute short term symptoms leading to a race against time and a boolean toggle outcome healed/dead. They are rarely the 70+ year old ICU inhabitant with age related complications who is mentioned in the blog post with long periods of 'boring' illness to keep track of and treatment rotating between many doctors.
House gets to choose his patients, he pre-rejects any that he doesn't want to deal with or has no ideas about, or no interest in. Real world doctors can't do that. House gets to do basically any test for any cost without having to justify it or argue with insurance, scheduling, resource constraints, practicality or side effects. If he needs an MRI, it's available, if he needs his team to spend all night tonight on blood tests in the lab, they can do that and the lab is there and they have no consequences tomorrow of having no sleep.
House has plot immunity, the worst that happens to any hospital employees as a consequence of his behaviour is the loss of a lot of potential money, or some paperwork or audit. The show never focuses on the life of the patient who has to be on dialysis forever because of House's risky intervention before he knew what was really wrong. House blackmails and barters with and sleeps with the hospital administration to get away with things no real doctor could do.
House and Wilson are named as a play on Holmes and Watson, and the original Sherlock Holmes books were notable because Holmes walked the reader through deducing interesting conclusions by looking at evidence anyone present could see but with a fresh viewpoint, things like the height of scratches on a wall. Recent Sherlock TV shows and films, he's written to magically know things that nobody could know, by means the viewer isn't shown and can't participate in, and presents them as amazing accomplishments to wow the viewer. House is the latter, in an episode I saw recently (Series five, episode 1) he is absent all episode with the usual array of organ failures and suspected pregnancy and suspected cancer, then in the last five minutes he walks in, stabs the patient in the leg, declares she has leprosy because she looked youthful, and walks out. And of course she has leprosy. It's not even good storytelling, it's a background thread for House and Wilson's interpersonal problems and his assistant's own terminal disease diagnosis.
Or to put it another way, you read a blog post about heoric troubleshooting of some tech problem and it's good reading. That's self-selected from someone who had an interesting problem and the time and skills to diagnose it and the luck of it coming to an interesting conclusion. Most troubleshooting is not that, it's mostly the basics over and over, or it's above your skill level or outside your skills, or it might not be but you can't spend time on it, or it comes to a boring conclusion like "we never got to the bottom of it before the system was decommissioned".
In Series 3, Dr Foreman goes to be head diagnostician at another hospital, pulls a House move of risk taking treatment, saves the patient, and gets fired. The dean of medicine tells him the procedures work for 95% of cases, and everyone needs to follow them in all cases because everyone thinks their hunch is in the 5%. It works for House because that's the show.
This articulates very well what I've usually felt when dealing with doctors. It's like the story of a programmer finding that his code outputs 5 when it should be 4, and then adding...
...to fix it, and being satisfied. What I want is something like in the television show House. The main character is unhinged and anti-social and takes extreme risks, but at least he demonstrates curiosity to really figure out and understand the root of what's going on. To be fair, I don't actually think that doctors lack curiosity or are incapable of doing this, the medical system as it's set up just doesn't allow it. For chronic issues, I've usually figured them out for myself, as a layperson, by persistently keeping track of things, searching the web, reading, and experimenting over months and years.