Wednesday, December 2, 2015

Professional intuition

Profession intuition — the gut feeling doctors get with experience and instinct that something just isn't right — is under assault, Robert Wachter, MD, professor of clinical medicine at the University of California, San Francisco, told the audience at TEDMED 2015.

"It's suspicious, it's soft, it's squishy," said Dr Wachter, the physician who, along with Lee Goldman, MD, coined the word "hospitalist" in 1996 (N Engl J Med. 1996;335:514-517).

"There's not an algorithm for it, it's not evidence-based," he explained. And "it's antidemocratic, it's paternalistic."

Patients are urged to become their own doctors, to scour the internet and question their doctor's diagnosis. "They're egged on to buy apps and wearables and sensors that will monitor everything from the speed of their heart to the content of their sweat," he said. They buy do-it-yourself tests and treatments.

Much of that is a good thing, said Dr Wachter. For example, a mother can monitor the glucose levels of her diabetic child and suggest changes in insulin levels.

Dr Robert Wachter (Source: TEDMED 2015)
But under some circumstances, the benefit of minute-by-minute data is lost. "I take care of desperately ill patients in intensive-care units, patients whose lives are hanging by a thread, and knowing their heart rate variations minute by minute isn't particularly helpful," he explained.

"How those kind of data are going to be helpful to healthy 30-somethings is, frankly, beyond me, at least at this point," Dr Wachter said.

Two things have happened in the past decade that have changed the patient role. First, the use of electronic records means that a patient's personal records are just a password away; this makes patient engagement easier and cheaper, because they no longer have to pay per page copying fees. And second, health plan deductibles have increased, so patients are using the internet to avoid the out-of-pocket expenses associated with a doctor visit.
This can lead to patients convincing themselves they have a terrible disease when they don't, or skipping a consultation and deciding they are fine when they need help.

"The doctor as god is not the right model here," Dr Wachter emphasized. "But the patient as doctor is not right, either," he said.
To illustrate the continuing need for doctors, he cited a lecture delivered by eminent gastroenterologist Franz Ingelfinger (N Engl J Med. 1980;303:1507-1511).

Dr Ingelfinger described how, when he developed esophageal cancer, he was bombarded with varied and confusing advice about treatments from medical colleagues and family who deferred to him because of his prominence in the field. They would ask him, 'What would you do?' Dr Wachter explained.

Finally a friend said to Dr Ingelfinger, who had become immobilized with anxiety, "What you need is a doctor."

"These questions — when you need to see a trusted and caring expert who can take on some of the responsibility, who can interpret the data for you, who can give you the information that you need to be an active partner in decision making, who can sometimes be a little paternalistic — are no longer just for patients who are physicians," he said. "They will be questions for all of us."

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