Wednesday, January 13, 2016

Yogi Berra and medicine

When You Come to a Fork in the Road, Take It 

Indecision is a plague in clinical medicine. We order tests and imaging in order to advance our understanding and direct our management. If we look at results and they do not point to a clear differential diagnosis, then we may end up in a cycle of testing and be no better off than we were at the beginning...

For example, vague interpretations of results may occur in radiology or pathology. Such phrases as "clinical correlation is recommended," or the instruction to order a repeat film or other imaging studies "if indicated," are sometimes the beginning of a road to nowhere: recommending a CT if an MRI was done, an MRI if a CT was performed, or an ultrasound if both CT and MRI were done...

I have also read reports where detailed findings were repeated verbatim in the impression section, avoiding an interpretation that would have clearly stated a diagnosis and recommendations for follow-up.

By contrast, a good interpretation can make all the difference...

An expert consultant should be clear in recommendations to a referring physician... A good clinician is willing to make a decision and stand by it. Over time, it becomes apparent whether that clinician has good judgment—which is the best skill anyone could have.

We Made Too Many Wrong Mistakes

Damage can also be done when we commit to a diagnosis that is the wrong one. If a patient originally receives a mistaken assessment, that label will follow them through time, passed on in the chart (the old days) or the electronic medical record (EMR). Confirmation bias or anchoring will make it more likely that no one will stop and reassess the situation, and much suffering can result. We used to say, "The old chart comes back to haunt you."...

When a person diagnosed with a psychiatric illness turns out to have a medical illness, it is a painful irony—another "wrong mistake." A case in point: A patient I saw when I was a student rotating on psychiatry was diagnosed with paranoid schizophrenia, when he actually had neurosyphilis and could have been treated with antibiotics.

And a wrong medical diagnosis early on can go unacknowledged for a long time.

You Can Observe a Lot by Just Watching

Overtreatment and overtesting are defects of all our technological advances: We can do it, so we do do it...

Watchful waiting—non-intervention-- can sometimes be the most effective intervention. During my housestaff training, the patient's medical chart included a vital sign graph on which we recorded blood pressure and pulse, daily weight, intakes, and outputs. We also were required to chart medications with a downward arrow indicating which ones were started, and at which times on the graph. This allowed us to observe the effect of each medication on the patient's illness course...

Today we have a new approach to some findings of radiologic tests: Instead of immediate surgical excision of a tumor, at times the "treatment" is watchful waiting—that is, nontreatment.

Sometimes, primum non nocere means "do nothing."

Fifty Percent of Baseball Is 90% Mental

I have to admit that I am not completely sure what Yogi meant by this, but I interpret it as a comment on the importance of psychology in baseball and also, for my purposes, in medicine. There is more to an illness than just the illness; how people fare often has a lot to do with their reactions to the illness. There are patients who are "not sick"—the deniers who deal with their illness by trying to wish it away—or those who are "too sick," in that they are so obsessed with their disease that they are completely controlled by it. The ones who do best are "just sick enough": They acknowledge the illness, but they also put it aside at times in order to make room for living.

As physicians, we have to treat the experience of the illness as well as the illness itself.

We Sure Are Lost, but We're Making Good Time

This is one of my favorite Yogi epigrams. To my ear, it applies directly to modern-day medicine, to  the ironies of our current delivery system, where guidelines, efficiency, and emphasis on the handoff and the discharge rule our behavior, and understanding is increasingly irrelevant. I have written about anchoring—how an early wrong decision can lead to a cascade of wrong turns—and how EMRs, so digitally convenient, connote accuracy and precision, but can sometimes enshrine and perpetuate serious errors.

A phrase we all have used, on one occasion or another, is, "We see that." Some of clinical practice—a lot, really—is guesswork, a heuristic, a shortcut, a sound bite, but we begin to mistake our habits for the truth. There is confusion between truth and custom.

Then again, we're making good time.

I Never Make Predictions, Particularly About The Future

The problem with prognoses is that they are sometimes wrong. Using population statistics is not always applicable to a particular individual; a patient has the right to be the exception to the rule. We may use guidelines and evidence to initiate treatment, but we need to know when to hold off on treatment, and when to modify the treatment plan if our first effort is not working out as we predicted (or hoped). There is a lot of uncertainty in what we do, and we should be humble in our pronouncements and encouraging of the future.

No one has a crystal ball.

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