Heroes Not Zombies

In How Doctors Think, Jerome Groopman, argues against the modern tendency to reduce human beings to averages and medicine to a slavish adherence to algorithms.

Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment….But they quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact.

There are some people who think “science” (which has been defined as the study of what can be measured – not a definition I would accept!) is about “facts”. By this they tend to mean phenomena which can be isolated and observed objectively. But human life is more complex than the sum of the bits that such scientists study. This is especially obvious to anyone who has worked in a Primary Care setting where patients typically tell stories of “vague, or multiple and confusing” symptoms and where the test results are frequently ambivalent. You can’t understand a person by focusing simply on the measurable bits.

Today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers.

You know, it’s almost considered heresy in some places to raise any kind of question mark over the hegemony of EBM, but if we want to be rational human beings who think for ourselves and don’t just do what others tell us, we should question those practices. Those who would try to divide all therapeutic interventions into “proven” and “unproven” and devise “guidelines” which  only allow for the availability of the “proven” treatments are going to stop progress in its tracks. There are not two fixed boxes in medical practice with one containing “proven” treatments about which all that needs to be known is known, and one containing “unproven” treatments about which we needn’t bother finding out any more.

Statistics cannot substitute for the human being before you; statistics embody averages not individuals.

When I read that statement I thought about a talk given by a statistician which pointed out that the average number of legs which each person in the UK has is less than two – yes, think about it for a moment – because thousands of people have lost a limb the total number of legs is less than 2 x the population of the UK, therefore the average number of legs a UK resident has is 1 point something! I know, it’s silly, but it does make a valid point – you can’t treat individuals as averages – frequently, there is no Mr or Mrs Average!

What is Dr Groopman’s recommendation in the face of this? Well, he quotes one of the doctors whose conversations make up the text of this book –

Falchuk paused “And once you remove yourself from the patient’s story, you no longer are truly a doctor”

Patients’ stories are frequently dismissed by scientists as anecdotes (and they say that contemptuously) but in clinical practice they are really the key.

Here’s to the patients! You are the heroes of your stories.