The NHS in England is trying out an approach to Primary Care where the patient accesses the GP Practice website, completes an online questionnaire about their symptoms, has their identity checked by a member of staff on the phone, then receives a prescription for a drug.
This is pretty much what happened during the great swine flu epidemic, except I think they skipped the ID check – answer 4 questions online correctly and win a box of Tamiflu. Honestly, I thought Medicine had reached a new low at that point.
Here’s what I was taught at Edinburgh University then subsequently in GP training –
Start with the patient’s history. By the time you’ve taken the history you should have a diagnosis, or a differential diagnosis (a list of possibilities).
Next do a physical exam as needed to confirm the diagnosis
If you still haven’t confirmed the diagnosis, then ask for any investigation which potentially will confirm the diagnosis.
The next stage is treatment options (I’ll come to that later)
I was taught the history is not a data set. It is a narrative. Patients come and tell a story. They don’t come to share data.
Data can be collected on examination and investigation which can help inform the doctor and the patient but data is NOT “the truth, the whole truth, and nothing but the truth”
Human beings cannot be reduced to data sets. Mary Midgely, the philosopher, said
One cannot claim to know somebody merely because one has collected a pile of printed information about them
As a GP I learned that some people present with “minor” ailments as a “ticket” to access the doctor. There is actually a bigger issue they want to address (often emotional, psychological or related to a more chronic symptom) and the “minor” ailment is what precipitates the appointment request – it is neither the sole reason, nor even the main reason for the consultation.
As a GP I learned that noticing the patient’s body language, their speech pattern, their hesitancies and word choices opened up the potential to explore what they were really experiencing and concerned about – and so allowed a fuller, “better” diagnosis – and so a more appropriate treatment.
As a GP I learned that eye contact, my body language, the way I formed a question all either opened up, or closed down, possible other avenues to explore with a patient.
How often has a patient told me something important only to add they had never before told that to anyone?
What about patient centred care and compassion? Human beings don’t fit algorithms. Human beings, as complex adaptive systems (CAS), are open, emergent, dynamic, changing, contextually embedded creatures. What algorithms have been invented which can cope with the complexity of individuality? The complexity of everyday living?
We can squeeze people into algorithms, but we can’t make algorithms which fit the breadth and depth of natural variety.
And this is the heart of my concern.
Is the practice of Human Medicine about the health of human beings? If it is, we have to work with the reality of what a human being is. A complex, conscious living being who communicates and makes sense of the world through narrative, and who is embedded in a web of interconnections which inform their values and their choices. If it is, we have to work with the reality of diversity and uniqueness.
Please, please, let’s emphasise the need for a scientific approach to human health – one which is based on the science of living creatures, not one based on a delusional reductionist, materialistic science of complicated machines.
We are heroes, not zombies.
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Heroes Not Zombies 