Heroes Not Zombies

I believe diagnosis is one of, if not, the most important parts of a doctor’s job. It’s actually the main goal of the entire medical undergraduate curriculum. However, we’ve limited what we mean by diagnosis. A diagnosis is not just the identification of pathology, it’s an understanding of a patient’s illness, a point which is all the more important when you consider patients with “co-morbidities” (more than one thing wrong).
In an interesting personal article in the BMJ Gordon Caldwell, a consultant physician working in acute medicine, says

The time taken to reach the correct diagnosis may be crucial for the patient’s chance of survival. Over my career I have seen many errors in the working diagnosis causing harm to patients and even death.

He also considers the importance of creating the right working environment for doctors to make good diagnoses

I believe that we have not thought about the best places, the physical and psychological environments, in which doctors should do this complex clinical thinking. Often it occurs in small hot rooms subject to constant interruption or even in ward corridors without easy access to laboratory results.

He concludes –

We must design our working spaces and information systems to maximise doctors’ ability to see, understand, and deliberate on the information needed for more precise diagnosis. We must allow clinicians enough time to be careful in diagnosis, treatment planning, and treatment review. We must urgently consider how to provide rooms, time, and information for doctors to do the most difficult part of their job and the part most prone to error: the clinical thinking in making the working diagnosis and treatment plan.

This is absolutely right. The scandal of the NHS is that we expect good health care to be provided without giving doctors adequate time with their patients to really understand them. We also frequently fail to provide good working environments and to share all the relevant information amongst the various members of the team.

I recently discovered the American Board of Integrative Holistic Medicine. They’ve obviously thought very carefully about the practice of medicine and how a doctor should carry out his or her work. I’m particularly impressed with their ten principles and I agree wholeheartedly with all of them.

So, here are their principles. I sign up. These are the colours I want to nail to the mast. Do you agree? If you’re a doctor, would you accept these principles for your practice?

1.    Optimal health is the primary goal of holistic medical practice, deriving from the conscious pursuit of the highest level of functioning and balance of the physical, environmental, mental, emotional, social and spiritual aspects of human experience. The result is a state of being fully alive, a condition of well-being transcending the mere absence or presence of disease.
2.    The Healing Power of Love: Integrative holistic physicians strive to relate to patients with grace, kindness and acceptance, emanating from the attitude of unconditional love as life’s most powerful healer.
3.    Wholeness: Illness is a dysfunction of the whole person – body, mind and spirit – or the environment in which they live, rather than simply a physical disorder or a random isolated event.
4.    Prevention and treatment: Integrative holistic practitioners promote health, prevent illness and manage disease processes. Integrative holistic medical treatment balances relief of symptoms with mitigation of causes.
5.    Innate healing power: All persons have innate powers of healing of body, mind and spirit. Integrative holistic physicians evoke these powers and help patients utilize them to affect the healing process.
6.    Integration of healing systems: Integrative holistic physicians embrace a variety of safe and effective options in diagnosis and treatment, including education for lifestyle changes and self-care, complementary approaches, and conventional drugs and surgery.
7.    Relationship-centered care: The quality of the relationship between physician and patient is a major determinant of healing outcomes which encourages patient autonomy and values the needs and insights of patient and practitioner alike.
8.    Individuality: Integrative holistic physicians expend as much effort in discerning a patient’s uniqueness as they do in establishing what disease may be present.
9.    Teaching by example: Integrative holistic physicians continually work toward the personal incorporation of the principles of holistic health, in turn profoundly influencing patients by their own example and lifestyle choices.
10.    Learning opportunities: All life experiences including birth, illness, suffering, joy, and the dying process are profound learning opportunities for both patients and integrative holistic physicians.

A recent editorial in the BMJ asked a question you don’t often find in medical circles – how long should treatments be continued?
Even in acute disease, the evidence base for treatment duration is weak apparently, but when it comes to chronic disease, the situation becomes so complicated that it seems, it’s pretty much just avoided.
This hides two issues. Despite what drug companies and enthusiastic drug prescribers tell us, there are precious few genuine cures in modern medicine. We’re often presented with simplistic black and white claims about drugs which “work” or are “evidence based” as if acquiring those labels mean they are just a good thing, whereas, in reality most of those drugs don’t actually heal, or even enhance natural healing effects. They just modify symptoms. The second issue is related to the first, if these drugs don’t cure, do they give us better lives? Only you can assess your quality of life, so if you have to take a drug for decades, only you can decide if a drug-taking lifestyle a better one for you, but at least you should be told by whoever initiates your treatment, whether or not they expect you to have to take the drug for the rest of your life.
So next time your doctor is about to prescribe a drug for you, how about asking how long he or she expects you’ll have to take it, and if you really want to be challenging, ask what the evidence is for that expectation.