Thursday, September 26, 2013

Guest Post: Why clinical questions are only a starting point

Dr. Robert Bowman is a Professor of Family Medicine at A.T. Still University School of Osteopathic Medicine in Arizona. He blogs at Basic Health Access and Clinician Specific Medical Education.


People come to family physicians with some indication or faith that we can help them. As the learned “high priests” of medicine, we can answer their questions in various ways. The following 5 ways that Christians perceive that God answers prayers also provide a framework for how we address clinical questions.

"No, I love you too much."

Daily we see patients who already have answers to their questions. They come to us for many reasons. One reason is so that we can confirm their impression. If we do so wrongly, we contribute to their problem. We also know that what some people are asking is wrong. For this and for other presentations, we have to say “No, I love you too much.” This can be difficult for physicians who want to please all of their patients or improve their “patient satisfaction” scores.

"Yes, but you will have to wait."

We gather information and then do exams, tests or sometimes treatments. Haste can help answer a clinical question, but a hasty answer can be wrong. Hundreds of hasty diagnoses or treatments have been proven wrong in later years. For 20 years we were pushing an unproven test for prostate cancer screening when we should have been saying: “You will have to wait.”

Those on the front lines of care recognize that some diseases and conditions go away. Patience is needed. When people come in with fever, chills, and headache within 24 to 48 hours, chances are that this will resolve with little consequence. Deciding who can wait or not is a clinical decision, but one that does not necessarily lead to a diagnosis. We fail to measure much of clinical decision making. Those who measure immediately will find many clinical questions unanswered. This is about the patient, physician, interaction, the state of the science, and limitations in each of these areas. Immediate diagnosis and treatment can be wrong and harmful – but sometimes delays can be harmful. Outside players (legal, payers, practice pressures, daily situations) exert influences that can impede optimal decisions and care.

"Yes, but not what you expected."

This is always a tough situation as people have already moved their minds down one path. It takes time and effort on our part to erase this path so that they can move down another. Our treatments often do not work and some are harmful. Even with correct diagnosis and treatment, some patients find that our treatments are too inconvenient or expensive to continue and may or may not tell us.

"Yes, and here’s more."

Family physicians have more to offer than just diagnosis and treatment. Because of our tens of thousands of patient care experiences, we have experienced the impacts upon others and how they responded and what helped. The context of neighborhood, family, and individual past experiences is a rich database. Teaching of medical students and residents adds to the reflection, discussion, learning, and management. Ideally we have experienced the disease and condition and can speak with regard to practical matters, with evidence as a foundation. It helps to have access to pharmacists, behavioral professionals, and nurse educators who can step in and connect patients to needed care. But adding more can be difficult with financial margins so thin, with penalties for serving patients in settings where margins are thin, with fast rising costs of delivery, and with stagnant reimbursement. 

"Yes, and I thought you would never ask."

This is what we tend to focus on too much. People come in and we make the diagnosis and treatment together and have great agreement and all are pleased about expectation, diagnosis, treatment, and outcome. We like to measure this outcome since it is easy to measure. Much of what we do in family medicine, though, is in the first four answers rather than this last one. Saying no, getting people to wait patiently, or redirecting wrong impressions is often more important to individual outcomes than is the clinical question. Unfortunately, current designs for training and practice support make responding "Yes, and here is more" difficult unless we personally sacrifice to provide more care.

Family physicians generally do not experience the immediate rewards of diagnosing an inflamed appendix with confirmation during removal at surgery. But we do see the negative consequences of focusing on short-term outcomes at the expense of long term approaches to health, where the "clinical question" may only be a convenient starting point.