Medicine, the profession struggles
with its identity. Will we be physicians in the likes of the great scientist
philosophers and humanists since Hippocrates? Or, will we succumb to the trend
of commodifying the profession?
Health and Human Services (HHS),
National Institution of Health (NIH), Centers for Medicaid and Medicare
Services (CMS), Insurance companies, regional Health Information Exchanges
(HIE) will mandate certain quality metrics in the Electronic Health Record
(HER) and the uniform claims submission process for reimbursement. Programers
will likely build these metrics into the software developed by various venders
of the EHR. Doctors are familiar with Best Evidence and some of those treatment
standards are already appearing in EHRs. A new feature will be Clinical
Decision Support (CDS). Best Evidence largely deals with treatment protocols.
CDC will deal mostly with diagnosis. What follows is a discussion about how the
later, CDS, deals with differential diagnosis, diagnosis and the problem list.
The review of systems (ROS) and the
differential diagnosis lie at the heart of the matter and how electronic
medical records interface with these two intellectual processes. Each item in
the ROS, signs and symptoms related by the patient, becomes critical data in
the process to follow. The negative response is as significant as the positive
-- maybe more. Each positive response, when confirmed by further questioning,
evokes a list. The list is critical as well and might as well be indelibly
imprinted behind each data point or on the mind of the physician.
When completing the ROS, one then
has a number of responses, each with its list of etiological possibilities. One
or more diagnostic possibilities appearing on separate lists tend to point to
the underlying problem and contribute to the establishment of a differential
diagnosis.
Here is where statistics comes into
play. The more often a diagnosis appears on multiple lists and the more
completely the signs and symptoms on the ROS fulfill the attributes of a
diagnosis, the more likely you are on the right track. However, all overlapping
signs and symptoms are not equal and many illnesses have similar symptoms.
Furthermore, individual patients seem to have a limited range of symptoms to
account for a wide range of possible illnesses. Ongoing and realtime
statistical analysis of the differential diagnosis with apparent outcomes and
the coupling together of patient data with the vast store of medical
information greatly assists in the interpretation. Database mining can provide
statistics that the mind cannot grasp. The human mind, however, does far better
at final interpretation.
The
mindful and highly experienced physician sees the above analysis and assembles
a differential diagnosis with a scanning logic. Other physicians have another
sort of mind that rather than scanning has a concrete way of thinking. The
later demands clear cut answers. Both approaches work but with the same human
limitations. Most physicians navigate a differential diagnosis quite well but
the process demands a high degree of commitment to the art -- and still is
subject to error. There are in fact many missed and wrong diagnoses. Misses are
almost inevitably due to omitting the ROS or ignoring one or two of the
responses when they do not fit the assumption. Larry Weed, the inventor of the problem oriented
record (POMR), insists that any positive, not accounted for by the diagnosis,
belongs on the active problem list.
Our mind thinks and makes
individualized judgments that the computer cannot. The computer on the other
hand remembers and does statistics. We do not remember so well and we do not
manage statistics well on a large database. We do need to take into account the
computer’s future capabilities, however. So far the computer does not think,
but IBM's Watkins comes close.
Statistics are limited to the
relevant population. Do you depend on statistics developed on a national scale,
an international scale or limited to a local population that might be more
relative to the patient at hand? I say might be because each patient is a one
of a kind individual. The only statistics that matter might very well be the
patient's own genomics. The individual genome, despite the nail biting, is
falling in price and will soon be ubiquitous. We need to be sure the tests are
not sold like snake oil by bathers, naturopaths, charlatans and opportunists.
Arguably, we should do the thinking
and follow a strategy in which the computer remembers the data, the lists and
analyses statistically on a realtime basis, genomics included. Let the computer
couple your precise clinical data with the vast store of medical terminology,
nosology, and the salient features of each. The value here is in not missing
something and not getting stuck in a wrong assumption. The analysis should
present to the physician a credible preliminary differential. With or without
assisted memory and coupling to the vast store of medical knowledge, the ROS
and of course subsequently accumulated data are the key to patient safety and
care. The ROS would of course be only the beginning. The rest of the history
and physical examination-- hopefully you did a physical -- would yield further
support to one or another of the hypothetical problems suggested by the ROS and
your own pattern recognition. From this point on the human brain takes over the
thinking with the advantage of the computer's perfect memory and superior
statistical skill. The patient remains an individual, however, and will often
defy the best of statistics. The physician's thinking combined with an intimate
connection with the patient remains essential.
Some would advocate a process in
which the computer and pre defined procedures defined by best evidence as
written by so called experts take the prime role and relegate the physician to
insuring the validity of the data points. The rationale to this approach lies
in the frequency of diagnostic error and the never ending expansion of
diagnostic and treatment procedures that do more harm than good costing more
and more.
Others would say, we need to go back
to the physician as the humanist and scientist of old with vast experience and
ongoing medical education in a professionally structured society, dedicated to
excellence. Today we are at a cross roads. The road to subordination, however,
may have already been taken. Whichever path we follow, patient safety, access
and consistent in depth handling of the data are primary. The differential
diagnosis is critical to achieving anything like the health metrics of the rest
of the industrial world.
Summary and Conclusion
Physicians and Medical Schools struggle with a conflict
between physicians in the classic role of science, art, diagnosis and a newly
proposed role in which the physician practices in a role subordinate to the
computer, algorithms, protocols, check lists and the authors of Best Evidence.
At the heart of the conflict lies the complex process of
diagnosis and the choice of individual treatment. To meaningfully apply the
dictate of Best Evidence, one needs the right diagnosis. We suggest that the
best application of computers, statistics will be achieved when the computer
applies its faultless memory and capacity for data with dynamic real-time
statistical analysis not on mass populations but on the internal data at hand.
This strategy provides data more relevant to the individual patient. The
strategy also leaves the physician and the patient with the choices, the
judgment and the mindfulness of that data. The physician thinks, the patient
participates, the computer remembers.
Arguably, the critical focal point for achieving the right
diagnosis or at least having the right diagnosis in the differential rests with
the review of systems, ROS and subsequent physical and laboratory findings. If
this data is not complete, including negatives, the diagnostic process is
compromised.
When the differential diagnosis depends on the physician’s
memory, missed diagnosis often results from initial assumptions. Omission of
the ROS, ignoring positive or negative responses and findings when they do not
fit the assumption often leads to a wrong diagnosis. An inability to mindfully
apply valid associations to literally thousands of diagnostic possibilities
lessens the accuracy as well. When the best evidence, derives from
mass-population statistical analysis, that analysis may be all wrong for the
individual patient.
The direction medical schools point new physicians over the
next generation or two will greatly affect the health of our Nation and the
outcome for our individual patients. Reducing physicians to mindless gatherers
of data and surgical robots leaves the judgment in the hands of a few of
necessarily national experts. It stifles scientific advancement. Once you fix
procedures and protocols and define best evidence, you have a one shoe fits all
situation that may not apply to the individual. You have a static routine
devoid of the variety and experimentation that defines the core of the
scientific method. The unintended consequences of computer directed diagnosis,
best evidence and a unified standard may turn out to be ulterior motives of
political, religious, or economic entities driven by greed. Government, the
courts, drug companies, insurance companies or the association of hospitals in
which we work may inject subtle deviations for their own benefit.
Our further plea is for a continuation of classical medical
education with bedside teaching and advancement to even higher levels of
medical training. The honor should be limited to those worthy of the privilege
in the tradition of the great physicians and surgeons of the past. Further
advancement might require all to graduate as PhDs with core competence in
genomics and database management. The genomics seems obvious. Medical schools
must renew their covenant with patients and local providers serving both in
exchange for teaching material, autopsies and CME. There are too many providers
and peripheral merchants feeding at the healthcare trough. More physicians relative
to population will not help. We have far too many specialists. Less well
trained providers will not improve outcomes or meet the needs of our future.
Will we unionize and become nine to
five Feldshers who follow algorithms and protocols? Will those dictums of best
evidence be out of date or self serving? Will professional behavior be dictated
and enforced by political and economic interests? Or, will a renewed pursuit of
excellence and medical education put the patient first with the physician
directing the tools of health information technology, translational medicine,
biomolecular advances, research, science and genomics? The future is ours to
grasp.
Medicine
in Denial, Lawrence L. Weed and Lincoln Weed April 2011, Amazon
I think my most interesting character for next week, outside
of Hippocrates himself -- 2,000 years earlier, will be Thomas Sydenham. His father was a gentleman of
property, Thomas was born in Dorset, educated at Oxford, A Saxon, Sydenham
fought for the Parliament during England’s. Civil War as a cavalry officer. He
taught the Hippocratic method: inductive reasoning, virtue, credible signs and symptoms, and differential
diagnosis with meticulus attention to the patient.
