Monday, November 1, 2010

Cutting for evidence

Abe Verghese is not a fan of evidence. Well, to be precise, he is not a fan of evidence-based medicine. To be even more precise, he is not a fan of applying evidence-based medicine to the exclusion of all other ways of caring for patients. How do I know this? He said it. In those words.

I am at the annual meeting of the American College of Chest Physicians in Vancouver, where Dr. Abraham Verghese gave a keynote address this afternoon. These meeting are flat-out events for me, with a lot of work, very little sleep, and a different time zone added to the mix. So, some of what I say may be driven by raw emotion, as the more rational bits may be napping while I write this. Yet, when did this vital piece of human fabric become an insult? We are made of emotion, and there is no reason not to let it enter a discussion, to balance rationality. So, no apologies.

First, a disclaimer: I am a huge fan of Abe's -- I read his Cutting for Stone this past summer and thought it was one of the most brilliantly conceived and told stories ever, and this includes Tolstoy and Dostoyevsky. It enriched me and, equally importantly, it made me proud to be a member, no matter how peripheral, of what is really a noble and caring profession. I was so incredibly excited that Dr. Verghese would keynote our meeting -- I thought it showed real vision on the part of our President Dr. Kalpalatha Guntupalli (thankfully, everyone calls her Kay) to have this multi-talented man talk at what is usually a very dry data-driven venue. And I was not disappointed.

Dr. Verghese's talk was titled "Percussing the Chest in the Era of Homo Technologicus". It was a far ranging and erudite discussion of where we have been as a profession, where we are today, and what we have lost by giving up our physical presence at the bedside. Well, I don't mean presence altogether, but the unhurried mindful attention that doctors used to be known for has, as a rule evaporated. And this is a bad thing. Abe focused on the importance of the bedside physical exam, as that is one of the skills he so clearly excels at -- just reading his book makes clear what a brilliant diagnostician he is! In his understated, unrushed and witty way he captivated the audience with the wonders and intricacies of deciphering signs and symptoms of disease. Looking around I detected, in this brief respite from the manic pace of their every-day existence to keep just ahead of the bureaucratic avalanche of modern-day healthcare, physicians in the audience, starry eyed, "looking younger than their stated age", were clearly remembering those more idealistic days of med school and training, when all that mattered was the patient and the calling. This was a time before quality measures and protocols and check lists and MD grades and all the stuff that makes their heads spin outside this cocoon of annual professional exchange.

So, by wanting to go back to the low-tech encounter between two people, the patient and the doctor, was Dr. Verghese advocating willful ignorance? Was he saying that we should walk away from science and back into the age of medicine without antibiotics, a time before we could literally see through life with our imaging technologies, before our patients became a grouping of tissues and cells and molecules and paperwork? Well, no, not really. His argument was nuanced. Analytic evidence is important. So is the art of medicine. Using one without the other unbalances the equation and diminishes the effectiveness (and importance) of the therapeutic relationship itself.

There was one striking feature of Abe's presentation: unless I missed it, the only numbers he presented were the years corresponding to the historic artifacts and concepts that he discussed. There were no percentage symbols, no p values; no t-tests were hurt in the production of his talk. He used his hands to circumscribe his arguments. The hands that have brought comfort to many a patient at the end of the line, those relegated to unmanageable, untreatable, crazy. He used no data, just anecdotes. And patient e-mails in response to the New York Times article about him. Was this some kind of a cult indoctrination designed to deceive the gullible? Where was the evidence in all of this?

Well, the proof, as they say, is in the pudding. And while I vaguely remember from high school physics that this refers to some experiment by Rutherford, I am pretty sure that I can trust social sciences on this, as well as my own experience (perish the thought) of human nature: we need to hold hands. That is our instinct and our biological destiny. Do we need statistical evidence for this? Perhaps you do, but I do not. Is that heresy? Perhaps it is. Yet I trust my instincts on this enough to know that most of us wish that a doctor could focus on us, rather than our insurance or the next patient on the schedule, and apply the best evidence available to help us out in our hour of need. But for this to happen we need to stop worshipping at the altar of technology, and even the altar of evidence. Evidence is an easy target for subversion by bureaucrats looking for certainty. But to a competent and caring doctor evidence is just a tool in the belt filled with equal parts knowledge and compassion.

It is the bedside interaction and individual judgment in the context of evidence that were originally advocated by Cochrane, Sackett and Eddy. Do we need to do a randomized controlled trial of a physician's attention and the art of the physical exam to have the necessary data to push the pendulum back to where it ought to be? I, for one, do not think so, as in this respect I trust other ways of knowing. Mine and others' brains cannot be so addled as to be mistaken about this obvious truth, can they?

Regardless of where your threshold for evidence lies, we cannot ignore the dismantling of the doctor-patent relationship, the overuse of technology in the place of listening, feeling and percussing. Does the relationship provide a placebo effect? Perhaps. But, as you already know, I am not opposed to harvesting its positive fruit. And if the doctor gets less harried and the patient gets happier in the process, what's bad about that?

Once again, the Buddha's middle way may be just the antidote to the current excesses of our academic extremism. I was taught to treat the patient, not the numbers or the images. Again, thanks, Dr. Verghese, for putting the spotlight back where it belongs and giving context to the evidence. This is one boat drifting off course soon to be lost at sea. Does anyone remember where we left the anchor?                    

1 comment:

  1. Awesome. I get jealous when I hear about North American conferences like this. The buffet in Australia is very spartan for adult physicians, let alone paediatricians. Technology and the changes in consultation models you describe sure are undermining the value and performance of the physical exam and the human connection. A great blessing in paediatrics is that we largely remain generalists by necessity (a child changes what sort of patient they are in a few brief years so super-sub-specialist less often subsume the generalist), and also that high-tech investigations are less helpful in providing information and often unattractive, being invasive or carrying risks, so that clinical skills remain rewarding.

    For example a scenario I like to put to students is a neurological presentation (eg. first unprovoked seizure) and the question of whether an MRI brain should be done (requiring general anaesthetic). Which is more complex and informative, the fine detail of an MRI or observing a child in the consult room pick up a pencil, draw a person then say 'Mummy this pencil is broken', at age appropriate level?