On Training the Medical Mind

I fully understand this point of view, and I think it's invaluable to have said checklists and DDx lists. Having tools like UpToDate and DynaMed is awesome. Especially for emergency medicine, being able to DDx complex situations quickly and provide immediate life-saving care is very important.

But — and I don't say this to provoke — I think this view is myopic. It somehow misses the humanity at the core of the doctor/patient interaction. What is the ultimate purpose of medical care, really? Is it not to treat the patient, and not simply cure the disease?

A lot of times the checklist-style of medicine forces patients into a loop of patchwork solutions which don't address the root cause. To an extent, this is even true in emergency medicine. If someone comes in with their third heart attack, and they're clearly obese and in bad health and spirits, the problem that needs to be fixed goes beyond the immediate danger of the heart attack. There's something much more systemic, much more basic, which lies at the core of this person's suffering.

And I think the same is true for many chronic diseases and ailments, which are hard and time-intensive to solve in a holistic way, but which are easy to treat with patchwork solutions.

Take also the recent advent in hospice care, which I find wonderful. Hospice kind of rethinks the concept of "curative" medicine and treats the patient as a human being. How many people spend their last days in a miserable state, burdening themselves and their families by forcing themselves to stay alive? The "treatments" justified in the name of life-saving care can be incredibly diabolical and torturous. Doctors know this, and they often spare themselves that gruesome fate: https://www.rd.com/article/how-doctors-choose-to-die/.

Point being — treating the patient is not as simple as it sounds. The proper treatment is not only to fix the immediate disease.

But again, I am not against checklists. Doctors who use checklists and can care for the patient at the deeper level of soul and psyche are golden.

Maybe this just isn't the type of problem we should be looking towards a physician to address? They spend at least seven years in school learning to handle certain types of problems that can be addressed with certain types of solutions.

Perhaps this type of thing (lifestyle issues) is more in the wheelhouse of a dietician or a lifestyle coach who has a different type of training.

If you have sepsis, a dietician probably wouldn't be the safest bet. If you have lifestyle issues with diet and exercise, maybe a physician wouldn't be the safest bet.

You raise a good point, and I don’t disagree.

This article is interesting to me because it portrays a version of medicine which treats the patient as an integrated unit.

I think a physician who can interrogate issues more deeply in addition to treating symptoms is invaluable. Maybe someone’s weight is not just a function of their lifestyle or diet, but is also due to undiagnosed, low-level hypothyroidism, for example. I don’t know that a dietician can be expected to have the knowledge and expertise to treat issues like this. Who knows, with the rise of smart medicine we might be able to replicate such a care team through technology.

Also, unfortunately, quality of treatment is in large part a function of time. And in most countries, the level of medical attention one gets is very dependent on how much they can afford. I mean, even in places like Germany that have socialized medicine, the privately insured get better care, more time with their doctors, less time to schedule an appointment, etc.

Knowing that, this might be an insoluble problem until we automate the checklist-style medicine with chatbots and ML, and then reserve doctors for the tricky cases where DDx falters.