By Peter Laird, MD
During the course of my career in internal medicine, I have observed the changing of the gaurd from the days of indepth investigation of all symptoms and abnormalities to the new ethics of today that calls for limited investigations and more focused treatments. Many of the new physicians growing up under this new fiscal restraint truncate their considerations of the causes of these symptoms in algorithmic precision. For the majority of patients, this approach will work since what is common is common. However, algorithms fail when patients presents with illnesses not considered within these cook book medical recipes.
The only antidote for those patients is old fashioned, Oslerian methods of investigation of clinical inquiry and focus on the patient as a clinician-scholar making close observations and developing clinical hypothesis from these observations. There are no short cuts nor cook book medical rhymes that can replace the trained clinician applying the Oslerian medical precepts. Sadly, with the high tech, specialized clinical practice of today, the art of medicine is often overlooked often to the detriment of our patients.
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Sir William Osler
What is lacking today in many ways is the connection between doctor and patient that technology and fiscal policies dictate to the young clinicians beginning their practices. I observed many new physicians more concerned about getting home by 5:00 than taking the time to observe, collect data, hypothesize and produce a combination of effective diagnostic testing and treatment alternatives. And at the same time instructed the patient to feel comfortable engaging these plans.
Such an approach is not only time consuming but at times expensive. An in depth analysis always generates more questions needed answering than the cook book algorithmic methods of today that usually covers the top 90% of cases, but over looks the 10% that are rare and uncommon. Once again, the new methods work in a cost containing society but fail in the real world of individual patients.
Interestingly, a recent study supports the concepts of the Oslerian method of medicine more so than this new medical ethics focused on cost containment first and foremost. The common denominator speculated by one commentator was that of the pursuit of academic excellence at the bedside in teaching hospitals. The teacher-clinician model of medicine exemplifies the Oslerian method.
"Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive," they wrote.
In an accompanying editorial, Karen Joynt, MD, MPH, and Ashish Jha, MD, MPH, of the Harvard School of Public Health in Boston, added that the nature of a hospital's mission could also influence outcomes.
"Features that make a hospital high cost, such as a teaching mission or research mission, may actually be related to better outcomes," they wrote. "Thus, it is possible that it was not spending per se that improved outcomes but rather the teaching intensity or academic expertise more common at high-cost hospitals."
The idealistic aspects of medical training quickly fall to the constraints of time and limited resources for the majority of physicians in daily practice. During my training, one of the aphorisms I heard many times over was the the best medicine in the long run was the cheapest. Preventing complications and further hospital admissions and associated treatment costs is best approached by gettting the diagnosis and treatment alternatives correct the first time around.
I am at times appalled when witnessing the cost containing methods of home dialysis programs that skimp on medically needed supplies such as giving me one roll of tape for an entire month while over looking the tremendous cost savings of a home dialysis program after higher upfront costs are considered. The penney wise and pound foolish approach to medical care in America appears to be the new mantra in the health care industry, and especially for dialysis patients. Early in my career, I would ponder the consequences of the cost of the evaluation on my own ratings, but I soon put that aside and focused only on the patient. Needless to say, many times over I was less than popular with the bean counters.
The intensity and thoroughness of evaluations and therapies are the most important aspect of high quality medical care as taught by Sir William Osler over a hundred years ago. It all begins with a doctor that can listen and observe. It is time to return to the rudimentary traditions that gave us the most effective health care system ever known. There is a time to spend and prevent and repair instead of dealing with the inevitable costs of failing to seek the highest care for each patient that presents to a doctors office. In the end, the best care is the cheapest.