i i 1 Health and medical ethics Medicine has its own internal morality. This derives from a patie nt \200\231s illness and his or her subsequent vulnerability, coupled with the physician \200\231s intent to help the patient improve. Each time a physician asks of the patient, \200\234How can I help you? \200\235 there is an implicit understanding that the physician will use his or her expertise to serve the best interests of the patient. As members of a p rofession, physicians declare publicly that they will put aside their self-interest in the service of others. Although society grants physicians certain privileges (e.g., prescribing medication, determining 1 Pellegrino ED, Thomasma DC. The Virtues in Medical Practice . New York: Oxford University Press; 1993. 2 Tolstoy L. The Death of Ivan Ilyich. New York: Bantam Books; 1981. 3 Peabod y F. 1927, The care of the patient . JAMA. 1927;8812):877 \200\223882. disability), it also expects certain duties of the profession, namely that physicians be th e stewards of valuable societal resources. Professionalism is our contract with society and entails certain commitments on the part of physicians. 4 In the sphere of ethics, physicia ns are called upon to lead as often as to follow. To do this, we need to return to basic pr inciples and put society \200\231s expectations temporarily to one side. Our analysis start s with our aim: To do good by promoting people \200\231s health. Health entails being sound in body and mind, and having powers of growth, development, healing, and regeneration. How many people have you made healthy (or at least healthier) today? Good is the most general term of commendation and entails four chief duties: \212 Not doing harm (nonmaleficence). We owe this duty to all people, not just our patients. \212 Doing good by positive actions (beneficence). We particularly owe this to our patient s. There are four ways by which the patient \200\231s good can be defined: (1) the ultimate good, that which has the highest meaning for the patient; (2) the biomedical good, obtaine d by treatment of the disease; (3) the patient \200\231s perception of the good based on hi s or her life plan; and (4) the good of the patient as a person, deserving respect and the freedom to make reasoned choices. 5 2 \212 Respecting the person. Autonomy respecting (self-determination) is not universally recognized; in some cultures, such as those facing starvation, it may be irrelevant or even subversive. But re specting persons and their inherent dignity is to be found across cultures. This is manifes ted in medicine by upholding patients \200\231 rights to be informed, to be offered all the options, to be told the truth, and to have their confidentiality protected. autonomy or \212 Promoting justice \200\224distributing scarce resources fairly and treating people fairly, such as when we respect their legal rights. The point of having these guiding principles is to provide a context for our negotiations w ith patients. If we want to be better doctors, a good starting point is trying to put these principles into action. Inevitably, when we try, there are times when the principles seem to conflict with each other. What should guide us when these principles conflict? It is not just a case of decid- ing off the top of one \200\231s head. It requires further inquiry, deliberation, and aspiring to a synthesis \200\224if you have the time (time will so often be what you do not have; but, in retrospect, when things have gone wrong, you realize that they would not have done so if you had made time). Synthesis When we must act in the face of two conflicting duties, one of the duties will take precedence. How do we tell which one ? Trying to find out involves getting to know our patients and asking some questions: \212 Are the patient \200\231s wishes being complied with? \212 What do the patient \200\231s loved ones (family and/or friends) think? First, ask the patient \200\231s permission to sp eak to the loved ones. Do the patient \200\231s loved ones have his or her best interests a t heart? \212 What do colleagues think? Often having the input of other clinicians can help sort out the complexities of a difficult case. 4 ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American Colle ge of Physicians-American Society of Internal Medicine; European Federation of Internal Med icine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002;136(3): 243 \200\223246. 5 Pellegrino ED, Thomasma DC. For the Patient \200\231s Good: The Restoration of Beneficence in Healthcare. New York: Oxford University Press; 1988. \212 Is it desirable that the reason for an action be universalizable? (That is, if I say this person is too old for such-and-such an operation, am I happy to make this a general ru le for everyone? \200\224Kant \200\231s \200\234law. \200\235) 6 e n i c i d e m \212 What would the man on the street say? These opinions are valuable as they are readily available, and they can stop decision making from becom- ing dangerously medicalized. Seek ing these opinions also prompts one to think about the \200\234reasonable person \200\235 standard when getting informed consent. t u o b a g n k n h T \212 If an investigative journalist were to sit on a sulcus of mine, having full knowledge of my thoughts and actions, would she be bored or would she be composing vitriol for tomor row \200\231s newspapers? If so, can I answer her, point for point? Am I happy with my answ ers? Or are they tactical cerebrations designed to outwit her? i \212 What would I do if nobody were watching? Would I act the same way if there were no co nsequences in terms of public scrutiny? Will I be able to face myself in the mirror the nex t morning? i \212 Do I need the input of the hospital ethics committee? In some cases, eth- ics consult ants can help to facilitate discussion among interested parties, sort out the ethical issue s at stake, and provide an opinion about ethically permissible options for resolution of th e problem. 3 Good ethics starts with good facts. Understanding a situation completely, or as complete as possible, can go a long way in figuring out the most appropriate course of action. Four do mains of knowledge need to be explored: 1 Medical indications \200\224diagnosis, prognosis , goals of treatment, and prob- abilities of success; 2 Patient preferences \200\224the values and perspective of the patient relative to the me dical indications; is the patient competent to make decisions, and, if not, who will speak for him?; 3 Quality of life \200\224the prospects for improving or restoring the patient \200\231s q ual- ity of life and what to do if there is treatment failure; 4 Contextual features \200\224ranging from family or provider issues to legal, eco- nomic, or cultural factors. 7 The bedside manner and communication skills Our bedside manner matters because it indicates to patients whether they can trust us. Where there is no trust, there can be little healin g. A good bedside manner is not static: It develops in coordination with the patients \200 \231 needs, but it is grounded in the timeless clinical virtues of honesty, humor, and humi lity in the presence of human weakness and human suffering. The following are examples from an endless variety of phenomena that arise whenever doctors meet patients. One of the grea t skills (and pleasures) in medicine is to learn how our actions and attitudes influence pa tients, and how to take this knowledge into account when assessing the validity and signifi cance of the signs and symptoms we elicit. The information we 6 There are problems with universalizability: Sometimes only intuition can suggest how to r esolve conflicts between competing universal principles. Universal principles work in the a bstract but have drawbacks when applied to real-life situations. Also, there is a sense in which all ethical dilemmas are unique \200\224they cannot be universal. This leads some eth icists to favor case-based reasoning (i.e., casuistry). 7 Jonsen AR, Siegler M, Winslade WJ . Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 6th ed. New York: McGraw-Hill; 2006. receive from our patients is not \200\234hard evidence, \200\235 but a much more plastic c ommodity, molded as much by the doctor \200\231s attitude and the hospital or consulting ro om environment as by the patient \200\231s own hopes and fears. It is our job to adjust our attitudes and environment, so that these hidden hopes and fears become manifest and the ch annels of communication are always open. Anxiety reduction or intensification A simple expl anation of what you are going to do often defuses what can be a highly charged affair. With children, try more subtle techniques, such as examining the abdomen using the child \200 \231s own hands, or examining their teddy bear first. Pain reduction or intensification Com pare: \200\234I \200\231m going to press your stomach. If it hurts, cry out \200\235 with \200\234I \200\231m going to touch your stomach. Let me know what you feel. \200\235 The e xamination can be made to sound frightening, neutral, or joyful, and the patient will relax or tense up accordingly. The tactful or clumsy invasion of personal space The physical exa mination can involve close contact with the patient that is normally not acceptable as part of usual social interaction. Acknowledging this to the patient can set both parties at eas e. For example, during ophthalmoscopy, simply explain \200\234I need to get very close to your eyes for this. \200\235 The use of distraction to gather information Skillful practiti oners palpating the painful abdomen will start away from the part that hurts. They will wat ch the patient \200\231s face while talking about a hobby or the patient \200\231s family w hile they press as hard as they need to. If the patient stops talking and frowns only when the doctor \200\231s hand is over the right lower quadrant, the doctor will already have fo und out something useful. Awareness of the patient experience If you ask the patient to hol d his breath while listening to the carotid artery, also hold your breath, so that you know when it might be getting uncomfortable for the patient as you intently listen for the tell -tale bruit. Communication Your skills are useless unless you communicate well. Be simple, and direct. Avoid jargon: \200\234Remission \200\235 and \200\234growth \200\235 are freq uently misunderstood. Give the most important details first. Be specific. \200\234Drink 6 cups of water per day \200\235 is better than \200\234Drink more fluids. \200\235 Provide written information with easy readability. Aim for a sixth-grade reading level \200\224more like the Reader \200\231s Digest than the Wall Street Journal . If possible, show videos f or patient education. Do not assume your patient can read. Naming the pictures but not the words on our visual test chart helps find this out tactfully. Inquire about your patient \200\231s views of what should be done. Patient-centered care improves provider \200\223pat ient interactions and patient satisfaction. Find goals of care that can be mutually agreed upon. Learn more about the patient \200\231s values. We often talk of compliance with our r egimens, when what we should talk of is concordance , for concordance recognizes the centra l role of patient participation in all good plans of care. 4 Asking questions No class of questions is \200\234correct. \200\235 Sometimes you need to ask one type of question; sometimes another. The good clinician can shift from one kind to another, in order to use the most effective questions for each individual patient. The aim of asking questions is to describe , to find a shared world between the doctor and patient. Questions provide the means to offer practical help: Once the illness is described, a diag nosis can be made and a possible cure offered. If not curable, the experience can at least be shared, mitigated, and so partially overcome. Different kinds of questions either throw light on the experience or obscure it, as in the examples below. Leading questions On seeing a bloodstained handkerchief you ask: \200\234How long have you been coughing up blood? \200\235 \200\234Six weeks, doctor, \200\235 so you assume hemopt ysis for 6 weeks. In fact, the stain could be due to an infected finger, or to epistaxis. O n finding this out later (and perhaps after expensive and unpleasant investigations), you w ill be upset, but the patient was politely trying to give the sort of answer you were obvio usly expecting. With such leading questions as these, the patient is not given an opportu- nity to deny your assumptions. Questions suggesting the answer \200\234Was the vomit red, yellow, or black \200\224like coffee grounds? \200\235 \200\224the classic description of v omited blood. \200\234Yes, like coffee grounds, doctor. \200\235 The doctor \200\231s expe ctations and hurry to get the evidence into a pre-determined format have so tarnished the s tory as to make it useless. Open-ended questions The most open is \200\234How are you? \200\235 This suggests no particular answer, so the direction a patient chooses offers valu able information. Other examples are gentle imperatives such as \200\234Tell me about the vomit. \200\235 \200\234It was dark. \200\235 \200\234How dark? \200\235 \200\234Dark wi th little chunks in it. \200\235 \200\234Like \200 ? \200\235 \200\234Like bits of soil i n it. \200\235 This information is pure gold, although it is not cast in the form of \200 \234coffee grounds. \200\235 Close-ended questions Sometimes in obtaining the history, it i s neces- sary to ask specific, close-ended questions to round out the information. These ma y only require a \200\234Yes/No \200\235 answer or might prompt the patient to give more d etails. This line of questioning can aid in formulating the differential diagnosis and make sure you do not miss important clues. \200\234Did you have a fever? \200\235 \200\234Did you notice wheezing? \200\235 \200\234Have you had swelling in your ankles? \200\235 Pati ent-centered questions \200\234What do you think is wrong? \200\235 \200\234Are there any other aspects of this we might explore? \200\235 \200\234Are there any questions you want to ask? \200\235 (a close-ended question). Better still, try \200\234What are the other t hings on your mind? How is this affecting you? What is the worst thing? It makes you feel \200 (the doctor is silent). \200\235 Becoming patient-centered gives you a better chance of healing the whole person, and the patient may be more satisfied as a result. Framing que stions in the context of the family This is particularly useful in revealing if symptoms ar e caused or perpetuated by psychoso- cial factors. Family-oriented questions probe the netw ork of causes and enabling conditions that allow nebulous symptoms to flourish in a person \200\231s life. \200\234Who else is important in your life? Are they worried about you? Wh o really understands you? \200\235 Until this sort of question is asked, illness may be ref ractory to treatment. For example: \200\234Who is present when your head- ache starts? Who notices it first \200\224you or your wife? Who worries about it most (or least)? What does your wife do when (or before) you get it? \200\235 The spouse \200\231s view of the sympto ms may be the best predictor of outcome for the patient. Framing questions in the context o f culture In medicine, we may encounter patients from diverse backgrounds, sometimes quite different from our own. The skillful clinician will be self-aware enough to recognize any b iases he or she may have based on his or her own cultural identity. To be culturally compet ent, the clinician should be open to exploring the patient \200\231s health beliefs from th e patient \200\231s cultural perspective. Admitting ignorance of the patient \200\231s cult ure in an inquiring, respectful manner may provide clues as to how best help the patient wi thin his worldview. Curiosity can also fortify the relationship: \200\234Help me understan d what this means to you in light of your background. \200\235 Echoing Try repeating the la st words said as a route to new intima- cies, otherwise inaccessible, as you fade into the distance and the patient e n i c i d e m t u o b a g n k n h T i i 5 soliloquizes \200\234I \200\231ve always been suspicious of my wife. \200\235 \200\234Wif e \200 \200\235 \200\234My wife \200 and her boss working late at night together. \200 \235 \200\234Together \200 \200\235 \200\234I \200\231ve never trusted them together. \200\235 \200\234Trusted them together \200 \200\235 \200\234No, well, I \200\231ve alwa ys felt I \200\231ve known who my son \200\231s real father was \200 I can never trust tho se two together. \200\235 Without any questions, you may unearth the unexpected, important clue that throws a new light on the history. Empathic opportunities Remember that the purpo se of the medical interview is not just to gain information, but to develop a relationship. Are you asking questions in a respectful way that validates the patient \200\231s emo- tio nal experience? After getting facts about the illness experience, ask the follow-up questio n, \200\234How did you feel about that? \200\235 and acknowledge the emotions reported. Ma tch body language to build rapport and make it more likely that the patient will be open to answering questions. Be attentive to nonverbal communication, which may shed light on the patient \200\231s underlying feelings and increase the yield of the information: Does the p atient cross his arms in a defensive posture when talking about his wife? Maybe that \200 \231s a clue as to why he is getting headaches. The value of silence Sometimes not asking a question will give the patient the opportunity to share important information. There is va lue in the pregnant pause \200 If you only ask questions, you will only receive answers in reply . If you interro- gate a robin, he will fly away: Treelike silence may bring him to your hand. 6 What is the mechanism? Finding narrative answers Like toddlers, we should always be asking \200\234 Why ? \200\235 \200\224not just to find ultimate causes, but to enable us to choo se the simplest level for intervention. Some simple change early on in a chain of events ma y be sufficient to bring about a cure, whereas later on in the chain such opportunities may not arise. For example, it is not enough for you to diagnose heart failure in your breathl ess patient. Ask: \200\234 Why is there heart failure ? \200\235 If you do not, you will b e satisfied with giving the patient an anti-failure drug, and any side effects from these, such as uremia or incontinence induced by diuretic-associated polyuria, will be attributed to an unavoidable consequence of necessary therapy. If only you had asked \200\234 What is the mechanism of the heart failure ? \200\235 you might have found an underlying cause (e. g., anemia coupled with isch- emic heart disease). You cannot cure the latter, but treating the anemia may be all that is required to cure the patient \200\231s breathlessness. But d o not stop there. Ask: \200\234 What is the mechanism of the anemia ? \200\235 You find a low serum ferritin, and you might be tempted to say to yourself, \200\234 I have the root cause. \200\235 Wrong! Put aside the idea of prime causes and go on asking \200\234 What i s the mechanism ? \200\235 Return to the patient (never think that the process of history-t aking is over). Retaking the history reveals that the patient has a very poor diet. \200 \234 Why is the patient eating a poor diet ? \200\235 Is he ignorant or too poor to eat pro perly? You may find the patient \200\231s wife died a year ago, he is sinking into a depres sion, and cannot be bothered to eat. He would not care if he died tomorrow. You now begin t o realize that simply treating the patient \200\231s anemia may not be of much help to him \200\224so go on asking \200\234 Why ? \200\235: \200\234Why did you bother to go to the doctor at all if you are not interested in getting better? \200\235 It turns out that he on ly went to see the doctor to please his daughter. He is unlikely to take your treatment unl ess you really get to the bottom of what he cares about. His daughter is what matters, and, unless you can enlist her help, all your therapeutic initiatives will fail. Talk with his daughter, offer help for the depression, teach her about iron-rich foods, and, with luck, your patient \200 \231s breathlessness may gradually begin to disappear. Even if it does not start to disappe ar, you may perhaps have forged a partnership with your patient that can be used to enable him to accept help in other ways \200\224and this dialog may help you to be a more humane a nd kinder doctor, particularly if you are feeling worn out and assaulted by long lists of t echnical tasks that you must somehow fit into impossibly overcrowded days and nights. Const ructing imaginative narratives yielding new meanings Doctors are often thought of as being reductionist and overmechanistic. The previ- ous section shows that always asking \200\234 why \200\235 can sometimes enlarge the scope of our inquiries, rather than narrowing the fo cus. Another way to do this is to ask \200\234 What does this symptom mean ? \200\235 \200 \224for this person, their family, and our world. For example, a limp might mean a neuropat hy or inability to meet mortgage repayments (if you are a dancer) \200\224or it may represe nt a medically unexplained symptom that subtly alters family hierarchies, both literally (d uring family walks through the country) and metaphori- cally. Science is about clarity, obj ectivity, and theory in modeling our exter- nal world. But there is another way of modeling the external world that involves subjectivity, emotion, ambiguity, and the seeking of arca ne relation- ships between apparently unrelated phenomena. The medical humanities explore t he latter \200\224and have been burgeoning during the last two decades \200\224 leading to the existence of two camps \200\224humanities and science. If, while reading this, you are getting impatient to get to the real nuts and bolts of technological medicine, you are in t he latter camp. We are not suggesting that you leave it \200\224only that you learn to oper ate out of both camps. If you do not, your professional life will be full of failures (whic h you may deny or of which you will remain ignorant). If you do straddle both camps, there will also be failures \200\224but you will realize what these failures mean, and you will k now how to transform them. With reflection comes growth. Always remember that medicine is b oth an art and a science. In the tekn iatrik of medicine, 8 physicians are master cra ftsmen who must have the technical skill and knowledge to ply their craft, but also the art istry to practice it with compassion in the context of a patient \200\231s life. No matter his or her specialty, each physician should recognize that every contact with a patient in the practice of medicine has a technical dimension, to be sure, but also an artistic one. e n i c i d e m t u o b a g n k n h T i i 7 Medicine, art, and the humanities Let us start with an elementary observation: The most fam ous doctors are those immortalized in literature (e.g., Dr. Watson, Dr. Zhivago, Dr. Franke nstein, and Dr. Faustus). 9 Thus we demonstrate the power of the written word. And it is an extraordinary power. When we curl up in an armchair and read for pleasure, we open the por tals of our minds because we are alone. While we are reading, there is no point in dissembl ing. We confront our subject matter with a steady eye because we believe that, while readin g to ourselves, we cannot be judged. Then, suddenly, when we are at our most open and defen seless, literature takes us by the throat \200\224 and that eye which was so steady and con fident a few minutes ago is now 8 Pellegrino ED, Thomasma DC. A Philosophical Basis of Medical Practice: Toward a Philosoph y and Ethic of the Healing Professions. New York: Oxford University Press; 1981. 9 Of cours e, Dr. Faust, that famous charlatan, necromancer, and quack from medieval Germany, did have a real existence. In fact, there may have been two of them, who together gave rise to the myth of devil-dealing, debauchery, and the undisciplined pursuit of science, without the co nstraints of morality. perhaps misting over, or our heart is missing a beat, or our skin is covered in a goose-fle sh more papular than ever a Siberian winter produced. Once we have been on earth for a few decades, not much in our mundane world sends shivers down our spines, but the power of worl ds of literature and art to do this continues to grow. There are, of course, doctors who ar e quite well known as literary art- ists: Arthur Conan Doyle, William Carlos Williams, Some rset Maugham, and Anton Chekhov from the past and Michael Crichton, Oliver Sacks, Abraham V erghese, and Sherwin Nuland from more recent times. What about Sigmund Freud? Here is the e xception that proves the rule \200\224proves in the sense of testing, for he is not really an exception. We can accept him among the great only in so far as we view his collection of writings as an artistic oeuvre, rather than as a scientific one. Science has progressed fo r years without Freud, but, as art, his work and insights will survive: And survival, as Be rnard Shaw pointed out, is the only test of greatness. The reason for the ascendancy of art over science is simple. We scientists, in our humble way, are only interested in explainin g reality. Artists are good at explaining reality, too: But they also create it. William Ca rlos Williams wrote in Imaginations, \200\234 \200 now works of art \200 must be real, n ot \200\230realism \200\231 but reality itself \200\224they must give not the sense of fru stration but a sense of completion, of actuality \200\224It is not a matter of \200\230rep resentation \200\231 \200\224which may be represented actually, but of separate existence. \200\235 10 Our most powerful impressions are produced in our minds not by simple sensation s but by the association of ideas. It is a preeminent feature of the human mind that it rev els in seeing something as, or through, something else: Life refracted through experience, light refracted through jewels, or a walk through the woods transmuted into a Pastoral Symp hony . Ours is a world of metaphor, fantasy, and deceit. William Carlos Williams noted, \200\234There is neither beginning nor end to the imagination but it delights in its own se asons reversing the usual order at will. Of the air of the coldest room it will seem to bui ld the hottest passions. \200\235 11 He poetically linked his imagination to his experience s as a physician doing house calls in New Jersey to capture the essence of humanity. What h as all this to do with the day-to-day practice of medicine? The answer lies in the word \200\234defenseless. \200\235 When we read alone and for pleasure, our defenses are down \200\224and we hide nothing from the great characters of fiction. This openness to the stor y of another helps to keep us connected with our patients. So often, a professional detachm ent is all that is left after all those years inured to the foibles, fallacies, and frictio ns of our patients \200\231 tragic lives. It is at the point where art and medicine collide that doctors can reattach themselves to the human race and re-experience those emo- tions that motivate or terrify our patients. Art and literature can cultivate our empathy, so tha t, at some level, there can be truth to the statement, \200\234I understand what you \200 \231re going through, \200\235 even though we ourselves may not have had to endure the illn ess experience of the patient. We all have an Achilles heel: That part of our inner self th at was not ren- dered forever invulnerable to mortal cares when we were dipped in the water s of the river Styx as it flowed down the wards of our first disillusion. Art and literatur e, among other things, may enable this Achilles heel to be the means of our survival as thi nking, sentient beings, capable of maintain- ing a sympathetic sensibility to our patients. 8 10 Williams WC. Imaginations . New York: New Directions Publishing; 1970:116. 11 Williams W C. Imaginations . New York: New Directions Publishing; 1970:35. Anton Chekhov wrote, \200\234I feel more confident and more satisfied when I reflect that I have two professions and not one. Medicine is my lawful wife and literature is my mistres s. When I get tired of one I spend the night with the other. Though it \200\231s disorderly it \200\231s not so dull, and besides, neither really loses anything, through my infidelit y. \200\235 12 Narrative medicine allows us to see the patient as text , and thereby foster speculation and curiosity about the patient \200\231s worldview of illness \200 and hone our ability make a diagnosis. e n i c i d e m t u o b a g n k n h T The art and science of diagnosing The central processes of medicine are relieving symptoms, providing reas- surance and prognostic information, and lending a sympathetic ear (see Tab le 1.1). But it is very difficult to do any of this without a working diag- nosis. How is t his achieved? We diagnose, it is held, by a three-stage process: We take a history, we exam ine, and we do tests. We then collate this information, by a process which is never explain ed, and ultimately arrive at a diagnosis. So how are diagnoses made? Diagnosing by recognit ion For students, this is the most irritating method. You spend an hour asking all the wron g questions, then in waltzes a doctor who names the disease and sorts it out before you hav e even finished taking the pulse. This doctor has simply recognized the illness like he rec ognizes an old friend (or enemy). Diagnosing by probability theory Over the course of our c linical lives, we unconsciously build up a personal database of diagnoses and out- comes, a nd their associated pitfalls. We unconsciously run each new \200\234case \200\235 through this personal and continuously developing fine-grained probabilis- tic algorithm. Diagnosin g by hypothesizing We formulate a hypothesis from the moment we hear the chief complaint. O ur subsequent questions in history-taking, the focus of our physical exam, and/or our selec tion of tests provide the data to prove or disprove our original hypothesis, or to for- mul ate a new one. Diagnosing by reasoning Like Sherlock Holmes, we exclude each dif- ferential diagnosis; then, whatever is left must be the culprit. This pro- cess presupposes that our differential includes the culprit and that we have methods for absolutely excluding diseas es. All tests are statistical, rather than absolute \200\224which is why the Holmes techniq ue is, at best, fictional. Diagnosing by a \200\234wait and see \200\235 approach Some doc tors (and patients) need to know immediately and definitively what the diagnosis is, while oth- ers can tolerate more uncertainty. With practice, one can sense that the dangers and e xpense of exhaustive tests can be obviated by the skillful use of time. This cough might re present pneumonia, but I may choose not to get a chest x-ray or sputum culture. Rather, I m ay say \200\234take this antibiotic if you get a fever \200\224but you probably don \200 \231t need it, and you \200\231ll get better on your own: Wait and see. \200\235 Diagnosing by selective doubting Traditionally, patients are \200\234unreli- able, \200\235 signs ar e objective, and lab tests virtually perfect. When diagnosis is difficult, try inverting th is hierarchy. The more you do so, the more you realize that there are no hard signs or perf ect labs. But the game of medi- cine is unplayable if you doubt everything, so doubt select ively. i i 9 12 Chekhov A. Letter to A.S. Suvorin, 1888. Table 1.1 Diagnosis by iteration and reiteration A brief history suggests looking for a few signs, the assessment of which leads you to ask further questions and do a few tests. These results lead to further questions and tests. As this process reiterates, various diagnostic possibilities crop up and receive more or less confirmation. \200\234I feel my heart racing \200\235 \200\224and the doctor immediately puts his finger on the pulse, feels it to be irregularly irregular, and infers atrial fibri llation (AF; see p. 120). He wants to know why there is AF, so he asks about weight loss an d heat intolerance. This suggests hyperthyroidism (p. 298) as the cause of the AF. While he takes the pulse, he notices clubbing of the fingers, so he makes a mental note to do a che st x-ray to see if there are signs of cancer (could this cause the AF? \200\224yes). This r eminds him to ask about smoking: While inquiring about habits, he asks about alcohol, and e licits excessive drinking. \200\234Why now? \200\235 \200\234Because I lost my job. \200 \235 In the time it takes to assess the pulse, the doctor has many promising leads to follo w and is starting to formulate a diagnosis in three dimen- sions: Physical, psychological, and social. The patient \200\231s palms are clammy and the pulse is weak, so the doctor kno ws he must be prompt and decisive, and gently explains that admission for various tests is needed. Whereupon the patient, who has been holding back tears, now weeps. Now holding her hand, as well as continuing to take her pulse, the doc- tor becomes aware of a change in rh ythm. Is this sinus rhythm, brought on by the Valsalva-like maneuver of weeping? So the doc tor now says \200\234Well \200 let \200\231s see how you do over the next hour \200\224yo u \200\231ll feel better for crying. \200\235 \200\234Yes, you \200\231re right, I feel be tter already. \200\235 This is a microcosm of the intuitive world of medicine, which the so lely systematic doctor never knows. He would come on to the pulse only after a \200\234ful l history \200\235 \200\224and would have missed everything. The doctor who can work on man y different levels simultaneously will often be the first to know the diagnosis. 10 Diagnosing by computer Computing power is the only way of fully mapping the interrelatednes s of diseases (e.g., hyponatremia with eosino- philia points to Addison \200\231s disease , and if there is oliguria, the computer \200\234knows \200\235 that oliguria is a feature of shock, and shock is a complication of Addison \200\231s). Prevention Two mottos: \200\234The only good medicine is preventive medicine \200\235 and \200\234If prevent- able \200 why not prevented? \200\235 During life on the wards you wil l have many opportunities to practice preventive medicine, and, unconsciously, you will pas s most of them over in favor of more glamorous tasks such as diagnosis and clever intervent ions, involving probes, scalpels, and imaging. But if we imagine a ward in which scalpels r emain sheathed and the only thing being probed is our commitment to health, then preventive medicine comes to the forefront, and it is our contention that such a ward might produce m ore health than some entire hospitals. Ways of thinking about prevention Preventing a disea se (e.g., by vac- cination) is primary prevention . Controlling disease in an early form (e .g., carcinoma in situ ) is secondary prevention . Preventing complications in those alread y symptomatic is tertiary prevention . The best way of thinking about prevention is to ask \200\234 What can I do now with this patient in front of me? \200\235 On the wards, this w ill often be secondary or tertiary prevention (e.g., blood pressure screening in diabetes, or colonos- copy in ulcera tive colitis [looking for colon cancer], or endoscopic screen- ing for esophageal cancer in Barrett \200\231s esophagus). The first step in prevention is to motivate your patient to take steps to benefit his or her own health by asking Socratic questions. \200\234Do you w ant to smoke? \200\235 \200\234What does your family think about smoking \200\235 \200 \234Do you want your children to smoke? \200\235 \200\234Would there be any advantages in giving up? \200\235 \200\234Why is your health important to you? \200\235 \200\234Is ther e anything more important we can help with? \200\235 \200\234How would you spend the money you might save? \200\235 These types of questions, along with specific strategies in preve ntion (p. 87) are more likely to produce change than will withering looks and lectures on l ung cancer. In summary: In any preventive activity, get the patient on your side \200\224ma ke her want to change. Once you have done this, preventive activities you might promote inc lude: e n i c i d e m t u o b a g n k n h T i i Primary - and secondary disease prevention General health Cancer screening Vaccination (e.g., flu shot if Healthy eating Colon cancer screening Pap smears Mammography and 11 >65 yrs) Aspirin if vascular disease Cardiovascular risk Regular exercise Advice on smoking reduction and alcohol House and car dangers: Seat belts, accidents, falls, gun safety annual breast exam Osteoporosis prevention if on steroids or postmeno- pausal (calcium, vitamin D, bisphosp honate) Genetic counseling (e.g., if family history positive in two 1st-degree relatives) Sometimes referral to other agencies is needed (e.g., for genetic counseling, contraception , and preconception advice). Concentrate on those preventive activities that are simple, ch eap, and have a complication rate approaching zero. When considering a more compli- cated o r \200\234high-tech \200\235 preventive procedure, be on guard for unintended con- sequenc es, such as colon perforation in colonoscopy. When risk is involved with the preventive str ategy, weigh the procedure in light of the patient \200\231s history and other medical prob lems. Get the patient \200\231s input about whether the preventive measure is right for him or her. Individualized risk communication When counseling a patient about screening tests, communication should be based on a person \200\231s individual risk factors for a conditio n (e.g., age, family history, smoking status, choles- terol level). With some conditions, t his can be achieved with decisional aids or using formulas. A Cochrane meta-analysis sugges ts this kind of individu- alized approach will \200\234not necessarily \200\235 change beh avior, although uptake of screening tests is improved. At least this technique promotes dia log, and dialog opens doors, minds, and possibilities for choice. Informed partici- pation is the aim, not passive acceptance of advice. Improved knowledge, beliefs, and risk percept ions can be achieved with this approach. How clini- cal evidence is presented can make a di fference in certain patient popula- tions. Participatory decision-making is facilitated whe n the physician: \212 Understands the patient \200\231s experience and expectations. \212 Builds partnership. \212 Provides evidence, including a balanced discussion of uncertaint ies. \212 Checks for understanding and agreement. \212 Presents recommendations informed by clinical judgment and patient preferences.