Three Dimensional Doctoring

(Another chapter from IN PRACTICE)

“I keep six honest serving-men
(They taught me all I knew);
Their names are What and Why and When
And How and Where and Who.”

Rudyard Kipling

Medicine has become a very complex, multifaceted science, ranging from pharmacogenetics to psychoneurobiology. Doctoring, however, is increasingly viewed as so simple that you don’t actually have to be a doctor to know how it should be done.

What else could explain why IT people tell doctors what “workflows” to follow, instead of doctors telling them “we need computers that do this in this kind of way, so that we can better take care of our patients”?

What else could explain why the quality of our work can be measured by only a handful of parameters, all simple numeric indicators? Never mind that the target numbers change from time to time, and never mind that even well established individual targets sometimes disappear from the checklists.

What else could explain why it is the government that defines the overarching goals of health care in this country, and probably many others?

I’ve been thinking a lot lately about what it means to be a doctor, and particularly a good one, in the present era and from a historical perspective. Also, I have started to formulate a definition of what it takes to make doctoring a sustainable lifetime vocation in these times.

I think doctoring occurs on three levels, each one necessary for the physician to engage on:

1) The “How”

The most visible, and perhaps most intuitive, level is that of solid clinical knowledge and proficiency. This, of course, takes different forms in different specialties. Knowledge and proficiency are not enough, though. Judgment and critical thinking are essential but seldom emphasized in the lay debate on medical matters. The clinical art of medicine involves an infinite array of decisions about when general principles apply to the individual patient and when they do not. It also involves staying current with medical science and viewing claims, be they by drug companies, medical or political authorities, through the lens of the scientifically trained clinician. Today’s emerging practice of applying genetic research to individual treatment decisions moves us away from blindly following “guidelines”and validates the traditional importance of considering each patient’s unique social and biological makeup as manifested in their family history.

If the “How” of medical practice truly was as simple as some say today, guidelines and “best practices” would largely eliminate the need for independent, critical thinking and make a university education and the years of rigorous clinical training and practice unnecessary for delivering what we call health care today. Obviously, this is far from the truth.

2) The “Who, What, When and Where”

But doctoring goes beyond the technical proficiency and the scientific thinking that goes into each patient encounter. Borrowing from Kipling’s expansion of journalism’s “Who, What, When, Where, Why”, the first level of doctoring is the “How”. The technical “How” cannot be viewed in isolation. The “W” words of analyzing the locus of complex issues date back to Hermagoras’ “seven circumstances“, two thousand years ago.

A doctor doesn’t work without context or in complete isolation, although my wife sometimes (lovingly, I believe) calls me a Martian, implying that I somehow just landed on this planet as a doctor, ready to serve patients. Each doctor usually has a place of practice, a schedule, a way of collecting money for services rendered and these days also assistants, nurses and people who carry out administrative tasks.

In today’s society, doctors are increasingly separated from this necessary aspect of the practice of medicine. As employees of large organizations, they have their office hours, the length of each appointment and the number of patients seen on any given day determined by other employees.

Equipment purchases, from EMR’s to surgical instruments, are made by managers and supervisors with only varying degrees of physician input. And support staff are usually hired, trained and evaluated by management, not by the physicians.

In the day-to-day work of physicians, the seemingly inconsequential practical aspects of how a medical office functions can be significant impediments to good care as well as to both patient and physician satisfaction.

Involvement and input into the workings of the medical office are important aspects of being a doctor. Why would Michelangelo not care and instead have someone else pick out his paints and brushes for him? If a company of firefighters were issued pairs of only two left boots, would they perform to the best of their abilities, running toward the fire?

Another aspect of “Who, What, When and Where” is how medical practices relate to their customers, their physicians’ patients. All physicians, I believe, should be involved with how the office treats its patients, from telephone triage to billing and collections practices. Those things frame the office visit and may determine its outcome in many instances.

Only a one dimensional, disillusioned physician would have no interest at all in what happens in the medical office outside the exam room and the allotted fifteen minutes of appointment time. No disease can be effectively treated out of the patient’s context, so how can we imagine treatments working entirely without considering the clinic’s context?

Sir William Osler said: “The good physician treats the disease; the great physician treats the patient who has the disease.” The patient relates and reacts not only to the physician, but also to to the organization that employs the physician and defines the terms of engagement between doctor and patient.

3) The “Why”

The government wants most people to be healthy enough to be productive citizens, so it has defined health care with that purpose in mind and will sacrifice individuals to protect the collective. This happens when we go to war, too, for example.

Physicians generally feel a very strong obligation to their individual patients, and seldom face the choice of helping one patient over another.

So, why do doctors take on such obligations as their vocation?

I see doctoring as a calling with a higher purpose. My main professional motivation is to relieve suffering. In some specialties the purpose may be finding ways to enhance well-being, something I do to a degree as well.

Then, what defines a doctor?

The word “doctor” is derived from the Latin “docere”, which means “teacher”, and can also mean someone who has been taught, or educated. And if we think about this, every physician has been taught by another physician, which is the way it has been for thousands of years. Even though the profession has changed, just like the science of medicine, we are still carrying the legacy of those who went before us.

I really didn’t just arrive one day as a fully capable doctor from another planet; I went to a five hundred year old university, home of Linnaeus, Celsius, Ångström, Berzelius and Bárány. I owe whatever acumen I have acquired to the dozens of teachers and mentors, who shared their knowledge with me.

In a moment of passion, I thought of the phrase “The Apostolic Nature of our Profession”. It points out that physicians today are still carrying out an ancient tradition and also a fundamental role in our society and in people’s lives.

That sense of our place in history is necessary to navigate the rapidly changing currents in health care today. Without it, we are just technicians with ever-changing repair manuals, while our patients, just like patients two thousand years ago, are looking for a “docere” – someone learned, who knows not just the facts, like Google or Wikipedia, but understands their context and can help weigh their significance.

When the increasingly complex “How” of daily practice doesn’t always make sense, and when the “Who, What, When and Where” doesn’t take physicians’ accumulated experience into account, the “Why” is the ultimate question that defines us and our place in society as well as in history. All three sets of questions demand consideration as we think about our vocation as physicians.

Sir William Osler also spoke of three dimensions of medicine. His eloquent words define three somewhat different aspects than my musings, but the idea is still the same: Doctoring is something that takes place simultaneously on many levels. He placed doctoring in the arena of disparate definitions of medicine (religious in his day, political in ours), in the cross point of art and science and in the realm of morals and noble ideals:

“The critical sense and sceptical attitude of the Hippocratic school laid the foundations of modern medicine on broad lines, and we owe to it: first, the emancipation of medicine from the shackles of priestcraft and of caste; secondly, the conception of medicine as an art based on accurate observation, and as a science, an integral part of the science of man and of nature; thirdly, the high moral ideals, expressed in […] the Hippocratic oath…”

Physicians in today’s politicized, technocratic and materialized society are at constant risk of becoming one dimensional robotniks in a healthcare machine whose purpose is not the same as our ancient forbears’. We need to always remember “Why” we are here; we must be a strong voice in all discussions about “Who, What, When and Where”; and we need to guard our scientific integrity as we practice the “How” of our profession.