A CONSULTATION WELL DONE

When I was in active clinical medical practice, some times I ran late.  Patients could find themselves in the examining room a quarter or half hour after their scheduled appointment had passed.  I would explain that when an emergency arose, I had to deal with it and interrupt my normal appointment flow.  And then I explained that I would do the same for them if the need arose - and kept my word.

So, when my Cutaneous Oncology consultant ran late today for my scheduled appointment, it was not an issue. I kept in mind the reason I was in his office, mentally highlighted his credentials and skill set - and was rewarded by an excellent consultation experience.  The remainder of this blog will deal with my definition of an excellent Oncology (Melanoma) consultation.

1. Timeliness.  My consultation was scheduled in a timely manner, neither too quickly (which would have denied the consultant the opportunity to communicate with other doctors involved in my care or review my records) nor too late (after critical time periods for care had passed).  Adequate time was reserved and the consultant extended our session to cover important subjects.

2. History. The consultant was well-prepared through his discussion of my "case" with other professionals involved in my care and his review of my electronic medical record.  But he went through many targeted questions, eliciting additional information relevant to my melanoma, my general health, and specific conditions which would need to be considered before treatment recommendations could be made.

3. Physical Examination.  A medical assistant recorded routine vital signs,  but the consultant performed a targeted thorough physical examination.  An experienced competent physician, could cover all of the relevant physical diagnosis issues in five minutes or less. He did.

4. Discussion of Findings/Formulation of  Evidence-BasedTreatment Plan.  In a careful, thorough, humane and frank manner, and without leaving out important considerations, the consultant reviewed pertinent findings in my medical records, history, and physical examination.  He then discussed relevant data from scientific studies of melanoma from his own vantage as a hands-on treating physician, as well as an academic expert on the disease.  Going further, he discussed the strengths and weaknesses of the available scientific data, current professional biases among oncologists, the economics of treatment, and his conclusions concerning the application of all of the data he collected, and evidence-backed scientific  data to formulate a prognosis and treatment plan.  Throughout this process, he distinguished his professional opinions based on personal experience from positions favored by the weight of reliable data. All of this discussion was carried-out in understandable language, though reference to some of the currently available pharmaceuticals and intricacies of acquired resistance to treatment by melanoma and the biology of the immune response of one's body to melanoma may have been difficult for my wife, who accompanied me.

5. Planning for The Next Step. I left the consultation with a clear understanding of the next steps to be taken by the consultant and his plans for further communications with my other physicians and me.  

Some of the information I gained today was serious and disturbing. But there was a sense of completeness, professionalism and competence that made the consultative experience worthwhile.  After all, adults need to discuss major health issues seriously and make serious informed decisions.  

I left the consultant's office to attend a biomedical ethics committee meeting elsewhere, reassured by the high quality of the care I had just received. 

What Does A Lump Mean?

Physicians find lumps all of the time. Most of them are benign and transient (of course the pregnancy "lump" is transient but may not be so benign).  So how does a doctor know which lump merits concern and investigation?

The basic tools are straight-forward. A simple history, which addresses a variety of issues including some of the following, may lead to the correct clinical impression: Have you ever had cancer or any unusual growth on your skin or elsewhere?  What surgery have you had?  How is your appetite? Have you lost weight recently?  Have you had sweats at night or experienced fevers which have no obvious explanation?  Have you been exposed to toxic environments or  materials in your work or personal activities?

And then, the doctor takes the time to perform a competent examination, examining the lump, skin, lymph node areas, thyroid, abdominal organs, breasts, testicles and other areas which may harbor malignancy and which are accessible to palpation or examination.

Only then, does the doctor consider the differential diagnosis and possible laboratory and radiologic tests which may help to establish a diagnosis and differentiate a benign from a more serious condition.  And then,  after a discussion with the patient, the doctor orders the standard tests - and  specialty focused tests such as fine needle sampling (biopsy) of the tissue in question.

Then the doctor and the patient (and those the patient wants to be involved) discuss the findings, the diagnosis and the treatment options and plan. 

Medicine is not television drama. The physician - who has been carefully trained to understand and require each step that I have outlined - collects all necessary information to form an evidence-based diagnosis.  Scientific evidence trumps intuition and conjecture.

Evidence Is Only A Part of Evidence Based Medicine

EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician's cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. 

There are serious subtleties in Sackett's straightforward statement. Has the physician, addressing your problem, necessary cumulative experience? How is relevant cumulative experience defined? How do patients judge a physician's total  education? How does a patient assess a physician's clinical skills?

What are some of the other important issues? Does the physician have a stable personal life? Is he or she in financial difficulty?  Did he or she have a knock-down drag-out fight with his or her spouse or children the night before he or she is scheduled to perform a technically difficult procedure, requiring a sharply focused mind,  for you?  Does the physician use too much alcohol or is he or she a drug-user?  Does he or she have a health problem which affects medical practice and judgment?  Is he or she a personal risk-taker and is that a personality characteristic you consider useful in your care?

Is the physician intellectually aggressive and knowledgable? Is the physician energetic or lazy?  Is the physician inappropriately fearful or self-defensive?  Does he or she seek-out and value the opinions of other physicians in the same specialty or does he or she dismiss those opinions which are inconsistent with his or her views. Does he or she know what evidence is important in your case, obtain that evidence and then carefully review it, integrating it with the available history, physical findings and other medical data about you? Does your physician seek consultation or make referrals or does he or she believe that he or she can "handle it all" even though his or her experience may be very limited?

Does your physician work in isolation? Does he or she test his or her ideas in study groups, professional lectures or other activities? Does he or she read leading medical journals or rely on pharmaceutical company sponsored education programs for updates? Are your physician's extra-curricular activities primarily medical-political, or is he or she focused on activities benefitting the comunity?

Does your physician work in a medical group run or owned by lay people? Are the physicians in the group setting its course or are they only paid employees for whom working conditions, patient volume, practice philosophy, professional standards,  office facilities, and financial production numbers are dictated by others?   Do the physicians in the group carefully observe each other so that substandard care is addressed and high quality care is rewarded? Is referral outside the group discouraged? What are the ethical standards and practices of the group? What is its mission?

"Evidence" is a single factor in a many-faceted  physician-patient relationship.  While the preparation, interpretation and value of medical evidence changes rapidly, the physician's wisdom, personal and professional judgment, compassion and competence in addressing life's issues tend to be stable. Don't get hung-up on evidence. Look for the subtleties.