A WISH BEFORE SURGERY

My surgeon called yesterday to tell me that he had accomplished every reasonable goal we had talked about, for the surgery performed 9 days' earlier.  It is comforting to know that perhaps those prayers and wishes I had before the surgery were answered. 

My prayers and wishes were probably a little different what my readers might imagine.  So let me share them with you - to give you the advantage of my years of medical practice, sometimes in the operating room when things did not go well during a procedure.

I wished my surgeon a really good night's sleep.  I wished him a terrific relationship with his spouse and a home (including parental) life free of tension and difficulty. I wished him enjoyment of his surgical practice and a good professional relationship with patients, with his surgical team, with the nurses and staff people caring for me, and the hospital administration of the institution where he performs surgery (so that he has the environment, equipment, staffing and supplies appropriate for the day's work).  I wished him the ability to focus specifically on the issues at hand when he performed surgery on me, to the exclusion of any possible distractions, even momentary ones.  I wished him freedom from the oppression of economic burdens, good transportation between his home and the hospital, and a bright sunny invigorating morning which he could enjoy in good health. And I wished him knowledge competence and judgment appropriate for the procedure at hand.

If all of these prayers and wishes were granted, I - the patient - would do just fine. 

And I guess that's what happened.

Do You Get What You Pay For?

When I first practiced medicine, a visit with my internal medicine partners, was scheduled to last 20 minutes.  During that $9 visit, our standard of care called for taking the patient's history, performing a significant physical examination - including looking at the skin, checking for enlarged lymph nodes, examining the heart, lungs, abdomen and breasts, performing a brief neurologic examination, and preparing a chart note which listed significant items and findings. Because there was continuity of care, with patients not changing insurers and doctors every year, we knew our patients well and recognized important changes in their histories or physical examinations. We noticed unusual moles and lumps and masses and though we did not have electronic records, computers, or the extraordinary array of lab tests now available, we had the standards, skill, time and interest to establish early life-saving diagnoses leading to curative treatment for many.

When patients visit their "primary care providers" now, there is neither time nor interest nor a standard of care supporting the performance of anything other than a "focused" examination. The patient is asked what the major reason for the visit is, and anything else is likely to receive not even cursory attention. Ask yourself -  when did your doctor (or non-physician health care provider) last ask you whether you had noted any changes in a mole and actually had you remove sufficient clothing so that a skin examination could be done?

The June 6, 2011 New York Times front page features an article titled "Two New Drugs Show Promise In Slowing Advanced Melanoma" which describes two new drugs [also reported in the June 2, 2011 New England Journal of Medicine (Funded by the National Cancer Institute and others; ClinicalTrials.gov number, NCT00019682)) which offer a short window of response to advanced melanoma skin cancer. The article is well written. But  my readers, need to understand that if the melanoma had been found at an early stage in a routine office visit by a health care provider with sufficient professional standards, skill, time and interest to actually look at the patient sitting there on the examining table, that melanoma might have been diagnosed at an early curable stage when it would never require drastic new treatments with significant side effects which offer only short-term respite at enormous patient and societal cost.


So the next time you go to your doctor for a "focused" visit, ask that the doctor (or other provider) to spend enough time to actually look at your skin.  Maybe this simple request will save your life.

The adherence to professional standards, professional skill,  interest and willingness of my doctor during a recent visit, to look for, find and recommend treatment for my melanoma - hopefully - will save mine.

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.