Navonim - The Ramblings of Garnel Ironheart

Navonim - The Ramblings of Garnel Ironheart

Tuesday, 11 September 2007

A Push for Experience

There's something to be said about society's lack of respect for age, experience and knowledge. One feature of modern secular liberalism has been an emphasis on equality to the exclusion of all else. To the popular mind, the opinion of an uneducated illiterate is equal to that of someone with a PhD in astrophysics. Because, according to this creed, all people are automatically of the same worth, their opinions are too.

I see this in my profession on a regular basis. Back in the late 1980's and early 1990's, a new form of learning and practising medicine came into vogue. Called Evidence-Based Medicine, it demanded that decisions by doctors no longer be made through experience, trial and error, or gut instinct, but through the use of the medical literature and its findings. Systems were designed to analyze medical trials and determine their worthiness of being used to analyze patient problems. Medical research began to change their standards to produce more trials that would meet the new rigorous standards.

So far, this all sounds fine. Who could object to a doctor finding importance in knowing the very latest in medical knowledge and using it to help his patients? The problem with this system, as with all systems, is that the fanatics pushing it went too far with their agendas. When I was interviewing at one school, for example, I was given a paper to read which stated that "with evidence-based medicine, a first year intern is just as competent a clinician as a consultant who has been practising for 30 years because both have equal access to the literature and use the same skills to analyze it."

Right. Thirty years of experience, of trying therapies out, of interviewing patients and developing a feel for the art of medicine, all meant nothing. The only thing a doctor really needed to do was consult Medline, the all-knowing database of medical literature. Left unanswered were some very basic questions.

Why do we need doctors then? Nurses can check Medline just as effectively to give answers to patients. What happens if their no evidence? Do we just wave our hands helplessly and refuse to treat our sick patients? How exactly does one interpret the evidence? If the trial included males 46-58 years old, do I tell my 45 year old patient that I can't use its conclusions to assist him?

In the end, medicine is both an art and a science. Science can be learned, facts can be memorized. But art? You don't teach art from a textbook. You teach it through example, through encounters, and through the passing of experience from seasoned clinicians to new recruits. There are some things for which there will never be evidence, patient problems that will only be solved by consulting one's instincts. It must be remembered that there is inestimable value to that.


Ahavah B. said...

Good luck telling your insurance company that - whatever works for 51% of the people is the treatment you will get regardless of whether it is appropriate or works for you or not. They will not pay for anything else, and they don't care how much "experience" your doctor has. I know this for a fact - I have every single symptom on a 2 page checklist for low thyroid (you could make a carpet out of the hair I lose every month) but since one single blood test shows me in the "normal" range, I have not been able to get any treatment for over 5 years. When asked "how do you know that reading is MY normal" my doctor just gave a blank stare - they are so indoctrinated now in the idea of statistically driven diagnoses that they can't even think outside that box anymore. That, I think, more than anything has driven the alternative medicine market through the roof - many if not most people can't get treatment from modern medicine, so we search desperately for some non-prescription treatment that can bypass the HMO and their physicians. If you have a better idea, I'd love to hear it. But right at the moment I don't see any choice, and neither do millions of other people.

Garnel Ironheart said...

Some points in response:
1) Any "normal range" on a lab test is what is statistically normal for 95% of the population. What that means is that the normal range doesn't apply to 5% of people, so always be wary of the line: "But the blood test is normal".
2) I can't speak to insurance co's covering basic health. I'm up here in Canada where the government pays us all to wait in line. having said that, one of the principles of medicine is that lab tests are there to support a dianogsis, not to make it. The doctor should be looking at the whole patient. If he doesn't have an answer, he should look further or refer to someone who can help more.
3) Have alternative diagnoses be considered? One of the dangers of the Internet Age is pateitns looking up something on line, realizing they fit the pattern of a specific disease but then not realizing that there is often tremendous overlap with other diseases (this is especially true with hormonal diseases). Have you had other hormones checked? What if your testosterone or cortisol levels are off? You could develop identical symptoms to hypothyroidism.
4) The doctor can be a little adventurous too. It's basically harmless in most people to try a low dose of thyroid replacement and see what happens. Offer to sign a waiver that says you won't sue him if something goes wrong and tell him you want to try it for 4 weeks.