Sunday, October 21, 2012

Clinical Creativity In The Era of Evidence Based Medicine

One of the most interesting features of the i-Tunes store, is the effortlessness with which you may accumulate a listing of 'covers' to various songs. For example, I have play lists consisting of many, many versions of 'All Along The Watchtower', 'Boots of Spanish Leather', 'Moondance', and "Buffalo Skinners'. These songs fascinate me with respect to their lyrical value in my eyes and from my perspective.


I find it a fascinating and enlightening exercise to listen to familiar 'tunes' done by both the original artist in different venues as well as 'covered' by other artists. This activity emphasizes to me the centrality of individual creativity and stylistic differences; while the true essence of the music and lyrics are expressed and preserved at the same time you are compelled to undergo an expansion of your appreciation of the piece. Contrast this to an imaginary concert in which 30 'different' and 'individual' Elvis Impersonators all performed renditions of 'Blue Suede Shoes.' I hardly believe my appreciation of the song or the process of performing the song are deepened or enlightened by a mechanical attempt to reproduce the original effects of the 'king' during his performance of the piece.   

The question hidden within the above hypothetical 'mind' concert is what is the true relationship between the Evidence Based Medicine movement and the practice of medicine?  Should it be analogous to my playlist of versions of 'All Along The Watchtower' or rather a concert of 'Elvis' Impersonators? 

Tuesday, October 16, 2012

The Ghost In The Shell Vs The Ghost in The Machine .....



When trying to consider the full impacts of medical IT on the practice of medicine, it is difficult to not become cynical, discouraged, and frustrated.

As I have argued in previous posts to this blog, 'good medicine' is less mechanistic than is generally acknowledged. Furthermore, what my years of practice have taught me is that narrative medicine is the superior approach to obtaining the clinical history (http://en.wikipedia.org/wiki/Narrative_medicine). 

What I consider the narrative medicine based history is really encapsulated by the fervent and passionate belief that  'medicine is a dance, in which the patient leads.' Furthermore, allowing the patient the time and space to  present their problems in their own language, in their own way, and according to their own priorities is a highly efficient form of practice. When I was engaged in the teaching of house-staff in Internal Medicine, my trainee's were impressed with the speed and effortlessness at which my clinical interviews with their patient's would end at the right clinical conclusion. Why? Because at the core of the clinical encounter is the patient's true interest in having their issues acknowledged, dealt with, and hopefully solved. Only the rare patient, the explicit malinger or the Munchausen's patient has the desire to frustrate the search for clinical truth.  

All wise clinicians appreciate that at the core of even the most modern 21st century patient is a primitive sub-personality in perpetual fear of the extinguishing of the flame of mortality ever threatening at the perimeter of their personal event horizons.  Therefore, the true healer, wishes to be more than a highly compensated healthcare technocrat, the true and wise physician wishes to wield the power of the Shaman as well as the Scientist. 

Furthermore, all patient's long for a therapeutic relationship with their physicians... they wish to be healed and cured, not simply to be treated and processed. The more serious and grave the illness, the more the patient's vital needs and interests attempt to compel us to wield this ancient power  forgotten or ignored by physicians in our headlong rush towards automation and professional anonymity and a 'balanced' and manageable lifestyle.
When you embrace the practice of narrative medicine as well as understand the patient's quintessential longing for healing, as well as the healers existential need to heal; the use of current medical IT systems becomes to feel like a poisonous dart sunk deep, slowly leaking toxin into your living heart & soul, a evil and malign dart that simultaneously leaches your humanity, your compassion, and most importantly robs you of the time you need to effectively employ the hidden shamanistic dimension of medical practice.     

It is explicitly and manifestly true that 'Time Heals All Wounds'..... but time is ever vanishing for the medical practitioner. As Thoreau so presciently observed....But lo! Men have become the tools of their tools. (Walden, Economy, pg 64).  And the current state of these IT tools are sorry, sad, inept, and inadequate to the task. What takes time away from the consulting room, what stands between me and the careful, intelligent, and passionate interest in every patient's unique story of pain, suffering, and fear of illness and death acts to make me a more ineffective doctor. Medical IT tools need to optimize the capture of the patients narrative and story, while enhancing the healers ability to develop, deploy and employ therapeutic concern for the patient's welfare.