Thursday, April 4, 2013

Figure - Ground Dichotomy - Is It The Essence of Clinical Expertise?

The essence of the clinical art is perfection in diagnosis. The solution to most problems becomes relatively simple once the diagnosis is established. The role of modern informational tools in the practice of medicine should be to provide immediate  expert level advice and reference to the the best  therapies. This has been in fact the major use of medical information technologies over my own career, the use of so-called knowledge retrieval tools. Long before, UpToDate became a daily used tool, the StatRef CD collection followed me everywhere and to everywhere.

However, the art of diagnosis remains the extraction of pattern from a background of noise and distraction. Perhaps the 'smartest' Internist who ever helped train me in Residency was  simultaneously the worst diagnostician I have ever worked with. His approach to solving a clinical problem was too simply assign all pieces of data as equally probable, i.e., equally likely and equally important, generate a set of exhaustive lists of differential diagnosis, based on each 'fact' and than try to cross correlate his diagnostic logic within this context. In fact the approach was the epitome of the method of exhaustion, it exhausted his house staff, his patient, and ultimately exhausted the 'bank.'

As our figure/ground illustration demonstrates, a change in perspective, a 'fresh way' to see the data is often illuminating. My own approach to a difficult diagnosis revolves around identifying what I consider to be the 'organizing principle' of the case. That is I consciously look for how this case is unlike other cases I have seen, so that I might focus on what is unique in the case presentation. So, rather than rejecting a fact, observation, or measurement, especially if it is a 'fact' of high emotional significance to the patient, I embrace that case feature, as the basis for developing an explanatory pathophysiological mechanism for the patient's symptoms. This is contrary I believe to the usual clinical impulse driven by the 'need for speed' to prune the potential problem states by ignoring what is not recognized or what is felt idiosyncratic to the patient.

The difference in emphasis is profound and the result in my experience superior to the physician driven shot-gun review of systems approach, felt so essential to a complete history. Heretically I embrace the comment made in The House of God, articulated by the FatMan, "What did you ever learn from a ROS?" Elucidating an appropriate history should naturally result in the characterization of the pertinent negatives and positives associated with that patient's presentation during a naturalistic discussion with the patient. However, 'counting' the pieces of a review of systems is simple to do, and simplistic to do, and allows to outside reviewers the illusion that they can determine the quality of the data acquisition by the simple act of counting symptoms replied to in the negative or the affirmative.

However, the memory of my own undergraduate training in mathematics often whispers to me silently in the night..... 'elegance', i.e., brevity and relevancy of the fact set, is more profound and a more certain demonstrative of true art. Given two valid formal proofs of any mathematical proposition, the shortest proof is the superior proof.

So in a real and profound sense, the data set which supports a diagnosis that is the smallest such set, shows the greatest mastery of the clinical art. Because a computerized record of a clinical encounter is voluminous and 'complete' does not make it necessarily correct, appropriate, or even easily digestible.

The discussion ultimately focuses on a recurring theme for this blog, preserving the passion of the art of medicine, when the weight of all forces being brought to bear on the practice of medicine relate to cost control via hidden resource rationing. Furthermore, confusing counting with review, volume with quality, and substituting exhaustive exploration for true knowledge all muddies the waters and allows for the discussion of quality in medical care to become ultimately the comparison of isolated snippets of clinical care provider Vs provider, hospital Vs hospital in what will surly be exercises in superior marketing rather than the pursuit of superior care.

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