November-December Book Club - No Apparent Distress

Yes, I'll participate.

Well, the response so far has been underwhelming, but I'll take a stab at trying to start a discussion, and see if anyone responds.

One theme of the book is how inexperienced medical students, with some supervision, are thrown into the breach to take care of the uninsured and indigent patients that no one else is willing to help. In the prologue the author discusses her failure to diagnose stomach cancer because of an incomplete examination, and later she relates her neglect of a detail that indicated kidney cancer in another patient.

Mistakes are a part of any profession, but when it comes to health care no one wants the mistakes inflicted on them, at least not when anything significant is on the line. For prostate procedures people understandably want the best and most experienced doctors in charge, recognizing that there is a significant difference in outcomes. Locally, I've read about a series of lawsuits against the Cleveland Clinic that lasted for several years, where a patient alleged that the robotic surgery that left him incontinent and impotent was not actually performed by the surgeon he had engaged, but rather by two doctors in training. (The Clinic denied the allegation, and eventually won the cases on technical grounds.)

But where are medical personnel to get the experience that makes them the top providers in their fields, and who is to be left to be treated by those doctors who are not the elite? What should or could be done to improve care in general, so that care of the highest quality is not just reserved for the well-informed, the well-connected, and the well-insured?

I will be getting the book from Amazon. I have enjoyed the last ones.

The whole area of the potential distrust between patients and their doctors can also be deeply rooted in linguistic habits. In the past, perhaps, there was more of a power relationship gulf between the "expert" doctor and the patient who was given all kinds of signals of how to behave and acquiesce to be a "good patient". In more recent times, doctors often put things in their patient Notes like "patient denies pain at such and such location", no so much because that's what the patient actually said, but sometimes because it will help cover someone's liability if something undiagnosed raises its ugly head at a later date.

There is a very nice related discussion in this paper about the language still used when doctors talk about a patient using the terms COMPLAINT, DENY, and FAIL. And the author makes a pretty good case for trying to abolish those terms from compassionate, healing communications and relationships between doctors and patients.

"There Is No Denying It, Our Medical Language Needs an Update"

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4507913/

Charles

Charles,

That's an interesting little piece. I think more important than changing certain words is the need to move doctors off of the streamlined thinking that inevitably pushes its way into medical practice, an approach that is actively encouraged by the economic pressure brought on doctors.

Jerome Groopman, in his book "How Doctors Think," has some tips for how to get around this problem. First and foremost, he stresses the need for a fresh history to be taken when a doctor sees a new patient. Doctors tend to take the conclusions reached by other doctors as a starting point, and even patients often adopt doctors' conclusions and language about diagnoses. Especially where previous diagnoses and treatment approaches have been unsuccessful in addressing a problem, it often helps to start from the beginning, repeating tests if necessary.

He also recommends some questions to get doctors to stop and think, to avoid cognitive traps, and to expand their considerations: What else could it be? Is there anything that doesn't fit? Is it possible that I have more than one problem?