In a journal club I run for the orthopaedic surgical residents, we reviewed an article by a surgeon with a reputation for somewhat sloppy research techniques. As we dissected the article and found all the gaps in study design into which an investigator might insert his or her own bias, the residents began to think aloud about how much a reader must trust the writer of such an article. Indeed, information is power. Unfortunately, those who wield control over information do not always shoulder this responsibility humbly and honestly.
On too many medical charts, the text “WNL” intends to be read as “within normal limits.” It is usually placed next to a specific body part on the catalogue of physical examination findings. It probably more often designates something the physician did not check in detail, “we never looked.” In a meeting recently, a colleague of mine insisted that the solution to a specific problem in our field was so obvious and so widely appreciated, that no one in our field would possibly be willing to subject the different available solutions to a head-to-head comparison. I disagree. I disagree in part because I recently tackled just such a question pertaining to another disease, to which we all thought we knew the answer. Our research team found that at least one of our long-held assumptions (broadly agreed upon around the world, in fact) was simply not true. As unsettling as that was to find out, it is also an important reminder that we must strictly avoid the arrogance of assuming we know more than we do. When We Never Look, everything may appear Within Normal Limits, whether or not it actually is.
At a couple of the recent book events, someone has asked specifically about the challenges of having so much information available to patients via the internet. This reality bugs a few doctors. In my opinion, the key is the attitude with which information gleaned from the internet is introduced by a patient into the physician-patient conversation. Bringing information to a visit and asking your physician’s opinion on it can only help. Deciding from the internet exactly what you have and telling the doctors what they are going to do about it is less likely to be either successful or encouraging of a positive interaction. The problem with medical information on the internet is that many “articles” are really prepared as advertisements. Nonetheless, physicians should be skilled at sorting through such information. Asking their opinion on it can only spark a bit more of a dialogue between you. I’m not sure if Dr. Google levels the playing field as much as some thinks he does, but he can help you generate a conversation that might.
The book was officially released today for public consumption. Reflecting on the book’s ideas for an interview, I had two images come into my thoughts that match well both the problem I see in physician-patient communication and the solution I hope is possible. I take as frank fact that what we know in medicine is fuzzy, unclear, and less desirable than any of us want it to be. The image of what I wish would not happen has the physician, as salesperson, presenting this blemished and blighted product called Medicine to the audience of a potential customer, the patient. This physician stands in front of Medicine, almost shielding it from the patient’s clear view. The image of a scenario I much prefer is that of physician and patient, standing together, facing Medicine, in all its imperfections, with the physician pointing-out clearly for the patient what is good, bad, and ugly, as well as how to think about it. I like this teacher-student relationship much better because our product is necessarily flawed. I am NOT making any comment in these images about medical systems, politics, or the fact that Medicine is bought and sold. I am also not slamming salespeople. No doubt, any salesperson hopes to have a product really worthy of praise. No. I am talking about how physicians approach what they don’t know. Do they hide it from patients, or make it blatantly clear, but understood. Here’s hoping for the latter.
I shared a telephone conversation with my father, to whom the book is dedicated, on Sunday. As we talked, a thought came to me. Many look at the world and see only grays, no black and white. I think in medicine, a physician chooses where to force black and white and where to acknowledge gray. I cannot choose not to find gray in the facts of biological variation and uncertainty. It is inevitably there. I can choose to be as black and white as possible when it comes to presenting that gray to my patients. Some find it much easier to be morally gray and present Medicine as black and white. They think a doctor must simply have big shoulders and bear the uncertainty alone, or patients will lose faith. I’m just not all that comfortable with that premise. I feel as if I am abandoning the good faith they place in me if I am anything less than honest with them. My father corrected me that even my attempts to be black and white honest will fall short. He is right, but at least I sleep well at night knowing I tried.