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Sunday, February 5, 2012

More on the art and science of healthcare

Yesterday I suggested that there is a role for measurement and standardization in our quest to make healthcare effective, efficient and safe.  This is Medicine's "left brain."  But leaving the issue there dooms us to healthcare delivered with "half a brain."

The fact is that without the "art," the "science" doesn't work.  The science doesn't address the question, for example, of how physicians make a diagnosis in the first place.   It remains true, even in the age of advanced imaging, that the most informative data for determining what is the matter with the patient come from the medical history.  The process by which the skilled physician obtains this history is highly individualized and nuanced.  It is a dance and an acrobatic balancing act.  If the physician interrupts too much, he prevents the patient from sharing key material.  If he doesn't ask questions at all, critical clues will go unreported.  More than a century ago, William Osler, a founder of modern American medicine said with deceptive simplicity: "listen to the patient and he will tell you the diagnosis."

I like to tell our students and residents that EVERY interaction with the patient, every word we say, in fact, is either therapeutic or anti-therapeutic.  There is no middle ground.  Medicine (and, for that matter Nursing) is an inherently relation-based endeavor.  How we greet a new patient ("what seems to be the matter?"), how we explain a finding, even how we frame questions.  Imagine palpating an enlarged lymph node in the neck of a teenager most likely suffering from a routine case of mono and asking while doing so... "any family history of cancer?"  You get the picture.

These interactions have effects, for better or worse, building trust, empowering patients, encouraging healthy behaviors, allaying anxiety - or the reverse of each and every one.  A re-examination of the relational nature of healthcare, and more exactly the role of "story" in healthcare, is at the center of an exciting new program now known as Narrative Medicine.  More on that soon.

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