Monday, March 07, 2005

Retired Doc's Suggestions for Medical Curriculum-Part 4 : anti-hubris course

I do not have all the content of this course prepared yet but I do have the sense of it and some great quotes. The sense of it is from the writings of Norton Hadler and much of it can be found in his article on various European backache compensation systems (JOM,vol 31, pg 823, 1989). In it he speaks of clinical truth which he distinquishes from scientific truth-although scientific truth must be utilized in obtaining clinical truth-and from legal "truth"-which is incidental to settling the dispute at hand. Clinical truth is or is derived from a contract between a physician and a patient and is based on trust.He said it better than I can and his article would be required reading in this "anti-hubris" course.
Our approaches are provisional and based on fragmentary information and when I think about the algorithms and paradigms that are in our tool boxes, Boris Pasternak's quote appears as an emphatic "yes..but", "What is laid down, ordered, factual, is never enough to embrace the whole turth:Life always spills over the rim of every cup". Karl Popper said " we know a great deal but our ignorance is sobering and boundless...all things are insecure and in a state of flux".
All of this does not mean that we can't pull out the latest guidelines from whomever in our PDA and see if that does or does not apply to the case at hand.But the operative words there are "see if it applies to the case at hand." The experienced physician has one- at least one-advantage over the younger one, he has seen the 180 degree changes in a given algorithm or clinical guideline. Plaintiff attorneys are fond of saying to the expert witnesses ,"Doctor,were you wrong then or are you wrong now" in the situation where there is an apparent contradiction.
Medical students need to know-in regard to the "factual knowledge" imparted to them- that while that material may be the very best that the very best of minds can determine at this time that they need to stay tuned because all of that may change at any time and the physician will have to decide what to do for the patient even before the next authoritative pronouncement is prepared.In that decision she will have to call upon her knowledge,expertise and judgement and the patient's values and views and do her job the way physicians have for many years before guidelines were part of medical language and work with the patient for their particular clinical truth.

2 comments:

Anonymous said...

Outstanding - I linked to this on my blog today! - db

Epador said...

Succintly: always mix one dram of skepticism with each ounce of Evidence Based Medicine.