Sunday, December 16, 2018
I don't know if they still call it that or not - but back in the day when I was an intern Morning Report was a meeting of all of the admitting residents with the attendings or Chief of Internal Medicine. The goal was to review the admissions from the previous night, the initial management, and the scientific and clinical basis for that management. Depending on where you trained, the relationship between house staff and attendings could be affiliative or antagonistic. In affiliative settings, the attendings would guide the residents in terms of management and the most current research that applied to the condition. In the antagonistic settings, the attendings would ask an endless series of questions until the resident presenting the case either fell silent or excelled. It was extremely difficult to excel because the questions were often of the "guess what I am thinking" nature. The residents who I worked with were all hell bent on excelling. After admitting 10 or 20 patients they would head to the library and try to pull the latest relevant research. They may have only slept 30 minutes the night before but they were ready to match wits with the attendings in the morning.
Part of that process was discussing the relevant literature and references. In those days there were often copies of the relevant research and beyond that seminar and research projects that focused on patient care. I still remember having to give seminars on gram negative bacterial meningitis and anaphylaxis. One of my first patients had adenocarcinoma of unknown origin in his humerus and the attending wanted to know what I had read about it two days later. I had a list of 20 references. All of that reading and research required going to a library and pulling the articles in those days. There was no online access. But even when there was - the process among attendings, residents, and medical students has not substantially changed.
I was more than a little shocked to hear that process referred to as "intuition based medicine" in a recent opinion piece in the New England Journal of Medicine (1). In this article the authors seem to suggest that there was no evidence based medicine at all. We were all just randomly moving about and hoping to accumulate enough relevant clinical experience over the years so that we could make intuitive decisions about patient care. I have been critical of these weekly opinion pieces in the NEJM for some time, but this one seems to strike an all time low. Not only were the decisions 35 years ago based on the available research, but there were often clinical trials being conducted on active hospital services - something that rarely happens today now that most medicine is under corporate control.
Part of the author's premise here is that evidence-based medicine (EBM) was some kind of an advance over intuition-based medicine and now it is clear that it is not all that it is cracked up to be. That premise is clearly wrong because there was never any intuition based medicine before what they demarcate as the EBM period. Secondly, anyone trained in medicine in the last 40 years knew what the problems with EBM were from the outset - there would never be enough clinical trials of adequate size to include the real patients that people were seeing. I didn't have to wait to read all of the negative Cochrane Collaboration studies saying this in their conclusions. I knew this because of my training, especially training in how to research problems relevant to my patients. EBM was always a buzzword that seemed to indicate some hallowed process that the average physician was ignorant of. That is only true if you completely devalue the training of physicians before the glory days of EBM.
The authors suggest that interpersonal medicine is what is now needed. In other words the relationship between the physician and patient (and caregivers) and their social context is relevant. Specifically the influence the physician has on these folks. Interpersonal medicine "requires recognition and codification of the skills that enable clinicians to effect change in their patients, and tools for realizing those skills systematically." They see it as the next phase in "expanding the knowledge base in patient care" extending EBM rather than rejecting it. The focus will be on social and behavioral aspects of care rather than just the biophysical. The obvious connection to biopsychosocial models will not be lost on psychiatrists. That is straight out of both interpersonal psychotherapy (Sullivan, Klerman, Weissman, Rounsaville, Chevron) and the model itself by Engel. Are the authors really suggesting that this was also not a focus in the past?
Every history and physical form or dictation that I ever had to complete contained a family history section and a social history section. That was true if the patient was a medical-surgical patient or a psychiatric patient. Suggesting that the interpersonal, social, and behavioral aspects of patient care have been omitted is revisionism that is as serious as the idea of intuition based medicine existing before EMB.
I don't understand why the authors just can't face the facts and acknowledge the serious problems with EBM and the reasons why it has not lived up to the hype. There needs to be a physician there to figure out what it means and be an active intermediary to protect the patient against the shortfalls of both the treatment and the data. As far as interpersonal medicine goes that has been around as long as I have been practicing as well. Patients do better with a primary care physician and seeing a physician who knows them and cares for them over time. They are more likely to take that physician's advice. Contrary to managed care propaganda (from about the same era as EBM) current health care systems fragment care, make it unaffordable, and waste a huge amount of physician time taking them away from relationships with patients.
Their solution is that physicians can be taught to communicate with patients and then measured on patient outcomes. This is basically a managed care process applied to less tangible outcomes than whether a particular medication is started. In other words, it is soft data that it is easier to blame physicians for. In this section they mention that one of the author's works for Press Ganey - a company that markets communication modules to health care providers. I was actually the recipient of such a module that was intended to teach me how to introduce myself to patients. The last time I took that course was in an introductory course to patient interviewing in 1978. I would not have passed the oral boards in psychiatry in 1988 if I did not know how to introduce myself to a patient. And yet here I was in the 21st century taking a mandatory course on how to introduce myself after I have done it tens of thousands of times. I guess I have passed the first step toward the new world of interpersonal medicine. I have boldly stepped beyond evidence based medicine.
I hope there is a lot of eye rolling and gasping going on as physicians read this opinion piece. But I am also concerned that there is not. Do younger generations of physicians just accept this fiction as fact? Do they really think that senior physicians are that clueless? Are they all accepting a corporate model where what you learn in medical school is meaningless compared to a watered down corporate approach that contains a tiny fraction of what you know about the subject?
It is probably easier to accept all of this revisionist history if you never had to sit across from a dead serious attending at 7AM, present ten cases and the associated literature and then get quizzed on all of that during the next three hours of rounding on patients.
George Dawson, MD, DFAPA
1: Chang S, Lee TH. Beyond Evidence-Based Medicine. N Engl J Med. 2018 Nov 22;379(21):
1983-1985. doi: 10.1056/NEJMp1806984. PubMed PMID: 30462934.
That is the ghost of Milwaukee County General Hospital one of the teaching affiliates of the Medical College of Wisconsin. It was apparently renamed Doyne Hospital long after I attended medical school there. It was demolished in 2001. I shot this with 35mm Ektachrome walking to medical school one day. The medical school was on the other side of this massive hospital.