Love the wisdom of physician colleagues

Let’s be honest: If you are bold enough to hit the ‘publish’ button, it’s normal to care what readers think. I write about Medicine; I like doctors; I respect doctors. So it matters how colleagues react to my words.

I was both proud and concerned when the Greater Louisville Medical Society decided to republish my Changing the Culture of American Medicine piece in their monthly journal, Louisville Medicine.

The reaction of my colleagues has been interesting–and, in my humble opinion, worth telling you about.

Recall that the main point of the essay was to amplify the issue of medical reversals. Researchers from the NIH looked at a decade of NEJM studies in which an established medical practice was evaluated by current evidence. They discovered that 40% of the time prevailing medical dogma did not hold up to rigorous scientific inquiry. Examples included ear tubes for middle-ear infections, hormone replacement in women and aggressive therapy for advanced breast cancer. The paper listed 146 recent examples of medical reversals. No branch of medicine was spared.

Here are some excerpts of (in-person) feedback I received. A bigeminal pattern emerged.

A senior cardiology partner: “I read your pontification…[long pause with a facial grimace]…we aren’t that bad.”

A surgical oncologist: “I read your piece…[again a long pause]…we have learned a lot in surgical oncology over the years.” Then he said nothing else and walked away.

A cardiac surgeon sent a text message: “The aprotinin studies were flawed.” That’s it.

A few doctors simply congratulated me. One of them is an avid NY Times reader. That felt especially good. Grin.

The best reaction came from one of the most senior and respected doctors in the city. He’s practiced in Louisville for more than 40 years. He carries the distinction of being universally loved and admired by everyone. He’s soft-spoken and wise–and a true gentle man. If you were angrily stomping around a unit, mad at something you couldn’t control, and he walked onto the unit; you would stop misbehaving. He’s that kind of person.

“I read your article,” he said.

I stopped in my tracks and focused. Here was feedback that interested me greatly. Wisdom does that; it makes me tingle with delight.

But then the same pause came. (What’s up with these pauses?)

He thought for a moment. Soon, wisdom rushed out:

“John, this is old stuff. You know they killed George [Washington] with blood-letting. One voice of reason at the time dared suggest it wasn’t a good idea, but they pushed on. They killed old George.”

We went on talking more about the history of medicine and other failed therapies. He reminded me that when he started practice there wasn’t even an effective diuretic. The conversation steered to my thesis that awareness of reversals made it tougher to practice Medicine.

The wise doctor disagreed. He countered with this beautiful nugget:

“One guiding principle that has served me well over 40 years, one that allows me to sleep well at night, is this: We don’t control outcomes. All we can control is making the best decision possible at the time. Many times over, I’ve been sure a patient would die, and then she lived. And…there have been times when I expected the patient would do well, but he died.”

John…There’s something else that controls outcomes; we don’t.”

I love this philosophy. Patients sometimes say I saved them. But this isn’t really true. Biology, luck, or perhaps fate, saved them. I just succeeded in not mucking it up. The same decision in the same situation can work well on Monday, but terribly on Tuesday.

My wife Staci says she sees this principle in the hospice care of Veterans. The message goes something like this: You come to understand that, in most cases, Veterans are going to live or die despite what you do.

Make the best decision possible at the time. Don’t be foolish enough to think you control outcomes.

Okay. This helps me.

JMM

For the record: A busy hospitalist walked past us and noted our philosophical discussion. He passed on through, clearly too busy for philosophy. Grin.

5 comments

  1. Great post John. I think all involved among your colleagues cited have some truth backing their views. The ONE thing that bothers me is blind insistence by some providers that a certain path or approach is “right” without even allowing the slightest room to step back on occasion and revisit if their “proved approach” is really the “right path” for that case and the “only path” that could work. I’ve been truly humbled over the years by seeing many treatments that were “doctrine of the day” and totally “proven” turn out to be the opposite of the real story a few years later after we learned more. So – LOTS of wisdom conveyed by that “wise doctor” who you know – : )

  2. Perforate a colon during a routine exam, or puncture the ventricle or rip a coronary artery during some sort of manipulation, and see how quickly it becomes apparent that we, in fact, do control outcomes. Discover a stage 1 colon cancer in a 40 year old, or a 98% left main coronary artery lesion, and we have the chance to affect (control?) outcomes.

    To paraphrase Inago Montoya, perhaps the word “outcomes” does not mean what I think it means. In the sense that we all die, we don’t ultimately affect outcomes, but on a short term basis, if I truly believed I did not affect them, the whole doctoring affair would be pointless.

    Would you be willing to define your terms a bit more precisely?

  3. In other words – this is old stuff, so we can just keep marching along without doing anything different. Discouraging feedback. There is a chance to do better. To improve. To move forward.

    Instead, we’ll just muddle along at the same pace because (___insert excuse here___).

    We’re more connected than ever. Ideas travel more quickly. It takes more work to sort the good from the bad. We have superadministrators deciding which therapies are appropriate for the whole country.

    Doing what we’ve always done, ’cause things have always been this way, is what got us here in the first place.

    How’s that working out?

  4. I tell my patients the story of Beta Carotene and Vitamin E sometimes when they asked me about Vitamin D.

    I tell them there are two kinds of doctors, those who love new and improved and those who let someone else’s patients take the first million doses.

    I tell there is a different two kinds of doctors, those who wish to die of complications of the treatment and those who wish to die of their disease.

    They know what sort I am. I try to accommodate patients who are inclined the other way, but they usually drift off. If we’re stuck together for financial reasons we try to be respectful of each other.

    1. WWW,

      Welcome. Thanks for the comment. Agree. “Respectful of each other” is a policy that works well in the patient-doctor relationship.

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