As a baby doctor I am just about to jump off the interface between textbook learning and living patients. I still lie upon that boundary where the practice of clinical medicine has not yet seeped into my bones; where every patient brings up queries about guidelines I had revised just a year before.
As I spend more and more time on the wards, meeting spouses and children, great grandmothers and the caring neighbour three houses down, I begin to wonder if there is a gap between the journals I am supposed to be reading and the crying eighteen year old sitting in front of me with cuts down her arm and a bag of N-acetylcystine running through her veins.
How critical are the numbers needed to treat when a patient’s worst fear is that they have lost their identity as a husband and a father? How much do the words within the journals resonate with my days on the ward round running around with an obs chart in one hand and a list of jobs in the other?
If there is one thing I have learnt during my short time as a junior doctor it is that the problems patients present with in hospital rarely revolve around pathways or guidelines but issues that touch at the heart of what it is to be human: I can no longer cope as her carer. I am drinking to hide my stress and fear. I am too busy working a twelve hour shift to have time to sit down and eat, because I am too stressed to go for a run every Thursday.
Yet the past few months have raised even more questions – what exactly is the management of my patients? Is it symptomatic relief – some paracetamol and zopiclone to help sleep at night? Is it the latest drug that has found its way into a high impact journal? Is it support for the wife and kids while Dad lies in a hospital ward? How do I integrate the phenomenal pace of science with the patients who come through the door? Guidelines I had revised just a year ago have now been replaced. Management options have changed and new medications have been introduced. It is this tight balance between the journal article and the human being that I have found the most striking and most difficult to come to terms with in my first few months as a new doctor.
We no longer live in the world of the plague or cholera but the diseases of life: heart disease, chronic obstructive pulmonary disease, diabetes and cancers to name but a few. Our role as clinicians goes beyond the algorithms we have recited from the textbooks and extends into our patient’s lives. What is the benefit of a statin compared to an understanding of someone’s diet, the reasons for the constant fast food, the ongoing sedentary lifestyle, the refusal to leave the house? Where does science end and humanity begin?
Tim* was a fifty-five year old gentleman who had spent most of his life in the local industrial
area working in one of the factories nearby. His days consisted of an eight-hour shift in the factory sitting near the conveyer belt packing boxes with an occasional smoke to break up the monotony. After work he would come home to his wife, a teacher at the local secondary school, and after spending a few hours in front of the television he would spend the rest of the night at the pub with his old school friends.
Tim and I got to know each other well as we met regularly in clinic for his Diabetes. He would probably have fallen into the category of being a ‘difficult’ patient, not because he was unpleasant (indeed he was very pleasant) but because we found it incredibly difficult to manage his medical conditions. We trialled a variety of medications in different combinations in an attempt to keep his blood glucose under control. He was often apologetic when his blood results came back and our meetings were often filled with much humour and laughter as Tim glazed over his health with a light heart. Yet I often worried about Tim and knew there was something I wasn’t seeing. I had learnt a lot about the management of Diabetes during my brief placements and had read the underlying pharmacology of the various medications so often now that I probably could have given a lecture on them to the medical students myself. But there was something more to this story and I just couldn’t grasp it.
It took a while, but every clinic brought me closer to Tim’s life. As time went on I began to see the world from Tim’s perspective and it gave me an incredible insight into his health problems. For a start, I began to see food through his eyes. From a young age Tim had been taught that food was not important and his dinners consisted of a McDonalds or fish and chips from down the road. A meal was seen as an obstacle rather than something to be enjoyed, resulting in a quick burger for lunch and a convenient pizza to be eaten later in the evening. As a teenager Tim was self-conscious about his size and would often skip sports at school – a behaviour that stayed with him into his adult life. Thus, by the time Tim settled down into a routine job with a loving wife and kids, he had the excuse of a busy life to ignore everything else around him. Even once he was diagnosed with Diabetes, the diagnosis meant little more than taking a couple of medications everyday and ‘following orders from the doctor.’ Taking control himself and changing his lifestyle meant more than just going on a diet. For Tim, it meant transforming his perspective on life itself; it meant becoming a new person. Diabetes was a problem for the medical profession and not for him.
I tell this story because Diabetes is the perfect example of a disease that is managed primarily through behaviour, which itself is a complicated web of society, relationships and culture. But what I have just described is also the future of medicine; these are the diseases that will dog our footsteps. The future of our health lies not just in the quest for drugs but the very foundations that cause these diseases to grow in the first place; the lives that people lead and the choices they make.
“Evidence based medicine is the conscientious, explicit, judicious and reasonable use of current best evidence in making decisions about the care of individual patients.” (4)
Evidence Based Medicine is the heart of what I am trying to get at here. It is the integration of the research found within the bounds of the journals and the individual patient sitting in front of us. To quote Professor David Sackett, good medicine is the integration of clinical expertise and good evidence (5). Evidence Based Medicine revolves around a focused and tailored approach; scouring through journals with a goal in mind rather than reading through dozens of articles absentmindedly with no application to clinical practice.
Let us look back at Tim. The research in the area of poor glycaemic control in patients with Type Two Diabetes suggests a number of potential causes, ranging from a lack of knowledge about the condition to denial that their Diabetes is a problem to a concern with side effects (2). Indeed most of the barriers have been found to be related to self-care including diet and exercise and one’s perceptions of the disease (3). It is particularly interesting to note that one study found that a portion of participants felt that clinicians offered a ‘one size fits all’ approach to patients with Diabetes, assuming that following a set diet would be helpful for everyone (3).
“Actually when you have diabetes, you cannot be stressed. Previously when I was under stress [due to marital problems], my blood sugar level was very high because I did not eat and take my insulin. I was hoping to die.”—50-year-old taxi driver. (3)
Perhaps what would be helpful would be to sit down with Tim and discuss these possible concerns with him. How does he feel about his Diabetes control? How does he feel about his diagnosis? By tailoring my approach I am able to weave through Tims thoughts and feelings with the backing of good research to help me understand the depths of Tim’s life. I am able to combine the collective with the individual. With this combination of scientific knowledge from well-conducted research and a good clinical history with an exploration of values and beliefs, I am able to come to an understanding of the issues and potential solutions. I no longer see Tim as the peaks and troughs on a graph or a variety of hypoglycaemic medications that need to be continually altered. I see someone who has thoughts and feelings of his own; someone who has struggled with body image his entire life, who fears the word ‘diet’ and has developed beliefs about food through experiences that need to be understood if a change is ever to be created. I learn about other people who have had similar struggles through the studies that have been conducted and try to understand Tim’s perspective with this knowledge in mind.
This is what medicine is all about; using science to tailor our patients treatments rather than trying to fit our patients into tidy categories found within research studies. The multitude of genes that have been discovered and the drugs that are created may have little meaning for our clinical practice. Or they may have a lot. The difficulty lies in collating this information together into what is useful and real. This is where evidence based medicine comes in; as a way of thinking about science not as a hole into which we continue to dig ourselves into but with potential gems that could make a difference to our patients lives. It is a critical mind that is able to sift through this extraneous detail and find the important information that is needed.
In the past few months I have learnt that medicine is about more than prescribing drugs and ordering investigations. It is about individual treatment ranging from social support to reassurance to intensive monitoring and high dose medications. I compare my own history taking and management plans which are based on an obsession with guidelines and rigid algorithms with the senior clinicians who are able to filter out extraneous detail and use their expertise to focus on what is important. This is what I believe makes a good doctor.
“External clinical evidence can inform, but can never replace, individual clinical expertise.” (4)
We are moving at a pace that the human mind is unable to comprehend. Journal after journal throws out knowledge that overwhelms our brains. Labs across the country continue to create new drugs and battle new frontiers. The medical doctor stands at the centre, with the oncoming tide of science on one side and the stark emotions of hurt, fear, bereavement and the need for knowledge on the other. It is the ability to appreciate both sides of the equation, to take what is needed from the journal and offer it on a plate, well-cut and easy to digest to the patient that makes a good doctor.
The rise in science is neither good nor bad. What makes it so is how we use this knowledge in the care of our patients. It is an appreciation for the person’s values and beliefs and an understanding that science is just one part of the puzzle that will pave the way forward for medicine in the era of knowledge.
*Not a real patient
This essay was originally written for the 2017 Wakely Prize.
- Sackett, D. L., Rosenburg, W. L., Gray, J. A. M., Haynes, R. B., Richardson, W. S. 1996. Evidence based medicine: what it is and what it isn’t. The British Medical Journal. 312: 71
- Khan, H., Lasker, S.S., Chowdhury, T.A. 2011. Exploring reasons for very poor glycaemic control in patients with Type 2 Diabetes. Primary Care Diabetes. 5: 251-255
- Tong, W. T., Vethakkan, S.R., Ng, C.J. 2015. Why do some people with type 2 diabetes who are using insulin have poor glycaemic control? A qualitative study. British Medical Journal. 5: e006407
- Masic, I., Miokovic, M., Muhamedagic, B. 2008. Evidence Based Medicine – New Approaches and Challanges. Acta Informatica Medica. 16: 219-225
- Sackett, D.L., Rosenburg, W.M., Gray, J.A., Haynes, R.B., Richardson, W.S. 1996. Evidence based medicine: what it is and what it isn’t. British Medical Journal. 312: 71-72
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