[HSF] (OT?) Medicine as practice: what every surgeon should know

[Tea Acuff]

This post is a sequelae to thoughts on my brief attempt to provide care in rural Nicaragua. I have included the description of that effect for reference for any that missed or wish to refer to the details.
 
My first impression of the task to provide medical care in Nicaragua was that of an incapacitating nihilism. Not unlike the description of the residents today (and probably yesterday) that seem unwilling to prepare for an operation, I minimized my need to study for what seemed a daunting lack of knowledge and resources for my "mission". Surely we all remember that feeling from many of our firsts: first H and P as a medical student, first pelvic exam, first day as an intern, first "real" operation, first month in practice, etc. As mentioned I even "forgot" my only personal tool, my stethoscope, the first day. Sound familiar?
 
As I reflected on the why of this, being a practitioner of more than 20 years having set up both new pediatric and adult heart programs, why did I assume a nihilistic attitude at a rural medicine clinic where no doctors of any kind are readily available?
 
I think it comes from our standard or orthodox view of medical practice, which I would better call the naive view, similar to descriptive accounts of religious belief. It is a residual of the Lockean enlightened "tabula rasa" or blank slate. (Not unrelated to this discussion, John Locke is philosophically known as an empiricist.) It is a similar view for education or any "learned" field. In this presumed, if not officially espoused view, the doctor is one who accumulates a large amount of information and/or skill about the "real" and scientific world which makes his service as a benevolence to those in need for either reasons of incapacity or ignorance. This may further explain the doctor's proclivity to not see the need for his own care despite the fact that, he/she will also succumb to life's entropy.
 
This nihilism in the face of daunting need for information and responsibility makes clear sense to all neophytes of medicine either by virtue of time or situation. What is not so obvious is the other pole of this view. It is the certainty or at least colonial-like conceptualization that the "knows better" and conceived "benevolent" action confers on its adherents. I use colonial not to suggest malfeasance, but to convey the sense of correctness supported by the guidelines and mores of those that import their principles on others.
 
That I completely failed to fulfill virtually any component of my side of this orthodox but naive view, yet patients waited hours for a week worth of analgesics or H2 blockers, caused a profound and solitary realization of the mission of a physician independent his wealth of resources (as a cardiac surgeon in the USA) or lack of the same (as my situation in Nicaragua). Heroics are nice for us adrenalin addicts, but the true role of physician is to provide comfort and reduce to that extent possible the discomfort in which we find our patients and their loved ones. Period. Sometimes we are wildly successful, but most often we are able to obtain only more modest gains. In the scope of all that is life, modest or temporary relief seems a better description of our work than that of the life givers we seem so wont to assume.
 
A few of the patient situations that I encountered may better specify my more formal thinking about the practice of medicine. One 60ish year old woman had among a variety of complaints a swelling in her neck. By physical exam of this area she had a mat of nodes in her right supraclavicular fossa. By history she had a year or so ago an abdominal or pelvic operation in Guatemala (despite the admonition that no other care was available per my hosts) which was likely a malignancy. Although there was a small chance that I could be mistaken, I decided that she was "dead man walking". I could do little except share my "suspicion" that she may have her cancer back and she might wish to reevaluate that if she could. I wondered whether she was worse off in Nicaragua or my home town. I was betting that in the USA we had a better chance of making her time left worse or at least "invaliding" her than we had of making it better. She likely faced a more purposeful
 existence in Nicaragua. Why should this be so? Have we as doctors fairly squared our limitations with our successes? Is our treatment of our "end stage" disease in the US more humane than that in Nicaragua? Or is it less, either outcome merely by default and not thoughtful design?
 
As I was giving out a dollar's worth of analgesics for headaches or to those sore from carrying burdens daily, I wondered whether the pitiful value I was offering was a better value than the LVADs we offer to the pitiful patients that we discuss on HSF. If we look at it through the prism of personal economics (patient pays for the full value), I imagined both would have been less available than we currently observe, but likely the LVADs would be even less funded. Ben has already commented that social LVAD funding makes little sense from a developed country down under. I doubt he would say the same for the lack of generic drugs like ASA or ibuprofen.
 
LVADs are just a convenient extreme example, but not different in kind for an understanding of how to understand our practice of medicine. Societies, or the regulators and their complementary physicians, have already noticed that the naive view of medicine has its flaws. But I do not think the addition of economic (or my dismissive, Marxist) perspective alone adds much to the over arching understanding of medical practice. Rather it tends to re-enforce a bi-dimensional  (eg, cost versus care or recommendation versus incentive) aspect of medical care, and its largely ineffective corrections such as "financial disclosures" and regulation of "conflicts" of (economic) interest. 
 
This related "economic" or barter pattern I also noticed during my patient interactions. After a while I noticed a stylized pattern between the patients complaints and their expectations of which drug I would/ should give. It seemed as over time the complaints became more "focused" toward particular "stories". It was like there was a verbal barter for that which I had to offer the "right" drug. I imagined in retrospect that the "patients" debriefed their fellow patients and correlated their stories to match that which they wanted. For myself I "naively" tried to "practice" what I knew which was little. It may have been that they all had much of the same complaints, and that this style came from us. Part of this surely was. However, I never had much idea what would be the symptoms for parasites, and the complaints did not match much of what I did read about parasites. While it is possible (does anyone reading know) that "children grinding their teeth"
 became a symptom for "parasites", it seems more likely that this was an acceptable and imaginative synonym created by the patient culture for "I need parasite medicine". Toward the end of the clinic some patients returned and/or flatly asked for parasite medicine, if I failed to make the connection for which I could make no medical sense. This is not what we typically mean by the economic influence of medicine, but defining it as economic informs our predictable and insipid solutions. This barter was more of a dance than an economic contract.
 
So I moved from the more naive (orthodox) view,  that is I know (or should know) and would give to the tabla rasa of misunderstood needs of the patient, to the likely hood that what really was occurring was a barter between different cultures of doctor and patient. That I was not privy to most of their culture and even language made it somewhat more clear to me that this might be the case. In different words in the phrase we appeal to over and over, I could not imagine what I would want for "my mother or loved one" in terms of their culture. I am sure that we all have had glimpses of the same divide and this barter in our own practices. The question then becomes how often do we cross the line naively or by design in our own practices? Does everyone (populations) or anyone (individuals) really "want" in the language from the patient culture or "need" from language from the doctor culture LVADs, chemo, or bypass with or without three valves? Whom are we
 serving and why? If they (our patients) had to pay would that separate the cultures of care more realistically? Do we entice by advertisement, anecdotal success, guidelines and technology, or subsidized care? Who does not want something for nothing? Who can actually have it? Any answer or direction to seek to answer these questions is dependent on our presuppositions on the nature of evidence or knowing and the model of interaction between doctor and patient in the practice of medicine.
 
Enough for today. For anyone interested next time: Is there a better formal model for exploring medicine as practice? I think a different model leads to some interesting questions.
 
tea