Disease-ification: How a person becomes a pathology

"Every patient is the only patient."- Arthur Berarducci

"Each person in need brings to us a unique set of qualities that require unique responses." -Don Berwick, Escape Fire 1999


Disease-ify Verb
      To generalize and then classify a unique person's health complaint in order to match them with an effective remedy that ends to encounter; often done out of convenience, expedience, or for profit.

Unique is a funny word. Every time I come across it, I am reminded of my high school English teacher's admonition that qualifying the word--very unique, kind of unique--is inappropriate. Things are either unique, one of a kind, or not.

Although Dr. Berwick did not have my English teacher, I think he would agree that each patient's presentation is unique in this sense; it is one of a kind. Even the most mundane complaint is buried in a rich social and genetic context that simply cannot be reduced to a chief complaint.

As a moral enterprise, medicine seeks to serve patient interests, and few interests supersede the need to be treated as the unique identities that we are. Therefore, to disease-ify must be seen for what it is: a capacity to cause harm in a profession that professes to do none.

Disease-ification is an important cause of the well-documented harms of overtreatment. In order to serve his or her role in each patient encounter, the assumption is that a physician needs to identify a disease and then match it with a remedy. To do otherwise is to dither.

To Practice Medicine Verb
      To generalize and classify a unique person's health complaint in order to match them with an effective remedy, all the while acknowledging and preserving their uniqueness, in order to heal.

In his inspirational 1999 speech Escape Fire, Dr. Berwick states that "we are not finished--we have not achieved excellence--until each individual is well served according to his or her needs, not ours." Interaction with patients is not "the price of care; it is care, itself." A patient's question is "an opportunity, not a burden."

As I begin my internship next week, I hope to live up to Dr. Berwick's aspirations, to learn how to practice medicine, and resist the urge to just disease-ify.

Social Media for Medical Students

Image by Marc Smith

Social media use by medical students poses special opportunities and special risks. Although the need for an effective social media policy among students is widely recognized, few have developed a sufficiently robust approach that both encourages appropriate use and outlines the subtle risks.

In this document, Social Media for Medical Students, I have attempted to do both. In particular, I have outlined a basic strategy for using social media to become a better doctor and to plan a career. I have also organized the legal, ethical, and professional responsibilities students have to patients, institutions, and self.

All rights to this document are reserved, with plans for publication.
Social Media for Medical Students

Do No Harm in the Third Age of Medicine

The Doctor- Luke Fildes 1891

We are in the third age of medicine.

The first age ended in the 1930's with the development of antibiotics. Before then, the best doctors took Hippocrates's dictum to heart with the understanding that the profession really did not have much to offer the sick. Their principle tools were 1) First, do no harm--making sure their limited efforts, however well-meaning, weren't part of the problem. 2) Prognostication--explaining the course of disease and so enabling effective planning, estate management for the rich, choosing who will pick up the chores for the poor. 3) Relief--doctors could amputate and dress a shattered leg, as well as provide opiates to relieve pain. Though not cures, they were quite helpful. 4) Comfort--As a profession dedicated to the sick, often they were the only ones whose job description included tenderness and care.

The second age of medicine began with the advent of antibiotics in World War II. Suddenly, doctors actually had treatments to offer, a few cures that beat back some true scourges of mankind. Beyond vanquishing the streptococcus, antibiotics swept aside the sordid record of patent medicines to prove the concept that chemicals could be empirically be marshaled against any threat to health. In this second age of medicine, doctors were able to offer more and more treatments that actually worked against disease. Their jobs of prognostication, relief, and comfort were downsized. Instead, doctors's proper course was to stop doing house calls and set up clinics to efficiently distribute these treatments.

It's not clear when the third age began, but I will date it to 1997 when the FDA essentially green-lighted direct to consumer advertising of pharmaceuticals. Since then, drug companies have set the standard that is defining the age, and the standard is this: Broaden the market for your intervention by convincing people that they have a disease in need of your therapy. This is done explicitly by Big Pharma as they medicalize the slings and arrows of fortune, outrageous or otherwise, by creating diseases through multibillion dollar advertising and lobbying campaigns. It may also be done implicitly by well-meaning providers who conveniently conflate treatments and revenue streams. In this third age were face the paradox of witnessing the genius of modern medicine from our living rooms, illustrated with the best computer animation and doctors smiling serenely in their crisp white coats, while being told that our nation's health is second rate and threatening to bankrupt the leader of the free world. With the cost of unnecessary care estimated at $700 billion, this third age could be called the age of overtreatment.

What is the physicians' proper course of action in this third age?

Oddly enough, it is a lot like that of the first age: First, do no harm. The great challenge to physicians is to shield their patients from unnecessary treatments. They must stay up to date on which treatments don't help patients (PSA testing doesn't reduce prostate cancer deaths, coronary stenting doesn't prevent heart attacks better than medicines), and they must make sure their patients don't receive them. Doing so involves avoiding the tests (PSA) as much as the interventions (an elevated PSA in the chart can lead a different physician to perform the harmful biopsy and surgery).

Perhaps more startling in this age of overtreatment is the presence of undertreatment. In a heart disease center of excellence, patients are in fact more likely to get a stent and less likely to get aspirin, even though aspirin actually has the strongest track record of preventing heart attacks. Unfortunately, unlike drug-eluting stents, we've been using willow bark (from which aspirin derives) for quite some time, and no one makes money off a glossy commercial highlighting its effectiveness.

In the third age of medicine, doctors must recapitulate the first age: 1) First, do no harm by making sure we aren't a $700 billion part of the problem by shielding patients from private interests, and make sure they get the care, and ONLY that care, that they truly need. 2) Prognosticate so that patients can make informed choices, abjuring the rabbit hole of tests and treatments that may only be helping someone else's bottom line. 3) Never substitute tests and procedures for the provision of relief and comfort, which are timeless interventions that never age.



For more on this issue, see www.avoidablecare.org

The myth of defensive medicine: Part I

It's been a truism of the last four years of medical school- when in doubt, order some more tests so that you'll have more ammo in court when this patient sues you, commonly expressed: "sues your ass." Politely termed "defensive medicine," it's known on the floors as CYA, "covering your ass." It's no coincidence that this crass thinking is supported with crass dialog.

Doctors who are so keen to avoid lawsuits would probably be very interested to read this Archives of Internal Medicine commentary, which states:

"Ironically, some of these protective steps, far from reducing legal risk, may actually increase it."

This research is not at all new--it's been known since the 1990's that not all patients with even a bona-fide gripe sue, and that the primary reason for lawsuits is poor communication. A vast amount of research boils down to a simple point:

Listen more, get sued less.

But how many times on rounds have I been privy to a discussion where the attending physician justifies another CAT scan by saying:

"We have to cover our asses here: let's order a CAT scan."

If these physicians were so concerned about litigation, their warning should have gone:

"We have to cover our asses here: let's get in there and talk to this patient, share our uncertainties honestly, and listen to their concerns."