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State: Ntl. Gavin: What if We Hypothesized Instead of Diagnosed?: [2017-03-06] |
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The 19th century Romantic poet John Keats was also trained as a physician. And it's his definition of a "man of achievement" that gives Arabella Simpkin and Richard Schwartzstein their jumping-off point in a fascinating essay in the New England Journal of Medicine. Wrote Keats regarding the necessary quality of such a person: "... when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason." How many physicians do you know who would agree with that sentiment? Simpkin and Schwartzstein go on to make a noble and necessary argument for the place of uncertainty in modern medical practice. While the proposal is made for the entirety of the profession and the full span of specialties, I was struck by the applicability of the argument to chronic pain management, specifically.
This is how non-specific low back pain turns into a 15-year-old work comp claim. The authors make several recommendations, each of which targets the very heart of medical education and clinical practice culture. We need to cease viewing uncertainty as a threat, but rather embrace it as part of the iterative nature of care. We need to move away from multiple-choice tests in medical education that require definitive answers, and instead focus on evaluating medical students' tolerance for uncertainty and ability to posit based on incomplete information. Perhaps the most daunting recommendation the authors make, though, is the idea of moving away from the concept of diagnosis and instead focusing doctor-patient conversations on the concept of hypothesis.
This requires treating the whole patient. This requires recognizing the psychological and social contributors to pain perception and tolerance. This requires seeing through the psychotropic effects of opioids and other addictive medications to get to the root cause issues of chronic pain. This requires not just patient advocacy, but truly shared decision-making. Of course, this would also require us to move away from the dilapidated and counter-productive world of fee-for-service billing. This would also require payers and employers to pay for quality, a genuine willingness to pay more dollars for less care (in the traditional sense) and more shared decision-making (which will inevitably lead to better outcomes). So there's a little slice of utopia for you, this Monday morning, with a heaping side-helping of reality. Michael Gavin is president of Prium, a medical managed care provider for the workers' compensation industry. This column was reprinted with permission from the firm's Evidence Based blog. |