Blog | Monday, May 8, 2017

The best physicians are multidimensional


No, this is not a science fiction reference. Rather this represents, at least in my mind, the many skills necessary to become a superb clinician. I write this from the perspective of an internist, but I believe these skills are not specialty specific.
1. History taker. Most patient encounters start with taking a thorough history. We have to learn how to ask questions and varying our words according to the patient's background. We take a different history from a college graduate than we do from a rural farmer. History taking also requires understanding what each answer means and what follow-up questions those answers indicate. The best physicians also read body language and understand when to probe and when to wait for the patient to continue.
2. Physical examination. Not all situations benefit from the physical exam. Contrary to some experts, I believe the physical exam helps in some patients. I have made diagnoses primarily because a physical finding prompted a specific diagnostic process.
3. Test interpretation. Even though we seemingly rely on testing more in 2017 than 1975 when I was an intern, many physicians lack test interpretation expertise. This deficiency seems strange given the success of the CSI franchise. Too often I see tests ordered, and the results not interpreted or interpreted incorrectly.
4. Clinical reasoning. The process of understanding all the clues and working towards a diagnosis. We know that diagnosis is job #1, yet we are still plagued with many diagnostic errors, and they matter!
5. Patient explanations and education. We can develop wonderful, even brilliant plans, but if the patient does not understand and does not follow the plan we fail them. Again communication skills are the key. We must understand our patients and develop a diagnostic and treatment strategy that they will pursue. We should explain what we are doing and why. We need them to understand the essence of their health problems and why we are prescribing each treatment.
6. True evidence-based medicine. We need to know the relevant evidence and interpret that evidence in the context of our patient's situation. Too often we have conflicting guidelines. These conflicts should demonstrate the fragility of evidence interpretation.
7. Understanding. We are servants to our patients. We need to understand them, their goals, and their preferences. Our job is to help them achieve those goals. We must learn to view them as human beings and not diseased organs. We must treat the whole patient. We must remember the famous Peabody quotation, … For the secret of the care of the patient is in caring for the patient.”

I'm certain that I have left out some dimensions of the best physicians. Given this multidimensionality, how can we use simple performance measures to rank physicians. While we certainly should give ACE inhibitors to patients with systolic dysfunction, does doing that make us high quality physicians? We could have the wrong diagnosis and thus be giving the patient ACE inhibitors needlessly. We could prescribe it, but the patient decides not to take it because we failed to explain what was wrong with his heart, and why the medication would help him. You can imagine other scenarios where a performance measure is not met, yet the physician did an excellent job.

Being an effective clinician requires a variety of skills. Trying to measure the skills with unidimensional scales seems clearly a wrong idea. Perhaps performance measurement developers should all read Flatland.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.