Thursday, July 3, 2008

Regional variations , Reece, Personal musings - Maine Notes: What Weighs Three Pounds and Wakes Up Every Morning at 6 A.M.?

Kennebunkport, Maine - Here I am, in the heart of Yankee country. My presence here reminds me of a New England bank once ran bearing the title: What Weighs Three Pounds and Wakes Up Every Morning at 6 A.M.? The answer, if you haven’t already guessed is “The Yankee Brain.”

No region has a monopoly on brains. I’ve practiced and spent time in multiple states – Tennessee, North Carolina, Connecticut, Massachusetts, Florida, Minnesota, and Oklahoma, and I’ve found brains are equally distributed. .

From these experiences and from fiddling around with computers for 35 years, including writing a differential diagnosis program on an early version of the early 1970s, I ‘ve come to understand a number of things.

• Brains are not a regional phenomenon.

• Brains are superior to computers in evaluating patients at the point of care.

• Ordering technologies and consulting the Internet may sometimes supersede taking a history and doing a careful physician examination.

• Doctors are not particularly impressed by the use of computers for differential diagnosis purposes.

• Diagnostic support systems, though highly touted by experts outside medicine, are rarely used by physicians inside.

• Diagnostic and treatment and “best practice” algorithms, though widely thought to be essential tools for improving care and harbingers of the future, are seldom used by experienced clinicians.

• Having computers are every doctor’s fingertips may not be the breakthrough envisioned by enthusiasts.

• Among physicians talking confidentially and off-the-cuff, computers offer few revelations and no miracles,.

Why is this? One reason may be that many doctors think computers simply get in the way and slow patient interaction. Another may be that having a computer between a doctor and a patient changes the human chemistry and depersonalizes the relationship. Yet another may be doctors feel information technologies hinder accurate diagnosis.

Jerome Groopman, M.D. a Harvard Medical School professor, in How Doctors Think,k (Houghton-Miffline, 2007), has written doctor rely too much on snap judgments, often reaching a diagnosis within 20 seconds, This rapid fire decision making can lead to snap judgments and diagnostic errors. Groopman’s solution is more effective communiation betweeb doctor and patient rather than widespread use of algorithms. .

Thirty years ago, Franz Inglefinger, MD, another Yankee Brain, then editor of the New England Medical Journal, in a talk prophetically called “Medical Education: Algorithms or Algebra?” argued relying on algorithms was a bad thing because: one, algorithms are demeaning, requiring few skills, other than swinging from branch to branch on the decision tree; 2) algorithms devaluate the physicians as an independent thinker; and 3) algorithms discourage active use of the mind- pursuing ideas, entering into controversies, ferreting out facts, balancing merits of a case, reading in journals, and exercising a lively intellectual curiosity.

To me, this all boils down to the old Right Brain versus. Left Brain. An experienced clinician may have the knack for sizing up a patient at a fleeting glance and asking precisely the right question. Those addicted to protocols may ask all the right questions and do all the right things – and miss the problem altogether.


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I never thought that Franz was the person who was the author of New England Medical Journal, that gets me so excited because that guy is my hero.

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