Against cookbook medicine

"How can modern medicine be so dehumanized?" is a question posed by Dr. Leana Wen and Dr. Joshua Kosowsky in “When doctors don’t listen”. According to them, with a few exceptions, the practice of medicine is subjugated by the dictatorship of guidelines, algorithms, codes, protocols and rules. "Cookbook medicine" they call it. Everyone is aware that many requested tests are unnecessary and that many people are subjected to anxiety induced by the prescribed manual diagnostic processes to rule out infrequent pathologies. The theory of the book is based on the fact that the process to arrive at a diagnosis is complex, requires an interview in which the patient can frankly express the story of what is happening to him, a physical examination according to the hypotheses that arise and a clinical reasoning participated by the patient himself; all this, very far from a manual practice.

Dr. Leana Wen: "Unfortunately, many emergency doctors have found their comfort zone in the algorithms and clinical practice guidelines and for this reason, many resources are wasted in laboratory and image tests, which not only don’t contribute anything, rather they cause many patients to leave more anaemic and more irradiated emergencies, as well as being dissatisfied and disoriented as to the origin of their symptoms.”

Dr. Joshua Kosowsky: "We defend a personalized medicine that starts from a personalized clinical history, a personalized physical examination and an individualized approach for each patient, and this is a clinical activity opposed to the collection of variables to introduce in an algorithm, which is what most residents do in today's emergencies, there is no test that exceeds the sensitivity and specificity of a good clinical history.”

What happened?

The era of the depersonalized diagnostic process has been imposed and according to the authors, there are three main factors of influence: ‘technification’ (especially the appearance of diagnostic imaging), the fragmentation of medical specialties and the practice of defensive medicine. I want to emphasize however, that from the book I have taken note of some circumstances that despite not being decisive in themselves, influence dehumanization: a) the prioritization of the scientific level that some years ago applied the faculties of medicine in the selection of students, b) the pre-eminence of the impact factor in the academic career that has cornered teachers into a more clinical profile, c) the excessively competitive values ​​of the medical residents model and d) the imposition of codes and guides as the "gold standard" of clinical practice, which in turn fosters the culture of form versus the art of interviewing.

This exaggeratedly technified medicine is generating numerous diagnostic errors, precisely because many patients tell inconclusive (or even strange) stories, simply because they don’t know how to explain themselves, have memory problems or are not competent enough to decide whether they have to answer yes or no to the shift form questions. It can also happen that the patient is scared or that he is hiding details because he thinks that if he reveals them, they might contradict the doctor. The book talks about a survey demonstrating that in 37% of consultations, doctors don’t know the patients main concern that gave rise to the visit.

Proposals to improve the diagnostic process

According to Dr. Wen, "Our goal is not to ration tests but to be prescribed appropriately by doctors who have the thought in clinical reasoning, and who know how to do it in collaboration with patients who understand the benefits, risks and the limitations of each test they accept.” In this spirit, the text makes eight proposals to improve the diagnostic process, of which the recommendation to the patient is that they make the effort to concentrate on an understandable story about what is happening to them, that they are not afraid to confirm that the doctor has understood them, and make it clear, if it’s the case, that they are someone who wants to be involved in the diagnostic process.

Evidence-based medicine needs doctors to know how to make it compatible with the values ​​of humanism. That is, find the necessary time to listen to patients, ask open questions to understand their stories and knowhow to involve them in the diagnostic process, to the extent that they would like.


Jordi Varela
Editor