Monday, 10 September 2018

Tolerate uncertainty: the pending revolution

Arabella Simpkin (Harvard Medical School) and Richard Schwartzstein (Beth Israel Deaconess Medical Center) have published "Tolerating Uncertainty - The Next Medical Revolution?", An article that inspired me to continue with the speech I began in "Against the medicine of manual ", following the reading of “When doctors don’t listen” by Leana Wen and Joshua Kosowsky.

"Although physicians," the authors say, "know that the uncertainty lies in clinical work, the current culture of medicine pushes them to give unequivocal answers, often impossible or even implausible yes/no answers, essential for labelling codes, which pretend, clumsily, to pick up narratives full of nuances, coming from people full of doubts or even forgetful. "

To make matters worse, the millennial generation, who are genuinely digital, have now reached the faculties of Medicine. They are young people educated in environments in which uncertainty is experienced as a threat but in turn, in their professional future they must face attending to many people with problems moving through grey areas, territories in which they will feel uncomfortable.

To overcome this impasse, I make two revolutionary proposals: a) that doctors spend more time talking to complex patients and b) that clinical quality reasoning is promoted, far from manual medicine.

First proposal: more time to talk

All over the world, often rightly, doctors complain about not having time. They say almost universally, that it’s more efficient for them to prescribe and prescribe and not to explain themselves and listen and that if they had to spend too much time talking they could not meet the efficiency goals imposed on them by those above. However, in "Adding Value by Talking More", Robert Kaplan and colleagues dismantle these arguments by identifying several studies that show that doctors' time, despite being expensive, is cheaper than treatments, tests and hospitalizations that are excessive because of not having spoken enough with patients and even more, if we consider chronic patients, it has been shown that the mere fact of feeling heard improves their adherence to treatments and therefore, the clinical effectiveness.

At Kaiser Permanente Colorado they have established a program ("Primary Care Plus") for complex patients who as a priority, need to be heard and therefore, the professionals who dedicate themselves to the program have no time restrictions. As a result of this new receptivity, the costs of each visit is 21% more expensive, but those of hospitalization are 74% cheaper (both figures have been compared with a control group).

Second proposal: higher quality clinical reasoning

Having the required time to care for people with clinical complexities is an essential condition, and now we can see that it’s efficient and even effective, but this won’t help if doctors are not prepared to ask open questions instead of filling out forms. The trainers (teachers and tutors of residents) must return, like the teachers in the past, to teaching the younger ones that within the patients' stories, within the clinical history and within the physical examination is where the unblocking of the diagnostic process lies and for this reason, millennials who are so well prepared in so many aspects, if they want to practice good medicine, must learn to tolerate uncertainty.

The pending revolution is in knowing how to incorporate patients in the management of the uncertainties of many pathological processes. Some had thought that now was the time for artificial intelligence, but no matter how hard you try, this great innovation of the cybernetic sphere is still far from replacing the essence of clinical reasoning.

Jordi Varela

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