Humanism and reasoning versus cookbook medicine

Soledad Delgado
 

From "criaderas" to "soleras"

At the onset of autumn, my land fills with the smell of must. Freshly extracted from the pressed grape, it ferments and then passes to American oak barrels for ageing. The containers are stacked at three levels. From the lower one, the "solera", a third of its content is extracted for consumption. That part is filled with wine from the intermediate level, the first “criadera", and the same happens with this one, which receives wine from the upper level, the second “criadera". It's the one who receives the fresh must, full of life and potential. This wine, still young, is mixed during its ageing with matured wine, from which it takes some characteristics and to which it gives back the freshness of new aromas and flavours. The two wines are enriching each other, sheltered by the flower veil that promotes biological ageing. 

Not many days ago, while on duty, I was involved in a debate about the value of troponin in a patient with atrial fibrillation. My resident, with a carefully studied protocol, relied on a normal troponin value that had suffered a 5% increase in a second blood test (which, even so, was still normal) to defend the admission of a patient for observation, but not for the reason that brought him to our service, which was palpitations, but hiding behind the possibility that he had a heart attack. I tried very hard, and not very successfully, to make him see that our patients are not an analytical value or an X-ray: they are people, who must be evaluated as a whole, giving the necessary value to the clinical history, examination and the additional tests we have.

While I was defending my position, I was reminded of the book by Leana Wen MD and Joshua Kosowsky MD "When doctors don't listen," in which current clinical practice is compared to a cookbook medicine, where everything is measured and directed: if you have symptoms A and tests B, you have to do test C and you will arrive at diagnosis D. Using the same phrase as Wen and  Kosowsky in their book, I tried to make him see that the best way to treat patients is to join scientific knowledge, common sense and the, sometimes so forgotten, art of medicine. Despite all these arguments, the resident continued to cling to troponin as the only element that justified his decision. The debate was enriching: we shared different and complementary points of view, scientific and clinical.

At that moment I was struck by an anguished doubt: if scientific knowledge is prioritized in medical schools over practical training and humanities, will we be training doctors who only see algorithms and results of complementary tests? Where will the lesson of how to take care of the person? The anguish ended when, staring at him, I said: "Let's take the patient to the consultation, let's see what happens to him."

In Jordi Varela's book "5 intensidades de provisión para 1 sanidad más valuosa," we find a chapter dedicated to the value of medical training, research and innovation from which we can draw the following conclusions:

1. Research must leave the scientific field and approach clinical reality, giving greater importance to effectiveness than to efficacy.
2. Innovating must also mean having a critical capacity with the way of doing things, with the established protocols, and proposing new ways that give more value to medical practice.
3. It is necessary to train doctors with scientific knowledge, researchers and innovators who, in addition, possess social and communication skills.

All this raises the need for a change in the current training system, the Flexner training model, based first on training in basic sciences (anatomy, biochemistry...), followed by training in the human body (healthy and sickness) to finish with clinical practice. This change implies giving way to another training model, such as the one proposed by Prasad and Cifu, whose basis must be clinical reasoning, shared decision-making and learning the clinic and above it basic sciences, always linked to the practice.

There should  be three levels in training, interrelated with each other and whose fundamental basis is clinical reasoning, research and experience. Levels, training, knowledge, acquisition of value, nourishment from experience... all this seems familiar to me.

Our winery, healthcare, is nourished by the best fruits: students who have been required to excel to access medical schools. A winery that has the best containers: faculties and health centres where, under the flower veil of scientific knowledge, research and experience, professionals grow and develop, acquiring values and further increasing those they already have. Our healthcare has great potential, with the best raw material. Perhaps the time has come to change the way of doing things; to prioritize the quality of the results and not their quantity. For that, we have to continue counting on the best and not let the best harvests go to other wineries. Let's take care of their upbringing, and their training, so that they have the knowledge, but above all so that they become doctors and practice this wonderful, and sometimes forgotten, art of medicine.