Medical Matters Muiris HoustonFollowing last month's column on what sort of doctor will best serve our needs in a rapidly changing health system, I am grateful to you for sharing your thoughts on the matter.
So what sort of attributes do you think are important for a modern doctor? A common theme running through your responses was that of time: to give the patient time to tell his story and also to use time to assess the prognosis or otherwise of symptoms without feeling the need to rush in with a diagnosis or treatment.
A doctor from Co Cork recalled the words of James O'Donovan, a former professor of medicine in UCC, who exhorted his students to "listen to the patient and you will hear the diagnosis". She went on to observe that "sadly, the capacity or the time to listen seems to have vanished with some of the present, younger doctors".
A thoughtful correspondent from Co Waterford listed waiting and exercising caution around immediate therapeutic decision-making as "crucial fundamentals employing time as an active and enriching ingredient to unmasking medical mystery".
He said "the security and reassurance of patients lies in the respectability of the medic as a rounded, caring person first, and a wisely experienced, balanced professional second. Such comforting contributes significantly to the journey life of health dilemmas."
Specifically, he suggested that doctors: engage in active, dynamic and attentive listening; give time generously; offer appropriate information at a patient's individual level of awareness; and value the occasional use of "I don't know/I'm not sure" as reassurance rather than as an admission of ignorance.
A south Dublin reader felt the most important attribute of a modern doctor was to convey to patients the ability of the human body to look after itself. "With a little regular care and maintenance by its owner, it [ the human body] will give little trouble and should last a lifetime. Even with this regular care and maintenance it may occasionally require intervention by a medical practitioner but this should be avoided if at all possible," he says.
This is a refreshing take on the value of "doing nothing" as a form of medical "intervention". Perhaps the contributor has direct experience of the sometimes harmful effects of medical treatment and an awareness of the rising incidence of healthcare error.
A consultant from the west of Ireland, commenting on the need for doctors to be able to tolerate uncertainty, recalled the words of a mentor who advised: "don't just do something, stand there". He also quoted the British neurologist, William Gowers, who in 1905 wrote in the Lancet: "If you must wait before forming even a probable opinion, at any rate be decided in delay. Remember, decisive hesitation is wiser than hesitating decision."
The doctor also recommended Kathleen Montgomery's How Doctors Think (Oxford University Press) to readers. Unfortunately, it is not a book I have to hand, although I have enjoyed reading Jerome Groopman's similarly titled offering (How Doctors Think - Houghton Mifflin). This book is specifically written for a lay audience by Groopman, a Harvard professor of medicine. Essentially a series of essays, it explores the rational and irrational factors that influence medical decision-making.
Groopman explains some of the flawed thinking that can lead to misdiagnosis, including commission bias - the urge to act rather than do nothing, even when nothing is the better option. He argues that the frequency of medical mistakes, as well as their severity, can be reduced by understanding how a doctor thinks.
"Cogent medical judgments meld first impressions . . . with deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments to minutes. What can doctors and patients do to find time to think?" he wonders.
In an epilogue titled A patients questions, Groopman suggests three questions patients and their carers might like to ask when an initial diagnosis or treatment has not worked out.
"What else could it be?" allows a doctor to acknowledge the uncertainty inherent in medicine. "Is there anything that doesn't fit?" will prompt your doctor to pause and encourage his mind to think laterally. "Is it possible I have more than one problem?" helps challenge the conventional medical school teaching that a doctor should seek one cause for a patient's many complaints. Posing this question is a safeguard against one of the most common cognitive traps that all doctors fall into: diagnostic satisfaction.
Groopman finishes his book with the following: "I realise that I can have another vital partner who helps improve my thinking . . . That partner is present in the moment when flesh- and-blood decision-making occurs. That partner is my patient or her family member or friend who seeks to know what is in my mind, what I am thinking.
"And by opening my mind I can more clearly recognise its reach and its limits, its understanding of my patient's physical problems and emotional needs. There is no better way to care for those who need my caring."
Dr Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he is unable to reply to individual medical queries.