The Complexity Of A Medical Consultation

By Gerrit Van Wyk.

Peptic ulcers.

When I was at medical school, we were taught high acid levels in the stomach caused peptic ulcers. Lifestyle activities like, smoking, obesity, coffee, and spicy foods aggravated it, and we treated it with antacids and drugs to lower acid levels. If the symptoms were severe, various complex surgeries were performed which not infrequently ended up with a cure worse than the disease.

During the 1980’s, two Australian doctors, James Marshall and Robin Warren, came up with the idea peptic ulcers were caused by a bacterial infection instead, which no-one believed, because common wisdom was no bacteria could grow in stomach acid. When they submitted a paper about it, it was turned down with the comment it was one of the worst papers of the year. To prove he was right, Marshall drank stomach fluid from a patient with a peptic ulcer and promptly developed one as well, which became one of the most famous medical publications ever. Marshall and Warren were awarded a Nobel Prize for their work in 2005. Today we treat peptic ulcers with antibiotics and it works, if… the diagnosis is correct.

Scheduled patient appointments for family practitioners is usually for 15 minutes. That includes the time from when Dan is called to the office and perhaps shuffles in with a walker, introductions: “hi Dan, how are you, how is Sally doing, has your granddaughter delivered yet”, etc., undressing: “just lift your shirt up and drop your pants”, dressing again, and leaving the office. Some research shows the actual consultation time is 9 minutes. It baffles me that we think we can solve problems and particularly complex ones in that short a time.

All doctors are taught a simple formula for diagnosis which is no different from baking a cake; gather information, run some tests if required, make a diagnosis, assign the condition to a category, look up the right treatment, and administer it. The one thing they don’t teach in medical schools is logically reasoning through complex problems. By that I mean following a scientific or learning cycle.

For that you collect information which points to a system of interest, you then add information by examining that system for additional clues, and based on that create a list of possible causes of the problem. Tests are used to eliminate or confirm each item on the list, until a final diagnosis remains. To test the hypothesis or diagnosis, a treatment is given and the outcome observed to see if it solved the problem, and what may be learned from it. If it didn’t, you learn from the experience and run through the cycle again.

For cookie cutter diagnosis a physical examination is often skipped, meaning important information may be missed, diagnostic tests are used to diagnose rather than eliminate or confirm, and there is no learning outcome. It mistakenly assumes negative findings from tests or an examination is a failure, whereas falsifying a hypothesis is a key feature of the scientific method.

The general population, regulatory authorities, planners, consultants, leaders, and academics assume all doctors are the same, but they are not. They show a distribution of knowledge and skills within which most on average will be similar, some more knowledgeable and skilled, and some less. Consequently, diagnostic ability varies amongst them, experts don’t always agree on the same diagnosis, mistakes are made, and doctors change their minds.

There is another bigger problem. That 15- or 9-minute conversation, depending on how you see it, is an enormously complex social interaction influencing decision making, the diagnosis, and treatment. Patients come with perceptions of the doctor and their complaints, nowadays often influenced by a first online consultation with Doctor Google, their cultural background, religion, life experience, friends, etc., impact their expectations about the condition and disease in general. Doctors in turn have expectations of their patients, expectations about patients in general, and are also influenced by culture, religion, experience, the medical community, the health care system, management and funder expectations, etc. It means diagnosis and treatment is not a simple matter. Yet we all treat it as if it is.

The consequences of treatment decisions can be good: the problem is resolved, or bad: the treatment had unwanted side-effects or complications, or was wrong because the diagnosis was incorrect, all of which add a social and economic cost. I had a disagreement recently with someone who said if there are no clear answers it’s better to do something than nothing. I argue it’s better to do nothing than something with an unwanted cost attached to it. Besides, doing nothing is often the best course of action.

Some doctors counter: the treatment I tried worked, forgetting about the placebo effect. If you randomly give patients a treatment or a sugar pill to see if it works, somewhere around 20-40% of patients taking the sugar pill report they are better. To say the active pill works, it must significantly outperform the sugar pill. Studies of sham surgeries show the same outcome. It means if I do something rather than nothing and a patient reports a positive outcome, I don’t know whether my treatment really worked or not, and, if it was placebo, I wasted resources.

No doctor I know of starts the day with the intention to deliberately mess up. But it’s important to know the complexity of how treatment decisions come about and what influence them, because that can unintentionally be the outcome. We should also know their decisions have consequences and there is a social cost to those consequences. The traditional diagnostic formula is obsolete and should be replaced by one emphasizing critical thinking skills.

The people creating curricula and teaching in medical education facilities don’t seem to get that.