Practicing Medicine in Hippocrates’ Shadow

Peer Review with Christopher Carpenter, MD
 

“When a doctor says, ‘I don’t know,’ it is rarely a sign of weakness or ignorance. More often it’s a sign of a physician who knows and appreciates the limits of our science and is willing to be a partner. It’s an olive branch of commiseration about what is not, and a hopeful readiness for what is.”
-Excerpt from Hippocrates’ Shadow (Scribner, $26) 

David Newman, MD, an emergency physician in New York City and an editor for Annals of Emergency Medicine, is the author of the new book Hippocrates’ Shadow: Secrets from the House of Medicine. The book merges Newman’s philosophy, history, and medical backgrounds to illuminate a startling picture of 21st century medicine. He highlights the flaws of today’s practice priorities and charts a way to heal the patient-physician divide. The book has garnered Newman significant attention in the lay press, from the Today Show to NPR. EPM editor Christopher Carpenter caught up with him recently to get the physician perspective.

The title is intended to refer to a few different ideas. One is that we’re still trying to fill Hippocrates’ shoes. In many ways we’re still living and working in his shadow. Patients want what Hippocrates offered – a listener, empathic healer, and scientist, all in one. That’s been difficult to live up to. The other allusion in ‘shadow’ is darkness. The title alludes to the darkness that scientists, doctors particularly, live in, and the uncertainty of our Art. The shadow idea also refers to the many secrets, conscious and unconscious, that we use as coping mechanisms and, oftentimes, as cover.

The book is subtitled “Secrets from the House of Medicine.” Do you feel most doctors are consciously hiding something from patients?

I think if we’re all being honest with ourselves we understand that there are moments of dishonesty. Sometimes it’s omission rather than commission, most often because the structure of our system makes complete honesty seem difficult and foreign. But my sense is that conscious deception by doctors is rare. Most doctors are trying hard to do the right thing, it’s why most of us chose this path.
 
Why should EPM readers pick up your book?

Good question. I know that I read EPMonthly for awareness – awareness of my world, and how my work interacts with that world. That’s not a perspective that I get from working in the ED, where I’m concentrating hard on the work at hand. It’s the global perspective and the sense of integration that EP Monthly offers, and that’s hard to find. Hippocrates’ Shadow is, in many ways, an attempt to do the same thing.

In the book you discuss the problem of physicians replacing patient communication with an overreliance on testing and prescriptions. You offer numerous examples including antibiotics for strep pharyngitis and mammograms for asymptomatic women. How can EPs strike the balance between educated consultant and medical business person given our medical-legal, paperwork, and volume constraints?

This is the million dollar question. The book offers a way out, I think, but it takes a wide view to get there. It’s a journey of sorts, and it has to start with an open mind. The book attempts to walk us through some of the starker examples of misinformation about things like ACLS and mammograms and strep throat, etc., and how we’re taught and inculcated in many ways to promulgate that misinformation on a wide scale. Seeing the evidence up close is always the first step in breaking through. After that, the book attempts to question a few important underlying concepts that also guide us, and in the final chapters it asks the larger questions that inevitably arise. From there, my sense is that most readers will view the path to balance that you’re talking about as remarkably simple – a lot easier than any of us thought that it would be. 

I find that patients want to know three things: what’s wrong with them, what are we going to do about it, and when am I going to be better? If patients really want to “look under the hood” how do physicians most effectively bridge the enormous knowledge/communication gap?
 
My sense is that most patients do indeed want a look under the hood, they’ve simply been trained that it’s over their heads. I think it’s our job to re-train them, to show them that they need to be partners in their care, that medicine isn’t perfect, and that if they understand and take responsibility for their health they’ll find this, in most cases, to be more powerful and effective than any test or pill can ever be. Our job is to show them that concepts like the “number needed to treat (NNT),” with all of its uncertainty and its uncomfortable truth, are exactly what real medicine is, while fancy tests and expensive pills are exactly what real medicine isn’t. My experience is that when we’re honest with patients about that, when we show them our own doubts and vulnerabilities, and those of our science, they become engaged, and empowered, and their expectations become real, and manageable.

Do you believe that the majority of making the diagnosis is in the H &P? In your opinion, what is the appropriate role for diagnostic tests?

The idea that medical testing is the pathway to diagnosis is so deeply ingrained in us that it’s become difficult to imagine medicine without high-tech tests. And yet there are places where medicine is practiced around the world that use testing in a much more limited fashion than we do, with similar or better outcomes. Tests should be used the same way any intervention is: to improve and extend life, and to limit suffering. Our approach has been to use medical testing as a default, or in a fruitless attempt to find certainty, and in the process we’ve often lost or forgotten the original purpose of the test. In most cases it’s not difficult to tell when we’re ordering tests because we’ve lost sight of their purpose. Most often it’s a matter of self-examination, of sitting down and thinking about it, and the truth reveals itself.

How do we help our colleagues to recognize defensive medicine and work towards avoiding unnecessary tests?

We do it first in ourselves, and we lead by example. When our outcomes are just as good, and when patient satisfaction is as good or better, the issue reveals itself.

Will economic factors shift EPs towards minimizing tests and prescriptions in favor of better communication to create a sense of value, or are we going to try to simply see more patients?

Hopefully economic factors won’t be the driver of this, since it’s exceptionally difficult to use economic mandates to win hearts and minds, and we need our own hearts and minds to be convinced in order for our patients to believe. We need to convince ourselves first that we’re doing the right thing for our patients, and if we pay close attention to the evidence, less testing and less prescription writing will follow. Good communication follows too, even in condensed time periods where it feels very difficult.

Traditional family physicians, the ideal people to establish long-standing, personal relationships with patients, are all but gone. Although EPs can certainly enhance patient rapport, how can we build the kind of Hippocratic relationship you advocate?

Hippocrates’ approach endeared him to his patients and his colleagues because it was apparent that he cared. The message in his advocacy, his meticulous examinations of each patient, and his rapport, was visible caring. In 1925 Dr. Francis Peabody famously said that “…the secret in the care of the patient is in caring for the patient.” That’s something that patients can see and feel, and while it may often be difficult, it’s always possible, whether the setting is someone’s home in ancient Greece, a modern primary care office for the hundredth time, or an ED for the first time.

You devote an entire chapter to the placebo effect. What should EPs understand about the placebo effect and how can this understanding improve patient care in the ED?

The placebo effect, often called the ‘meaning response’, is a critical part of our practice. In the placebo chapter of the book I walk through much of the data that has come from research involving the meaning response, some of which is spectacularly difficult to accept or understand for modern physicians. The purpose of walking through the data is not however the novelty of the results, although it certainly is fascinating data. Rather it’s intended to help us understand that our training has put us in an impossible position, a position in which we’re asked to deny (in fact, deride) the placebo effect, even while we’re asked to seek it and recruit it, particularly when it suits our larger purpose. The conceptual fallout from this affects everything we do, including our understanding of modern medicines and pills, our understanding of where healing happens, and our belief in the impact that we can have. When we see the meaning response for what it is, and discuss it openly, the prism through which we’ve been seeing modern medicine begins to fall away, and we can understand our purpose and our mission, I think, a whole lot more clearly.

Any advice for aspiring emergency physician authors?

Go for it. Start writing, and don’t stop. Commercial success can’t be the object of the game though, too finicky. Writing has to be an end in itself: those who write usually find it comes with tremendous rewards.