Most experienced physicians expect uncertainty in caring for real people with average everyday problems. Yet those inexperienced or uninitiated in medicine tend to see the practice of medicine as exact or even absolute.
I remember waiting in vain as a medical student and resident for my instructors to illuminate a path towards certitude. Instead, I was given something far more real and lasting: An acceptance of the indeterminate mixed with the drive to be compulsive on behalf of my patients.
During my internal medicine internship, I remember a more-senior resident during our daily morning report bemoaning her uncertainty by saying, “But I just don’t know what’s wrong with my patient.” Although she was visibly upset, our program director’s reaction to her comment bordered on amusement, culminating with, for me, an unforgettable response: “Well, you certainly have chosen the wrong profession.”
I can remember my program director explaining his role in our development: “I’m not trying to make you smart. I selected you, in part, because of your intelligence, but it’s my job to make you compulsive.” This surprised me as I previously had thought compulsion to be a negative trait — one that could identify a personality disorder or eventually lead to obsession.
However, now I realize that much about today’s medical profession reads like a Lewis Carroll novel, and so I see compulsion as a powerful tool in a time when the value of common sense and logical thinking is being diminished by innumerable outside influences.
Compulsion can be used for the good of any patient as it drives us to doggedly pursue a set of symptoms and signs, craft a working diagnosis, and tirelessly work to discover a cause — hopefully with a treatment available to help a patient at the end. Today, compulsion is needed at every step in medicine. Perhaps I will need to fight with an insurance company to get a test approved, repeatedly call a lab to track down a test result, or make sure that claustrophobia doesn’t prevent my patient from having an MRI.
Physicians should be comfortable with the lack of certainty as we move forward through this process but we will be hindered by those who see uncertainty as a failure or act in a way that belies a belief that uncertainty doesn’t exist. My medical school mentor, Dr. B., derisively referred to anyone hindering his medical practice as a “bean counter.” I worked with Dr. B in the early 90s and watched him struggle with the growing use of ICD-9 codes which imply certainty in their use- there is a paucity of symptom codes while no codes exist for ruling out a problem.
The current diagnostic code book (ICD-9) has roughly 12,000 numerical codes to identify a specific disease or problem. Failure to report a string of numbers correctly can result in a variety of negative consequences spanning from denied payments to refused tests and treatments.
Dr. B kept a file of letters from insurance companies that he considered nonsensical yet tragically funny. One was a letter from Medicare denying payment and admonishing him for his decision to admit a patient to the hospital on a certain date for a condition that “did not warrant a serious enough illness for hospitalization.” Stapled behind this reprimand was a copy of the patients’ death certificate with the same date as her hospitalization. His failure: using a code for simple urinary infection instead of urosepsis.
Dr. B began his medical practice in a time that understood and expected ambiguity, a time when patients might be admitted to the hospital for tests — an absolute anathema today. He struggled loudly against the restraints being placed on his practice as the years advanced and resisted focusing his attention on codes. While those of us practicing medicine today are largely used to our insane daily struggles, I imagine it must have appeared to Dr. B. and other doctors of that era that mid-career they had been dropped down the rabbit hole with Alice or forced to practice medicine from the other side of the looking glass.
Each day I feel more concerned as common sense and logic seem scarcer and it does appear to me that we have arrived in our own strange counterintuitive Wonderland. As I struggle to understand and function effectively, I feel a deep gratitude towards my teachers for showing me the power I can wield for my patients by remaining compulsive so that I may help them navigate the medical “reality” that envelops us all today.