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Category: Medical Practice

The Science of Clinical Intuition

By HANS DUVEFELT

In 2002, Dr. Trisha Greenhalgh published a piece in the British Journal of General Practice titled Intuition and Evidence – Uneasy Bedfellows? In it she writes eloquently about the things Christer Petersson and I have written articles on and emailed each other about. He mentioned her name and also Italian philosopher Lisa Bortolotti, and I got down to some serious reading. These two remarkable thinkers have described very eloquently how clinical intuition actually works and describe it as an advanced, instantaneous form of pattern recognition.

Clinical Intuition (should we start calling this CI, as opposed to the other, electronic form of pattern recognition, AI – Artificial Intelligence?) begins with clinical patient experience but is cultivated through reflection, writing and dialogue with other physicians. And as Petersson and I have both written, there isn’t enough of the latter in medicine today. Both of us do as much reflecting and writing as we can, but we both know that more collegial interchange can make all of us better clinicians. Greenhalgh writes:

The educational research literature suggests that we can improve our intuitive powers through systematic critical reflection about intuitive judgements–for example, through creative writing and dialogue with professional colleagues. It is time to revive and celebrate clinical storytelling as a method for professional education and development. The stage is surely set for a new, improved–and, indeed, evidence-based–‘Balint’group.
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC1314297/

Bortolotti, the philosopher, makes the case that experts are more intuitive than novices, a skill that only comes with experience, and have developed advanced pattern recognition abilities that allow them to make decisions faster than possible when only using analysis and reasoning. Her article is quote-heavy. She writes:

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Why I Seldom Recommend Vitamins or Supplements

By HANS DUVEFELT

People here in northern Maine, as in my native Sweden, don’t get a whole lot of natural sunlight a good part of the year. As a kid, I had to swallow a daily spoonful of cod liver oil to get the extra vitamin D my mother and many others believed we all needed. Some years later, that fell out of fashion as it turned out that too much vitamin A, also found in that particular dubious marine delicacy, could be harmful.

This is how it goes in medicine: Things that sound like a good idea often turn out to be not so good, or even downright bad for you.

Other vitamins, like B12, can also cause harm: Excess vitamin B12 can cause nerve damage, just as deficiency can.

Both B12 and D can be measured with simple blood tests, but the insurance industry doesn’t pay for screening. That is because it hasn’t been proven that testing asymptomatic people brings any benefit. In the case of B12, it is well established that deficiency can cause anemia and neuropathy, for example. But here is no clear evidence what the consequences are of vitamin D “deficiency”. A statistically abnormal result is not yet known to definitely cause a disease or clinical risk, in spite of all the research so far, but we’re staying tuned.

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CareAlign, fixing that physician workflow–demo & interview

By MATTHEW HOLT

I recently interviewed Subha Airan-Javia, the CEO of CareAlign. CareAlign is a small company that is working to fix the clinician workflow by creating a tool for all those interstitial gaps that the big EMRs leave, and now get moved to and from paper by the care team. In this interview she tells me a little about the company and shows how the product works. I found it very impressive

Full transcript below

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Doctor-Patient Relationships: I Don’t Babysit – I Want to Empower

By HANS DUVEFELT

I have known doctors that cultivated a dependence among their patients by suggesting their health and safety depended on regularly scheduled visits and laboratory testing for what seemed to me stable, chronic conditions. People would come in every three months, year after year, to review cholesterol numbers, potassium levels and glucose or blood pressure logs and have a more or less complete physical exam every time. Patients would also get scheduled for rechecks of ear infections and other simple conditions I always thought patients can assess themselves.

Compare the effort on the part of the physician with that type of practice versus seeing stable patients less often, doing more urgent care, and being more available for new patients. The first approach seems comfortable, possibly complacent, and the second more demanding, but also more satisfying, at least to me. My goal is always to make my patients as independent and self sufficient as they can be. I don’t want them to be dependent on me in an unhealthy way.

It is a matter of temperament, but it is also a matter of stewardship and resource management if we see ourselves as serving the populations and communities around us.

Maybe it is because of my Swedish upbringing and education, but I would feel guilty if sick patients or even relatively healthy people don’t even have access to a personal physician if I were to spend my days over-monitoring stable conditions.

In this medically underserved state, don’t we have a responsibility to consider whether we are getting too comfortable in our chronic care routines? Patients check their own blood pressures and glucose levels. They could get in touch if their numbers worsen. Do we really need to bring them in to make sure they don’t stray when there are people in our communities without access to care?

I sometimes actually use the phrase “I don’t babysit”. I don’t necessarily use the word “empower”, but that is what I always try to do with my patients.

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Did Covid and Telemedicine Finally Make the Physical Exam Obsolete?

By HANS DUVEFELT

Left to my own devices, I would be selective about when and how much of a physical exam I do: either not at all or very detailed for just those things that can help me make the diagnosis. I have no patience for boilerplate normal exams. Any doctor who uses the term PERRLA (pupils equal, round, reactive to light and accommodation) is probably faking it. First, most of the time this isn’t actually tested completely and, second, even if it’s done correctly, it has no relevance in the majority of chart notes I have found it in. I have actually seen it in office note templates for urinary tract infections!

It is well known that the history makes the diagnosis in the vast majority of cases. But that task – or art, actually – is sometimes relegated to support staff or forced into unnatural click boxes. Because reimbursement until very recently was tied to how many items were asked about and examined, there was a loss of the story, or narrative, of the patient’s illness. And you could get more brownie points by including things that were extremely peripheral to the clinical problem at hand.

EMRs make it easy to produce long office notes with lots of reimbursement and quality scoring points of uncertain clinical value and accuracy.

Specifically, the physical exam has in many instances become a corrupted, fraudulent, one-click travesty of the art and professionalism we swore an oath to hold high when we graduated from medical school.

The pandemic and the rush toward telemedicine made it clear to most people that medical diagnosis, advice and treatment is entirely possible without physical contact. It was just a matter of getting paid for it, or the healthcare industry would have come to a stop, or at least a crawl.

Now that we have admitted that listening, talking and a certain amount of looking or observing can be done without being in the same room, it is time for us to be honest about the value of the physical exam.

Our medical education in universities and tertiary medical centers taught us how to handle complex and baffling cases that had eluded diagnosis in the primary care setting: Start from scratch, assume nothing. This is a method we need to use in select clinical situations.

But in everyday practice that is inefficient and unnecessary. Most of what we see is simple stuff and part of our job is to triage, to know when something seemingly ordinary is or has the potential to be more serious.

We need to know how to do a really good and relevant physical exam when the situation requires it. But we also need to know when that would add nothing and only waste our time and effort.

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Why “Radiopharmaceutical” Should be Part of your Healthcare Vocabulary

By JAY T. RIPTON

Not to sound too alarmist, but the radiopharmaceutical industry is on the verge of an explosion. But don’t worry; it’s not the type of explosion one often associates with nuclear materials… I love those movies too! It’s the beginning of a new wave of innovation for the diagnosis and treatment of certain cancers and other diseases.

This new radiopharmaceutical boom quite literally has the life sciences industry in a nuclear arms race of sorts, as companies like Y-mAbs, Novartis and others are pushing through clinical trials for the next blockbuster for the treatment and detection of hard-to-treat diseases like medulloblastoma and metastatic castration-resistant prostate cancer. But all this excitement has many wondering, “what are radiopharmaceuticals anyway?”   

Radiopharmaceuticals are simply a group of pharmaceutical drugs containing radioactive isotopes. They are being used primarily for the treatment and detection of certain types of cancers, but they are also being developed for cardiac disease as well. And what makes radiopharmaceuticals so unique is that they can be targeted to extremely precise areas in the human body.

Although gaining ground with more precision today, this type of therapy actually began in the 1940s with I-131 – which has become an important agent for the treatment of benign and malignant thyroid disease. The development of radiolabeled antibodies began in the 1970s, and Radium-223 dichloride was approved by the FDA in 2013 for the treatment of castrate-resistant metastatic prostate cancer. Lu-177 PSMA is one of several recent developments that are making their way through FDA approvals.

“The radiopharmaceutical industry has actually been around for some time, but today it is at a tipping point,” says SpectonRx president Anwer Rizvi. “Over the next few years, it is estimated that our industry will triple. With more radiopharmaceuticals making their way through clinical trials and FDA approval, we are starting to see more data that highlight their effectiveness. This is why we are now starting to see more life sciences organizations committing real resources to radiopharmaceuticals.”  

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The Art of Medicine is Not an Algorithm

By HANS DUVEFELT

The Art of Medicine is such a common phrase because, for many centuries, medicine has not been a cookie cutter activity. It has been a personalized craft, based on the science of the day, practiced by individual clinicians for diverse patients, one at a time.

Unlike industrial mass production, where everything from raw materials to tools to manufacturing processes are standardized and even automated or performed by robots, physicians work with raw materials of different age, shape and quality in what is more like restoration of damaged paintings or antique automobiles.

The Art of Medicine involves knowing how and with which tools to take something damaged or malfunctioning and make it better. There are general principles, but each case is different to at least some degree. In many cases there are different ways to improve something that is malfunctioning, but patients may prefer fixing certain aspects of a complex problem because of their individual needs.

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Voicemail, Repeat Requests and Multitasking: Inefficiencies in Today’s Healthcare

By HANS DUVEFELT

My nurse regularly gets at least 50 voicemails every day, many saying “please call me back”.

I have one patient who frequently tests the patience of our clinic staff by calling multiple times for the same thing. He is the most dramatic example of what seems to be a widely held belief that physicians, nurses and medical assistants sit at their desks and answer phone calls all or most of their time. But when we do, we are often hampered by busy signals, phone tag or “voice mail not set up”. Electronic messaging isn’t a panacea, because patients don’t necessarily know what we need to know in order to answer their questions correctly and efficiently at first contact.

Pharmacies, too, create duplicate requests that bog down our workdays. In my EMR, if an electronic refill request doesn’t get a response the day it comes in, the “system” sends a repeat request every day until it gets done. This is one reason I look like I am further behind on “tasks” than I really am. To top it off, every single refill request generated by the “system” comes with a red exclamation point next to it. This happens even when a patient has just picked up their last 90 day refill – a case where I theoretically should have 89 days to respond. Meanwhile, my system has no way of flagging truly urgent refill requests. This “alarm fatigue” is common in EMRs today.

The business model in today’s healthcare is that reimbursable activities (seeing patients in person or via telemedicine) are scheduled back to back, all day long. There is a universal assumption that this will still provide enough slack to deal with prescription refills, phone calls, incoming reports and the further ordering and feedback to patients prompted by them. And did I mention EMR documentation? Multitasking, or rather, constantly switching between different kinds of tasks, is not a sane or efficient way to work.

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Off Our Chests: No Secrets Left Behind

By CHADI NABHAN

She was a successful corporate lawyer turned professional volunteer and a housewife.

He was a charismatic, successful, and world-renowned researcher in gastrointestinal oncology. He was jealous of all breast cancer research funding and had declared that disease his nemesis.

They were married; life was becoming a routine, and borderline predictable. Both appeared to have lost some appreciation of each other and their sacrifices.

Then, she saw a lump, and was diagnosed with breast cancer. Not any breast cancer, but triple negative breast cancer. The kind that is aggressive and potentially lethal. The year was 2006, and their lives was about to change forever.

This is the story of Liza and John Marshall, who decided after 15 years of Liza’s diagnosis to disclose all, get all their secrets out in the open, and “off their chests”. They did so by writing a book that I read cover to cover and could not put down.

The authors decided to not only share their cancer journey as a patient and a caregiver, but also to share much of their personal and intimate details. They wanted us to know who they are as people, beyond patient and oncologist husband. We got to know how they met, when they met, and how they fell in love from the first sight. We got to know some corky personal details, and as a reader, I felt that I was part of their household. John shares how losing his mother at a young age to lymphoma affected him personally and professionally. We learn that they attend church every Sunday. Both are people of faith and they let us know how their faith helped them during these challenging times. Losing a dear friend to breast cancer took a toll and certainly made them less certain whether Liza’s fate would be any different.

They alternate writing chapters so that we get to know various events and stories from their sometimes-opposing points of view. We get to understand how a cancer diagnosis affects a caregiver, who happens to be a busy academic oncologist with little time to spare in between clinical practice and traveling for his work. At some point, John expresses resentment that all of the attention was being diverted towards his wife -the patient- and that he was left alone with few people caring how he felt and what struggles he was going through.

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What Does Your Patient Need to Hear You Say Right Now?

By HANS DUVEFELT

Today a patient told me a cancer doctor had told her husband that he only had a year to live. She was angry, because she felt that statement robbed her husband of hope and she knew well enough that doctors don’t always know a patient’s prognosis in such detail.

“Would you want to know if you only had a year to live”, she asked me.

I thought for a moment and then answered that I probably would want to know. I explained that I would want to make decisions and provisions because I live alone and am responsible for my animals. As I told her, I am well aware that if I dropped dead right now, things would be pretty chaotic for a while.

Two and a half years ago, I wrote a post titled Be the Doctor Each Patient Needs. In it I presumptuously coined the phrase I later put right on top of the sidebar of this blog:

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

I still believe we need to be incredibly sensitive to all the verbal and nonverbal clues our patients give us about what they need. In my 2018 post, I used the analogy of being like a chameleon. That’s not the same as being dishonest. It is a matter of knowing that your education and title give you an authority, an opportunity and an obligation to use your position of trust in your patient’s life to say things they need to hear in order to carry on or perhaps to take the first step in a new direction. We all wear the mantle of a superhero in a sense, and we can use this symbol for good. But that carries a responsibility to use our powers wisely.

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