Plenty of interesting observations and suggestions about improving doctor-patient communication in the context of a just and equitable health system.

"Find the really fine thing inside every person; and that will help you want to take really good care of them"-- Mr Rogers

I was mid-way through my third year of medical school, post-call, exhausted, and curled up on the couch with my son, watching Mr. Roger’s Neighborhood together on my laptop: he with a sippy cup and some snacks, me dozing off intermittently, remembering the past 27 hours on Labor and Delivery:

Wheeling the ultrasound to triage to confirm a vertex presentation, teaching an excited father-to-be how to hold counterpressure on his wife’s lower back as she settled into the contractions that meant labor was finally happening.

The team huddle at board rounds with the nursing staff, reviewing the strips, the numbers of dilation, effacement, station.

The scrutiny applied to a screen full of fetal heart rates and tocodynamometers; the hills and valleys of category I and II tracings.

A stat section: chaos finely controlled as a symphony, a team galvanized by the necessity of the moment. APGARs of 5, pinking and shrieking to a 9.

Mr. Rogers was now on the screen again, telling us about caring, what it means to have parents take care of you, what it means to take care of other people. I recalled the downcast eyes of a tough young woman who came in to the medical students’ clinic for a 3-month postpartum depo shot. It wasn’t until the end of the visit, when I asked about her upcoming appointments, that she told me about her depression, escaping her abusive partner, her hope for new life with her baby. I had found out, almost by accident, a really fine thing about this patient. And just like Mr. Rogers had said, I wanted to take the very best care of her.

Miriam Segura-Harrison is a 4th year medical student at the Boston University School of Medicine. Her interests are, in no particular order, women's health, parenting,  Jewish studies, feminism, medical education, and lactation counseling.  She lives in Brighton, Massachusetts with her husband Josh and their son Hasdai.

Thinking about linear assumptions in healthcare, thanks to Jordan Ellenberg's blogpost. Theoretically, we should have dodged that bullet of unthinking linearity. We know that blood pressure too-low is as bad as too-high (or even worse). The extremes of blood sugar are also bad. This should be easy stuff: non-linearity should be in our bones, since we (health care providers and patients both) encounter it often enough.

Why, then, when it comes to quality metrics do we seem to think that more is better? We need to get EVERYBODY MAMMOGRAMED, EVERYBODY SCREENED, or the world will end, amen.

There's got to be a sweet spot. It's gotta be non-linear. If we don't screen ANYBODY, that's a problem. People get cancer and die - we should stop that. On the other hand, if we screen EVERYBODY, that's not good either. People get false positives, get biopsies, feel terrible, and don't live any longer. We should avoid that.

The graph should look lumpy. For certain groups of people, their screening rates should be as high as possible - for others, low; and, for still others, it depends.

Now we have to operationalize that curve, get it into the hands of doctors and patients, make people understand it, and help our computers remind us to do the right things at the right time. Without skiing headlong down a linear graph and ending up in a confused heap at the bottom.

Medicine is an art, many a doctor has written, often meaning  that medicine is not “just” a science, not reducible to numbers. This is usually a veiled poke at evidence based medicine. “Those pencil-pushers and bean counters want to judge the quality of our care - but we know that high-quality care is more than just these checkboxes! There is something else.”

But what is that something else? You say medicine is not getting the hemoglobin A1C (a measure of blood sugar in diabetes) between 7 and 7.5%, but rather fitting the treatment to the patient’s individual wishes and needs? So do that, but then we can surely count how often this happens, and make sure it’s done as often as possible. You say your “art” consists of doing tests which there is no evidence for? Okay, but then specify why you are doing them. And that reason, presumably, is something that can be recorded and generalized to all applicable cases.

Perhaps what “medicine is art” practitioners mean, when they set this statement against evidence-based medicine, is that Art is subjective, wholly unmeasurable. But art involves quantifiable aspects too: discipline, rule making, judicious constraints. If medicine is really art, we should figure out what makes good art and bad art. Or, at any rate, how different skilled practitioners of the medium create healing.


In any case, medicine as art has always struck me as an inappropriate metaphor. Artists make art, for or perhaps together with their audience. But health is not a creation so much as a compromise, a hard-won trek over unforgiving terrain, a negotiation with angry neighbors over some precious piece of lost property whose whereabouts no one will admit to.


In other words, medicine - as least as practiced in the real world - is politics in its most basic definition: a debate for control. The pendulum swings back and forth. For many years, the physician was comfortably in control; now, for the past decades, the patient has sought to redress the balance of control kept from her for so long.


As in politics, we would like cooperation to be the goal in the service of larger aims. But we know that things are messy, we don’t always get what we want, and we leave wanting to get things right on the next time around. It’s not science - we are not aiming at eternal truths. Neither is it art: we are not looking to create something beautiful. No, we are just trying to make life better, within a set of rules and conventions, ideally recognizing that anyone suffering from a health complaint has citizenship (albeit unwanted) in the democracy of the ill.

Making Sense of Medicine: Bridging Doctors' Guidelines and Patients' Preferences

More details soon!