Kenneth Brigham - The Good Doctor: Why Medical Uncertainty Matters

Cover

THE GOOD DOCTOR

Why Medical Uncertainty Matters

Kenneth Brigham, M.D. and Michael M.E. Johns, M.D.

Seven Stories Press

New York Oakland Liverpool

Copyright 2020 by Kenneth L. Brigham and Michael M. E. Johns

A SEVEN STORIES PRESS FIRST EDITION

All rights reserved. No part of this book may be used or reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review.

Seven Stories Press
140 Watts Street
New York, NY 10013
http://www.sevenstories.com

Library of Congress Cataloging-in-Publication Data

Names: Brigham, Kenneth L., author. | Johns, Michael M. E., author.
Title: The good doctor / Kenneth Brigham, M.D. and Michael M.E. Johns, M.D.
Description: New York, NY : Seven Stories Press, 2020.
Identifiers: LCCN 2020008106 (print) | LCCN 2020008107 (ebook) | ISBN
9781609809966 (hardcover) | ISBN 9781609809973 (ebook)
Subjects: LCSH: Physician and patient. | Communication in medicine. |
Medicine--Decision making. | Uncertainty.
Classification: LCC R727.3 .B72 2020 (print) | LCC R727.3 (ebook) | DDC
610.69/6--dc23
LC record available at https://lccn.loc.gov/2020008106
LC ebook record available at https://lccn.loc.gov/2020008107

College professors and high school and middle school teachers may order free examination copies of Seven Stories Press titles. To order, visit www.sevenstories.com , or fax on school letterhead to ( ) - 1411 .

For every complex problem there is an answer that
is clear, simple, and wrong.

H. L. MENCKEN

CONTENTS

Prologue:

PART I.

Chapter 1:

Chapter 2:

Chapter 3:

Chapter 4:

PART II.

Chapter 5:

Chapter 6:

Chapter 7:

PART III. Some Things That Your
Doctor Should Know

Chapter 8:

Chapter 9:

Chapter 10:

Chapter 11:

PART IV.

Chapter 12:

Chapter 13:

Chapter 14:

Chapter 15:

PART V.

Chapter 16:

Chapter 17:

AUTHORS NOTE

This book is an inside job. Combined, the authors have spent a century immersed in American medicine as teachers, practitioners, researchers, administrators, and a variety of less well-defined roles. In recent years, we have also been patients with the kinds of issues that come with age and life experience, sometimes trivial and sometimes not. So, we know some things about doctorswhat kinds of people they are, why they chose their profession, how they were educated, what drives them, what disappoints them about their job, how they relate to their patients and colleagues, etc.that we think will interest anyone seeking their services and will help the medical outsider (of course thats most folks) to choose well. And weve seen health care from the other side too. For reasons that will become obvious, we think that some understanding of the human, scientific, and technical intricacies of medicine can smooth out the potential rough spots where health care happens at the interface of the profession with the people it serves.

Uncertainty plays a ubiquitous and critical role in health care, which is why we think that doctors who are too sure of almost anything can be dangerous. The best possible health care means partnering with a doctor who is intimate with uncertainty and not intimidated by it. If this emphasis on uncertainty doesnt sound as serious as the subject deserves, dont be misled. There is probably no more serious and challenging issue in all of medicine than coming to grips with this fact. In the medical world, maybe is a pretty serious word.

Our hope is that the reader will come away from this book with a better understanding of doctors, who they are and how and why they do what they do. And most of all, we hope that each reader emerges better prepared to identify the health care setting that is the best possible one for them (hint: they wont all be the same). That would change health care for the better and possibly save lives.

If by chance you are contemplating a medical career or are a ways down that path already, we hope the book will influence the kind of professional yo u strive to become.

PROLOGUE

What This Book Is About

There are a couple of critical facts about health care that a lot of usdoctors, patients, administrators, managers, insurers, and health systems peopledont really understand. Because of that, we too often choose doctors for the wrong reasons, doctors who give us less than ideal care in inefficient clinics that are driven by the wrong motives. It doesnt have to be that way.

One critical fact is that uncertainty is integral to medicine . Uncertainty is the trigger for discovery and discovery is what enables a new future for medicine and health care. Uncertainty also makes medical evidence pliable enough that it can be made to fit the unique person that is each of us.

Another critical and underappreciated fact is that your personal health care is a collaboration . Neither you nor your doctor can do this alone. The best possible health care involves a partnership between two real human beingsyour doctor and youwho need to get to know each other; computers are important and will become more so, but they will never be able to do the whole job.

If we, that is the royal we, can understand and act on those two basic facts, we can exploit the scary power of exploding science and technology to make our health care better than it has ever been. But if we ignore the vital role of uncertainty, underestimate the value of the doctor-patient partnership, and count on the technologists to solve the problem, we will not be pleased with the results. And you dont need the politicians and policy makers to start you on the path to good care. You can begin to nudge things in the right direction by dealing with your personal health care wisely.

This book is an attempt to explore how those two basic facts affect the kind of doctor we think you need to look for and to suggest how to go about finding and relating to such a doctor. There is also some discussion of the effects of these two facts on how new truths are discovered and communicated and how health care is perceived, organized, and carried out. After all, what medical scientists discover, what our society decides to do with those discoveries, and how new truths get translated into medical practice are the ammunition that you and your doctor have to help you take on the particular uncertainties in your personal care.

The good doctor never gets too comfortable with accepted dogma. She questions herself and everyone else from the time she begins her medical journey until shes done. But shes okay with uncertainty. In fact, thats maybe one reason she chose medicine as a profession, and it certainly explains her comfort with the essential human ambiguity that practicing medicine keeps forcing her to face. If you want to be as healthy as you can be, this is the doctor you need to get to know.

PART I

Some Basics

CHAPTER 1

The Doctor You Want (Its Not Who You Think)

Why would you entrust your health care to a doctor who is always looking for alternative explanations, questioning whether the obvious is really true, and wondering whether something important is being overlooked? When you fall ill, you feel a pretty urgent need to be told exactly what is wrong and what to do about it. You want your doctor to give you clear yes-or-no answers that you can believe and act on. After all, the doctor spent all those years learning how bodies work, what can go wrong, and when things go wrong how to get them back on track. And at least since the late nineteenth century when William Osler, the much revered godfather of modern American medicine, took over the reins at Johns Hopkins, medicine has benefitted from the rigor and genius of cutting-edge science and technology. With all of that incredible history and the consequent chain reaction of medical discovery that continues to expand, isnt it reasonable to expect your doctor to be pretty darn sure of whats causing that cramping pain in your stomach that comes and goes, sometimes waking you up at night, and to either cut it out or give you a pill that will fix it? You dont want to wait too long to see the doctor, huddled with a dozen other miserable fellow humans, thumbing through old magazines or watching repeating rounds of Headline News stories, just to come away with a list of possibilities. No, you want to come away with a concrete diagnosis and precise therapy. Isnt that what doctors are supposed to do for you?