Often, when we take the time to understand a person’s context, we find that a raft of problems are tangled at their roots, and that addressing one causes a shift in another, a sort of game of pickup sticks in which piles vibrate easily. It can then be easy to lapse into nonaction, to let inertia determine the course of future events rather than to choose them actively. How, in the face of complexity, do you choose the next right action for your patient?
Maybe I’m taking it too far, or that the sentimental and idealistic mindset I felt when applying to medical school hasn’t quite warn off yet, but possibly the way to create a care plan for a patient is to step back and see his or her humanity. St. Augustine captures this well, encouraging us to “love human beings in a human way” – recognizing that we all have our faults, gifts, sources of joy and fear, and, most of all, are fragile. Taking the time to know a patient in this way, to create a type of filial love, opens us up to the real risk of disappointment. Our rational and scientific minds want to boil down sets of variables that can be easily manipulated in equations, quickly derived to maximize the functions we create. But we’re messy beings and even the body of our scientific knowledge about the human body falls well short of explaining the complex interworking’s of even an isolated human not burdened by the complexities of life and its web of connections with others.
Having a strong foundation of knowledge, both of basic science and optimal treatment plans, is an important place to start. Learning from those with more time in medicine and those who best understand the condition at hand (the patient and caregiver) fill in the gaps in our “book knowledge”. This clinical training seems to be a process of building what Daniel Kahneman calls “System 1 thinking.” We’ve spent the first two years of medical school building up “System 2” – facts we can logically, deliberately apply in a perfect setting. But we’re never in that setting and so our instinct, biases, and the heuristics we’ve collected through life and the early part of medical school take over, not because we’re lazy but because our minds have evolved to be efficient especially in the face of complexity – Kahneman’s System 1. We refine these heuristics, discarding some and collecting others, and, more importantly, being to learn to recognize those instances when “optimal care plans” — the way it’s always done — are inadequate. It is then that we need to engage our critical thinking skills (kind of sounds like something my 5th grade teacher would say, but still important). And eventually we begin to understand those words made famous by Kenny Rogers: “You’ve got to know when to hold ’em, know when to fold ’em, know when to walk away, and know when to run”. Still we will sometimes fail to change the course of a disease at all, but during our time with the patient we were able to join them on their journey and hopefully provide some benefit. Not to rationalize or take an overly game theoretic approach to modern health care, but maybe the measure of success is did we help make a patient better off than the she or he would have been had there been no encounter with health care – is this what is meant by “do no harm”?
I’m sure there will be times in medicine when throwing up our hands and letting it all play out doesn’t seem like such a bad option and yet we’re hopefully able to provide healing sometimes and comfort always.
Benjamin Mundell is a student at the Mayo Clinic School of Medicine, where he wrote the following response to a prompt from his family medicine clerkship.
One thought on “In the face of complexity, do we choose the right action for the patient?”
This is an excellent essay and, after 32 years of practice, I concur. Very well stated and might you consider getting this published in NEJM/JAMA/BMJ? Would be well worth the effort.