How Doctors Think Outside of the Medical Box

It was a tough week in Pookieville.  I worked all week at one of my favorite hospitals.  I like working there because the specialists I work with are hypercompetent and always willing to help.  Furthermore, they like to chat. Well, they like to chat about interesting cases.

I was particularly challenged this week because I had to think out of the box.  I will not share the details of the case, as I don’t intend this blog to be about medical cases per se.

When I picked up  my service, I  assumed care of a very complicated patient, with a disease process that was appropriately handled.   Unfortunately, there was an outcome that was unexpected and completely unpredictable .  It was also quite serious.  What I want to share is how hard it was to think out of the box, which was what was required.  Medical statistics and medical science can not predict all outcomes, which is when the “art” of medicine comes in to play.

I walked in to the room to discuss the latest bump in the road, and the various treatment options to remedy the latest bump.  Now, before I went in the room to talk to the patient, I had done my home work.  I had reviewed the latest bump in the road with the surgeons, specialists,  the sub-specialists and several of my co-hospitalists.  There was no clear consensus as to what should be done about this problem, just a general agreement that this problem was indeed, a big problem.  Most of my colleagues were glad they were not me, because it felt as if all options were fraught with danger to the patient.  “Glad I’m not the one that has to write those orders,” was the general feeling.

Great.

I explained to the family what the issues were, and that we were now in rock and hard place territory.  I explained that there were no randomized, double blinded placebo controlled studies for where we were at.  I explained the options, risks, benefits and side effects of each option.  I explained that  I had done my home work.

“Do you just fling sh– at the wall and see what sticks?”  One incredulous family member asked.

It must appear that way, when we can’t quote studies, and cite statistics and supply comfort from numbers.  We must appear like idiots when we have to use our experience, and our colleagues’ experience to make a decision when there is no clear cut decision, and when the road is paved with ill feelings and anger at an outcome only God could have predicted. 

But none the less, a choice on treatment had to be made. 

Here is how I made my decision on how to treat the problem:

  1. Identified the problem.
  2. Said “@#%*!”
  3. Asked everyone involved in the case their opinion, including the PharmD, and the head of the department of medicine.
  4. Came up with three options, and picked the one I felt was the safest with the best outcome.
  5. Reviewed options with the patient and family.
  6. Realized that there may be MORE options, once I talked to the family.  (Interestingly, the family was the most creative in looking at solutions.)
  7. Walked out of the room, made more phone calls, and finally came upon the solution that we ended up going with.
  8. Called a renowned specialist at the local University and got the specialist’s opinion, who was in concurrence with the ultimate solution I had crafted.
  9. Went back in the room (a bit demoralized, as I had said there were no other options, but now had come up with one.)
  10. Heard the family’s  intense relief at the more moderate, middle of the road option that we ultimately agreed to implement.
  11. Went for it.

So why I am writing about this?  Because it took me TWO hours to do all of this.   It took two hours for me to think and explore every option, and to finally come up with an option that seemed workable, and the least dangerous.  I took the time because I wanted to do what was best.   It was the family that was most able to think outside of the medical box, and who encouraged me to explore further.

Now, was this the right choice?  Only time will tell, and yes, sometimes as physicians we just have to throw sh– against the wall, and then throw some more, and then consult our colleagues, and then think again to find the answer when there is no right answer.

I just hope that in the future, I have enough time to think out side of the medical box.

How do you think out side of the box?

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3 Responses

  1. Rx: any of Edward deBono’s work on lateral thinking, or Roger vanOech’s “Creative Whack” series PRN.

  2. How do you think out side of the box?

    Since there is no financial incentive to do this, any damn way I please.  And yes, this means sometimes I choose not to over-tax my staff and resources, allowing for just slightly better than the standard of care.  If we decide to take it up a whole nother level, it will be for the intellectual stimulation and/or emotional reward of providing creative and exemplary care (I’d suggest describing it thus, to avoid the hackneyed term “out side (sic) of the box).

    When it happens, it is by behaving as a physician should, and how he hopefully has been trained.  This entails disregarding the monied parties whose job it is to excert inappropriate influence in truncating the care delivered.  It is by acting as an advocate,  an agent  of beneficence, and the trust you have for your conscience as a premise in superlative judgement.

    From your entry, this is what you did, and by inviting commentary, you acknowledge how perverse it is becoming for “doctors” to behave as physicians.  Ironically, you also demonstrate this perversity by failing to recognize that when the relationship between patient and physician is as it should be,  it is it’s own reward, transcending qualification.

  3. My point was that I HAD the time to spend on this problem. I don’t begrudge spending two hours on this patient, but rather, hope that the next time I have such a challening problem, I will have the time needed to spend on it. Thanks for your comments!

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