Medical poetry and healing

To the editor:

I read with interest the article by Slawson and Shaughnessy¹ in the January issue. As usual their insights are brilliant. They offer an approach for using the medical literature to determine cost effective health policies and encourage the rational use of medical technology.

I see a number of challenges to their vision, however. Systematic reviews can only answer a tiny fraction of the clinical questions that patients and clinicians face each day. More of this research is not done because it is frequently impractical for technical, logistical, and financial reasons. The savings that could be realized by reducing the use of unproved or ineffective therapies must be counter-balanced by the high cost of doing quality clinical research. With the exception of a few very common complaints, it may cost more to research a definitive answer to a clinical problem than to treat it empirically. Also, the academic promotion system does not allow researchers to spend an entire career answering a few narrowly defined clinical questions.

Instead, early in their careers successful researchers must publish volumes of smaller research studies. This limits the types of study designs they can choose. Finally, many important clinical problems cannot be reduced to questions that can be answered rigorously. Even if these challenges could be addressed, the vision of Slawson and Shaughnessy is incomplete. Inherent in that vision is the fundamental assumption that healing happens when physicians choose the right diagnostic test, medication, or treatment for their patient. However, as most family physicians know, the process of healing is much more complex and mysterious than that. Whether you call it the biopsychosocial model, the art of medicine, the physician-patient relationship, or God, healing is fundamentally a spiritual practice. It is informed by science but cannot be conducted by algorithm. The interaction between healer and patient is profoundly personal. It involves the senses, hope, connection, intuition, trust, empathy, and respect for the capacity of the body and the mind for regeneration. Healing can happen in any place and at any time—often not in the examination room.

Any new model of health care delivery that ignores this powerful force will fall short of satisfying patients. The reliance of Slawson and Shaughnessy on evidence-based medicine to guide our use of expensive technology is not antithetical to this. Perhaps the reason that technology is overused and misused so frequently is that we have been taught to use diagnostic tests and prescriptions as surrogates for making healing connections with patients. To implement a policy of rationing technology, we cannot also simultaneously ration our time, attention, empathy and touch.

Clarissa Kripke, MD
University of California at San Francisco

REFERENCE

• Slawson DC, Shaughnessy AF. Becoming an information master: using ‘medical poetry’ to remove the inequities in health care delivery. J Fam Pract 2001; 50:51-56.

The preceding letter was referred to Drs Slawson and Shaughnessy who responded as follows:

We appreciate the opportunity to respond to Dr Kripke and her kind feedback regarding our manuscript. We agree that the costs of doing large randomized trials and thorough systematic reviews must be considered when prioritizing which issues in medicine should be evaluated. This is precisely why we listed in our article some of the most significant issues facing primary care physicians. As David Eddy¹ reminds us, a few big-ticket items in medicine can take a huge chunk out of yearly health care expenditures. For example, he estimates that the cost of screening for premenopausal breast cancer and prostate cancer is in the range of $100 billion per year. Given the large volume of primary care practice, even less expensive interventions can result in significant costs for our health system.

Considerable evidence already exists for common problems that if applied in clinical practice would make a huge difference in improving the value of health care delivery. Despite the fact that calcium channel blockers are significantly more expensive than diuretics and b-blockers, and that the available evidence including a recent meta-analysis² shows that they are clinically less effective than other agents, calcium channel blockers remain the number one prescribed antihypertensive in the United States.

Finally, we agree strongly with Dr Kripke about the importance of paying attention to the therapeutic relationship and the interplay of evidence with the clinical experience.³ Clinicians may not have all the right answers, but they need to find and verify those that do exist. For the rest, they need to ask the right questions and keep watch for the right answers. Improving the value of health care by increasing the quality of patient care and decreasing unnecessary expenditures may pave the way to increasing the amount of time clinicians have to spend with their patients.