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Beyond Illness Roundtables: A Nuanced Era of Medicine

“This wine is growing on me,” Emily remarked as she tipped her head back and took another long sip from the now oxblood stained glass. “It’s a lot more nuanced than I originally thought.”

“I figured it out!” someone quipped from across the room. “Good wine and shared tasty meals make for happy physicians, and happy physicians make good physicians, right?”

“You can spearhead the randomized controlled trial on that theory — I’ll look for it in the New England Journal,” Emily replied, reaching for another decidedly tasty-looking cheesy biscuit.

There were eleven of us seated around the table that night, and while we were all third-year medical students at the same institution, we had been on different clerkships for the past half year. Yet, by some inconceivable scheduling miracle, here we were at my apartment, gathered around a biscuit centerpiece, trying to answer the seemingly straightforward, yet at its core more tortuous question of “What makes a good physician?”

“The scope of this question is giving me palpitations,” my friend Jon admitted. There was a murmur of agreement, as inquiries about what metrics one might even use to define “a good physician” peppered the air. Ultimately, it was decided that for the purposes of the ensuing discussion, for a physician to be deemed good, he or she was to be well liked and trusted by patients, to be able to optimize clinical outcomes, and to be able to produce these outcomes while minimizing health care costs. So then what overarching, ideally teachable qualities, should a physician possess to fulfill these criteria?

A hesitancy hung suspended from the tips of our tongues as it soon became clear that no one wanted to relay the kind of generic, canned answer that, while not unpalatable or wrong, has a desperate need for seasoning. After all, weren’t we systematically taught the answer to this question our first and second years of medical school, in those incessant courses called “doctoring” and “essentials of clinical medicine” and the like? Didn’t we scrawl down on the back of some handout that doctors were to be empathetic, to be sensitive, to be good listeners, to be dedicated, ethical, compassionate? And even now in third year, as we hand out evaluation after evaluation to more senior physicians, are they not determining, on a scale from 1 to 5, just how good of physicians we’ll become based on the extent of our “medical knowledge,” the prowess of our “interpersonal and communication skills,” the palpability of our “professionalism”?

While embodiment of these qualities and strengthening of these aforementioned skills certainly would help one become a more trusted and effective doctor, we couldn’t help but think that there had to be a more elegant unifying principle behind it all, rather than just this sort of calculated compendium of criteria.

“We have to reel it back in — we have to simplify things a bit to see the big picture,” Rachel said, with a shaking motion of her hands, as if to shoo away a clingy cloud of complexity hovering over the salad.

“If you had to pick one word that kind of sums up one underlying principle — I don’t know — that all physicians should embrace, that kind of encompasses all good doctoring or whatnot — does anyone know what i’m trying to say — anyway, what would that word or principle or whatever be?” she finished exasperatingly.

She was met with scrunched up faces and thoughtful pouts, before it, as it inevitably does, came back to the wine.

“How about just nuance, as in, physicians should always appreciate and embrace nuance?” Emily suggested, refilling everyone’s glass. The proposition was met with intrigue, and further unpacking of this word — and concurrent dissection of the barriers to optimal health care in this day and age — led us to recognize how this central theme of nuance might play out in various aspects of a good physician’s practice. So without further ado, outlined below are some key musings from the Biscuit Summit of December 2016.

The advantage of nuanced-vision in diagnosis and work-up

This application of the theme is perhaps most obvious. As anyone who has attacked an especially arduous boards-style question would know, the devil is in the details. In real practice, patient symptoms, lab and imaging results often fit together even less neatly than on exams, and taking complaints and results in context of the patient as a whole is a key step toward timely, cost-effective and accurate diagnosis. For example, careful review of a patient’s chart will reveal elements of a patient’s health history that allow practitioners to better understand a current presentation, and focused, thoughtful history-taking can reveal crucial nuances of a broad complaint. While it is tempting and easier than ever to, in the click of a button, order a barrage of lab panels and radiological studies to smoke out a diagnosis blitz-style, it better serves patients and the health care system as a whole to avoid this un-focused, costly and inefficient practice. Good physicians discerningly take the time in the beginning to carefully dissect a presentation, and wouldn’t necessarily order the same work-up for two different patients’ abdominal pain.

The role of nuanced-care in formulating patient plans, troubleshooting patient plans/procedures

Although much of medical education would lead one to believe that there is a constant, definitive answer when it comes to management of a disease process, adaptation to a patient’s unique care goals is essential. Good physicians present options and make suggestions that are not only evidence-based, but considerate of a patient’s personal preferences (no matter how much this preference may differ from the physician’s own) and financial capacity. In matters of procedural or surgical-based care, adaptability to and anticipation of nuanced anatomical variations, adjusting approach based on patient response and adept troubleshooting of unanticipated intraoperative course are all key skills that go beyond simply performing by the book.

Attention to nuance in the physician-patient relationship

In the current era of medicine, we tend to shy away from the idea of physician superiority over the patient. While it is true that physicians often possess specialized knowledge about a disease process and its treatment that must be conveyed to a patient who is, in a way, dependent on that physician to alleviate his or her suffering, this does not equate to physician dominance over the patient. Awareness of these subtle balances of power, and when they may be shifting out of line, is crucial to creating productive, respectful physician-patient relationships where care is truly patient-centered and decision making is truly shared.

The nuances of physician authority and judgment; acknowledging the fallibility of the physician

While many physicians, due to decades of experience and continued learning, may easily be considered experts in their field, this does not exempt them from errors in judgment and practice. Patients can often see doctors as infallible and all-knowing, but of course the truth is more nuanced than that — there are not just good and bad doctors. It is thus important for physicians to acknowledge mistakes when they are made — to be transparent about lapses in judgment and knowledge — so that patients can more accurately comprehend the clinical situation as it truly is, and not merely what the doctor portrays it to be. Ultimately, physicians should not let pride and the self-serving notion that because a physician’s job is difficult he or she should be exempt from admitting to mistakes, as this hinders honest, meaningful discourse with patients.

The advantage of nuanced-vision in establishing empathetic, non-judgmental care relationships

Being medical students in Chicago, we are fortunate that we are able to serve such a uniquely diverse population. Although it is often our job as physician to synthesize symptoms and exam findings to make an ultimate judgment about a patient’s disease process, it is never our job to judge unrelated aspects of that patient’s lifestyle or beliefs. Yet, this does not mean we ignore these patient details as they are often inextricable aspects of a patient’s identity; acknowledgement of and effort to more deeply understand these intricate factors will strengthen the bond between the physician and patient, allowing for more honest communication and higher levels of trust.

After the night wound down and my guests departed one by one, I was still left with one unopened bottle of red, and one of white — a true bacchanalian dichotomy — and a foil to the predominating thought of the evening. As I sunk heavy and deep into my couch, I thought about how much more straightforward medicine and the ever cacaphonic issues of the world would be if things were just red and white, and not all the shades of nuance in-between. Yet, in the end, if we are to thrive truly in this complex, rich, blend as physicians and as inhabitants of this earth, I believe that it is imperative that we champion the reality of the full and infinite spectrum.

Interested in hosting your own Roundtable? Please read the documents here and contact us at editorinchief@in-training.org.

Yuli Zhu Yuli Zhu (1 Posts)

Medical Student Editor Emeritus

University of Illinois College of Medicine

Second year medical student living and eating in Chicago. Here by way of Brown University, and missing clam chowder every day. Have recently come to realize all my medical interests pertain to parts of the body from the neck up, so there's that. I have a needy cat, like literary theory and often make really hit-or-miss jokes. Feel free to email me to chat about medicine, architecture, the indigenous foods of Chicago or hot fire Spotify playlists. Friends describe me as "girl" and "a 7/10 conversationalist."