A (re)Visit to an Old-Fashioned Doctor
A (re)Visit to an Old-Fashioned Doctor
A great irony of Twitter/X, a site that epitomizes 21st century ephemerality, is that it can also engender the persistence, or rebirth, of a work. On the one hand, studies that authors worked on for years, or essays that were wrestled with for weeks, are only tweeted for a day or two before disappearing into our collective amnesia. On the other, articles will sometimes find second life on the site.
This was recently the case with the essay, Old-Fashioned Doctors, published in 1998. It probably speaks to my narcissism (rather than my senescence) that I took it as flattering when a dozen or so people sent the tweet my way.1
Being alerted to this article was a gift for several reasons. First it let me dive into the history and the work of the author, Herbert L. Fred, who sounds like an incredible man. I read many of his essays including Hyposkillia and Medical Education on the Brink. I now count Dr. Fred, along with Faith Fitzgerald, Robert Hirschtick, as one of the masters of health humanities writing.
The article itself also got me thinking. Initially, I was tempted to dismiss it as one of those “back in the good old days” screeds until I realized the article was published in 1998.2[ii] I was only about 18 months into a faculty position then, so the article could have been addressed to me. I think I would have agreed with a lot of what it said in 1998. I still do find much to like about the article but I think I might have a more nuanced take on it than I would have when it came out.
So, with the greatest respect to Dr. Fred, who cannot respond, a point by point reflection on Old-Fashioned Doctors.
Old-fashioned doctors spend whatever time it takes to obtain a good medical history and physical examination.
The history and physical exam is not something to be fetishized but something to be recognized as a time saver. A thoughtful H&P can avoid unnecessary tests that in turn produce false positive results that then demand further evaluation.
But, 20th century labs and 21st century imaging has made the 19th century physical examination less important. It is a benefit to all, aside from maybe the surgical trainee, that we no longer accept a 5% rate of normal appendixes after surgery for appendicitis. The physical exam adds information only a small minority of the time – more in the outpatient setting than inpatient. An exam finding does, on occasion, make you feel more comfortable with your diagnosis.
Old-fashioned doctors routinely seek all of the patient's previous medical records, not just the discharge summaries.
There are cases when it is necessary to pore through old records, but the EMR and diagnostic technology has undermined this claim. We are lucky to work at a time when a review of a discharge summary, lab findings, and radiology results can usually give you a pretty perfect sense of what has happened and what remains necessary.
Old-fashioned doctors do not order sophisticated, expensive studies when simpler and cheaper procedures can supply the needed information.
This is another statement, one which now rings somewhat hollow. The debate has mostly changed from simple and cheap vs. sophisticated and expensive to the right test at the right time. While it is true that a urinalysis is often as useful as a pre and post contrast abdomen pelvic CT in a patient with a suspected kidney stone, usually the important decisions are in line with: of the options we have to risk stratify this person with angina, which is the best test.
Old-fashioned doctors order tests to substantiate, not generate, their clinical impressions.
A. Amen. Diagnostic reasoning is (at least partially) deductive reasoning. You make a hypothesis - a possible diagnosis - and then you test that hypothesis. The progression is not abdominal pain – CT. It is abdominal pain – epigastric pain and tenderness – 12 other clues – probably pancreatitis – lipase.
B. However, sometimes we are stumped and diagnostic tests can be hypothesis generating. Sometimes we are working with trainees who have not mastered reasoning skills and need to be taught the steps between the symptom and the diagnosis.
Old-fashioned doctors use their brain and their heart, not an army of consultants to manage their patients.
And
Old-fashioned doctors view consultants as opinion givers, not decision makers.
I know where these are is coming from, but I think it is more complicated. I am sure Dr. Fred knew this well. It is true that sometimes consultations are called out of laziness – let someone else think about this case or have the difficult conversations with the patient. Sometimes consultants are called out of ignorance – I have no idea what is going on here, I hope someone can help me out.
These days, certainly more than in 1998, when hospitals are filled with patients with impossibly complex illnesses, when many treatments are the sole purview of highly specialized doctors, when medicine is more of team sport, consultants are necessary opinion givers and even, sometimes, decision makers.
Old-fashioned doctors treat patients not numbers.
If it only were that simple.
“Will you please stop checking the lactate. I don’t care if it is high, the patient looks fine.”
But
“I know she was supposed to go home today, but her creatinine went from 1.5 to 2.2.”
Old-fashioned doctors do not blindly administer a ton of drugs in an attempt to alleviate every possible ill.
AND
Old-fashioned doctors recognize that doing nothing is, at times, doing a lot.
AND
Old-fashioned doctors understand that patients often get well despite what we do, not as a result of what we do.
AND
Old-fashioned doctors are aware of their own fallibility and are never afraid to say, "I don’t know".
I love this quartet but I think the correct moniker is less “old-fashioned doctor” and more “mature” or “experienced doctor” – who, truthfully, can be any age. Some medical students seem to know that the body is complex, that time heals many wounds, that we often do harm while trying to do good. Some senior physicians seem to never grasp these truths.
Old-fashioned doctors realize that good rapport with their patient is their best protection against lawsuits?
This is statement is true, though the empirical data was just becoming available when Fred’s article was published. In this context however, the statement bothers me by bringing to mind the grand old doctor, who looks like he (he is still usually a he) should be the subject of an oil painting, who doesn’t know much, who makes mistakes, yet is beloved and worshiped by his patients.
I’m thankful that, for all Twitter’s flaws, it brought this 26-year-old article (and its author) to my attention. There is a lot still to be valued about the old-fashioned doctor; so much so, in fact, that maybe we should just refer to him or her as the good doctor.
In reality, it really only speaks to my twitter/substack persona. For all anyone knows I am terrible doctor IRL but just sound like a good one on the internet. I do have a friend who told me I was much pithier on twitter than in person.
My favorite “good old days” quote from Kurt Vonnegut: I apologize because of the terrible mess the planet is in. But it has always been a mess. There have never been any 'Good Old Days,' there have just been days. And as I say to my grandchildren, 'Don't look at me. I just got here myself.'
Much as I like a lot about this post, I would quibble with the term "old-fashioned". This conjures up, at least in my mind, an old, dottering, out-of-date physician who still uses medicines and procedures that have not only gone out of vogue, they were likely pretty useless even in their heyday. I prefer "traditional" or even the more specific "Hippocratic, physician". These physicians meet nearly all the criteria of the so-called "old-fashioned" physician. They see patients themselves and take the time necessary to obtain a proper history and perform an appropriately focused or broad physical examination. They assemble a differential diagnosis then set about obtaining the necessary tests to confirm or refute each. They try hard to avoid over- or under-treating patients. They are slow to adopt new things and only when they are convinced these are better than what came before. They ask for help or consult appropriately but maintain oversight over the patient. They operate only when necessary but do not hesitate to do this when appropriate. They follow the patients themselves. I could go on. While advances in pharmaceuticals, procedures, devices, and operations will render much that we used to do obsolete, nothing will change the underlying sine qua non of good medicine: the relationship between physician and patient. Patients cannot be reduced to RVU's, their medical care dictated by flow charts and "best practices", their physicians pressured to do ever more in ever less time, and primary care relegated to "mid-levels" (who came up with this term?) whose education and training is a small fraction of that obtained by MD/DO's without the quality of medical care suffering, as it is clearly doing in my view. As I near then of a 46 year medical career, as a general surgeon first and later a plastic surgeon, I would like to be able to say I am leaving medicine better than I found it. Alas, I cannot. R. Bosshardt, MD, FACS
My last piece 'In the beginning Part 3' underscores your thoughts on this issue - thank you!