Friday Reflection 20: The Clinical Set Point

Kwashiorkor

BS was a one-year-old boy admitted with two months of diarrhea. The child was healthy until weaning at six months when he suffered from an episode of dysentery. He recovered but then developed diarrhea at 10 months of age which continued unabated. The diarrhea was accompanied by occasional, irregular fevers, and the passage of worms in his stool. For the last two weeks, BS’s condition has worsened with vomiting, inconsolable crying, and scant oral intake. In the week prior to admission, he developed anasarca, at times severe enough that he could not open his eyes. His mother fed him barley water and oral rehydration solution, diluted 3:1.

All physicians have a practice philosophy, a clinical mindset or set-point that dictates how they practice. There are those who are “aggressive” in their evaluation of patients and those who tend to take a “wait and see” approach.^[i] There are therapeutic maximalists and minimalists (and even nihilists). There are medical conservatives and whatever the opposite of that is.

As a physician, I tend toward minimalism and conservatism. I’ve over tested and overtreated at times in my career, especially if that seems what is called for in a specific situation (or will put a patient at ease) but my reflex is to act deliberately and parsimoniously, recognizing that identifying a diagnosis is sometimes not beneficial, that test results often don’t change our management, and that many of our treatments are associated with a risk of harm not much less than their likelihood of benefit.

This is not necessarily a superior practice style.^[ii] I have a close friend and valued colleague whose medical expertise and clinical skills I respect absolutely. I value his counsel. We consult each other about cases at least twice a month. He will evaluate concerns urgently that I will observe for a couple of weeks before beginning a workup. I have made fun of his decision making and he has claimed to be frightened by mine. The difference in our management style is so stark that I’ve been told by more than a couple of listeners that our disagreements are what they liked best about a 39-episode S2D podcast. Did I mention that we wrote a textbook of medicine together?

Separate from a doctor’s set point is her diagnostic calibration. Diagnostic calibration is defined as the relationship between diagnostic accuracy and physician confidence in that accuracy. In general, a physician with a low level of confidence in his or her level of diagnostic accuracy will overtest, whereas an overconfident physician will under-evaluate patient concerns. Because the feedback we get on our practice is imperfect, doctors can feel well-calibrated at very different set points. I imagine that most skilled and experienced physicians are pretty well-calibrated. Over the course of a year, compared to a maximalist, a minimalist probably spends a bit less money and probably is slower to diagnose a small number of patients’ problems. However, I doubt the difference in actual clinical outcomes is significant.

What is the origin of our set points?

As a fourth-year medical student I participated in a program called the Externship in Human Rights and Healthcare. Students from three medical schools were sent to medical practices around the world. These practices all cared for locally underserved populations. Students lived and worked in the location for three months, kept a detailed journal, tried desperately to have an experience that was more than medical tourism, and returned home to present the details of their experience to the other externs.

Students worked in places as diverse as an indigenous people’s healthcare center in rural Alaska, an impoverished area in Malawi, a psychiatric hospital in Pune, India, and a displaced persons camp on the border of Thailand and Cambodia. I worked at the Child in Need Institute (CINI) in West Bengal India, just south of Kolkata (still Calcutta at the time). The Institute combined a clinic, an acute care ward, and a residential malnutrition treatment and education center. There were opportunities to visit other settings: a nearby TB clinic, villages our patients came from, a homeless shelter for boys at the Sealdah Railway Station, and an aid station in the Sundarbans.

As a medical student, I worked hard to actively participate in patient care but I was primarily an observer. What I saw were children, both sick and healthy, living precariously. Given poverty, institutional failures, and tenuous nutritional status, small misfortunes could have devastating consequences. The converse was also true, small, inexpensive interventions reaped enormous benefits.

I met BS the day after he was admitted to the acute care ward. During my pediatrics rotation on the upper east side of Manhattan, I had never seen a child so sick. I was scared to even hold him, certain I would do him harm. Over the course of about six weeks, I watched him become a healthy child. His infections were treated, and he ate a nutritious diet. BS and his mother lived at our center where she learned to use resources available to her to guarantee the health of her child.

I got comfortable holding BS. I played with him. I helped support his first steps. I treasure a photo of me with him and his parents on the day he left the clinic.

I returned to medical school after my three months at CINI to complete my sub-internship. The sub-internship, then and now, is an opportunity for senior medical students to experience what life will be like after graduation. Other than fear and anxiety, what I remember about the experience was the feeling that my work was futile. Overwhelmingly, we were taking care of people whose conditions couldn’t be helped. We were caring for late-stage cancer, AIDS in the early 1990’s, elderly people with dementia. Each day we made changes to drip rates, medication dosages, and management plans that would have little effect over the next few days and none over the next few weeks. I left this month with the impression that the medicine I watched in India was impactful while the medicine I practiced in New York was futile.

As I progressed through residency, I gained a more nuanced perspective. I recognized that what we did in American medicine was not useless. Interventions were sometimes lifesaving and often life-prolonging. Some of the care I provided did not change outcomes but allowed people to die well. Sure, there was excess, but it was well-meaning excess. There were, however, management controversies, that given my experience abroad, I just could not engage in. When we debated medication doses meant to improve a lab result that I knew had little likelihood of translating to better outcomes for the patient, I’d want to scream, “IT DOES NOT MATTER!” I couldn’t help but think about children who would go blind unless their mother fed them rice fortified with vitamin A. For some time, I attributed my clinical set point, and even my specialty choice, to my time at CINI.

Over time, however, I realized that the origin of my clinical set point was a lot more complicated. I met gifted physicians whose backgrounds and clinical experiences were nearly identical to mine whose practice tended toward maximalism. I began to realize that my CINI experience was associated with my clinical tendencies but not the cause. I chose to do the externship, and found it so impactful, because it was in line with my clinical mindset.

I’ve come to think that our clinical set points are an extension of our personalities, some combination of genetics and life experience, similar to why some of us are extroverts and some of us are introverts. There is some great writing on other sorts of intellectual structures and ways of interacting with the world. Jerome Groopman and Pamela Hartzband have suggested that we all have a “medical mind,” an individual approach to weighing the risks and benefits of treatments. They use terms like “minimalists and maximalists” and “believers and doubters.” The political scientists J. Eric Oliver and Thomas J. Wood have suggested similar dichotomies, seeing us as aligned as either rationalists or intuitionists. I’ve tried to apply such contrasts to the way people behaved in the face of COVID.

Being mindful of one’s clinical set-point is important for doctors. A minimalist should not exclusively practice minimalist medicine, even if that is his default. By recognizing a set point, one can intentionally change her practice when appropriate. When patients meet a new doctor, both patient and doctor should be aware of each other’s philosophy. What kind of medicine does the doctor usually practice and what kind of care does the patient wish to receive? I can recall a few patients who left my care largely because they wanted more aggressive care – lower thresholds for preventative treatments and diagnostic testing. Had I recognized how important this approach to care was to them earlier, I could have worked to provide it and saved them the hassle of changing doctors. Of course, maybe they are best served by a physician more aligned with their treatment philosophy. Had we explored each of our “medical minds” early in our relationships, they may have established care with someone else sooner.

I believe a clinical set point is present before a doctor becomes a doctor. Like we differentiate into introverts or extroverts early in life, we identify as minimalists or maximalists as we progress through training. It is possible to practice in ways beyond this anchoring, but to do so takes insight and energy. When choosing a physician, besides considering the location of the practice, the smarts and experience of the doctor, the insurance plans accepted, the bedside manner, it is important to consider a doctor’s clinical set point.

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^[i] Aggressive is one of those words that have different connotations in our medical usage than it does in real life. Similar to deny, refuse, and heart failure, the term is pretty bland when used among doctors but can sound downright awful outside the clinic. Some of these even irk me inside the hospital.

^[ii] All of the people who responded unkindly to our Medical Conservatism article would support this sentence.