Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, January 12, 2009

The More People Think They're Different...

One of the cries dominating the medical landscape is the false truism, "Everyone is different."

Patients use it as an excuse for why amoxicillin doesn't work for them so they need Biaxin (when what they have is a viral infection.) Or why they don't want to try an antidepressant; "How do you know what it's going to do to me?" Or why they need brand name Nexium instead of generic omeprazole over-the-counter. After all, Doctor, everyone is different.

Doctors use it as an excuse to avoid following guidelines. Don't get me wrong; there are a myriad of guidelines out there, promulgated for everything from preventing blood clots in hospitalized patients to managing ear wax, devised by all kinds of different bodies, using assorted methodologies. Certainly they don't always apply to every patient, but there are still far too many doctors ignoring what are now accepted treatment protocols for reasons that aren't terribly convincing. To do otherwise is to be accused of practicing "cookbook medicine." Still, there is a balance to be struck between individualizing therapy and re-inventing the wheel. Because we doctors should know that everyone is different.


We spent four years learning about the human body; its structure and function, how and why it malfunctions and the basic principles of how to fix it. This entire body (pardon the pun) of knowledge is predicated on the idea that the information is generalizable to all humans.

We understand that there are variations. Congenital defects produce an incredible variety of abnormal anatomy. One of the things that always strikes me upon first examining a newborn baby is that I can't take anything for granted anatomically. That's why we count fingers and toes, and examine the kid carefully from head to foot, while still wondering what abnormalities might lay beneath an otherwise perfect-appearing surface.

We also understand that there are genetic variations in metabolism, but they are far more specific and narrow-ranging than people seem to think. We are beginning to personalize anticoagulation by becoming aware of genetic differences in the response to warfarin. Eight percent of Caucasians are missing the gene for the enzyme that converts codeine to morphine; when they say "Codeine doesn't work for me," they're right. Of course there are countless others we know about, and undoubtedly many more yet undiscovered.

Yet the default assumption is that for medical purposes, people are pretty much the same.

This is a good thing. When someone comes in with a nausea, vomiting, fever and right lower quadrant pain, I usually don't have to worry that they have a herniated disk in their neck. If they're having crushing chest pain and tombstoning on EKG, you don't have to treat them for prostate cancer. Hell, if everyone were truly different, protocols for ACLS and CPR would be impossible. The reason they work is that one human body really does function pretty much the same as every other.

Certainly when patients have multiple problems, the permutations and combinations of their co-morbidities create the need for individualized treatments (though even then, it usually consists of tweaking the usual treatments for each problem.) This kind of complexity will always be part of both outpatient and inpatient medicine.

And people are different, even though their bodies all work the same. Everyone has two eyes, one nose and one mouth, and yet faces demonstrate infinite variety. No one likes being sick, although different people can approach the experience differently. (Even so, there are behavior patterns in illness that can be mighty predictable.) By and large, they tend to be more alike than different, preferring to be treated with dignity and caring. Some thrive on more touchy-feely attention; others prefer to be left alone in their suffering. Without a doubt, the art of medicine has more to do with discerning how patients want to be treated when ill than any actual difference in medical care provided.

But the bottom line is that people are basically the same, even though they're all different.

It's also intensely human to feel unique; special; one of a kind. At the same time, the great irony of at least 50% of my practice is reassuring people that they are normal. In this context, that translates to "not different," or "the same as everyone else." So I suppose the true art of medicine is making everyone feel as if they are different, ie, special and unique, while recognizing that everyone is fundamentally the same.


At Mon Jan 12, 10:09:00 AM, Blogger Sara said...

Nice post.

At Mon Jan 12, 12:31:00 PM, Blogger The Happy Hospitalist said...

I think you're different.
I have a tribute to you on my blog.
Enjoy. :)

At Mon Jan 12, 06:12:00 PM, Anonymous Anonymous said...

But I'm still special, right? :)

At Mon Jan 12, 08:56:00 PM, Anonymous Anonymous said...

hooray you said art of medicine!!! good for you

At Mon Jan 12, 11:34:00 PM, Anonymous Anonymous said...

Best post so far. Beautifully stated. I'm keeping this one.

At Tue Jan 13, 06:26:00 AM, Anonymous Anonymous said...

As a biochem student and a former pharma intern, I can appreciate generalizations in the human race. After all, if everyone were different, we would need 6 billion different drugs for one condition. Also, as a child of a certain saurian doctor, I appreciate being special.

At Tue Jan 13, 07:15:00 PM, Blogger Nurse K said...

Even though you touched on this, I think it's important to note that there are HUGE age and co-morbidity related differences in how a disease presents itself sometimes. Kids will compensate with asthma up to about 5 seconds before they respiratory arrest while adults will give you more warning. Elderly UTIs sometimes/oftentimes present with acute confusion. Children with severe hypothyroidism may just have stunted growth and no other symptoms while adults will lose their hair and get chunky. And on and on and on.

At Thu Jan 15, 02:27:00 AM, Blogger The Frog said...

If I see 100 polar bears, I can make a valid assumption about how polar bear 101 is going to look, act and behave.


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