Uniqueness, not separateness. Separate and unique aren’t the same thing. By separate I mean independent but disconnected. Unique means independent AND connected.
Health 1.0 is the practice of medicine that’s independent and separated from a unified health care system. Health 2.0 looks to bring all the independent practices of medicine into that one unified system. But it’s okay with homogenizing them. In Health 3.0, practitioners care about the health care system as a unit. At the same time, they maintain their independence while moving about the system.
This is where my stance on evidence-based medicine comes into play. Health 3.0 is what I like to call evidence-informed — not evidence-ignorant (1.0) or evidence-enslaved (2.0).
We’ve seen, for example, that infection-control measures and validated checklists can successfully decrease avoidable errors and improve patient safety in operating rooms and intensive care units. And we can make clinical guidelines based on meta-analyses, where we carefully analyze individual studies together. These recommendations can guide us through situations in which the potential benefit of a recommended action clearly outweighs the potential harm. Those are good Health 2.0 moves.
But we have to recognize that there’s a big gray zone in evidence-based medicine. Where the potential benefit of an intervention isn’t that clear-cut for a particular situation. And where guidelines based on objective data can vary from one expert to the next. Why? Because they reflect the subjective values and preferences of the experts interpreting the data!
It’s in this gray zone that uniqueness thrives. Each clinical situation, in the moment, is unique. And each unique clinical situation is the interplay of the unique psychological, cultural, sociological, and spiritual aspects of both the patient and caregivers. The more uniquely the patient and caregivers relate to each other, and to the specific situation, the more effectively we navigate through the vast gray zone of medicine. Health 3.0 says that, in truth, this is the only way we SHOULD navigate through the gray zone.
I’ll go into more detail on the limitations of evidence-based medicine in future posts. But let’s make uniqueness in health care concrete with two examples.
In 2013, the American College of Cardiology and the American Heart Association put out new guidelines for treating a certain kind of heart attack called ST-elevation myocardial infarction (STEMI). The goal is to open up the blocked coronary artery, and there are two options. You can have an ER physician give intravenous fibrinolytics immediately to bust the clot blocking the artery. Or you can have a cardiologist thread a catheter into the artery and open it up with a balloon and stent, which is called percutaneous coronary intervention (PCI). According to the guidelines, PCI is favored over fibrinolytics if you can do PCI within 120 minutes of the onset of symptoms.
ER physician Amal Mattu calls this widely accepted blanket guideline into question. Here’s his unique clinical scenario: A 50-year-old man is visiting the emergency department at 11:00 P.M. to see his mother. He suddenly develops chest pain and is found on EKG to have a STEMI involving the anterior wall of the heart. Only five minutes have passed from symptom onset to diagnosis. What’s better for him: PCI or immediate infusion of the fibrinolytic?
Say the cardiologist on call assures the emergency department that the patient can expect PCI within the time recommended by the national guidelines. But you can’t mobilize the cardiac team to do this immediately. Is this still the right thing to do?
Mattu says, maybe not. Maybe this patient would be better served by receiving fibrinolytics immediately in the ER rather than letting him infarct heart muscle for up to two additional hours while awaiting PCI. Maybe strict adherence to fixed time windows in choosing PCI over fibrinolytics is a flawed, one-size-fits-all approach that can actually harm patients. Maybe factors such as infarction location, duration of symptoms, age, cardiac risk factors, and other circumstances unique to a given case should influence the clinical decision.
That’s a Health 3.0 attitude.
The other example involves me and my mother. I’ve written about her ordeal with a ruptured brain aneurysm before. After her surgery, she stayed in the ICU for a few weeks.
In Health 1.0, if a nurse were to insist that a doctor wash his hands before seeing a patient in the ICU, he might have told her to get lost. He may have seen it as an impingement on his autonomy. Independent, but disconnected.
But evidence has shown that infection control measures matter in the ICU (and outside). As patients are connected to each other in the ICU through their caregivers, everyone is potentially affected when handwashing measures break down. So in Health 2.0, it’s not cool to disrespect the interconnected system.
There’s one particularly nasty infection called C. difficile, which causes diarrhea. It tends to occur in patients on antibiotics and/or in the hospital — because it’s easy to pass it around. And for some patients who get it, it keeps coming back over and over again. Reason enough to wash your hands with soap and water before entering a patient’s room. Which this gastroenterologist son insisted every visitor to my mom’s room do.
At one point while in the ICU, my mom became constipated. Not surprising, as people don’t move around much in the ICU. One of the residents asked me if he could give her laxatives. I said fine. She was then given three laxatives at once. She promptly had diarrhea.
Someone then ordered her stool to be tested for C. difficile. Because she had diarrhea. Who cares if it was right after getting blasted with laxatives!
Apparently this particular hospital’s ICU policy was to initiate contact isolation precautions as soon as the test was ordered. So one box click in the electronic chart to order stool for C. difficile was enough to put up the neon-green contact isolation sign and roll out the infection control cart — complete with gloves, gowns, and the Fisher-Price throw-away stethoscope that’s only a touch more sensitive than your naked ears.
Notwithstanding the absurdity of this situation, I bit my tongue and obliged. I put the gloves and banana gown on while I stayed in the room with my mom. I didn’t want to be the stubborn Health 1.0 rebel. And I didn’t want to risk getting kicked out of the ICU if I didn’t comply.
I lasted about twelve hours. Then I threw the gloves and gown into the trash. By then I had connected with the nurse who had been taking such dear care of my mom. I explained to her why I thought testing her for C. difficile infection was silly. And I told her that I wanted my mom, who was still in a stupor at the time, to feel me stroking her arm with my bare hands. Not with nitrile gloves.
In that moment, we saw each other as the unique individuals we are. The word “doctor” comes from the Latin root “docere,” which means to teach. The word “nurse” comes from “nutrire,” which means to nurture. And the word “patient” is linked to “patiens,” meaning suffering.
Here we were, three people in the room. In that moment, our nurse respected me as a doctor (and as a concerned son), teaching about when testing for C. difficile is relevant — and when it isn’t. I respected her as a nurse, who was working so hard to nurture my mom back to health. And both doctor and nurse wanted to tend to the suffering of this patient.
We’re not hierarchical command units, as exists between doctor and nurse in Health 1.0. Nor are we generic “providers,” as Health 2.0 likes to lump us all under. In Health 3.0, we’re unique artisans with fluid roles that tailor themselves to a unique patient in a unique situation. Sometimes the nurse teaches, and sometimes the doctor nurtures. Sometimes the patient relieves suffering in the doctor and nurse! But we don’t operate with generic names, under rigid hierarchies, with fixed clinical rules.
Our nurse understood my perspective and sided with me.
We were practicing Health 3.0. Fully connected to the importance of infection control in an interconnected health care system. But applying independent thinking to this unique scenario.
This is the difference between separate and unique. Outwardly, separate and unique may look alike. But they come from very different perspectives. Uniqueness transcends and includes separateness.
In the same way, Health 3.0 sometimes looks outwardly like Health 1.0. But it’s not the same. It transcends Health 1.0 and Health 2.0. AND it includes them. Because neither Health 1.0 nor 2.0 is inherently bad. Both have their shadowy sides (so will Health 3.0, I might add). But the goal of Health 3.0 is to bridge 1.0 and 2.0 together, in a way that results in something emergent, something new in health care. Something better.
Early the next morning, I noticed the infection control police making their way to our nurse outside the glass doors of my mom’s room. They looked at me, gown-less and glove-less while the results of the stool test were still pending. They spoke to the nurse…she spoke to them…and they left.
Later that day, the stool test was confirmed to be negative for C. difficile. The contact isolation sign came down, and the infection control cart was rolled away. I asked our nurse what happened outside the room that morning. She said, with a wry smile, “They looked at you and wanted me to tell you that you should be wearing a gown and gloves while in the room. I told them, ‘He’s a gastroenterologist — if you want him to gown and glove up, walk in there and tell him yourselves.’ And then they left.”
In Health 3.0, we honor infection-control measures. We appreciate validated checklists. We stay abreast of the guidelines. But we practice medicine with context always to the moment at hand. We practice medicine as distinct practitioners with individual perspectives. We practice medicine with uniqueness.