Will the art of medicine be lost in the sea of guidelines?

I don’t like doctors!

It was always the same with Ronald. After years of absence, he would appear at my doorstep with some particular problem that had progressed to alarming proportions. Once, it was the abscess that seemed to swallow up his whole back. The next time, it was a hernia that had grown to the size of a grapefruit hanging out of his undergarments. But today was different. In fact, when I asked what was wrong, he told me that he was feeling fine.

Doc, I had a funny dream last night. At least I think it was a dream.

The night before, Ronald woke up to a gentle nudging on his left arm. When his eyes opened, he almost fell to the floor. His teenage daughter, who died decades earlier, was standing above him. She called out to him like she had when she was alive.

Papa … Papa, you’re not breathing right. Go to the doctor.

***

Ronald tried to convince himself that it was just a dream. He tried to ignore his daughter’s words, but her voice paralyzed him. He walked in to my office cautiously as if embarrassed by an urge that he couldn’t explain.

While I was skeptical to say the least, there was something about Ronald’s story that moved me. There is a time when clinicians drop algorithms and guidelines and work from the gut.

I felt it would be reasonable to obtain basic lab tests and a chest x-ray. I also informed him that given the lack of indications, Medicare wouldn’t pay for any of it. He took my referrals and left the office. I suspected that he would eventually think better, and decide not to go for testing.

I was wrong.

***

Three years later Ronald is disease free. The lung cancer found coincidentally on x-ray was early stage, and was surgically cured. The thoracic surgeon marvels that if Ronald had waited any longer, he wouldn’t be alive today.

Ronald did end up paying a few extra hundred dollars for the tests, but he now feels it was money well worth spending.

And I am left to wonder about the future of medicine. As guideline based care pervades health care reform, I fear that something will be inexplicably lost.

You may call it divine intervention. It might be described as having a hunch. Or one could lay this gift on the doorstep of lady luck.

But if you ask me, I call it something completely different.

The art of medicine.

-Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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