AN

INTERNIST'S

PERSPECTIVE

Dr. RODRIGO CAVALCANTI

Dr. Rodrigo Cavalcanti is program director for the General Internal Medicine Subspecialty Training Program at the University Toronto and director of scholarship at the Centre for Excellence in Education and Practice (cEEP).An assistant professor of medicine at the University of Toronto, he holds anM.D. degree and an M.Sc. degree in clinical epidemiology, both from the University of Toronto, and a diploma in tropical medicine from the Gorgas Course (University of Alabama and Universidad Peruana Cayetano Heredia).

The offspring of a quebecois mother and a Brazilian father, Dr. Rodrigo Cavalcanti developed an interest in biology as a youth and was initially torn between studying plant or molecular biology. In time, however, he found pure science unsatisfying, because it lacked the human element. "Medicine," he says, "was biology with a human interaction." Drawn at first to neurology, he ultimately concluded that, too often, once the diagnosis was made, there "was not a lot to offer the patient. And I enjoyed the diagnostic process which is central to internal medicine."

He was first exposed to Dr. Herbert Ho Ping Kong as a second-year resident, in 1998. "His reputation preceded him," Cavalcanti says. "He uses the Socratic method, asking questions that make you think, not the standard questions, but questions that force you to think laterally I was impressed not only by his knowledge, but by his ability to connect with patients — with everyone really — on a human level and to prioritizing that connection."

Cavalcanti maintains that the long, three-decade run of hard, science-driven, evidence-based practice has reached the end of its course, as a paradigm. Increasingly, he says, organized medicine is recognizing the signal importance of the art of medicine, "the need to make a connection between two human beings, the healer and the patient." In fact, he points out, that art was originally embedded in the core elements of the evidence-based model.

"I like to remind people that its fundamental tenets were to make decisions informed by evidence, to interpret the quality of the evidence, and a third principle, which people forget, of incorporating patient preference." The original intent, which grew out of the work of David Sackett and others, was to have that conversation. "Research and statistics gives you a good idea about what the average experience will be," Cavalcanti says. "But the uncertainty will be greatest at the individual level. Even if you had perfect evidence, you have to make judgment calls."

The human factor became diminished, however, as physicians wrestled with the massive gaps in the quality of the scientific evidence. Most of the profession's energies were directed toward filling those gaps.

Among Cavalcanti's current research interests is the Grey Zone of diagnostic medicine. "We conceptualize diagnosis as firm, rule-based clear-boundary categories," he says. "But the reality is they are somewhat artificial labels that we assign to these biologic phenomena. Experienced clinicians get that. They've seen enough to know the label covers a large variation."

Recently, for example, a middle-aged woman presented with liver disease. Certain signs pointed to Budd-Chiari syndrome, a rare condition caused by hepatic blood clots. But other variables, including liver enzyme levels, did not fit the disease at all. In that situation, he says, you either need the clinical experience or a healthy dose of skepticism to challenge the weight of evidence. In the end, the patient turned out to have partial Budd-Chiari.

"So you have two Grey Zones, effectively," Cavalcanti observes.

"The first is what is the proper label to attach to this condition? And then you have the suspicion of a clear label, but doubt and uncertainty. Western medicine is built on the foundation of diagnosis informing prognosis and treatment. But sometimes there is no clear diagnosis, just a patient with symptoms and a need for care. That's the art of medicine, recognizing that the ultimate purpose of medicine is to comfort and treat and help them cope with their experience. It's managing uncertainty because you won't always get the answer. In that situation, you devise a plan of action that seems reasonable, but you must come clean about the limits of knowledge and where your thinking is going. I tell patients, 'Here's what we know and here's what we don't know and here's where we can possibly go together."'

Many young medical students, he concedes, are more interested in acquiring raw medical knowledge than in the niceties and nuances of the bedside art. "The science is important, but I think educators need to communicate that there's more to it than that, and communicate it early on."

Cavalcanti says he detects among the newer generation of graduates a shift away from the embrace of medical science as the only thing. Part of that is the result of choosing more well-rounded candidates for med school. Narrative medicine — recognition that the patient's personal story carries as much weight as the more objective classification and recommendation for treatment — is also gaining traction in a few major American medical schools, but, he adds, "I think there's still a lot to be done."

"During patient encounters, many students are so preoccupied with remembering everything they are supposed to remember that they have trouble being open about what they don't know."

"And the amount of information is so overwhelming, it's easy to default on thinking on the knowledge side of things."

And although modern technology has made medical information more readily accessible, so that it may no longer be necessary to have to retain it all, the reality is that "you still have to internalize and organize that knowledge," he says. Exams usually have right or wrong answers. In the real world of medicine, Cavalcanti says, patients are more complicated. "There, the challenge is to apply your knowledge in search of the best answer and to acquire more knowledge. For example, if you find fluid in the patient's abdomen, you need to know where else to look. I have to know what I know in order to ask the right questions."

Even then, because any specific piece of information likely has at least a degree of uncertainty, "You need to be able to integrate your other knowledge to help make the diagnosis," Cavalcanti says.

Perceiving "what is really there" is an art best developed over time. "It takes years. When I teach students how to palpate the heart, I tell them, "This is a marathon. It will take you four years or longer to learn to do this properly. Today is the first step in the marathon."

An ETHICIT'S PERSPECTIVE

Dr. PETER SINGER

Peter Singer studied internal medicine at University of Toronto, medical ethics at University of Chicago, public health at Tale University and management at Harvard Business School. Since May 2010, he has been ceo of Grand Challenges Canada, a federally funded project aimed at improving lives in low- and middle-income societies through integrative scientific, health-related and business initiatives. A director at the Sandra Rotman Centre, University Health Network and University of Toronto, Singer — an Order of Canada recipient—is also a professor of medicine at University of Toronto, and the foreign secretary of the Canadian Academy of Health Science. He has served as an adviser to the Bill &"Melinda Gates Foundation, the UN. Secretary General's office, the government of Canada, BioVeda China Fund and several African governments on global health. With Dr.Abdallah Daar, he co-authored The Grandest Challenge: TakingLife-Saving Science from Lab to Village.

Peter Singer's interest in medical ethics — and ethics as a portal into the art of medicine — began in high school, in the late 1970s. Long before bioethics was even a blip on the profession's radar screen, a grade 13 biology teacher assigned him a paper on the ethics of human subjects research. It immediately galvanized his interest. But his real epiphany came during his years as an intern at Toronto Western Hospital.

"I was caring for a patient on the hematology ward and she had widespread cervical cancer and was dying," he recalls. "And I came to realize that, while we could rattle off 15 causes why her potassium or phosphorus levels were low or high, when it came time to decide whether we would resuscitate her, we would scribble it in pencil on the nursing notes and then rub it out afterwards. There was no honest conversation, either with her or her family or among the staff. I thought we could bring more rigour to that kind of situation."

Among his most memorable teachers at Western was Herbert Ho Ping Kong. HPK was considered a paradigm of the old school master of the art of medicine, "both in the way he taught students, at the bedside and on rounds, and in respect to physical exam. Herbert was particularly good at elements of problem solving, taking cognate factoids and turning them into a diagnosis and plan, the judgmental part. There was a lot of lateral thinking. He would always examine things no one else would examine, such as the Sister Mary Joseph's Nodule, a lymph node close to the belly button that, when bulging, maybe a sentinel of abdominal cancer. Or he'd always be listening for abdominal bruits, which no one else did."

In a more formal classroom setting, to test the class's knowledge of symptoms, HPK would demonstrate a patient's gait, or ask a student to emulate it, making education more interactive. A favoured gambit was a form of paraphasia, in which he would "say something seemingly irrelevant or tangential. It might be drawn from the day's weather forecast or from a current event and, by the end of the process, the search for the diagnosis of the case under discussion, you'd understand that he had provided a clue to the right answer." Some of that, Singer suspects, was derived from HPK's Jesuitical training and thinking. And his playfulness, he adds, may have spring from the joie de vivre embedded in Jamaica's cultural context.

In general, Ho Ping Kong was, for Singer, a major resource for the less common illnesses and syndromes. "He wasn't the evidence based person who covered the more common things you saw 90 percent of the time; he was the guy who covered the thousand things you might see 10 percent of the time, the rare and the exotic — dengue or break-bone fever, porphyrias, malaria."

Singer's work ultimately went a different direction—bioethics.

What is framed at the surface of the ethics issue, he says, has a lot to do with the prevailing narrative of people's lives. "An individual's previous contextualized narrative experiences influences a lot of their responses to health care situations."

The art of medicine is a term that encompasses a broad range of professional skills — from taking the patient's history and conducting the physical exam, to the bedside diagnosis and plan of action, to the broader sense of caring. One of the best quotes on the subject, Singer suggests, is American clinician Francis Peabody's dictum, "The secret of the care of the patient is in caring for the patient."

Peabody's full quote, from a 1927 paper, provides a deeper context.

Disease in man is never exactly the same as disease in an experimental animal, for in man the disease at once affects and is affected by what we call the emotional life. Thus, the physician who attempts to take care of a patient while he neglects this factor is as unscientific as the investigator who neglects to control all the conditions that may affect his experiment. The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is caring for the patient.

Singer also cites a landmark 1978 journal article by American bioethicist Edmund Pellegrino on "Ethics and the Moment of Clinical Truth" — the moment being that point at which the physician must make a clinical decision and choose what should be done from the menu of things that could be done.

After earning his medical degree in Toronto, Singer studied under two giants in the field, Mark Siegler, director of the University of Chicago's MacLean Center for Clinical Medical Ethics, and with Alvan Feinstein at Yale. In one journal article, Siegler argued that the art of medicine requires knowledge of many ethical issues, including informed consent, truth-telling, confidentiality, end-of-life care, pain relief and patient rights. "Medicine, even at its most technical and scientific," he wrote, "is an encounter between human beings, and the physician's work of diagnosing disease, offering advice and providing treatment is embedded in a moral context."

Feinstein, in his work on clinimetrics, maintained that medicine had become too hardened and too scientific. Blood potassium levels, to cite one example, were much easier to measure than the degree of pain. That professional bias, Singer contends — the dominance of hard-side data over soft—is at least as true today as it was when Feinstein wrote, or when Abraham Flexner published his groundbreaking report on medical education in America in 1910.

But the art of medicine isn't only about BigThink moral issues. Sometimes, Singer says, it's about what might otherwise seem to be the most inconsequential aspects, of practice. "A doctor enters a hospital room to take a patient's blood pressure and other readings. The patient, in bed, is thirsty, and there's a beaker of water and an empty glass on the portable bed table. But he can't reach it or pour it himself. Well, the art of medicine here is taking the beaker and filling the glass and handing it to- the patient, even if you are there to do something else. It sounds trivial, but is actually archetypal."

In terms of end-of-life care, he says, "It really came down to three questions to be asked at the bedside. Is the patient in pain or experiencing other symptoms) Have they prepared with family for the end of life? And are there wishes regarding life-sustaining treatment known?"

Singer believes that the easier part of these skills—more effective communication and sensitivity— can and are being taught to medical students. "The harder part is teaching leadership and judgment. That too can be taught but to what degree?" Empathy is an important factor: "The ability to put oneself in the shoes of the patient, separated from family and children, dealing with disease and death, and translating that empathy into a higher standard of care."

Does the art of medicine apply to Singer's current work in social innovation? He's convinced that it does. By the summer of 2013, his Grand Challenges Canada had funded 400 separate projects, many of them just beginning to deliver results. One of them involved working with an NGO in Nigeria around women's and children's health issues. Traditionally, he says, the messages delivered at Friday sermons in mosques implicitly or explicitly discouraged women from seeking medical care for themselves and their children. The NGO intervention is aimed at using more educated imams to teach conservative imams about the importance of vaccination and other aspects of neonatal care. The evaluations so far are encouraging.

More broadly, it is clear that the same questions that determine attendance at health clinics in the developed world — do women feel safe and comfortable? — are critical determinants of attendance in the developing world as well. "It's exactly what you would expect," Singer says, "but we tend not to think about the interpersonal aspects of care. And they are critical, because the goal is to encourage women to come to these facilities for care. And they need to feel comfortable." Some of this, he says, is the result of "the callousness of physicians and other health workers, mistreating women, often poorer women." Cultural mores are "hard to change quickly, but they can be changed with time."

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