Wednesday, November 20, 2013
Non-Judgementalism Is Not An Ethic
Appearing non-judgemental is necessary but it is not an ethic or moral code. It is a superficial communication device and strategy to get the patient to open up and engage. It plays an essential role in communication but it is nothing more than that, a superficial strategy.
That is where the non-judgementalism stops except in terms of dealing with a clinician's own prejudices in providing the highest quality healthcare to all.
From there on in, non-judgementalism is a dangerous lack of clinical judgement. It can put the patient's life at serious risk. Putting the raw data of what the patient says into diagnostic and therapeutic algorithms can produce the wrong diagnosis and treatment.
In the earlier blog, A Tragedy of Time Limited Medicine (http://clinicalarts.blogspot.mx/2013/11/a-tragedy-of-time-limited-medicine.html), the one subtle clue, right at the start that would have stopped this terrible human tragedy from happening, would have been if the family doctors had identified the patient's stoicism that made her under-report the pain from the day before. It was a series of highly objective judgements about her and the initial history she gave that led to her life being saved from the rack and ruin that it had descended into.
In these days of the diagnostic protocols of Evidence Based Medicine, one of the primary reasons that a trained, experienced human doctor must be included in the loop is to objectivise the data with their clinical acumen. Just think of a patient who has fallen into and is trapped in the sick role. Think of the psychology patient banging the table in denial of their repressed anger. On the other hand, the calm, contemplative person is the most likely to admit to the possibility when it is least true of them.
Validated psychological questionnaires really have to trick patients into indirectly revealing the truth about themselves. People answer what they wish to be true of themselves and what they wish to portray to others. It is often the exact opposite of the reality about themselves that they are trying to cover up.
Clinical judgement is all about assessing a patient's personality and how it colours and affects their history telling and reporting of symptoms.
A fundamental part of the incredible art of diagnosis by careful observation described in the last blog, Arts 1 Science 0 (http://clinicalarts.blogspot.mx/2013/11/arts-1-science-0.html), is that the non-verbal communication of the patient when they are not aware that they are being observed can be more enlightening than formal history taking and examination. It is a means of judging patients beyond their words. The reactions of the body to pain do not lie. This is the very reason that doctors place so much emphasis on any physical examination of the patient.
Clinical judgement is an essential clinical art. We all do it all the time. There is no point in denying it. All clinicians know it but none dare say it. Few dare even think it because society does not like it.
Did we, the medical profession, invent the term 'Clinical Acumen' because the customer does not like the phrase 'Clinical Judgement'? Acumen is judgement. It is subjective judgement by a professional trained and experienced in the incredibly difficult task of making their own subjectivity objective. One of the greatest and most difficult of all clinical skills is the extraction of reliable data from the raw subjective data that the clinician is presented with constantly.
There is no point in denying it. This is a skill that needs to be deliberately and consciously refined and honed. Those that do not admit to being judgemental and wish to see themselves as non-judgemental will resist developing that fundamental skill.
It is a really difficult skill that takes a lot of conscious work. It is too difficult for empiricial scientists. They simply ignore the existence of the subjective evidence of human reports of perception as untrustworthy. Doctors cannot do that. They do not have that luxury. They must deal with subjective evidence, their own and the patient's, and use their clinical acumen to extract the grain of objectivity beneath the colouration and interpretation.
Where would medicine be if it completely ignored the patients' subjective reports of symptoms, especially pain? That is exactly what empirical science would do.
Yes, I am ranting. I am standing up for the rights of doctors to make clinical judgements for the good of their patients whether they like it or not. This is one of the primary roles of the human doctor in modern medicine. It is one of the roles that cannot be fulfilled by a machine.
This is about the human clinician's role in substantially improving hard health outcomes.
Or we could take the route of the empirical scientist and dehumanise medicine further without making a fuss, drawing attention or offending society. We could quietly devalue the patient's history and the time that they have to speak with the human clinician because we know that the tests and machines will give us objective answers that are so much easier to deal with than what the patient has to say.