Diagnosis and Treatment

Here is an interesting concept that you have perhaps not heard before....

It is to divide modern medicine in two. It is to divide the medical mind in two and disassociate the usual connection between modern medicine as a diagnostic system and modern medicine as a therapeutic system.

The Diagnostic System

Although I write on the artistic side of medicine, I do not undervalue what scientific medicine has done for health and humanity. I write about the arts because nobody else does and I believe that the two are entirely complimentary to one another. They have a synergistic relationship and are disempowered one without the other.

In fact, I am enamoured and enthralled with medical science and even its technology. I have a thirst for such knowledge and power. I am the one that other doctors come to when they have forgotten something from the medical school sciences or to learn about understand something new in medical science. I am considered exceptional in my applied science, especially my ability to integrate the workings and interactions of the various organs, systems and pahrmaceuticals from first principles. I know and love medical science. I just keep it in perspective.

I am still stunned and amazed at the wonders of scientific medicine and knowledge especially when it comes to modern medicine's diagnostic understanding of the human body and the classification and description of diseases. I am absolutely awestruck at this system based on physiology, biochemistry and pathology.

The modern medical diagnostic system is just peerless and beyond comparison. There is absolutely no competition. It is simply always the best. 

Modern western medicine is the first port of call for any patient suspecting a physical illness unless their symptoms really are trivial and short lived. The only exception I can make there is muscle strain and back pain but physiotherapists, chiropracters and osteopaths work along similar health models and have close contact with the medical profession if they have any doubts.

Every physical health problem needs a medical diagnosis or lack of it. With the latter non-diagnosis, at least the patient knows there is nothing seriously wrong.

And that is where the mental break comes in. It is time to stop. The knee jerk reaction that medical diagnosis leads to medical therapy is not necessary.

The fact that a patient needs medical diagnosis does not mean that they necessarily need medical treatment. Although the western medical diagnostic system has no competition or viable alternative, the same is not true of the therapeutic side of modern western medicine.

The Therapeutic System

I have the greatest respect and perhaps even love for the therapeutic system of modern medicine but I only value it for what it is. Its pharmaceuticals and surgery are by far the most powerful system of intervention available. 

They are not subtle. They are a sledgehammer. They are perfect to bring down a wall but not to crack a nut when that is all that is required. Whether it is pharmaceuticals or surgery, they interfere with a delicately balanced organism. In general, that gives them the worst side effect profile of any available therapy.

Medical education, training and a license is essentially to allow the clinician to make difficult risk/benefit analyses on a case by case basis for therapies that could be dangerous in uneducated, untrained and unlicensed hands. All surgery obviously has its risks but pharmaceutical licensing does not mean that a product is safe. The situation is quite the reverse. The decision to license a pharmaceutical is not primarily based on its effectiveness but on its potentially serious side-effects and contra-indications. Any substance that is believed to have minimal risks to its wanton use by the public is classed as a food or supplement and many foods and supplements have clinically proven health benefits. 

Fundamentally, modern medical therapy is last line therapy not first line therapy. Where life and limb are in proximal danger, it is a no brainer because nothing is as powerful and the risk benefit profile is favourable. However, when they are not, the effect/side effect equation usually favours another option,

Lifestyle measures are the first option. Improved diet and exercise always have a positive, global influence on both objective and subjective health in addition to specific health benefits. They are also empowering and repel the transfer of power and responsibility for an individual's health to the medical profession, reducing the patient driven culture of over-medicalisation and dependency which both have significant health costs.

In the next tier come ancillary medical specialties such as physiotherapy and evidence based psychology. There are also a few evidence based alternative therapies, such as acupuncture for pain control and a few other medical conditions. 

In the last category, which is reserved only for subjective symptomatic relief and minor self-limiting illness, could all be placed under the heading of The Great Healer, Time. Medical intervention carries little benefit in such situations but it can have serious side-effects. The risk benefit equation could be against it compared even to therapies that fail to show more than placebo effect but that have no significant side effects.

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. 

Arts 1 Science 0

There are just some diagnoses in medicine that science cannot make. All that is left is the clinician's human acumen and skills. This is a life saving story of just such an experience....

The tap on the door was unexpected. So was the condition of the patient without an appointment as she half collapsed through the door supported by her partner.

I was sitting chatting to a friend, a general surgeon of the highest caliber, congratulating him on his acceptance into a top international cardiothoracic residency. Oh, he was good. He was the best.... but only at modern style medicine. I had studied the arts of medicine under various masters with infeasible who had taught me the keys to those arts and how to learn them.

I already knew what was wrong with her. I had seen it is her fevered face and in the way that she painfully moved. It was a reasonably common surgical problem, everyday stuff for him.

He was on his home ground. He had more experience. All I had was a year of surgery a decade earlier before pursuing a career in family medicine. He really should have won hands down.

So I challenged him, his science against my arts.

He took a brief history. Her vague lower abdominal pain with right loin pain and fever started two weeks ago and progressively got worse. During this time, she had seen five specialists from both gynaecology and surgery. Each had ordered blood tests and scans but none of them could offer a diagnosis. None of them could even decide if it was an intestinal, gynaecological or kidney infection. Each had just given her more antibiotics blindly. Her pain had just got worse. Now she was vomiting all over the place. Her general condition had deteriorated dangerously.

His examination was no help. Vague diffuse lower abdominal tenderness and tenderness over the right kidney. He could not make the diagnosis. He was unsure what system was infected. He would repeat the bloods and scans.

By now her blood results would have been frightening. She was entering septic shock and multisystems failure. But the blood tests would only show that she had severe bacterial infection, not its source. The scans would still pick up nothing specific.

It is all so easy when you already know the diagnosis and the history and diagnosis are only to prove that first impression. I teased out the history as a textbook example of a slowly exacerbating lower abdominal pain and low grade fever with minor loss of appetite and nausea. A sudden increase in pain and fever came with the onset of back pain which slowly spread upwards.

He had had his forehead slapping moment by now. The patient had appendicitis, the other sort of appendicitis, and all the doctors had missed. It was the rarer form of appendicitis, the one that haunts surgeons. In 10% of cases, the appendix does not come forwards as it does in 90% of cases to give that area of well defined tenderness on the front of the abdomen but flops back behind the large bowel. It does not cause specific tenderness, even in the back because it is hidden behind the muscles and pelvis.

Without treatment, her appendix had formed an abscess which had ruptured and filled the anatomical gutter behind the large bowel on the right with pus. And that is exactly what the textbooks say happens.

We sent her to the surgeon on duty with the history told my way and the diagnosis. She immediately had the surgery she needed two weeks earlier but spent a few days in high dependency. She recovered fully, except for the extra abdominal scarring from an extended incision, drains and the bill. Regardless of the fact that her life had been saved in the end, she was not a satisfied customer. She had to be talked out of a pointless attempt to sue before some predatory lawyer took over. She could not understand that the medicolegal system is not about getting the right diagnosis. It is about being average. It is about ordering scientific tests and proof. All the doctors who had missed the diagnosis had dotted every medicolegal I and crossed all the Ts.

After my vehemently ranting about the ridiculous legal system culturally dumbing down medical practices to dangerous levels, we finally agreed that the law was an ass, which I suppose makes it an ass's ass.

It really was a textbook case. The only problem is that a many other infections can cause superficially similar symptoms and the differences in their history are only in the finest details. You need to already have the highest suspicion of this diagnosis to clarify those details.

And examination just does not help. Blood teasts do not tell you where the infection is. Nor do x-rays or ultrasound scans. Bowel gas gets in the way of the abscess and once it is ruptured, the thick viscous pus has a similar density to normal and blends in with it. CT and MRI have a similar problem making it easy to miss.

This is one bitch of a diagnosis. It is notorious. It is feared. When surgeons operate on a patient for appendicitis and find no appendicitis, it is through fear of this diagnosis that can only really be diagnosed with the most intuitive art. They have a 100% hit rate with normal appendicitis.

I have a 100% hit rate with the difficult form of appendicitis: zero false positives and zero false negatives. It is not just experience otherwise my more experienced colleague would have got the diagnosis, not me. It was not the vague phrase of experience, 'I have seen it before'. The other cases I had seen were early and unruptured. I had only heard this scenario described. I had never seen a case like this.

No, I was taught the art of objectively assessing what a body is feeling from facial expressions, tone of voice and the way that it moves under non-exam conditions when the patient does not think anybody is looking. Hell! The standard medical examination hardly asks the patient to move at all.

Perhaps I was not taught this art of astute observation. I experienced it. Somebody showed me that it was possible. Somebody showed me its power. They opened my mind and spurred me on to learn such levels of clinical acumen through experience. They showed me that the extra dedication that it would take would pay off. It has saved patient's lives.

This person was not a doctor. She was not even a nurse. She was an untrained nursing auxillary but she had worked on the same ward for nearly two decades.

At first I thought it was a joke on a young doctor to teach me a little respect for the nursing staff of all levels. I was told she could diagnose a patient just from one look at their face as they were wheeled past her. I was warned never to disagree with her diagnosis. If ever I did not know a diagnosis, I should ask her.

It stopped being a joke when I witnessed the hospital's senior surgeon ask for her opinion when he was undecided between two diagnoses and he took the patient to surgery on her word. She was right of course, as ever.

The only exaggeration had perhaps been her ability to diagnoses the patient with a single glance. She also greeted them. More than that, she was always the one transfering the patient from the trolley to the bed, watching their every move like a hawk.

Despite the fact that it was not in my job description, that is what I did. I mucked in with the most mundane tasks of the nurses and paid acute attention to the patients' every gesture and move when they thought they were not being observed. I did not analyse or categorise. I cannot give words or descriptions to what I learned. I took complete four sense impressions, including with my nose (not taste, thank you very much). And I correlated these sensations with the textbook descriptions of the pathology going on behind their diagnosis. I imagined and felt how different diagnoses felt.

And that is how I learned to diagnose patients at a glance. It is why my surgical friend, qualified and experienced as he was, could not compete with my clinical acumen. He had stuck to his job description and the hierarchy of the ward and so had the nurses he had worked with. Despite all their experience and that they are the only ones who really see patients move naturally, they were not allowed to use their invaluable perceptions and suggest diagnoses. More than anything, he had never had the five minute mentor that I had been gifted with to show him just what is possible with careful observation under non-exam conditions.

I thank this great mentor from the depths of my heart. Many of my patients owe her their gratitude. Some of them owe her their life.

A Tragedy of Time Limited Medicine

Once upon a time, not so long ago or far away, there was a lovely little princess and her parents loved her very much. They brought her up beautifully to be educated, well-mannered and beautifully spoken. And they were all so happy. Even when she became a teenager, she was a perfectly adorable child. They were a perfect happy family.

Then the princess got abdominal and back pain. The family did not want to make a fuss. They were a stoical family who did not want to bother the doctor unnecessarily. So they waited until the next day to tell the doctor of the pain after it had gone.

In her two minutes of medical time, the lovely princess had a choice. Should she mention the abdominal pain first or the back pain. Her parents had diagnosed that her problem was her poorly little tummy so that is what she told the doctor. The doctor did as he should and asked her questions about her tummy and examined it like any good doctor should. Of course, there was nothing to find because the pain had already gone.

A diagnosis of Irritable Bowel Syndrome was made, which was the most probable diagnosis from a two minute history and examination. She was given some peppermint capsules and other antispasmodics. 

But they did not work. The patient returned three more times, always after the pain had gone because she was a very polite little princess. And every time, the story was the same. The doctor told her parents that there was nothing terribly wrong with her and there was nothing to worry about. So when she complained of this pain that modern medicine was not relieving, they ignored her.

It was only her friends, and the worst of them, that listened, sympathised and took her pain seriously. First, they recommended marijuana but that did not help much. So she worked her way up to heroin for her pain and that worked! But how does a teenage girl pay for her street heroin?

She had nothing to sell but her body. She became a prostitute. So her parents, based on the doctors' advice that there was nothing really wrong with her, kicked their princess turned drug using prostitute out of house and home.

She kept seeking medical attention, turning up to accident and emergency in the waning hope that the doctors could help her. Low abdominal pain. Prostitute. Heroin abuser. Send her to gynaecology. Low abdominal pain. Prostitute. Probably a sexually-transmitted pelvic infection. Heroin addict. Probably just putting on the pain and looking for a free hit. Do not give strong pain relief. Take some swabs. Return to outpatients in a few weeks for the results.

She never came back to find the results were negative and there was no sign of infection. She had all but given up on the medical profession. Somewhere along the line, a doctor had told her that it was almost impossible to diagnose the cause of the pain after it had gone and that the only chance of helping her was to see her when she had the pain. She deduced that there was no point turning up to a routine out-patient appointment.

Then one fine day, after about twenty of these admissions and seeing twice that many doctors, all of whom had done the right thing according to the cost-effective probability medicine that they are forced to follow, came across a doctor who made a subjective judgement and ran with it. He ignored standard practice and spent time with the patient to unravel the whole of their history. He was the first doctor to hear how and why she had fallen into that life. He was the first doctor to hear about the back pain.

It was a complex subjective impression. He saw that lovely princess behind the superficial words of this life that she had been forced into. Her voice and attitudes were not street wise and cunning but spoken of childish innocence. This life was not hers. Far from exaggerated, her pain was understated. Her body reacted more than her face or words. And there was something in the way that she moved....

Her luck was to find a doctor who was new to gynaecology. He was not yet indoctrinated to thinking like a gynaecologist. He was still thinking like a surgeon and urologist. He had seen her movements before. Patients with renal colic move like that. On examination, it was her kidney that was tender. That was the source of her pain.

No previous doctor had found time to sit her up and examine her back. It is not standard practice for patients complaining of abdominal pain.

I offered her the correct treatment for her new diagnosis, the strong pain relief that she had been denied, but explained that t could impede her diagnosis by the urologist I was sending her to. She declined. That was the type of person she was. 

Her face was alight with a hope that had been so long absent. 

A plain x-ray was at first confusing. There was nothing in the textbooks like this. Her ureters, the tubes between the kidneys and bladder, were visible. Their walls were three millimetres thick parallel lines when they should be invisible. The muscles should be so fine and thread-like that they are too small to see. 

There is only one thing that can do that it a muscle and it is long-term, stenuous exercise similar to a body builder going to a gym. She had been suffering severe renal colic on a daily basis since these symptoms started five years earlier. It was the only viable theory. It is not in the textbooks because this cannot happen. It never happens. Renal colic is one of the worst five pains humanly imaginable alongside heart attacks, labour, sciatica and a dislocated shoulder. An x-ray finding like this has never been recorded because the pain associated with it would be humanly intolerable. Something would have been done long before it got to this.

The admitting urologist would not believe me until he saw the x-rays himself. We were both sickened by the ordeal of pain that she had gone through. She had been through the worst pain imaginable for five years and nobody had helped her. The medical profession had failed her.

Every fairy story has a moral and lesson. First amongst the many lessons here is that when the history taking process is abbreviated, a practice that has been forced upon doctors culturally by politicians, accountants and administrators, the patient is effectively forced to self-diagnose and the patient decides which protocol they should be put into rather than the doctor. For that decision to be made by an informed and experienced medical professional, they need time to ask everything and examine everything.

The time constraints that are externally imposed on doctors forced a thirteen year old girl to choose between prioritising her abdominal pain or her back pain. Nobody was consciously aware of this or the terrible consequences of getting that decision wrong. She would be internally tortured beyond imagination by her own body for five years. Her beautiful life and future would be devastated. She would be forced into heroin use and prostitution because she got that innocent, uninformed and apparently innocuous decision wrong.

She never wanted that decision. She did not know what was wrong with her. She went to the doctor hoping and expecting an informed, trained and experienced professional to make that decision for her.

Standard  practice has replaced best practice on the basis of probability calculation in cost-effective analyses. Ninety percent reliability in as short a time possible is good enough for a bean counter despite the fact that more time means better diagnosis in the life and death world of health. This kind of probability medicine is accountants playing Russian roulette with health.

There are also important warnings about hyper-specialisation and the fragmentation of modern medicine. The evidence proves that modern specialists are exceptional at looking after their own part of the body. What nobody ever talks about, thinks about or dares investigate is when the patient gets into the wrong protocol and sees the wrong specialist. Medical care is usually exemplary when is in the right specialty but care is haphazard and flawed outside that specialty. Almost every medical tragedy I have come across has happened when the patient is in the wrong diagnostic protocol and specialty.

Fortunately, this real life fairy tale appears to have had a happy ending but I do not know what came next. My part in her care was over. She was finally in the best hands, the urological hands that she should always have been in. 

Still, two decades later I remember this case as if it were yesterday. The memory of going beyond the call of duty burns strong. The good that it did, the life that it saved, forever affected my medical practice. And the human satisfaction of these exceptional cases where you are a human clinician outperform standard practice, other doctors and the machines is what makes this job worth doing. It is the reward in itself for the effort and the only one worth having. It is reward beyond measure that too many doctors in the modern world are denied by imposed standards.

I would have loved to have known the ending but again, time pressures with other patients made that impossible. I doubt if any doctor had the time to even consider the important story, the huma story behind the disease. They will have cured her and never seen her again. They will never know if she managed to put this behind her and rebuilt her life as it should always have been.

As I reminisce, I hope it is true in my mind. My heart and soul know it is true. They saw her. They knew her instantly. Her essence shone through. That is what made me distrust the superficial facts. It is what makes me know that she had the inner strength to live the life that she should always have lived.

Magical History Taking

An Esoteric Art in Taking A History

One of the most esoteric arts of taking a perfect medical history is to subtly move the patient’s consciousness to that tranquil and highly perceptive level. In this state, they will tell you exactly what you need to hear to make the correct diagnosis. They will know and tell you what is relevant to the diagnosis even when it appears unconnected or an irrelevant detail. Suddenly they will forget all of the details that they previously thought were important.

I have seen a true master of the clinical arts use this on a patient to suddenly be able to think clearly and know their own diagnosis. Without the doctor saying anything, the patient had been guided to a realisation of inner knowledge. Suddenly, they knew exactly what was wrong with them and what to do about it.

After a short silence, the patient stood up and apologised for wasting the doctor’s time. They admitted that there was nothing really wrong with them that a healthy life of a careful diet, exercise and avoiding certain foods, activities and stresses would not cure. They knew exactly what to do and they left.

The master smiled his approval. He also approved of the fact that I was left open-mouthed and agog. He winked cheekily.

He knew that at some level, I had comprehended what he had just done. A part of me had understood what he had just done. One day I might even learn to do it myself.

It takes patient participation in the decision making process and their empowerment to another, inconceivable level. And this master of the clinical arts had hardly guided the patient at all in words. He had let the patient do most of the talking. He had let the patient talk themselves out and into catharsis and then to talk themselves into a deep and positive realisation.

A mundane version of this can be practiced by carefully guiding a patient to self-realisation through the guidance of specific questions that makes the patient think anew about themselves, their lives and their health. It is a process of questioning that leads to self-questioning, careful clarity of thought and answers. Fragments of missing knowledge are filled in and the patient is asked to think about how that new understanding rearranges their knowledge and suggests new explanations and solutions.

It is the same as an educationalist’s use of the independent learning process. In modern workshops, it is called ‘ownership of knowledge’. The process of history taking becomes self-diagnostic. It becomes therapeutic. When the patient has come to their own understanding and taken ownership of it, they do not resist change as they do if they are ordered to do something that they do not really understand. They change willingly, which is becoming increasingly important in health as the importance of lifestyle, diet and exercise become more evident.

This process is a major ethical concern in medicine in terms of the modern psychological understanding and ethics of consultation dynamics. It transfers power and responsibility back to the patient.

Some clinicians just seem to have knack or gift for it. It just seems to naturally happen in their presence.

Some clinicians have this powerful gift without being taught it or knowing how they did it. However, it can be taught and learned by any clinician if it is understood. In part, it comes as an inevitable response to practicing deliberate guidance of the patient towards their own diagnosis. Eventually, the miracle happens.

It also requires that the doctor wants the patient to make their own diagnosis, which contradicts usual, mundane medical teaching. It is the doctor’s responsibility to make the diagnosis not the patient’s. The doctor is supposed to be the diagnostic genius and not the patient.

That belief is the socially acceptable, even desirable tip of the iceberg of medical dependency. The danger below the water line is powerlessness and a lack of responsibility in lifestyle with over-medicalisation. The deepest danger is the sick role where patients use their symptoms and diagnoses to attract attention and sympathy. They do not want to let go of their symptoms and diagnoses and get better. They block that process at a subconscious level.

Patient participation, empowerment and the ownership of knowledge is the gold standard of medical practice for objective reasons of hard health outcomes. Done right, any convergence with the subjective motivation of keeping the customer satisfied is merely happy coincidence. It is a part of a complete mindset where everything consistently falls into place to perfection.

This is true Emotional Intelligence. It is the only way to resolve the conflict between the objective and the subjective. It is not to try to change objective reality to conform to unrealistic, subjective and emotional expectations and desires. Reality cannot be changed by the subjective expectations and desires but those expectations and desires can be changed to conform to reality. Emotions can be reprogrammed by example, experience and consciousness so that they do not cause conflict with reality. Harmony is assured.

The doctor is guiding the patient to realistic, objective, rational and informed decision making. In effect, they are teaching the patient to think as a doctor does using their applied knowledge and understanding.  The patient is subtly guided to agree with the doctor’s diagnosis and therapeutic decisions without the doctor ever mentioning what they think. Done right, the patient hardly notices the hand that has guided them. They believe that they are a genius for working it out all by themselves.

So this comes from the doctor’s humility. They have no inner need for the patient to look up to them as a hyper-intelligent, all curing hero. They have the self-assurance not to need to be propped up in that way. They must also have absolute inner confidence that they are guiding the patient towards the right diagnosis and decision.

The clinician must take unequivocal responsibility for the decision that they are guiding the patient towards. There must be no sense of wanting to delegate that responsibility to the patient so that it is somehow the patient’s fault if the outcome is suboptimal. If that happens, the clinician will be compromised in their objectives. They will be half-hearted.

Only the wholehearted clinician can practice and succeed at these wondrous techniques. That is the mindset that is required to even start learning these techniques. They are practiced by the clinician who practices with heart and soul. They do not come from the confused uncertainty of the ego or mind.

The deepest magic where the patient’s level of consciousness can be moved to make this possible without words of guidance is an explicable mystery of the clinician’s heart and soul. It comes from the clinician adopting the mindset of inner silence where they can be intuitive and inspired. They pro-actively share that mindset and silence with their patient. They actively and deliberately infect their patients with inner silence so that they can hear their own intuition and inspiration.

The outwardly visible signs that this is being done are a relaxed but pensive clinician. Their every word, expression and tone is that of an open-minded listener. Their facial gestures, head movements and posture are interested yet at peace.

And the actively, passively and innately react to what is being said to them in both words and actions, rewarding the patient’s inner thought processes with signals of approval and subtly discouraging undesirable mindsets. It is so subtle, even disguised, that it passes straight past the conscious mind of the patient.

This might be nothing more than non-verbal communication between subconscious minds. Effectively, non-verbal communication is how subconscious minds talk to one another and affect each other. The subconscious is involved with actions not words. It is involved with subconscious emotions not thoughts. Thoughts are left to the conscious mind.

And what subconscious minds are good at is copying. Whenever two subconscious minds see one another’s emotions expressed in the tone of voice, gestures and postures, each tries to align itself to the other. It tries to pull the other into its subconscious point of view and worldview. Face to face, this is what makes subconscious mindsets and emotions infectious. In person, it creates a collective subconscious mind.

Nobody knows that they are doing this except those with a deep and practical understanding of psychology. It is not a conscious process. It is beyond their conscious control. It is an unconscious and subconscious process.

A deeply committed, whole hearted clinician can stay firm in this tug of war. Their subconscious mind must be convinced or it will communicate its doubts and fold. It will be dragged towards the patient’s subconscious perspective or fears, confusion and chaos that disguise the obvious conclusion. They will lose their inspiration and intuition. They will no longer be able to pull the patient towards their silent tranquillity.

That may be the whole of the mystery. It may be nothing more than a subconscious tug of war where non-verbal communication is the rope joining the clinician to the patient. This infective inner silence that makes intuition and inspiration possible is only effectively communicated when the clinician has this abstract mindset.

Non-verbal communication is the physical expression of this inner process. The mindset behind it is the abstract side of the same process. They both conform with one another and simultaneously co-exist. They are both interdependent and one cannot exist without the other.

The pragmatic question is whether it is easier to learn and practice absolute conscious control over non-verbal communication knowing that the mindset will be learned or whether it is easier to adopt the abstract mindset and subconscious mind that control the non-verbal communication. The answer is to do both simultaneously. Moving both thought and action towards a shared and consistent goal under the direction of informed consciousness is the most effective method of learning this deepest art of history taking in clinical practice. It is the harmonious way.

This approach prevents conflict between the conscious and subconscious mind. It stops one fighting against the other and resisting the process through mental blocks.

One of the chief mental blocks is to believe that such feats are possible and that anybody can learn them if they know how. Those that practice them are not exceptionally and mystically gifted. In fact, they simply stumbled upon the secrets without understanding how they achieved such magnificent. Any healthcare worker, doctor, nurse, psychologist can become so talented if they open their mind to the possibilities and the outer skills and inner mindset practice diligently.

The Podium Of Good Clinical Practice

The Gold, Silver and Bronze Standards In Clinical Medicine

There is a correct and acknowledged relationship between the clinical acumen of the doctor and the technology that is at their disposal to help and support the clinician. The best, healthiest, safest, most certain and economical medicine is practiced by an experienced and talented clinician who wisely uses their clinical experience, skills and even intuition to use the science and technology of medicine wisely. The appropriate use of the technology available to medicine is in itself a part of their clinical arts. Another part of their clinical art is to be able to reliably interpret the results of investigations by placing them into the perspective and context of the clinical picture that includes all of the evidence from their clinical acumen.

This gold standard of medical practice is only achieved by the most exceptional doctors, the real geniuses of modern medicine. To reach this level requires immense amounts of scientific and clinical knowledge, outstanding clinical skills, brilliant thought processes and a vast experience.

The silver standard of medicine is the protocols and algorithms of modern Evidence Based Medicine which have been designed by the very best doctors mentioned above to try to imitate their thought processes and use of technology under normal circumstances. As such, they improve the standard of doctors that cannot live up to the gold standard of the medical profession, the truly exceptional and highly experienced doctors. If this is clearly understood and the algorithms and protocols are used correctly, they can become a learning experience for less experienced doctors along the path to becoming one of these gold standard masters of the clinical arts as well as masters of the science and technology.

However, these algorithms and protocols are second rate. They are poor imitations of the real thing. They only work reliably under usual circumstances. They fail in exceptional cases when patients and their diseases do not present or behave like the textbooks say that they should, which is not uncommon. They can also be confounded by the complexity of a modern medical reality in which many patients suffer multiple pathologies that interact with one another. Complexity is increased by factoring in the subjective influences and restrictions of the patients’ psychological and social situation. Then, only the brilliance, experience and intuition of an excellent doctor can cut through the complexity and produce a complex, holistic treatment plan.

Medicine where science and technology predominate over human clinical acumen and the clinician becomes subservient to their machines is at best third rate and does not deserve to be given a podium finish. It is not an end in itself. Properly understood, this style of medicine is taught in medical schools as fragments of a puzzle to be put together later as clinical acumen is learned through experience.

Medicine is not supposed to be practiced in the real world. The indiscriminate, knee-jerk use of science and technology in medicine for diagnosis, decision-making and treatment is dangerous. Every investigation and treatment that requires a doctor has a significant and measureable risk. The definition of a pharmaceutical product is significant side effects rather than effectiveness. Relatively safe products are classified as foods and supplements and many foods and supplements have therapeutic benefit.

Every scientific or technological investigation carries a risk, either directly or indirectly, the latter being largely the consequence of false positive results leading to further unnecessary investigation and treatment. Normality is defined by the results of 95% of the population and so for every parameter, five percent of the normal population has an abnormal result. In modern blood analysis a barrage of over twenty indices are measured ensuring the majority of normal, healthy people have at least one abnormal result. And sometimes scientific investigations do go wrong producing exactly the wrong result.

If the test result is inconsistent with the clinical picture, it is wrong and must be repeated. To do that requires that the doctor has great confidence in their clinical skills, more confidence in themselves than the science and technology of medicine.

And the interpretation and meaning of every test result is always dependent on the clinical context. In isolation, they say nothing. They have very poor discrimination between many conditions that can cause the same results.

The professional and public trust in the certainty of science and technology in medicine is a false hope. It has been repeatedly and categorically disproven. Science and technology without the clinical arts is a poor and dangerous way to practice medicine. The use and interpretation of the science and technology of medicine is an art in itself.

At least this third rate practice of medicine usually gets to the finishing line. Subjective medicine, which usually revolves around the doctor ingratiating themselves to their patients for popularity and cash invariably gets lost along the way and heads off in the wrong direction. This is the absolute antithesis of the clinical arts. The clinical arts are the objective use of subjective evidence. Subjective medicine is the subjective abuse of objective evidence.

To practice subjective medicine requires that the doctor throws all of their medical school education and experience out of the window for the most immoral and unethical motivations. This is what happens when medicine is practiced without the arts.

The root cause of this style of medicine is a society that confuses the lowest common denominator sales pitch of ‘The customer is always right’ with a life ethic or morality. Even in modern sales this passive aggressive, lose/win strategy is reserved only for conning the unwitting into buying worthless, inferior and overpriced products. In the end, it leads to both conflict and long term disaster. The win/win scenario is that the customer listens to and respects the knowledge and advice of the expert as they educate them into making a competent and informed decision in which they have also participated and understand.

  The present situation is that society is pressurising modern medicine into practicing a toxic mixture of subjective and technological medicine based on the false morality of ‘The customer is always right’ and their false certainty in science and technology. The only way that the senior medical profession can keep this in check is through the rigid imposition of the algorithms and protocols. This is dragging doctors towards a situation where medicine is at best second rate but in reality, corrupted below that level. The doctor becomes the sympathetic human interface to buffer the patients against the harsh reality of the algorithms and protocols and under constant pressure to ignore them for the sake of popularity, reputation and cash. That pressure is even stronger in uncoordinated private healthcare systems where the patient is permitted to shop around for a doctor who will say and do whatever they want.

An Insane Society

It is with the greatest pride that I admit my sociopathy against an insane and immoral society that is degenerating into abomination and oblivion. I whole-heartedly believe that it is the moral duty of everybody, especially healthcare professionals, to oppose that insanity, not to pander to it.

In individuals, insanity is rare; but in groups, parties, nations and epochs, it is the rule. 

Friedrich Nietzsche

The fact is that society is insane and sending its population insane. Mental health statistics prove it.

Forget the genetics and the eugenics myths. They are at best statistical associations. They have no known mechanism. They have only been accepted on the disproven axiom that everything must be in DNA. Now that axiom has fallen apart, there is longer blind faith as a mechanism.

In contrast, psychology has proven mechanism. The mindsets that lead to mental health problems are learned. The problem is that it requires the highest levels of objectivity concerning the insaity of our society to admit it. It forces the admission that our modern society is worse than just flawed. It is positively evil. The media is full of those profiting by commiting psychological crimes against humanity and its mental health.

Depression is caused when unrealistic, subjective expectations are devastated by reality. The evil of subjectivity is to blame and that is exactly what society promotes.

Stress is caused when people resist necessary inner and outer change. It is society telling them that it is their inalienable right not to change, least of all their minds.

Society and its industries promote the egoism of short-term profiteering. Many have to work to such low morality. Has nobody heard of conscience? No wonder they cannot sleep at night.

Psychologists have found the root cause of our new mental health epidemic of Borderline Personality Disorder. It is a lack of emotional self-control. Every whim is believed sacred and followed instead of having a rational, problem-solving mind. Yet everywhere, especially in the media, all we see is the active and subliminal programming of the audience to the value of emotions. 

Emotions define our humanity. Wrong. They are nothing more than a leftover inheritance from our primitive evolution. We are Sapiens. The much vaulted human difference comes from our rational, knowledge based thought processes.

If society and the advertising industry that sponsors the media had their way, humanity would degenerate to Erectus and blood engorged genitals would be all that it lived for because they are the subconscious that are so easily conned into buying.

No, I am not buying it. I am not selling it. I will not pander to it.

Every model of developmental psychology says that we change worldviews during life. Society tells its members to stay the same. All mental illness issues can be seen as the consequence of not growing up through the appropriate lifestages appropriate to our age. Society worships youth at every level. We are forgetting what it means to be a normally functioning adult.

And that includes children who have no normally functioning adult as a role model. Yes, that is how children predominantly learn. The direct, conscious interactions of the parent with their child is a marginal part of the equation based on Do as I say, not as I do. Of course, society teaches that it is only our pretty words that are important and how we and others feel. Actions and outcomes are irrelevant.

So now, we have the increasingly dependent Why Me? Me! Me! Me! generation. They are stuck in child consciousness and are they in for a devastating psychological shock. They inherit a world bush-wacked by society and its politicians. They face a life of living standards in decline. They will never have the wealth and comforts that their parents worked for and enjoyed, including spoiling them as children. 

Hubble, bubble, toil and trouble.... this evil sorcerers of societal morality, including and especially the New Agers and Conspiracy Theorists, have brewed up an explosive connoction that will predictably explode into a psychological catastrophe on a scale that not even modern clinicians have experienced.

With my medical knowledge, objectivity and morality, I could not sleep if I was an active participant in this societal insanity.