What the hell is good clinical medicine, anyways? That’s hard enough to answer. It’s even harder to find reliable clinical information to use as a guide to practice good medicine.
Good Clinical Medicine
The way I think about this is how I would want my physician to act clinically when I need them most. Good clinical medicine to me would be in line with my own definition of health. Which, by the way, I haven’t yet figured out. I know when I don’t feel healthy, basically when something feels off.
I want my clinician to mostly advise and intervene only when absolutely necessary. My physicians shouldn’t fear me suiting them. Nor care what my insurance company will say or do. And if they are practicing good clinical medicine then the results should speak for themselves.
So that’s the other part – patient education. I might go to my doctor for a headache and they tell me it’s because of a migraine. So get a Toradol shot, IV diphenhydramine, and go home with Imitrex, verdad? No. At least not for me.
Knowing What not to Use
With the commoditization of healthcare and medicine, it’s that much more important to know when to say no. Yes, we have this clinical intervention available but knowing when to use it is far more important.
The reason for that is that all clinical intervention comes with side effects. Even though we downplay these side effects or hide them in research studies we know as clinicians that they exist.
I could put a stent in you because your coronary arteries show high degrees of blockage. I can also find 100 case studies and research papers to justify that. Not to mention expert opinion groups backing up this move.
But I can find a handful of high-quality studies which justify not stenting. These studies show that morbidity and mortality aren’t affected by stental intervention. In fact, the side effects or long-term problems from this clinical act outweigh the benefit.
Good Patient Selection
Without the right patient, you can’t practice good medicine. I know this is controversial but I’m writing for an audience of physicians so I feel you have the maturity to appreciate this. Though if you disagree the comment section is the perfect place to continue the conversation.
So what’s the right patient? What’s the wrong patient? Why even create these categories? These categories exist in my lexicon because medicine is no longer a scientific field – it’s riddled with $ signs and defensive medicine.
The traditional patient gets their insurance through their employer. They might believe that good health is owed to them and they will obtain it by entering the healthcare system.
This kind of patient will be really tough to please and will likely have expectations which aren’t in line with what medicine can deliver.
The right patient can help me deliver proper clinical care because they are on the same page as me. They understand that prevention trumps intervention and that magic bullets exist only in movies.
Arguing for Traditional Care
Let me take a break and argue the other side – practicing traditional medicine, in-line with the standard of care.
This would look something like prescribing antihypertensive to a patient with HTN and insulin to uncontrolled diabetics. Stents for stenosed coronary vessels, gastric bypasses for those meeting insurance criteria, and antibiotics for sinus congestion lasting >10 days.
Chances are the patient will be fine in the end. They will end up married to western medicine, however, because one treatment begets another. The antibiotics will require an antifungal for the subsequent fungal infection. The gastric bypass will lead to lifelong blood tests and supplements.
This standard system however also protects the physician. The standard of care is after all the standard-of-care. It can be defended in court and no specialist will fault you for it.
You can bill insurance companies much easier following the traditional care model. Your patients won’t require an explanation. They won’t look at your like you’re a whacko for recommending conservative management of a mild UTI or otitis media.
Where to Practice Good Clinical Medicine
You won’t be able to practice good clinical medicine at UCLA, that’s for sure. I know, I trained there and practiced there. I don’t mean to say they deliver shitty care but their care fits their patient population and satisfies the research-citing clinician.
You likely will have to go out on your own. I know, that’s scary. But fortunately, at least in the US, practicing medicine as a sole proprietor is insanely easy.
You will need to market yourself and you can hire tons of companies to help you with that. And you’ll need to make your stance on clinical medicine clear – that’ll require a little bit of foresight and insight.
Now you’ll have to see patients; likely cash-paying patients. But you already got the hard part behind you, you selected the right patient. This patient wants to avoid unnecessary interventions and will agree to any necessary clinical intervention.
I am biased towards virtual medicine just because I’m the digital nomad physician, after all. But you can do this in a brick & mortar just the same. This leads to the practice of niche medicine which I think is the future of good healthcare.
You might even convince your large medical group to let you practice this weirdo style. But they’ll likely ask you for your functional medicine and integrative medicine license and want to call your center the east-west center or the holistic institute or something @%#! like that.
Resources for Good Medicine
First of all, let me tell you it feels great to use the phrase good medicine. I’ve had such a contentious relationship with medicine for so long that it’s hard to believe that there is such a thing as good medicine. But I believe there is.
How do you treat your menopausal patients? By reading the books of physicians who have done the hard work of researching what’s right for them.
How do you manage headaches? Again, books by physicians who have mastered migraine management. You’ll also have to peruse the patient boards where patients share their personal stories. 90% of which will be pure garbage. But you’ll come across the occasional gem of a post where someone shares their genuine experience from which you can learn a lot.
Youtube. Yes, the TV of the 21st century. Kitten videos aside, you’ll find incredible physicians who will educate you on how to manage all sorts of diseases. You can even find NHS doctors on there who don’t profit from excess clinical intervention.
Go beyond physicians. Some dieticians (few) and many physical therapists have incredible channels where you can learn to practice high-quality medicine.
Podcasts like that of Dr. Peter Attia is very useful if you have the time and patience for detailed dives into clinical issues.
Questioning the Status Quo
I admit this requires a certain type of personality. But as a physician you have not only earned the right but are expected to doubt shit – that’s a good thing.
The CDC comes out and says that everyone should do XYZ, okay, but what do you think? Maybe you want to dive into the data and pull out the calculator and do some of the statistical work yourself.
No? That’s fine. You can read the opinions and explanations of other physician nay-sayer and see if their arguments are valid or if the status quo is legit.
It isn’t about right or wrong. It’s a matter of how you want to practice and how you think medicine should be practiced for patients with your same mindset.
If you think everyone should be sprayed with statins and antibiotics that’s okay. And those are the patients you should aim to see. If not, you can question that practice and search for yourself if the opposite method holds water.