Matt Morgan and Peter Brindley: Doctor does not always know best

For centuries, old white men have argued about whether medicine is more of a science or an art. That is until, belatedly, some smart Alec—or some smart Alexa—realised that patient safety and medical predictability mattered too. Accordingly, we now spout language as recognisable to engineers as to Osler. We talk about standard operating procedures, and fail-safes, and checklists. However, what determines patient outcome is as much about old-fashioned relationships, rather than new-fangled whizz-bang. Without getting too “Oprah”, it really does take a village to help a patient. Doctor, you are in the “relationship business”; are you fit for task?

This medical job is, and has always been, “relationship before task.” This is true whether within harmonious specialties or across embittered hospitals. To truly “get stuff done” means knowing the booking clerks, thanking the porters, and not forgetting the secretary’s birthday. It’s about the relationships between those that buy sutures and those that tie the knots. It’s even about the ergonomic relationship between your hands and your beloved pieces of kit. Obviously, the relationship that matters most is the one between patient and provider, especially in chronic disease, and especially as we transition care. This can be tricky stuff.

It has been estimated that admission to Intensive Care comes with approximately 180 steps per-patient per-day. While clichéd there really is no “I in ICU” and “teamwork really does make the dreamwork”. We do not so much look after patients as conduct a large skilled orchestra. This comes with the side effect of pharmacists interrogating our antibiotic choices, physiotherapists advocating for early mobilisation, and the dietician suggesting a few calories might not be a miss. It can also be the social worker arguing for more time to get support in place and a family member reminding us discharge includes more than whether we need the bed. It is good that we have many eyes on the prize. Our decisions are regularly questioned. We appreciate this, even if our facial expressions sometimes suggest otherwise.

Sign-over and discharge-planning may be exasperating but keeps us all honest. These medical procedures also happen thousands of times per day. They are therefore as necessary as hand-washing, but have received far less attention. Get it wrong and we lose the plot. However, get it right and we can challenge assumptions and confront cognitive bias. Sign-over can be as tedious and discharge can be tiresome. However, it is also a much needed second opinion in a system that doesn’t otherwise encourage descent. We want you to speak up and we want you to prove us wrong. We really don’t want to be incorrect a moment longer than necessary.

We have gnashed their teeth through more team meetings than post-night shift breakfasts. This is because we are impatient buggers. It is also because there is a clear and present danger that time will be wasted, nuisance will be missed, details will be morphed, and hard-fought relationships will be scuppered. These risks are real. However, a “second” opinion” is often the best first strategy. This is the case when we do not know what to do and even when we are certain that we do. We do not always have the humility to admit that doctor does not always know best. Thank you for disagreeing, we know it takes effort and resolve. Thank you, in turn, for accepting that we may disagree right back.

Our brand of acute care medicine comes with built-in second opinions. The danger is that these opinions lie unmolested in the chart (the Ninja consult, anyone?). Some opinions are also little more than repetition of the blindingly obvious. Regardless, we are the lucky ones. We have ready access to the hospital’s hive mind. In contrast, other inpatients and outpatients are exposed to the same weary assumptions for weeks and months and sometimes decades. Perhaps the benefits of the relationship built-up over years of chronic disease outpatient clinics can be outweighed by a regular rotation through fresh eyes? Without this, it may mean one-doctor, one-opinion, and one-direction. Nobody needs to hear more from One Direction. There are great advantages to fresh eyes, new ideas, and good old-fashioned differences of opinion. Maybe medicine is not just art or science, or even engineering. Maybe medicine is a branch of the social sciences. That’s just our opinion; you are welcome to disagree, or ask a colleague for their thoughts.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan 

Peter Brindley, Professor in the Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada @docpgb