Caught Between Scylla and Charybdis

by Academy of Clinical Excellence on November 12, 2009

Recently Dr. Scott Wright took a first “cut” at how to display clinical excellence by enlisting two physicians who were members of The Miller-Coulson Academy of Clinical Excellence, and a resident in a medical grand rounds format at The Johns Hopkins Bayview Medical Center. He chose a patient unknown to the three clinicians and asked them to discuss the case step by step as the story unfolded. Important clinical points were made by each of the physicians. In the end, heart failure due to Thiamine deficiency turned out to be the cause of the illness. The patient was not alcoholic and had no signs of central or peripheral nervous systems deficits. The rounds emphasized the diagnostic acumen and clinical thinking of three exceptional clinicians. However, there is a further challenge. How can other less tangible traits of expert physicians be displayed to students and colleagues in a traditional academic arena?

The consummate physician has many attributes beyond diagnostic acumen, among these are a reasoned judgment of when and when not to do diagnostic tests, how to engage, listen to and communicate with a patient, and above all how to treat each patient as an exceptional individual person with a unique history and genetic makeup, a person who often wants to be and needs to be a partner in any decisions to be made. The adventure Dr. Wright and his colleagues have embarked upon raises formidable challenges. How in a public albeit professional arena can one display publicly what is intrinsically very private? (e.g. the content of what goes on between a doctor and his or her patient.) One approach may be choosing instances which require an expert physician to depart from the guidelines established by large epidemiologic studies when individual patient circumstances may make such an approach neither necessary or rational.

How physicians and patients must make such judgments will probe the treacherous water every physician must deal with on a regular basis. Dr. Wright has taken an important first step. Now we must move into more treacherous waters that may distinguish an exceptional captain of the fragile ship of physicians and patient dialogue and display how treatment can be individualized in a way that can successfully navigate between the Scylla of slavishly following guidelines and the Charybdis of ignoring evidence.

William B. Greenough III, M.D.
Professor of Medicine
Division of Geriatric Medicine
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Anthony Phan March 6, 2010 at 6:40 pm

I feel so blessed that during my elvolving maturation as a physician I was under the tutelage of Dr.Geenough.I love the way Dr. Greenough taught to us interns .His teaching was full grace and goodnessFinding this site again,is like having a Double Blessing.The grace of Dr. Greenough has revitialize my lost but found -the passion to be a physician again. Thank you

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