Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Thomas, Eric Eric.Thomas at UTH.TMC.EDU
Tue Jan 13 14:15:35 UTC 2015


David,

Thank you for recognizing Bob Centor's important contribution to medicine.  The Centor rule is one of the most commonly used and effective evidence-based tools we have to improve diagnosis in healthcare.  It's an approach others should try to replicate.  My residents and I use it just about every week (and I don't see patients every day).  I'm thankful that we have role models like Bob Centor who recognize the benefits and limitations of applying rules and evidence to the patient-physician encounter.  

Eric
-----Original Message-----
From: David Lawrance [mailto:david.lawrance at GMAIL.COM] 
Sent: Monday, January 12, 2015 6:24 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Recent article From the Sunday New York Times: "Doctor, shut up and listen!"

Let it not go unsaid that Dr. Centor is the creator of the Centor Rule which has revolutionized the treatment of pharyngitis, and that he is a hero of mine. I devour all of his articles and I have tremendous respect for his ability to so thoughtfully challenge the prevailing common sense with data-driven enlightenment and reflection.

The practice of clinical medicine is neither art nor science. Those things are both experimental. Whatever I do is not so much that. I think I'm more of a skilled technician. My skills were largely learned, but not taught. I have a lot left to master even after 35 years of practice. I wish what I did was experimental so that I could twist the knobs and measure the effect and characterize the linkages.

I am also sure that nothing that I do is supernatural except for that wonderful thing that happens when animals assist each other through empathy. Since it seems to be possible to design self-driving cars, I have greater hope for what machines will be capable of doing in medicine. I don't know how much insight that engineered intelligence will do toward teaching me to perform better, though, as machine intelligence is unencumbered of my human failings. The kinds of mistakes that I make are strengths in other spheres, heuristics that usually work in making hasty decisions that are often good enough. I can't rid myself of that hard-wiring, I can merely hope to dampen its effect in certain situations. (Perhaps diagnosis will be best conducted from outside the human realm.)

The Centor Rule scores a sore throat from 0-4. In the original version, 0-1 is treated as a cold without diagnostics, without antibiotics, 2-3 as needing a rapid strep or throat culture for determining whether an antibiotic is necessary, and 4 was treated empirically with an antibiotic. Dr. Centor revised his algorithm after a decade or so to considering an antibiotic when the score was 3. Not all that causes morbidity or mortality is strep, and not all of it is easily culturable, or not simply culturable in an appropriate timeframe. To look at the patient for those signs of toxicity that are not so easy to always describe.

David

On Mon, Jan 12, 2015 at 11:29 AM, Ross Koppel <rkoppel at sas.upenn.edu> wrote:
> Yes! of course... and several things included that are wrong or 
> misunderstood.
>
> Ross Koppel, Ph.D. FACMI
> Sociology Dept and Sch. of Medicine
> Senior Fellow, LDI, Wharton
> University of Pennsylvania, Phila, PA 19104-6299
> 215 576 8221 C: 215 518 0134
>
> On 1/12/2015 12:41 PM, Robert L Wears, MD, MS, PhD wrote:
>>
>> I have to strongly agree here.  A history is not a collection of 
>> facts, but a narrative co-constructed by doctor and patient (and 
>> often, family).  It's much more akin to interpreting literature than 
>> it is to following an algorithm.
>>
>> And it's never 'complete'.  In any communication, there are always 
>> more possibilities than can be realized; something is always left 
>> out, something else also could have been said.
>>
>> bob
>>
>>
>
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