Non-linear Bangkok
by Gary Wong

Most doctors treat simple medical problems similarly. The presenting problem leads to a single diagnosis, which leads to a treatment; all in an uncomplicated, linear pattern.

But in primary care, things are often not so simple. For multiple problems with complex underlying issues, no two consultations are ever the same. And a surprising amount of the variation depends on the doctor.

A shorter, edited version of this article will be published at The Conversation and a longer version will be published as a book chapter in late 2014. 

The non-linear consultation

When we think of what defines a medical consultation, we quite reasonably think of the ‘presenting complaint’: the medical problem which the patient brings to the doctor. In movies, literature, common wisdom and jokes, the doctor’s role is simple and rather passive—make the diagnosis and treat it.

Sure, some doctors might be more skilled than others—think of TV’s Dr House, who brilliantly diagnoses an incredibly rare disease at the end of each episode—but even then it all boils down to the systematic application of technical knowledge. A clever computer algorithm could, in theory, work through the same deductive process of ruling out alternative possibilities to reveal the unique diagnosis.

I call these consultations linear: each step could be diagrammatically linked to the next by a sequence of arrows heading towards a specific diagnosis. The line of arrows then continues through to the correct treatment pathway.

Doctor, doctor. I get terrible pain when I press my finger here. And here, and down here too…and even when I press lightly, both here and over here. What on earth could be wrong with me?

You have a broken finger.

But many primary care consultations are non-linear. Newtonian laws don’t apply; instead, they have been supplanted by chaos theory. Because of the underlying complexity and multiple possibilities, each question or reflection from the doctor might twist the next arrow in any direction—even split it into many parts. And, as happens when you follow the arrow of time, entropy only ever seems to increase.

This tangle of potential paths through the consultation varies not only according to patient factors, but to the doctor’s particular approach. An identical patient with an identical presenting symptom of ‘tension headache’ might lead to a thousand different discussions, from smoking cessation, to walking the dog daily, to the gastric side effects of anti-inflammatory tablets.

The poor sod with a broken finger exemplifies a linear problem. Protagonists in ‘doctor, doctor’ jokes are simple folk—two-dimensional people with one-dimensional issues. ‘My hands keep shaking. Do you drink a lot? No, I spill most of it.’

Single-issue, new problems, even if serious, usually require little imagination to manage, as most doctors would approach them in the same way. A previously healthy sportsperson carried in with a broken leg is a significant medical event, but even a junior doctor would usually comfortably set off on the well-signposted path of pain relief, X-ray and transport to somewhere inhabited by an orthopaedic surgeon.

But many interactions in general practices and emergency departments are not so clear-cut. People have complex chronic conditions: diabetes, obesity, depression, drug and alcohol problems, loneliness, chronic pain, confusing symptoms, difficulty telling their story, dementia, overwhelming family responsibilities, a bagful of medications, and nagging problems for which no cause or cure can be found.

In this chaotic, real-world space, the attitude and approach of the doctor can completely change the outcome of any given consultation.

This variation is starkly highlighted during ‘role play’ doctor’s exams, where different doctors are faced with precisely the same patient-actor. The content covered during the consultation depends even on the doctor’s first couple of questions, let alone what happens from there.

This medical butterfly effect is particularly prominent where the exam scenario has no single end point (“Aha, you must have Lyme disease!”), but reflects a more common real-life scenario (“I think your shortness of breath may be due to your size. Let’s think about how you might lose some weight.”)

These non-linear consultations test not so much the doctor’s diagnostic acumen, but their empathy and listening skills.

Doctor, doctor. My ex-husband is so ill—is there no hope?

That depends what you are hoping for.

Doctor as the drug

Michael Balint, born in Budapest, became the world’s first Professor of Psychoanalysis, and moved to London in 1938. In his seminal book The Doctor, the Patient and His Illness, Balint examined the patient-doctor interaction at both conscious and subconscious level. He introduced the concept of the doctor acting as a ‘primary therapeutic agent’.

Balint realised that, rather than just being a passive dispenser of medication, doctors frequently use themselves as the agent of change: this starts with the act of actively listening to the patient’s story about their illness. This interaction was coined ‘doctor as drug’, where the relationship with the doctor became the therapy itself.

Of course, this wasn’t a far cry from Freudian psychoanalytic theory, but Balint was more interested in what went on in a mainstream medical practitioner’s office rather than on the psychiatrist’s couch. Many doctors around the world now regularly attend local ‘Balint groups’, discussing with their colleagues the emotional content of the patient-doctor relationship.

Physicians in Balint’s era often saw their role as limited to a dispenser of the right medicinal cure—an extension of this idea is the fallacy I noted earlier, where a computer or robot might replace a doctor using a linear pathway which ends with the correct prescription.

But which headache medication does the robot choose when consulted by an impoverished mother of five whose partner has lost his job and started drinking?

In the words of American Steel, There ain’t no cure for a broken heart. Or if there is, then typing in the precise characteristics of the pain ain’t gonna find it!

Balint realised that the medical consultation comes as an entire ‘package’, which is itself part of the therapy. A medication prescription or a referral to a specialist may be a part of the package, or it may not.

The therapy starts when the patient walks in the door. Does the doctor greet them warmly, or fuss impatiently with the notes? Does the consultation begin with an open-ended exchange or rapidly home in on technical detail about the first problem the patient happens to mention?

At its best, the therapeutic effect of seeing a good doctor can be extraordinary. George Bernard Shaw’s line from ‘The Doctor’s Dilemma’ is only a slight exaggeration: 

Even broken bones, it is said, have been known to unite at the sound of his voice.

Interestingly, the surprising popularity of homeopathy could well be due to its practitioners using this ‘therapist as drug’ concept. After all, in its purest form, the only ‘drug’ a homeopath will prescribe is a few drops of plain water, ambitiously labelled as various other things.

In other words, an identical water cure is offered for a wide array of ailments and seems to help far more often than would be expected if the patient instead drank free tap water at home.

The magic ingredient is not buried between the water molecules; it lies somewhere in the interaction between the homeopathic practitioner and their client. Call me a sceptic if you will (please), but I would imagine successful homeopaths spend more effort listening and using their communication skills than they do choosing which particular label will grace their vial of water!

The patient-centred method

The concept of patient-centred care was fairly new when I was taught the art of medical practice twenty years ago. I couldn’t have defined it, but had some idea of what it wasn’t: disease-centred, technology-centred, the sort of treatment you would find in an intensive care unit.

Medicine-by-algorithm is quite appropriate if you’ve been run over by a car. Life-threatening situations demand a linear pattern of thought—DRABC; secondary survey for injuries; run some tests; correct discrepancies and run the tests again. In ICU, you want to be looked after by someone with a deep understanding of crushed organs and machines that go ‘bing’.

But the patient-centred approach finds its natural home among the chaos of primary care. For non-linear problems, patients must be given the opportunity to describe in their own way the various things that are troubling them. The doctor must encourage feedback as to whether the medical summation of the issues rings true, and the patient should help craft the management plan.

Some doctors haven’t mastered this, or choose not to spend the time and intellectual effort required. When faced with a non-linear consultation, they will quickly try to reach closure by printing a prescription, test request or referral. They bend the arrows to point straight to the nearest conclusion, ignoring all the opportunities down alternative paths. At the end of their crammed working day, they will have done a reasonable job with linear consultations (a repeat script and some paperwork please) but have—usually unwittingly—failed the patients with non-linear problems.

In contrast, an effective primary care practitioner will seamlessly switch between linear and non-linear consultation styles as occasion demands it, many times a day.

At times, they find themselves channelling Dr House, our modern-day Sherlock Holmes, focussed on hunting down that single elusive diagnosis.

On other occasions, they must instead feel their way through a foggy consultation, listening intently for echoes, continually judging the best direction forward.

These clouded journeys may lead to places neither participant expected at the outset. And perhaps neither will be quite sure what to do when they get there. Some management plans have no need of desktop printers.

Anatole Broyard, editor of The New York Times Book Review, wrote before he died of prostate cancer in 1990: 

What do I want in a doctor? I would say that I want one who is a close reader of illness and a good critic of medicine…I see no reason or need for my doctor to love me, nor would I expect him to suffer with me. I wouldn’t demand a lot of my doctor’s time, I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.

A non-linear consultation is an opportunity to survey the soul.