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Emergentology: Medical Problems Are Not ‘Problems’

Walker, Graham MD

doi: 10.1097/01.EEM.0000515686.67918.2c
Emergentology

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at http://bit.ly/EMN-Emergentology.

Did you know it wasn't until the late 1960s that we had the foundations of an organized medical note? It was Lawrence Weed, MD, who said “a good scientist focuses on a single or very limited number of problems, pursuing each until he finds a solution, [but] the physician is asked to accept the obligation of multiple problems in a given clinical situation and yet to give each the single-minded attention that is fundamental to developing and mobilizing his enthusiasm and skill.” (N Engl J Med 1968;278[11]:593.)

Dr. Weed noted that a physician's education suggests that his attitude should be scientific, but the multiplicity of tasks in clinical training often defeats this goal. “He can act as a scientist, however, if he is able to organize the problems of each patient in a way that enables him to deal with them systematically,” he wrote.

So Dr. Weed came up with the “Problem List” and proposed that each medical problem be listed, along with the status and plan for each problem. It's fascinating to look through this paper; he included sample medical progress notes with and without this level of organization, and it's clear that we take organized medical notes for granted.

The one issue I have with the “Problem List” is that most medical problems aren't problems at all. They're dilemmas.

I first learned about this concept from Dike Drummond, MD, who approaches physician burnout from a wellness perspective, but I'll take the medical focus instead. A problem, of course, is “a matter or situation regarded as unwelcome or harmful, and needing to be dealt with and overcome,” while a dilemma is “a situation in which a difficult choice has to be made between two or more alternatives, especially equally undesirable ones.” (The Happy MD. Feb. 27, 2017; http://bit.ly/2lhtfNx.) This is why you have math problems and ethical dilemmas. If 4x=12, there are no “undesirable alternatives” to x equaling 3. Similarly, it's the prisoner's dilemma and not the prisoner's problem because there are multiple different outcomes, none of which is really a “solution.”

We as a medical culture have moved from curing acute disease to managing chronic illness, and we still call them medical problems, but they're really not. They're dilemmas or quandaries. Problems have solutions; dilemmas have options.

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Managing vs Solving

We're fortunate that our fast-track shifts, by and large, still allow emergency physicians to treat problems. Pus? Drain it. Laceration? Suture it. Fracture? Splint it. But think back to your last shift, how many of your patients had some slam-dunk, curable disease, and how many had something that you were temporizing or managing? Even appendicitis, the most classic textbook example, is now being managed instead of cured with antibiotics or drains, depending on the patient.

Why does this even matter? Because patients walk through our doors and want us to fix their problem. They want a solution. They don't seem to understand that their heart failure, diabetes, or COPD is not a problem but a dilemma. We talk so much about curing cancer, but a cure is a distant glimmer of hope for most of the cancer patients in my ED. What their oncologists are offering is management. And just like oncologists, emergency medicine often doesn't have a solution, just management. Patients just want their transmission to be fixed; they don't want a recurring payment plan to do monthly transmission tune-ups.

And where else but medicine are these choices not available to people? On Amazon, I can click to buy or rent a movie. I can buy or lease my car; I can buy a home or rent instead.

Is it maybe depressing for patients to accept that their disease state is their new normal? And that their trajectory will be very slowly downward, with some blips and bumps along the course? Maybe. But it might make them more likely to be realistic about what they want out of their lives and what they should expect when they're wheeled through the doors of the ED for the 10th time, wondering why they're back.

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