Best Practices in Medicine: Observations from Iceland
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In 2020 I wrote a book, How to Get the Right Diagnosis: 16 Tips for Navigating the U.S. Medical System. He captured the main lessons learned in 2014 after a five-year struggle with an undiagnosed disease. I had no idea then that I was going to spend the next six years dealing with a second undiagnosed disease!
Recently, while on vacation in Iceland, my health seriously deteriorated. I was hospitalized for 18 days with a rare form of vasculitis. During this time, I observed five best practices that should be emulated by every medical system:
- Consider and test several hypotheses
- Encourage all team members to challenge assumptions
- Encourage physicians to avoid becoming captive in their specialty
- Listen and collaborate with the patient
- Foster a strong collaborative team effort
Multiple assumptions. In Iceland, doctors and nurses worked as a group to generate a list of candidate alternative diagnoses (think of the TV show lodge). Instead of testing hypotheses in series, they conducted synchronous assessments. As a result, the diagnostic process was much more efficient.
Key assumptions. In complex cases, it is important not to rule out a hypothesis prematurely. In Iceland, two initial assumptions that made sense turned out to be wrong and one that seemed implausible turned out to be correct. The team discovered this only because a culture had been established in which anyone, regardless of rank, could raise questions and challenge an expert’s judgment.
Overspecialization. During my stay, I was followed by doctors representing nine specialties: rheumatology, hematology, infectious diseases, cardiology, pneumology, dermatology, oncology, gastroenterology and internal medicine. In Iceland, I was impressed by the willingness of doctors to step out of their âspecialty boxâ. I suspect that one of the reasons for this behavior is that the practice of medicine is much less contentious in Iceland. In addition, I felt that the doctors felt more empowered to focus on the larger context of my illness and more compelled to make the correct diagnosis.
The ability to listen. The first question the doctors and nurses asked me at each visit was “How are you feeling?” When I mentioned a symptom that didn’t fit their pattern of what might be wrong with me, they wanted to explore the gap, not ignore it.
Collaboration. Finally, what really impressed me was the strong culture of collaboration demonstrated by everyone associated with my case. On at least three occasions, a panel of doctors and nurses met to think about diagnoses, decide on the best treatment and estimate a discharge date. For 18 days, I was seen by 12 doctors, and the knowledge transfer between them went smoothly and completely. During my time in the emergency room and in the hospital, I had conversations with over 100 healthcare professionals. To my surprise, they all seemed to be working on the same sheet of music. The way they managed to collaborate so effectively was unexpected and impressive.
In summary, my recent health emergency in Iceland taught me a lot about what makes a medical support system work well – and I’m alive today to tell the story!
To better understand these fundamental techniques, consult Pherson and Heuer Structured Analysis Techniques for Intelligence Analysis, 3rd ed.
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