Zen and the Art of Human Medical Maintenance

The word Zen is derived from the Japanese pronunciation of the Middle Chinese word dzjen, which in turn is derived from the Sanskrit word dhyana, which can be loosely translated as "absorption" or "meditative state".

Zen emphasizes the attainment of enlightenment and the personal expression of direct insight in the Buddhist teachings.  As such, it de-emphasizes mere knowledge of sutras and doctrine and favors direct understanding through zazen and interaction with an accomplished teacher.

Wikipedia describes the following for evidence-based medicine- EBM:

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.  Trisha Greenhalgh and Anna Donald define it more specifically as the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients.

in the novel Zen and the Art of Motorcycle Maintenance: An Inquiry into Values is a 1974 philosophical novel, the first of Robert M Pirsiq's texts in which he explores his Metaphysics of Quality, the author attempts to reconcile the natural, inexplicable forces of nature with an analytical approach to everything.

A comparable task is the fine tuning of EBM with the "Art of Medicine" to enhance the quality of medical care received and given.  This would lead EBM to become "Evidence Enhanced Medicine".

Number Needed to Treat

Wikipedia states the number needed to treat (NNT) is an epidemiological measure used in assessing the effectiveness of a health care intervention, typically a treatment with medication.  The NNT is the average number of patients who need to be treated to prevent one additional bad outcome (i.e. the number of patients that need to be treated for one to benefit compared with a control in a clinical trial).  It is defined as the inverse of the absolute risk reduction.  It was described in 1988.  The ideal NNT is 1, where everyone improves with treatment and no one improves with control.  The higher the NNT, the less effective is the treatment.

Recently, the American Heart Association and American College of Cardiology gave out new guidelines on the preventing atherosclerotic cardiovascular risk in adults.  These guidelines suggest the most "Americans" being on statin cholesterol lowering drugs.  This has created some controversy.

NOT being an expert, I cannot tell you whether these are ideal suggestions, but as a consumer there is a question to be asked.  How many people need to take these medications for life to make it a valuable endeavor?

All medications include cost, side effects, and compliance by the patient.

Conclusion- ask your provider and/or pharmacist for all chronic medications, what is the number needed to treat to obtain benefit from these ongoing therapies.  Once you know the number, work with your provider to assess your risk and need for any and all medications.

Continuing Medical Education

Staying current in the rapidly changing world of medical education, guidelines, protocols, and technological innovations is a continual challenge for most practitioners.  Having practiced since 1975, multiple reinventions of the wheel, standard of care, and now evidence-based medicine have all had their days in the sun. 

Evidence based medicine is now the buzzword for all education, but unfortunately, a lot of the data was not obtained in blinded, multi-center, prospective studies.  Much of the information is gleaned in meta-analysis format that uses flawed data as the source of their conclusions.

Treatment plans, protocols, and guidelines are far superior then in the past, but again contain "expert opinion" not necessarily the true facts.  What is left out in these plans is the "Art of Medicine".  An experienced clinician can take the best of the information and cater it to the individual patient.

How does one keep up?

1. Develop a consistent plan that teaches you what is presently being taught in the residencies and medical schools.  Take this information and adapt it to the reality of your practice.
2. Maintain Board Certification because it forces one to take an extensive review course in 8-9 years.
3. If possible, work with others.  Isolation leads to "antique practices".
4. have continuous access to the Internet at work- the former peripheral brain, or notebook in the pocket, with modern enhancement!

What to read/review?  These are what I use and have kept me pretty current.  These are not direct recommendations, but suggestions based on my specialty and practice.

1. Emergency Medical Abstracts- reviews the literature.
2. Risk Management Monthly- all the lawyers I know listen to it!
3. Emergency Medicine: Reviews and Perspectives (EM:RAP)- current real-time podcast education with practicing professors.
4. American Board of Emergency Medicine- Lifelong Learning and Self-Assessment (LLSA)
5. Medscape

The Art of Medicine: Evidence-Based vs. Evidence-Enhanced

Medical care has evolved from using the individual practitioner’s training belief system, and own personal bias to using data, studies, and evidence to make appropriate decisions. This more scientific approach has yielded better results and more rational treatment programs.

However, in the mantra of “double-blind-controlled study," there is another side of medicine that needs to be addressed. This is the “Art of Medicine”.

Medical care not only includes scientific assessments and treatment protocols but also the human side. Patients come for the best scientific care but also for compassion, empathy, measured opinions, and guidance.

The Electronic Health Record (EHR) gives access to the data, but not the whole story.

By combining “evidence-based medicine” and the “art of medicine” you will achieve “evidence-enhanced medicine” giving the patient a holistic approach for which they are grateful. There is a reason other than scientific medical care that patients are nostalgic for their “own doctor."