One Patient at a Time: Individualism in Medicine

Mocking stereotype

Bedside medicine is individualistic on both sides of the bedrail. Doctors treat one patient at a time. Patients receive care in the same way.

Talk about teams applies to coordination and general working together. When you get to the bedside — doctor, nurse, RT, whatever — you are an individual treating another individual. Everything else disappears.

Mocking Stereotype

Sagging skin made her look even more shrunken than her 94 years. Oxygen tubing tangled with IV lines and ECG leads; restraints worthy of Lilliput.

She stared at her toes.

Her family stared at me, then her, then back to me. They cut vacation and carried Grandma home convinced she would die soon. They convinced me also.

We whispered a history and discussed death, dying, and advanced directives.

I turned to examine my tiny patient, scared I might break her porcelain frame.

“Excuse me,” I said, stethoscope in one hand reaching with my other for her shoulder. “I need to listen to your breathing…Could I bother you to move forward…just a little, so I can put my stethoscope…”

A fighter pilot never ejected as fast. Millimetres closer and her shoulder would have beaned me.

She sat up straight, perfect posture, hands lightly on thighs; a mixture of military and schoolmarm.

“Wow!” I leaned away. “Thirty-year-olds can’t sit up like that.”

She beamed.

Her family did not flinch; anxious frowns, alternating looks at her, then to me, back to her. This was no surprise for them.

“Seriously, I have never seen anyone sit up like that. Ever!” I said smiling.

“How did you do that?”

“Do you do sit-ups every day?”

“No,” she said. And without pause, “But I’ve been thinking about starting!”

She turned her head to me now; flexible neck, sparkling eyes, a giant smile to mock my prejudice.

Individual Patients

Society defines groups, and those ideas infect doctors. Doctors adopt nonsense in society and bring it to the bedside. It infects our brains until a little old lady knocks it out.

Medical charts used to contain shorthand for stereotypes. LOL meant “little old lady.” It is gone now for good reason. There is no such group or any group in clinical medicine.

Every time we make a group, individual patients prove us wrong. Something about our patient always makes him the atypical drunk or head-injured person. He actually is not drunk. He is delirious and septic or something more serious.

Patients suffer when doctors reduce individuals to nothing but members of a group.

Classic cases define pathology. We can group gallstones by type. We cannot group the individuals the gallstones came out of, even though some features increase the chance of getting stones.

Individualism

Doctors who insist on treating groups instead of individuals cannot practice good medicine, if they can practice at all.

Unless doctors focus on the unique physiology in front of them, their patient is at risk. In the same way that children are not just little adults, individual adults are not just little old ladies or any other group.

Individuals frustrate collectivists. Patients think and behave in ways that place them outside what the collectivist wants.

An individual makes decisions. She ruins group outcomes. “It happened so fast” stands out as part of so many patient stories simply because every other part is so unique.

One Patient at a Time

Collectivist thinking corrupts the mind and confuses care. We think we are treating little old ladies when we are actually treating someone unlike anyone we have ever met before.

Doctors must resist the collectivist bias to clump and categorize. Each patient is a scientifically and socially unique being unclumpable beyond the fact that she is human and in need of help.

Medical individualism needs no apology.

Even if a patient’s profile makes heart attack the most likely cause of his crushing chest pain, all the more reason to make sure we rule out the diagnoses we miss by the bias we bring.

People suffer when reduced to nothing but a prototype of a stereotype.

Medicine offends the whole concept of groups and collectives in order to help one patient at a time. Medical individualism will continue long after the collectivist fad fades again.

Photo credit: Old woman smiling, as yet unaccredited.

16 thoughts on “One Patient at a Time: Individualism in Medicine”

  1. Collectivism has already changed the doctor patient relationship and of the manner of the distribution of services throughout the world in particular in the more collectivized societies and will soon do so in today’s Canada as it raises its ugly head.

    Under collectivism the rights of the individual are trumped by the “ what’s best” for the community ( as defined by the ruling “those who know best” class) in Communist countries they had / still have a “revolutionary duty” to fulfill that trumped / trumps everything else, in particular the rights of the individual.

    One notes the abuse of psychiatry , in particular, in the USSR to control dissidents and how the medical profession was perverted in National Socialist Germany to euthanize and carry out its state sponsored eugenic program.

    With the collapse of the USSR I returned to the liberated land of my birth and was interviewed on the radio about the concept of western family medicine , of birth to end of life care, tending to each individual as an individual….a completely foreign concept to listeners.

    It may well be that health care in the ex collectivized countries will be more cognizant of caring for the individual whilst we, in the once called “ free world” will go in the opposite, collectivized, more woke direction.

    1. Great comments, Andris.

      I cannot understand why so many doctors seem to advocate against stereotypes and yet embrace collectivism, which is just stereotyping by another name.

      Thanks again for reading and posting a comment!

      1. It’s likely due to group identityitis , is going around and is just as harmful as COVID.

        1. Love that -itis. It has mixed with COVID and made a monster more malevolent than either on its own.

  2. Great article Shawn. Any article that makes me reflect on my practice is worth reading.

    I would not be me if I didn’t push back slightly with a comment.

    I think it is absolutely consistent to reject stereotypes and to embrace collectivism.

    Stereotypes can cause us to make mistakes in medicine, as you eloquently pointed out.

    But collectivism is simply acknowledging that the needs of the many may take precedence over the whims of the few. You may disagree, but many would say that everyone must have dinner before some can have dessert.

    2. I love pushback, Hal! Am honoured that you would take the time.

      You raise a good point: we need to define collectivism. If we describe collectivism as the common good, or the health of the community, or helping families, we arrive at a very different set of ideas than if we describe collectivism as group identity: kulaks, gypsies, whatever (I tried to used groups not used in Canada today).

      You’ve done a brilliant job of juxtaposing needs vs whims. Who defines needs and whims? Does the ‘need’ for everyone to wear a red shirt trump the whim of a mom who wants to provide something nice for her children? When does the mom’s whim become intolerable? That, for me, is the crux. While it sounds nice, history shows that pitting collective needs against individual whims too often leads to massive individual suffering.

      Having said that, I would love to share a coffee with you and talk about this.

      I worry about unrestrained individualism — as you do, I suspect. Atomistic individuals in a fight to the death with each other does not seem attractive to me. Having said that, the answer is not to embrace group labelling and stereotypes.

      Sure great to hear from you! I hope you are well.

      Talk soon,

  3. The trouble is, the medical individualist is an offense to his collectivist group as defined by supposed colleagues in his practice environment, politicians, and worst of all, regulators. Will he or she survive as an endangered species long enough for the collectivists to have met their inevitable and well-deserved demise ? “Veritas nunquam perit” (Truth never dies – Seneca, 1st Cent. AD), but not so those who espouse it. The loneliness is worse than the practical hardships often endured thereby.
    Collectivists Offer Virtue, Individuals Die from the consequences. (Addendum currently required to demonstrate topicality).

    1. I don’t think that Dr. Whatley was suggesting that we tolerate the “individualist” who advocates, say, for example, treating Covid with oral bleach (or hydroxychloroquine). Or other quacks who sell unproven “cures” and prey on desperate patients and family members.

      I think he is advocating that we treat each patient as an individual, and not make assumptions.

      1. Excellent clarification, David!

        Yes, precisely. As you said.

        Thanks for adding this. I hadn’t thought that some might take that tack.

        Cheers

    2. You know of what you speak, Roger! You raise another level of individualism. Professionals who stand out amongst the crowd get whacked down for sure.

      I hope you are doing well. Great to hear from you.

      Cheers

    3. One thinks of Barry Marshall of Kalgoorlie , Australia with his crazy idea that a bacterium used peptic ulcers and gastric cancer…and that crazy Semmelweis who advocated the washing of hands and the use of sanetizers in hospitals…and that earlier crazy fellow Harvey and his bizarre ideas about blood circulation.

      The secret comes from an individual who think for him or her self…no collective…no committee , no collective is so capable , turning most participants into idiots.

  4. Shawn,

    The problem for me, is that collective good (politically speaking) is necessarily defined by some individual (or small committee of same).

    Why them ? We all know there is no answer to that question, without falling, as Marx did, into the depths of mysticism based on collective consciousness (à la Hegel).

    Much better to have individuals walking around, each trying to work out what is best, at the most detailed possible level.

    And as a last thought : why is it immediately assumed that individuals will always be trying to do nothing other than slit one another throats ? Why do we assume a complete absence of personal morality ?

    Everybody in this conversation is attempting to do something “good” in the world. And I have no reservations about allowing them to do it.

    Actually, I would be much more suspicious of the morality of anybody who thinks he should be enabled to dictate the nature of “higher good”, acting, according to the theory, as the selfless tool of collective will and consciousness. Or in modern terminology “the dude who follows science, and digs where society is at”

    Best Regards,

    Gordon Friesen, Montreal
    http://www.euthanasiediscussion.net/

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