Medicine For People!

November 2015: Cookbooks and Shotguns

The Art of Cookery Frontispiece
"Art of Cookery frontispiece" by Scan: Contributor. Original: W.Wangford c.1777 - Scan by this contributor from c.1770 original in own possession. Licensed under Public Domain via Commons.

Cookbooks and Shotguns


  • Cookbooks and Shotguns: Use with Care
    • Mary Flick, ARNP
    • There's a Place for the Cookbook
    • And a Time to Look at the Patient
    • Rifles or Shotguns?
    • Is Medical Care Improving or Not?
  • Laboratory Service
  • Facebook Favorites
  • October Schedule

Cookbooks and Shotguns: Use with Care

Mary Flick, ARNP

The best nurse practitioner I ever worked with was Mary Flick. She worked full-time in supervisory jobs in hospitals, such as director of the intensive care unit or the director of emergency services. But she liked to keep her hand in as a nurse practitioner and for a time cared for our patients during my weekly afternoon off.

On my return the next day, I would review her medical records. Mary was naturally curious, and therefore significantly above average in her ability to arrive at an accurate working diagnosis. She connected well with people and wasn't prescription happy.

Once a month we'd sit down for a supervisory chat. She genuinely enjoyed going over her work and was always happy to learn a better way to do things. She brought pen and paper to write down my suggestions for refinement. Ultimately, her advancement in her other jobs monopolized so much of her time that she had to leave us.

I did not have the same experience with every nurse practitioner I hired. Not all had Mary's diagnostic skills. But more than that, they inappropriately shotgunned colds, sinus infections, and bronchitis with inappropriate and often unnecessary antibiotics. Their prescription choices seemed to mirror the advertisements in the medical journals more than they did the real facts on the ground. When I sat down with them to review their records, they expressed surprise. "What are we doing this for? I've got my book from my training right here in my bag! I know what to do!"

There's a Place for the Cookbook

In a way, there is logic in their protest. In certain medical situations we absolutely need to go by the book. Atul Gawande, one of my favorite physician writers, wrote a book titled "The Checklist Manifesto" in which he points out how we have learned from the airline industry how checklists improve safety and can be lifesaving, especially for high-tech procedures. But not all medical encounters mirror the safe takeoff of an aircraft.

And a Time to Look at the Patient

For an example of harm from medical cookbooks and shotguns, decades ago every woman with breast cancer underwent a radical mastectomy, in which her entire breast was removed along with the lymph nodes in her armpit and the pectoralis major muscle beneath her breast. The reasoning was that if a single cancer cell had migrated to any of those places, it could kill her. This sounded prudent and logical, but as observations accumulated it appeared that less disfiguring surgery prolonged life just as much and caused less disability. Proponents of the old technique-the cookbook-would simply fall back on "How irresponsible! Don't you care about the woman's life? This is how we've always done it."

This surgeon shows why we must get our head out of the cookbook when we care for people. Many changes we call cancer, such as many forms of DCIS (ductal carcinoma in situ), don't harm people at all. The Dr. Esserman discussed in article is not alone in recognizing that many women with DCIS will live far better lives if left alone by their surgeons. Rather than reflexively removing such tissue, she engages in the far more difficult task of treating each woman as an individual and identifying who will really benefit from surgery. She knows what is in the cookbook. She well understands what I call the shotgun approach -treating for the "worst case" every time-and makes the extra effort to go beyond it.

The story of Dr. Esserman mirrors the story of modern medicine in general. The burden of our payment systems, the ever-increasing pace of physician work, the straitjacket of liability, the comfort of the cookbook-all these conspire to make the path of a Dr. Esserman more challenging, and to make business as usual, cookbook medicine, difficult to escape.

Rifles or Shotguns?

There are many difficult aspects to medical practice. Let me name just a few:

    • You need to know which cookbooks are best and what is in them.
    • You need to know when to go beyond the cookbook.
    • You need to understand the difference between diagnosis-specific treatment (the rifle), and "let's throw a bowl of spaghetti at the wall and see if something sticks" treatment (the shotgun).

Is Medical Care Improving or Not?

Today a nurse practitioner or physician's assistant in a specialist's office, going by the book, treats many conditions better than the average family practitioner. The skill levels of family physicians continues to improve.

And still we can do better. Doctor Esserman has fought and is still fighting an uphill battle to provide the best care for women with alarming results on breast lump biopsies. Mary Flick is concentrating now on administrative work and has discontinued her work as a nurse practitioner out of concern that she cannot devote enough time to it to meet her own high standards.

My plea in this newsletter is that we identify and encourage the best practitioners, such as Dr. Esserman and Mary Flick, so that we can do the best we can for suffering humanity. We in the medical business need to own, not just know, the healing arts. We need to know when to go beyond the cookbook. We need to take full advantage of the physical examination and our other diagnostic tools so that we can prescribe appropriate treatments chosen more from the point of view of the rifle and less of the cookbook and shotgun variety.

Laboratory Service

Just to remind you, when you need laboratory work, we can usually save you a great deal of money over other local options. For example, the very reputable laboratory in Seattle, Labcorp, will determine your chloride, potassium, sodium, carbon dioxide, glucose, alkaline phosphatase, albumin, globulin, total protein, bilirubin, total, calcium, ferritin, uric acid, total cholesterol, triglycerides, ALT (SGPT), AST (SGOT), CBC/differential/platelets, cardiac C-reactive protein, GGT, LDH, BUN, HDL cholesterol, creatinine (includes eGFR) , high sensitivity TSH, and vitamins B12 and D for $246.

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November Schedule

We will be closed November 5th, 6th, and the two days of Thanksgiving.

You can find my home telephone number in the book. Please don't hesitate to call for urgent needs when we are not open.



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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.