Medicine as we currently practise it is at the highest level ever, but of course it is still not perfect.
Jacob Stegenga, a Cambridge philosopher, coined the term ["Gentle Medicine"](https://aeon.co/ideas/how-gentle-medicine-could-radically-transform-medical-practice), a concept that tries to circumvent some of the problems of contemporary medicine. I do not agree with him on all points, but I would like to consider what "gentle medicine" might mean in diagnostic disciplines such as radiology.
Stegenga refers to "Gentle Medicine" in terms of three aspects that should be changed by this philosophy of medicine: Medical practice, the scientific agenda of medicine, and political frameworks.
I would like to focus here on medical practice.
Stegenga writes:
> Physicians could be less interventionist than they currently are. Of course, many physicians and surgeons are already conservative in their therapeutic approach, and my suggestion is that such therapeutic conservatism ought to be more widespread.
One can be conservative not only in therapies but also in diagnostic measures. One problem of modern medicine is that we have an incredible number of diagnostic possibilities. The question is no longer "what can we do?" but "what should we do?“
You can examine every pimple with MRI or ultrasound these days without doing obvious harm to the patient, because both examination modalities are in principle harmless to the human body. The problem is compounded by the fact that the doctors who order the examinations are not the ones who perform them and thus do not directly feel the consequences of their actions. I am sure that there would be far fewer ultrasounds if they were carried out by surgeons themselves and not by radiologists.
Not everything has to be further examined. But that requires courage and good communication with the patients. Courage to say "no" to further examinations. Courage to simply do nothing. To simply leave it at that.
You need good communication to explain to the patient that you don't have to further examine everything just because you can, and that some things just go away on their own. Today's examination methods are so sensitive that much of what is discovered nowadays is merely unimportant "noise".
As Stegenga writes:
> Similarly, the hopes and expectations of patients should be carefully managed, just as the Canadian physician William Osler (1849-1919) counseled: 'One of the first duties of the physician is to educate the masses not to take medicine.'
Osler's quote could be rewritten as: "One of the first duties of the physician is to educate the masses not to diagnose everything."
Even though an ultrasound examination may not cause any physical harm, unnecessary diagnostic measures often unsettle patients unnecessarily. Not every abnormality of the human body requires the attention of a diagnostic test.
The problem, of course, is that such an approach is unattractive from an economic point of view - at least in Germany. It is simply not in the interest of a doctor (a radiologist, for example) to do fewer examinations. Just as a bookseller who only lets every second customer buy a book, it cannot be in the interest of a doctor to provide less service for which he is paid. I know that this sounds cynical and of course the majority of doctors does not order an examination just because of pure economic benefit for themselves. Nevertheless it is best not to let this temptation arise in the first place.
This is one of the reasons why ["value-based healthcare"](https://www.nejm.org/doi/full/10.1056/nejmp1011024) is such an interesting approach. The incentives of patients and doctors should overlap as much as possible. Doctors should be incentivised in such a way that they, too, have the medical benefit of an examination in mind when ordering it, and not their own profit. Idealism is good but the right incentives are better. This is not meant to be a criticism of us doctors. This is how our reimbursement system works to a large extent. But that doesn't mean that it can't be fundamentally improved.
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