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Best Practices in Medicine: Observations from Iceland

In 2020, I authored a book, How to Get the Right Diagnosis: 16 Tips for Navigating the US Medical System. It captured key lessons learned in 2014 following a five-year struggle with an undiagnosed illness. Little did I know then that I would spend the next six years dealing with a second undiagnosed illness!

Recently, while on vacation in Iceland, my health deteriorated severely. I was hospitalized for 18 days suffering from a rare form of vasculitis. During this time, I observed five best practices that should be emulated by every medical system:

1. Consider and test for multiple hypotheses
2. Encourage all team members to challenge assumptions
3. Incentivize doctors to avoid becoming captives of their specialty
4. Listen to and partner with the patient
5. Foster a robust collaborative team effort

Multiple Hypotheses. In Iceland, the doctors and nurses worked as a group to generate a list of candidate alternative diagnoses (think of the TV show House). Instead of testing the hypotheses in a serial fashion, they conducted synchronous evaluations. As a result, the diagnostic process was much more efficient.

Key Assumptions. With complex cases, it is important not to discard a hypothesis prematurely. In Iceland, two initial assumptions that made sense turned out to be wrong, and one that appeared 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 expert judgment.

Overspecialization. Over the course of my sojourn, I was attended by doctors representing nine specialties: rheumatology, hematology, infectious disease, cardiology, pulmonology, dermatology, oncology, gastroenterology, and internal medicine. In Iceland, I was impressed by the willingness of the doctors to think outside their “specialty box.” I suspect one reason for this behavior is that the practice of medicine is far less litigious in Iceland. In addition, my sense was that the doctors felt more empowered to focus on the broader context of my condition and more compelled to get the diagnosis right.

Listening Skills. The first question I was asked by doctors and nurses on every visit was “How are you feeling?” When I mentioned a symptom that did not fit their pattern of what could be wrong with me, they wanted to explore the discrepancy, not ignore it.

Collaboration. Lastly, what truly impressed me was the robust culture of collaboration demonstrated by everyone associated with my case. On at least three occasions, a panel of doctors and nurses convened to brainstorm diagnoses, decide on the best treatment, and estimate a discharge date. Over 18 days, I was seen by 12 doctors, and the transfer of knowledge among them was smooth and comprehensive. While in the ER and the hospital, I engaged in conversations with more than 100 medical professionals. Much to my amazement, they all appeared to be working off the same sheet of music. How they managed to collaborate so effectively was unexpected and impressive.

In sum, my recent health emergency in Iceland taught me a lot about what makes a medical support system work well….and I am alive today to tell the story!