It seems our society lives in dread of cancer, one word that is the purgatory of the modern western world. How often does a patient reply, when you tell them the positive results of an investigation, “Thank heavens it isn’t cancer” even though the actual diagnosis may be more life threatening than many neoplasia. The almost biblical belief system behind the word cancer comes with a corollary that poses a major problem to effective rational health care, namely the “must get it out” association. That medical school surgical dictum “When in doubt, cut it out” may have been superseded by more politically correct phrases, but the thought remains ensconced in our own and our patients’ minds when faced with a diagnosis of a solid neoplasia.

But why is this so? Why do we believe that a diagnosis based on visualisation of some cells down a microscope has a 100% positive predictive value, especially when the patient has absolutely no symptoms or clinical signs to support the diagnosis? Have you ever tried to explain the gap between a histological and a clinical diagnosis to a patient?
Not easy, yet we know from the prostate screening studies that a histological diagnosis of prostatic carcinoma is poorly predictive of subsequent death from that cancer. Try the melanoma studies demonstrating a significant interoperator variability in histology results. What about the phenomenon of diagnostic drift, especially the recent study showing that, in current day reviewing of skin biopsy slides diagnosed as normal in the 1990s, a significant number were found to be low grade superficial spreading melanoma. Little wonder we are removing more melanomas than ever before.

What we really need is a change of thinking, more focused on a “cancer” diagnosis based on metastatic disease potential (ignoring the problems caused by primary tumour enlargement, but remember that this includes plenty of non malignant growths). This requires a different diagnostic method and is the likely way things will move in cancer diagnosis. Consider if we had a test for prostate cancer that had a better predictive ability for the development of metastatic or local spread disease. Same for breast cancers, especially the very problematical DCIS.

Sentinel node biopsy seems to have potential, at least in terms of identifying if metastasis has already occurred, but greater potential is likely to lie in biochemical indicators of metastatic activity and potential, such as have already been found in inflammatory breast cancer. It’s unlikely imaging as we know it will be a suitable answer, but perhaps, in conjunction with metastatic markers, we may be able in the future to reassure patients that their cancer is better lived with, rather than without.

Our challenge will be to shift this cancer belief system and the associated concepts of appropriate therapy.

I’m a doer. I like being a doctor who can fix things, whether it is treating an ear infection, suturing a laceration, or managing a patient through DKA. But I don’t just like to “do” – I like to serve. I enjoy home visits. I enjoy going to the nursing home. And I particularly enjoy volunteering at our local free clinic for the uninsured. With the cost of healthcare in the USA steadily increasing, I enjoy being able to be a part of serving those who are left out.

I also like to be a thinker, and feel it is important for us as doctors to THINK about why we do what we do. So, when I’ve had the opportunity to speak about the opportunities and challenges in caring for the uninsured, I’ve been a bit flummoxed when listeners have told me they want more on “how to” and less on the ethics, principles, and ideas behind service and care for the poor. And, having had that feedback, I actually felt a bit vindicated to see the program for a recent conference on health care for the poor included a whole track on issues of service, professionalism, and the doctor’s identity. “At last!” I thought, “more recognition for the issues of identity, and not just ‘getting the job done!’”

However, I’ve also been reminded recently, that there is still more to medicine than thoughtful service – doctoring is more than just thinking and doing. Several encounters, with students, patients, and colleagues, both at home an abroad, have reminded me yet again of the foundational importance of the relationship. Medicine is nothing, if we lose the human, “I-thou”, person-to-person connection with our patients.

As doctors, it’s easy for us to see the need for our service. But for our service to make a difference, we also need to think carefully and reflectively about what we do. However, for our care to have VALUE, for it to be HUMAN medicine, we need to pay as much, or probably more, attention to the relationships with our patients and our colleagues.

Relating, thinking, and doing – each is a vital piece of medicine, and put together they make for even better doctoring.

A recent commentary in the Journal of the American Medical Association (JAMA vol 302, p994, http://jama.ama-assn.org/cgi/content/extract/302/9/994) proposes "systems medicine" as a new paradigm for moving medicine "from reductionism to holism." However, commentary itself takes an unfortunately narrow view and primarily biologic view, focusing mainly on the integration of genomics with disease prevention.

It seems to me a true systems approach must address issues at multiple levels that affect patients individually or as communities: biology, personality, communication, culture, lifestyle, socio-economics, and environment. For example, while diabetes risk may be partially related to genetic vulnerability, an individual's risk of diabetes is also significantly mediated by lifestyle factors and socioeconomic factors, while cultural and communication factors may play a major role in his or her understanding of the disease.

This broader view of systems medicine is nothing new to those in primary care. Focusing on first-contact care, long-term person-focused care, comprehensiveness, and care coordination we are already well-positioned to practice "systems medicine". Family physicians, in particular, are trained to address the multiple systems levels that bear on patients' lives and well-being.

Shifting to a truly systems based approach really would represent major advance forward for medicine. But in order to make the first step towards this advance, we must ensure adequate funding, institutional and academic support, and clinical structures to support a strong primary care enterprise.