The Rashomon Effect

The 40 year old gentleman was in deep distress. His wife was caressing his left shoulder in a bid to alleviate his pain. Within the last 48 hours, he has met three doctors (specialists to be precise) and underwent an ECG, ECHO, MRIs of shoulder and neck bone, and a battery of blood tests. The wife’s hands were overflowing with the prescriptions, bills and the lab reports. Being an IT professional, he has been suffering from neck pain often. Three days back, the pain started to shift to his left shoulder and arm. Naturally, he googled his symptoms which indicated the possibility of an imminent heart attack. The couple had rushed to a local doctor who performed blood tests and ECG and sent him to a cardiologist.

The cardiologist thought it could still be a myocardial ischemia and performed an echo test and Troponin. It turned out to be normal but to be on the safer side, he prescribed low dose blood thinners, cholesterol medications and advised him to get an orthopedic opinion.

The pain was excruciating and the orthopedician being a specialist in keyhole surgeries suggested that it could be a tear in the shoulder tendons since the patient was a diabetic. He performed an MRI of the shoulder which was equivocal. He gave him some more medications and suggested he meets a neurologist ‘just in case’ it could be a nerve problem. After examination, the neurologist too thought it could be a diabetic or viral neuropathy based on the high diabetes. He advised a few tests and an MRI of the cervical spine. Finally, it turned out to be a slipped disc in the neck bone and he landed in our net.

What we see here is a common healthcare situation of late. Every specialist sees the patient and his symptoms from his specialized narrow perspective. The clinical notes, investigations and management are tailored to the doctor’s specialization. This is what I would state as Rashomon Effect.

Rashomon was a famous movie directed by the celebrated Japanese auteur, Akira Kurosawa. In this movie, a murder scene is described by the different witnesses in their own point of view. All their views are different from one another. But they all believed that they are speaking the truth because it is their own correct perspective.

Similarly every medical specialist has their own approach towards the patient, typically focussed on the system in which they have specialized. Upper stomach pain is seen as esophagitis by gastroenterologist, angina by cardiologist and costochondritis by the orthopedician. If we look at their clinical notes and examination findings, it would match their diagnosis since their mind is blinkered. The specialised mind fills the gaps with his previous observations, knowledge about their organ system and myopic training.

With increasing super specialization, the patient is not seen as a whole but an affected organ system. The specialist of the organ system falls prey to the Rashomon effect and explains the patient’s symptoms from his perspective. It is difficult to avoid this in the upcoming future since general practitioners are on the wane now. Unless the medical community talks about this, this could reach tremendously dangerous proportions.