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MEDICAL PRACTICE-ITS GREY ZONE. |
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One
of my dear friends asked me to highlight the achievements
of modern medicine. This is being done daily in medical
newspapers and even in lay press that I need not repeat
the same. This kind of publicity has brought the medical
profession to the level of Gods. Playing God has landed
us in deep trouble with the consumer movement. It is time
to take stock of the real situation, so that the veil is
lifted and the true picture presented to the "
purchaser", lest there should be misgivings on his
part. So far the attempt has been to paint a very rosy
picture of the so called achievements in the field of
curative medicine, and to underplay the realities. Time
has come, with the changing scenario of consumerism, to
be frank with the public. One of my friends had once
advised me not to tell the whole truth to the lay man,
but I do not agree with that view. Now there is an
awakening in the field even in the West, where they want
the " purchaser " to know the truth.
" The fact that medical treatment is not invariably
followed by clinical improvement is not one that those
interested in medical quality- be they patients or
doctors- can ignore." says Dr. William G. Pickering,
in his article in the recent Lancet entitled " Does
medical treatment mean patient benefit?" He goes on
to add that " among the diverse selection of
problems presenting to the medical oracle, a proportion-
appendicitis, fractured limbs, and pneumonia- are
unmistakably curable; and success in anesthetics,
fertility regulation, and sundry other specialties add
weight to the inaccurate but extant notion of
limitless medial power." ( emphasis mine ).
There are three kinds of human problems; treatable
diseases which are in the minority,diseases and human
problems for which medical treatment may or may not help,
and the third, untreatable diseases. Anecdotal evidence
abounds in showing us that we are fallible, but in the
statistical scientific world anecdotes have no place. In
reality they do tell us the sad tale. There is no
incentive to report the uselessness of medical
interventions, although they occur regularly. Even in the
eyes of the law if enough doctors practice a particular
remedy, then it becomes right. ( Bolam Vs Friern Barnet
Hospital Case 1957).
Clinical medicine abounds in uncertainty at all levels.
So far the effort has been to sweep it under the carpet
and never face the reality in medical practice. The trend
is changing and there is an awareness now that clinical
decision making is very complex and complicated involving
both rational scientific thinking and in equal measure
intuitive thinking. In fact, Dr. Katz goes one step
further when he says that the doctor’s defense
against ignorance and uncertainty are a greater
difficulty in doctor-patient relationships than the
patient’s ignorance.
In contrast to the usual industrial way of working,
medical practice has always been beset with imprecision
and imponderables, in terms of diagnosis, treatment and
the outcomes of the former. These tend to increase in
relation to individual patient care. In the present set
up it has become much more than in the past, what with
medico- legal, ethical, and sociopolitical changes having
entered the arena. Clinical medicine confronts the
clinician with his ignorance daily, which is due to the
deficiencies in medical knowledge as a whole. The
imprecision and uncertainty will increase inversely
proportionate to the pressure on the time of the
physician, making him spend less and less time with the
patient. There is a need to educate the new entrants to
the profession about the role of uncertainty in medical
practice, as otherwise they will get overwhelmed by it
when it confronts them head on.
Another area which makes medical practice imprecise is
the impossibility to predict the future in the human
system with the present scientific methods. I have
written about this many a time in the past.The science of
probabilities started with philosopher Pascal in the 17th
century, we did not use it in medical science because of
the influence of Descartes. We have now realized our
folly. To give one small example let us take the exercise
stress ECG test being done on asymptomatic apparently
healthy population to predict the future outcomes. The
results are presented to the patient as positive or
negative. Both the above may be wrong because of the
large number of false positives and false negatives which
are the rule in this situation. Life becomes miserable
for most of them as either they get reassured for wrong
reasons or are are lulled into inaction where the vulcano
could erupt any time. Sense seems to have prevailed on
the thinkers and Drs. Gray Diamond and JS Forrester have
devised a probability scale to aid the diagnosis of
coronary artery disease, in place of the present
positive-negative paradigm, which is meaningless.
Clinicians must realize that their uncertainty is at the
root of many unnecessary technologies used in diagnosis.
Diagnosis is subjective and needs, in addition to all the
textbook rules, the experience of the clinician. It is
now accepted that clinicians should develop better
communication skills and be able to share their ignorance
and doubts with the patients honestly. This is the best
method to make the patient also a partner in the decision
making process rather than keeping him in the dark and
getting into trouble later because of medicolegal
problems. Paternalism in medicine should give place to
partnerships between patients and doctors. Afterall
ignorance is universal and both the doctor and the
patient could have their legitimate ignorance although
both have their expertise in different areas. There is
one exception to this and that is in dealing with
patients who have emotional and anxiety states as their
main problem. The doctor should be able to understand
that during the initial interview and be able to diagnose
the problem then and there. The latter situation warrants
the greatest care to see that their anxiety is not
enhanced by the doctor expressing his doubts to the
patient.
With the present day knowledge explosion there will be
more confusion in the field of medical practice like in
any other field and doctors will have to be on their
guard. Simplistic market forces are not likely to work in
the medical field and society may demand much more from
the medical profession in times to come in response to
new knowledge in all fields of human endeavour. We must
enter into a new understanding with society and then face
the challenge squarely, putting all our cards on the
table and not keeping any close to our chest. Honesty is
the best policy even here. Law of probabilities is our
better bet than the reductionist science paradigm. Chaos,
a new science, is making headway in all fields including
physics, and we in medicine should wake up to understand
that human dynamic organism obeys only the holistic
chaotic rule, rather than the organ based specialties.
All aspects of the outcomes of our interventions also
should be made known to the patients. Recent meta
analysis of Coronary bypass surgery after twelve years
showed that in terms of increasing longevity, the
operation did not benefit 84%, but in terms of relief of
pain and severe disability it did help a lot. When this
is made known an asymptomatic patient will opt out of the
offer, without any risk for the clinician. One more
reason why we should be open in our attitude. To do that
with confidence we should keep in touch with new
knowledge pouring in at a phenomenal rate daily. The
knowledge changes so fast in medical field that one
should be a life long student. Change is science and
dogma is ignorance and unscientific.
" Clinicians can not afford to avoid uncertainty or
pass it off as inherent aspect of the art of medicine.
Certainty is a delusion-only uncertainty is
certain......this must be acknowledged and addressed
explicitly, especially in clinical training, if reason is
to be used most effectively to improve the quality and
cost effectiveness of clinical practice." say
Drs.Logan and Scott, from Auckland in NewZealand. To come
back to my friend who thinks that medical science has
done wonders, I may have to admit that we have been able
to conquer only one disease so far, that is small pox- it
was done with the old granny’s wisdom of the
vaccine, and not by any hi-tech stuff that we talk about.
Before believing that spare part surgery and the like are
a panacea for human ills, one must have some measure of
understanding of the type and cost of life for the
unfortunate patient following these procedures. Medicine
has been doing and will continue to do, the same old
dictum of Hippocrates " to cure rarely, comfort
mostly but to console always." [index]
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