Wednesday, December 11, 2013

Being “Certain” in an Uncertain Medical World

The art of medicine is managing uncertainty. Yet, be honest: Have you ever met a more certain group of people than physicians? As a physician, I am no different. This past week, a close friend of three of my sons called me, as he was having severe abdominal pain. I spoke to him and his wife and quickly determined he needed to go to an emergency room. I told them that while I could not diagnose over the phone and without examining him, I did think this was most likely a kidney stone attack and not appendicitis. The next morning -- when he was out of surgery for his appendicitis -- I thought about how my relative certainty about it being a kidney stone was so wrong. I actually thought about asking to see the pathology report to make sure it was really an inflamed appendix, and not a kidney stone.  I was certain even in the face of uncertainty and conflicting data. 

That incident got me thinking about another time when I was wrong in a very similar situation. At that time, more than 35 years ago, I was an intern in internal medicine and I developed severe abdominal pain. My wife -- the smartest physician I know and at that time an intern in pediatrics -- took me across the street to the emergency room where I gave a perfect story to the surgical resident for appendicitis (this was in an era before we did CT scans to rule out appendicitis), and they started to get me ready for the operating room. The surgeon, my wife and I were all positive this was an acute appendicitis, but then I gave a pre-operative urine sample that was filled with blood.  My wife and I were surprised, as was the surgeon, but we all realized that while we were certain it was appendicitis, we were wrong. It was really a kidney stone. 

Even in this day of advanced technologies, much of medicine is still mysterious, and the practice of medicine is all about understanding that diagnostics and therapeutics are based in science, but are only rarely in concrete isolated fact.  More often, there are competing facts and multiple complicating factors; physiologic, sociological and psychological -- as well as different communication styles and contextual issues that make truly good doctors understand and learn to cope with a fundamental level of uncertainty in all that they do.  Perhaps coping with that uncertainty is why physicians often seem so sure.  Perhaps that is one way people survive as physicians. 

The secret behind the physician’s bravado is that caring doctors have to also manage their own anxiety and their own uncertainty while they manage the patient. They deal with this influenced by their own communication style and their own life context. The idea of a physician being perfect is a myth, and many excellent physicians struggle internally with carrying that myth. So doctors manage this internal uncertainly in various ways. Here, I offer my own characterization of doctors’ techniques for managing the uncertainty inherent in medical care -- and their own anxiety that occurs as a result. These techniques can be very adaptive, helpful – and, at the same time, dangerous to the patient and the physician:

When most uncertain, appear most certain:  Early in my career, a very prominent leader in academic gastroenterology told me his rule for handling patients with chronic irritable bowel syndrome:  “The less specific the treatment, the more specific the instructions should be.”  He told me of prescribing tincture of opium for these patients in the 1950s and telling them to place 11 drops -- not 10 or 12 -- in one-quarter of a glass of water, not half a glass, and drink it quickly. While he knew the efficacy of the treatment he was giving was uncertain, he believed that showing certainty as a physician would make it more likely the treatment would help than if he wavered.  This maximizes a placebo effect, which is real and effective; however, in the long run, this also carries the risk of harming the patient’s trust in the physician. 

Use specialist consultants generously:  This is the other extreme of the first technique. Instead of appearing to be totally confident in all pronouncements, the physician is quick to send a person with any illness to a specialist. In my previous life as a gastroenterologist and nutritionist, I was often frustrated by consultations that appeared more related to the referring physician’s lack of knowledge than the patient’s need.  The really skilled physician knows when to use the specialists in terms of both timing and condition. A consultation made too early creates risk for the patient, as the specialist may feel the need to “do something” -- when doing nothing and waiting for a self-limited illness to run its course may minimize harm and maximize benefit for a patient. The doctor who farms everything out due to his or her own internal uncertainty does the patient no favors while the doctor who never uses specialists may create risk by delaying needed care that only a specialist can give. 

Order every test to rule out the less likely diseases:  In this case, the fear of missing a disease drives over-testing.  While the good physician is compulsive and complete, the advances in medical technology and the ability to order newer and newer tests often lead physicians to downplay the harms that can come from over-ordering.  Every test has false positives and false negatives. I have seen people saved from devastating illness from a test they didn't really need (the cancer found on a CT of the abdomen for pain that was “incidental” and not related to the pain), but I have also seen people die as a result (the person who has surgery when a finding on a similar CT scan is thought to be a tumor, and who dies during the surgery in which no mass is seen).  The risk of harm from over-testing is higher than the likelihood of benefit however if the physician treats everything as routine and not needing investigation, that too can be harmful. 

Follow the algorithm: In this era, the more we learn, the more important standards and guidelines are.  However, the doctor who only relies on the algorithm and does not “see” the person behind the disease will miss important opportunities for diagnosis and treatment.  It is often easier for physicians to take solace in following an algorithm than to understand that algorithms are limited and cannot take the place of the decisions a good physician needs to make in managing uncertainty.  Dr. Saul Weiner’s research on the context of medical care shows the need to understand the patient’s life in order to maximize the benefit of the algorithm and minimize the risk of blind obedience to it. 

Go to the academic medical studies: I usually believe that this is the most useful technique, yet the doctor who needs to look everything up is neither efficient nor maximally effective.  You need to know enough and, at the same time, know what you don’t know and what you need to investigate. You need to understand that facts change and that the latest pronouncement of a breakthrough in the medical literature may be followed by later reports showing the breakthrough to create harm as well as benefit.  At the same time, I always will trust a doctor who says “I am not sure” and “I want to look up more information” more than a doctor who tries to show he or she has mastery over everything. 

The good doctor manages uncertainty. The great doctor also effectively communicates that uncertainty to the patient while still maintaining the patient’s trust.  That is the high form of the art called medicine.