Monday, 14 February 2011

The House of God

When I began as a resident I was allowed to ask for any diagnostic tool. The only requirement was that I needed to show the specialist I worked for how the results would influence my decisions. Imagine ordering an X-ray of the left foot to evaluate a possible heart attack. As it is impossible to make any reasonable connection between the two (foot-heart) no radiograph would be allowed.

Before that, as an intern, I was impressed to see an orthopaedic surgeon evaluate patients in order to find reasons not to operate. Later, as a resident I found that it is a trait seldom found among those trained to use a scalpel. The reasoning was, obviously, that we as physicians do cause complications, and as such may end up hurting patients.

With that in mind I just read an article, by Harriet Hall, which underscores that point:
We are healthier, but we are increasingly being told we are sick. We are labeled with diagnoses that may not mean anything to our health. People used to go to the doctor when they were sick, and diagnoses were based on symptoms. Today diagnoses are increasingly made on the basis of detected abnormalities in people who have no symptoms and might never have developed them. Overdiagnosis constitutes one of the biggest problems in modern medicine. Welch explains why and calls for a new paradigm to correct the problem.
To me, this is not rocket science. If anything, we were already warned by Samuel Shem that medical interventions inevitably introduce risks. His "good medical care is to do as much nothing as possible" I interpret to stand for:
  1. There are so-called self-limiting conditions. This means they resolve by themselves without any treatment: i.e. common cold.
  2. Medical interventions are inherently dangerous, there is always the risk it leads to complications.
These points should make any physician question the necessity of any intervention. The following examples are meant as illustration to those points, and of how I view diagnostic and therapeutic interventions.

One day a patient did not sufficiently produce urine. The medical history showed abdominal surgery the previous day, while the current status showed an i.v. drip with NaCl 1 liter/24h, an NSAID to counter the post-operative pain, blood tests suggesting deteriorating kidney function, and diuretics to correct for the diminishing urine production. At this time I was consulted to look at the kidney function. To the trained eye there already are several clues.
  • Fluid replacement at 1 l/24 h is not much (the patient did not yet eat or drink), especially in abdominal surgery. This alone might cause dehydration. After evaluating the patient I concluded this was what happened,
  • Of course, once a patient is dehydrated using diuretics appears somewhat counter productive: you need fluid to urinate, not lose more by stimulating diuresis,
  • Then the use of NSAIDs, they are known to cause stomach, and kidney problems. In a patient that already has a compromised kidney function these drugs should be immediately discontinued, and replaced by another type of analgesic,
After concluding this was prerenal kidney failure, or dehydration, the fluid volume parenterally administered was increased to 2 l/24h, the NSAID and diuretic were stopped. Several hours later the urine production, and lab tests, returned to normal. This is not meant to embarrass any colleague but as a warning that something trivial as a painkiller may have devastating effects. In this case the patient might have ended up requiring haemodialysis.

An example of the risk diagnostic methods pose is perforating the colon, which is rare, when taking a specimen to evaluate polyps. To prevent you from falling asleep I will stop illustrating the point. You undoubtedly understand my point.

Thinking about these possibilities today my view is that we should always ask ourselves: is the possible complication from the therapy/diagnostic method I want to prescribe worth the expected benefit?

In short, is this test required for a diagnosis, and is non-treatment more dangerous than treatment? Only then should one proceed with the intended intervention. Or, "good medical care is to do as much nothing as possible."

As an aside, this maxim is applicable to other professions too.

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