Uncertainty and clinical truths

Anjan Banerjee
Cambridgeshire, UK (Fall 2017)

 

“Medicine is a science of uncertainty and an art of probability” (William Osler)

 

Monday 15:35 pm

Franciso Goya. Self-Portrait
with Dr. Arrieta, 1820.

The ninety-eight year old patient with piercing blue eyes and a quizzical expression sat in her wheelchair in the colorectal clinic. We sat facing each other in a bare, windowless room, knees almost touching. She was a retired mathematics teacher, and as a young woman had helped the Royal Air Force ground navigation effort during World War II.  I held her hand as I told her that the mild symptoms and anemia she had been experiencing was probably colon cancer.

“I don’t want any surgical treatment so I am not sure why I have been referred for a staging CT scan and an MRI. I just want to be kept comfortable and enjoy my great grandchildren for a little longer,” she insisted. I agreed.

 

Tuesday 08:15 am

At a tumor board meeting, an assembly of more than twenty doctors and nurses steadily trawled through a list of colorectal cancer cases. Yet another  CT scan appeared, together with a pathology report. “This asymptomatic eighty-seven year old man who is six years post right hemicolectomy has a five millimeter nodule in the middle lobe of the right lung.” After a short discussion it was agreed that the new nodule should be investigated and followed with more scans, along with a referral to the lung tumor board. No one dissented.

 

Wednesday 14:20 pm

The  eighty-seven year old man with the lung nodule had returned to clinic for his results, accompanied by his eighty-four year old wife.

“Hello, Doctor,” he said in his West Country burr. “Is that scan clear?”

I explained about the CT lung nodule and our suggestion to investigate further.

“I wish you hadn’t told me. Does that mean the bowel cancer has come back? Or could it be a lung cancer? I’ve never smoked cigarettes.”

“Possibly, although probably not…hopefully not.”

“What would you do even if it is cancer? I’m too old for more surgery and I don’t really want more treatment.”

“George, you need to do as the doctor says,” his wife interrupted deferentially.

Although I reminded him that it was his choice, he went along with the tumor board decision.

 

Thursday 10:00 am

I stared at the faded list of phone numbers on the wall of the endoscopy room. I had been asked to retrieve a displaced feeding tube that in an anxious sixty-seven year old woman being treated for lymphoma. Although there was no obstruction, both the patient and I were trying to find out why her enteral feed, which her husband had been doing for her at home, had stopped. After waiting ten minutes for a call back from the on-call registrar, I explained the clinical circumstances and our question about the stopped feed. “I’m afraid you will need to speak to the nutrition team, as they make these decisions. But most of them are at an off-site meeting until later today.” After a couple of phone calls to the nutrition team went to voicemail, I proceeded to perform a colonoscopy and successfully retrieve the displaced feeding tube. I was relieved and the patient was ecstatic to be able to restart her enteral feed and go home.

 

Friday 14:30 pm

“Is Dr. Patel in today?”

“Unfortunately, he’s not working on clinical duties for the time being.”

I later found out that this distinguished generalist radiologist with twenty-five years’ experience was being investigated for missing seven diagnoses in recent months.  He was suspended and I was forbidden to contact him.  After an achingly slow process taking three years, he returned to clinical work fully exonerated (with his error rates actually being better than the average).  Over half a million dollars had been spent on the exercise.

 

Discussion

With the availability of increasingly sophisticated tools, the rate of diagnosis has increased, often at the expense of clinical skills. But is this good medical practice? Burgeoning clinical guidelines have evolved into diktats at the expense of clinical judgment and freedom. Because these diktats coexist with the increasing risk of complaints and lawsuits, many clinicians practice fearful, defensive medicine.  Driven by a laudable goal of minimizing clinical error, patients are entered into an unstoppable juggernaut of unchallenged diagnostic tests. While these tests are aimed at achieving the best treatment outcomes and giving accurate prognostic information, they are often not tailored to individual patient’s circumstances.

The mere availability and feasibility of a technology is not the best indication of its utility. Incidental findings reported by radiologists and pathologists often result in referrals for other tests “in case something is missed.” Although there is a serious shortage of radiologists and pathologists, some institutions use valuable resources to double report, whilst others obtain second opinions based on clinical relevance and need. Frequency of follow up interventions, scans, and blood tests varies widely, often with no impact on clinical outcome. An obsession with eliminating all diagnostic and prognostic uncertainty, at the expense of generating large volumes of false positives, does not bring us closer to reaching clinical truths. With increasing pressure on clinical and economic resources, is also unsustainable.

Ever-increasing specialization, ostensibly to achieve better diagnostic and prognostic accuracy, is not cost effective, leads to over investigation, and, although the specific disease may be better managed, ultimately may not achieve good holistic patient outcomes. Super-specialists may not have the flexibility to adapt to varying healthcare demands, and once specialized, it can become difficult to revert to a more generalist role. Although specialization is appropriate in the delivery of certain interventions where the best outcomes are volume related, the absence of generalists impacts treatment of acute conditions, and also fails to prioritize diagnosis and management of conditions in the individual patient context. Excess investigation, intervention, and specialization in a global environment with unequal and finite medical resources is inimical to achieving clinical truths for most.

Agreed error rates, reflecting different expected performance levels for generalists and specialists, would be welcomed. While the health economics of new drugs and interventions are evaluated for reimbursement, there seems to be no similar calculations done on the cost benefit impact of follow up scans and interventions.1 The tendency of individual clinicians to want to minimize clinical uncertainty irrespective of cost is laudable, but this may be erroneously equated with achieving a clinical truth.2  The cost effectiveness of many existing expensive tests and interventions is urgently needed, together with prioritization of scarce clinical and equipment resources. How often do repeat scans for asymptomatic lung or adrenal nodules in elderly patients result in improved survival or quality of life? Interventions that meet a pre-agreed cost-benefit threshold should be prioritized and those that do not should be abandoned. Guidelines should be revised to reflect this.  Acceptable “miss” rates that may result due to performing fewer scans and interventions should be published for medico-legal defense purposes, as well as to provide a yardstick for acceptable practice in the case of complaints against individual practitioners. Such an approach would also provide a context for a return to a more generalist practice. Society and the medical profession may have to accept that a generalist may not always be able to live the diagnostic and outcome standards of the super-specialist, but provided that agreed standards are met, this may be the right thing to do.

Such an approach not only affects policymakers, but also the design of undergraduate and postgraduate medical education. The public, as end-users, must also be part of this debate.3,4 The ultimate goal must be complete honesty both with our patients and ourselves that some clinical uncertainty is inevitable. My wise ninety-eight year old patient came to this truth herself. We should trust our patients in understanding the trade-offs they are willing to make, within an acceptable level of sensitivity and specificity, in the choices they seek for their health.

 

All anecdotes are accurate, although some individual identifiers and timings/chronology have been adapted to maintain anonymity.

 

Image credit

Franciso Goya.  Self-Portrait with Dr. Arrieta, 1820.  Oil on canvas, 45 1/8″ x 30 1/8.” Minneapolis Institute of Arts, Minneapolis. Accessed on 10.12.2017.

 

The words at the bottom of the frame read:

Goya gives thanks for his friend, Arrieta, for the expert care with which he saved his life from an acute and dangerous infection which he suffered at the close of the year 1819 when he was 73 years old.

Eugenio José García Arrieta (born Cuellar, Spain in 1770), better known as Dr. Arrieta who cured Francisco de Goya from a serious illness (undiagnosed at the time but likely to have been typhoid fever) in 1819, and in gratitude, Goya painted this picture in dedication to his doctor for his care, although no diagnosis was made nor prognosis given.

 

References

  1. Pathirana T., Clark J, Moynihan R. Too much medicine – what is driving this harmful culture? BMJ 2017; 358:446-8
  2. Groopman J, Hartzband P. The power of regret. N Engl J Med 2017; 377: 1507-9
  3. Joseph-Williams N, Edwards A, Elwyn G. The importance and complexity of regret in the measurement of ‘good’ decisions: a systematic review and a content analysis of existing assessment instruments. Health Expect 2011; 14: 59-83
  4. Kahneman D, Tversky A. The psychology of preferences. Sci Am 1982; 246(1): 160-73

 


 

ANJAN BANERJEE, DM, MSc, FRCPEd, FRCS (Glas, Edin), FRCS (Gen), FICS, FAcadMEd, MFPM, FRSB, MBA, is an independent consultant surgeon and pharmaceutical physician, and an Honorary Senior Fellow, at the Clinical Skills Centre at Nottingham University, UK. His medical degree was from Guys and St. Thomas’ Hospitals, London University, and his research doctorate from Nottingham University. He also has Masters Degrees in Biochemistry and Pharmaceutical Medicine and is an MBA. He has published widely in colorectal surgery, pharmacovigilance, patient safety and risk management of medicines and devices and in addition to senior clinical roles has previously worked as a Management Consultant with McKinsey & Company.

 

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