Thursday, May 29, 2008

“Medicine is knowledge, judgment, experience, and luck"

These past few days since 25 May 2008 has been a sort of a misty daze with me.

My mother who is going on 77 years, suddenly on Monday became very symptomatic from chest tightness, syncope and extreme fatigue. She has been having hypertension, chronic asthma and probable coronary disease for some time but had elected for medical therapy. She had become fearful of any surgical option after having undergone 3 painful and eventful knee replacement surgeries, the last of which was some 6 years ago. But she has remained physically active and mentally alert, and she certainly knew her own mind.

This time unfortunately, she is diagnosed as having calcific left main stem disease, where the only therapeutic option is bypass surgery. As a cardiologist, this is especially frustrating, because her disease extends into the ostia of both the LAD and circumflex (ironically they are relatively disease-free otherwise) which renders the option of percutaneous intervention extremely high risk.

Datuk Dr Zainal who had kindly consented to help look after her and carried out the angiographic study was also disappointed that we could not proceed to revascularise her via PCI. And so the urban legend that doctors' relatives are often those who present with the least expected of ailments, and complications, persists.

Some say that Lady Luck is simply not with us, or so it seems. But at least, she now has the chance for corrective surgery, for which we are hopeful, because her cardiac function remains very good.

These past few days also provided another insight for me as a relative, a son of a patient. It has not been easy. In fact it is quite frustrating to be on the other side now of the doctor-patient relationship. The agonisingly slow pace of events/test-results unfolding can be unnerving, and it becomes worse when unexpected unfavourable results emerge piecemeal. It is difficult breaking disease pronouncements to any loved ones; relatives and immediate family members are hardest.

Making decisions on loved ones are even more difficult, doubly so when as a doctor, you know so much more about the risks and possibilities of whatever occurrences and events which can go wrong, expectedly or otherwise.

Besides, the emotional sensations of being a son is felt especially acutely, and an overpowering sense of inadequacy and hopelessness seems to pervade my being. Little wonder that it is almost always advised that one should avoid having to treat one's own family members because this is fraught with ethical and objectivity concerns. Unless we are born so cold-blooded, the emotional attachment can be so enervating that it can transform many a physician into a powerless objectively-feeble wreck!

Aside from the emotional clouding and oppression, the choice of therapy or doctors for your beloved ones is also not as straightforward as it may seem. There are so many factors to consider--who you know, who your usual practice mates are, their perceived track records and reputation, logistics and proximity, affordability, availability, our own personal bias and who amongst one's influential family members who calls the shots, etc.

Yet, how many of us as doctors give our patients that right to make such informed or 'biased' options? Almost routinely in day-to-day clinical practice, we make automatic blase pronouncements on diagnosis and therapeutic plans for our patients.

How often do we spare a second thought for the patient/his/her family to reconsider their options, much less offer an opportunity for second opinion? Choice of referring to which other physician or surgeon is seldom considered, much less frequently, even offered.

Furthermore, how many times must our humdrum decisions appear arbitrary and severe to someone who might be justifiably anxious, a little more curious, or demanding or simply confused? But we appear to believe in our own routine judgment, our so-called experience to make that informed or accustomed decision. In reality we do so without the requisite thought that perhaps, if or when it occurs to us or our family members, we might consider otherwise... or would we?

Most importantly, have we not sometimes asked ourselves whether we have made the correct choice or the best possible decisions for our patients, or do we simply believe that we have done all we can, out of routine, hurried or tired and/or even lazy habit? Is it possible that there might arise complications or untoward outcomes because of our mistaken or dismissively/ dispassionately-made decision?

In a recent NEJM article (The Moral of the Story) Dr Perri Klass discusses how these niggling fears, incessant self-questioning and doubt can occasionally paralyse one's own thinking and decision-making process:

"So I have been thinking about the voices that echo in your head when you make a clinical decision — even a relatively low-acuity decision about a child who doesn't seem critically ill. You can't let all the what-ifs terrorize you...

you just go on practicing, haunted by stories — stories you're a part of, stories that happen to people you love or know well or take care of, stories you hear from your teachers and colleagues, and the occasional well-told story that enters your brain and lives there . . . all those ghosts that hover at your shoulder or in the dark places of your mind. I had a peculiar sense of multiple levels of precepting...

I'd like to think of it, in part, as a collective medical memory. And also as a way of honoring the patients who have suffered 'bad outcomes' — and their physicians, too, the ones who are grieving still, who have told and retold these difficult stories.

"Bad things can be only a step away, and we need to
absorb that knowledge and yet still do our job. It seems to me right and proper that even in everyday primary care, there should arise these unexpected, unpredictable moments when the collective memory catches at your sleeve, when the ghosts whisper to you to watch out, to think again, or at least to scribble a cell-phone number on a piece of paper towel and call later just to be sure that everything's truly okay."

Perhaps, most times in medicine 'luck' turns out for most patient-doctor encounters, so that far more benevolent outcomes trump the far and few in-between, bad ones.

However, this 'chancy' approach might be that possibly avoidable but significant weakness that undermines better and more consistent health care for our patients. Should we not have better and more failsafe systematic approaches, which would greatly reduce adverse or untoward outcomes or even life-threatening catastrophes?

Or do personal professional decisions honed out of determined knowledge-acquisition, prolonged preceptorships/training, engaged experiences, and a consciously-developing acumen and judgment satisfy our medical therapeutic approach? Luck should simply be too rare a dicey affair to matter... at least that is what we all hope it would be...

I wonder if we could ever realise or make a greater effort to ensure that the practice of medicine becomes more predictable, more consistent and ultimately safer for our patients, as well as for ourselves and our loved ones! For my beloved mother, I hope and pray this will all turn out for the best possible results, and that she be allowed to return to better health soon.

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