Monday, July 05, 2010

The role of masterly inactivity in treating patients !

The Doctor, by Sir Luke Fildes (1891)Image via Wikipedia

Today I saw a 28 year old woman who was worried because a 1.0 cm size uterine polyp
had been diagnosed on a vaginal ultrasound scan, and two gynecologists had advised that she needed to have surgery to remove this . She wanted a third opinion, because she was understandably reluctant to go through this surgery. A polyp is a benign finger-shaped outgrowth of the uterine lining, and is quite commonly found in young women.

The patient had no complaints . The polyp had been detected while doing a routine vaginal ultrasound scan during her annual health checkup ! This was an incidental finding, which was not causing her any problems, but when most doctors are confronted with an " abnormality " the "knee-jerk" reflex response is - "fix it ! After all, if you have a hammer, you are likely to see nails everywhere !

I am a conservative doctor, and I told her that no action needed to be taken at this time. The best course of action would be - masterly inactivity or watchful waiting. Now I am a senior doctor, and am comfortable advising patients that they do not need "treatment" for everything which a scan picks up, but I seem to be in the minority these days !

I feel the problem is that doctors only see patients with problems ! They do not see healthy people at all, and sometimes I feel most doctors would not be able to diagnose a healthy person if they saw one ! Infertility specialists only see infertile women, which means that they unthinkingly assume that every problem they find during their diagnostic testing is the cause of the patient's infertility and needs to be " fixed" . However, this is flawed thinking. The truth is that we we do not know the natural history of many of these conditions. Thus, we do not know how many fertile women have polyps - after all, most normal women have enough sense not to go to a doctor !

This means that we tend to over-diagnose and over-treat. Sadly, taking a second opinion does not solve the problem because most doctors will give the same advise - treat it ! After all, it's much more more profitable to treat it than to leave it alone. Incidentally, this is perfectly acceptable medical practise, and would not be considered to be unnecessary surgery, because most textbooks do advise that polyps need to be removed and most doctors are quite happy following these textbook recommendations ! For one, they can just follow the protocol blindly, which means they do not have to apply their mind or individualise their advise for the patient's unique circumstances - something which takes time and energy ! Modern medicine believes in protocols and guidelines, which leaves individual doctors with very little freedom to make decisions for special cases. Everyone has to be squeezed into the protocol, no matter what ! It's much safer for doctors to do this, as they cannot be criticised for following accepted guidelines. Sadly, there is no incentive for doctor to not do anything !

I think we need to remember that we do not treat ultrasound images - we treat humans ! The exact same polyp seen on an ultrasound scan in a 34 year old infertile woman needs to be managed completely differently as compared to a 29 year old asymptomatic woman !

Aggressive over treatment can have a downside , because it can end up creating more problems ( for example, operative hysteroscopy for polyp removal can result in infection or bleeding). The trouble is that our machines for making a diagnosis have become much better , and because the technology is so good, it's very easy to pick up normal variants and label them as an abnormality ! It's also easy to offer to treat, because modern treatment is minimally invasive , and does not involve scars or hospitalisations , which means that doctors are more willing to intervene !

However, remember that no surgery is minor for the patient which means patients are often confused. They are fine, so they are reluctant to do under the knife. However, their mind starts playing games with them; and when two different doctors advise surgery, most are happy to toe the line. They often feel - thank God the doctor diagnosed the " problem " early , before it became a major issue - let's fix it now when it's small !

Sometimes it's best to leave well alone - but it requires a mature doctor - and a mature patient - to be able to do so !

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