Thursday, July 31, 2008

Masterly inactivity - when less is more !

Modern medicine is full of activity - scans, tests and surgery. TV serials like ER popularise this image of an "action-oriented" doctor who "fights disease" by "battling it". These can be dangerous metaphors !

All diseases have a natural history and many will get better by themselves. Others do not require any "treatment" or management - for example, localised prostatic cancer in older men.
These are best managed by " watchful waiting" or " masterly inactivity". This was a skill older doctors were very good at, because they had very little to offer in the form of intervention - and were wise enough to realise this. " Don't just do something - sit there ( and hold the patient's hand !)" was extremely good advise.

Unfortunately, as medical technology has evolved, doctors have become overconfident . They have acquired a cocksure attittude, and are willing to do battle on the patient's behalf, to fix any problems their machines can find.

An extremely good example of this is endometriosis. This has rightly been called " an engima wrapped inside a riddle" because we understand so little about it. The problem is that our understanding still remains equally poor , but because we can make a diagnosis much more accurately ( with ultrasound scans, blood tests and laparoscopy), many doctors feel that we can "treat" much more effectively. Since many infertile women will have minimal endometriosis
( and we don't know yet whether this is coincidental - or even if the infertility causes the endometriosis rather than the other way around!) Sometimes the treatment causes more harm than good - but we don't even know this as yet.

We are now seeing an epidemic of overtesting and overtreatment. There are many reasons for this. Firstly, the technology has become much better. The newer scanning machines can pick up small abnormalities - and once these are documented and reported, they are grist for the medical mill.

Secondly, there is much more money to be made in treating that in "leaving well alone". Not only do medical equipment manufacturers push their wares, doctors are very happy to exercise their surgical skills - because this is what they are good at !

Senior doctor have the maturity to let sleeping dogs lie - and understand that you cannot make an asymptomatic patient better. They realise that not everything needs to be "treated" and that sometimes the cure is worse than the disease.

Unfortunately, it's the "trigger-happy" doctors ( whose trips to conferences are often paid for by medical equipment manufacturers ) who are very aggressive in promoting their "neo-treatment options". Since these are "new" toys, many doctors are very happy to play with them , which means they have a very willing audience. Few people are willing to listen to the older, senior fogeys - who maybe more mature, but don't have anything very interesting to say !

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