Thursday, June 14, 2012

Why it’s hard for doctors to leave well enough alone

When a doctor sees an abnormality ( either during clinical examination or lab testing or scanning) , his gut reaction is to “ treat “ it, remove it or correct it . Doctors are trained to worry about what can go wrong - and the first thing they think of when they see a scan or lab result is – what’s abnormal ? What problems and complications can arise as a result of this abnormality ?

Let’s take the example of fibroids noted on a routine ultrasound scan . The doctor is worried that the fibroid may grow ; or may cause a miscarriage . They therefore they recommend that the patient remove it now, to prevent problems in the future. Patients often will accept this advise , because they don't want problems either.

What they fail to realize is that doctors are not good at predicting the natural history of a lot of what they see. This is because of the nature of their work – they get to see only the few women who presents as patients, because they have problems as a result of their fibroids. They forget that there are lots of completely healthy women who also happen to have fibroids and go through completely uneventful pregnancies , without even realizing that they have fibroids !

A lot of fibroids are incidental findings , and they often don't cause an symptoms or problems all - many women will happily carry their fibroids to their grave. Unfortunately, given the way doctors are taught to think – look for problems and fix them – they will often jump to the conclusion that a fibroid always causes problems - and it is therefore better to remove it when it is small , rather than allow it to grow and create problems leter.

Suppose the doctor advises the patient to do nothing . Masterly inactivity is often the best advise , but this can be a difficult course of action - both for the patient , and for the doctor . For one thing , patients often demand treatment. If they have something inside their body which should not be there, they want it treated. They will often seek a second opinion – and if the new doctor is more aggressive, he will advise surgical removal . The patient’s confidence in her first doctor may get shaken up – why didn’t he advise surgery ? Maybe he isn’t competent enough to do the surgery ?

Now if the doctor’s advice is to do nothing , and if you remain problem free, you are happy, but not very grateful or appreciative ( after all, the doctor didn’t do anything, did he ?) However , if the doctor advises you to do nothing , and you are unfortunate enough to end up with a problem , not only are you likely to badmouth the doctor for not advising surgery , the doctor may also feel guilty that she did not advise treatment at the time of the first visit.

Unfortunately , doctors are not fortunetellers and cannot predict what the course of a particular lesion will be in a particular patient . This is why it's important that doctors share their philosophy of being conservative or aggressive with the patient , so that both the doctor and the patient are on the same page .

It’s easy for doctors to “ do something “- this is what they are trained to do, and this is often the knee-jerk reflex of junior doctors. It’s only senior doctors who have a lot more clinical experience and maturity who are likely to advise that you it’s sometimes more effective to do nothing at all. While doing nothing sometimes can be hard to do , this often has a far better outcome , because unnecessary interventions can create their own sets of problems as well.

Remember that it’s not that doctors are trying to scare patients – it’s just that the doctor’s world view is slanted towards looking for problems – and trying to fix them ! Also, in case the doctor does not fix the problem, he is at risk for being sued for negligence, in case something goes wrong. This is why there is a lot of pressure on the doctor to “treat” everything he sees !

Ironically, if the doctor does intervene and the treatment causes problems,  patients are much more willing to forget and forgive these complications – after all, wasn’t the doctor just doing his best to treat the original diagnosis?

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