Saturday, June 16, 2012

Why the VIP syndrome results in overtreatment.

I recently saw a patient who had had a miscarriage . The pregnancy had been uneventful and at seven weeks a routine ultrasound scan had shown a healthy intrauterine pregnancy. However, she had some spotting after this , and when she went for her next scan to her doctor , he noted that the gestational sac wasn't growing ; that the yolk sac was very large; and the baby’s heartbeat and become slow . These are all ominous signs which suggest impending fetal death , and he told her that this meant that the pregnancy was not healthy , and that she should allow it to miscarried normally . He then went on to see his next patient , without realizing that he had given her very bad news , without giving her the time to absorb the impact or ask him any questions. While his clinical advise was perfect, he was not being very empathetic, because he'd forgotten that this was a healthy young woman who come for a routine pregnancy checkup, just to confirm that everything was fine . Instead of being able to reassure her that all was well, he was having to tell her that she was about to lose her baby – the worst possible news a doctor can give to a pregnant woman !

What he actually needed to do was to sit down with her and prepare her that he had some major bad news to convey. Unfortunately, he did this in such a cold dispassionate manner, that she got put off.  Even though she is very articulate , she never had the chance to share her feelings with her doctor . She then took the next logical step – she want to another doctor for a second opinion.

This doctor put her on medications such as progesterone , to “ support the pregnancy “; and recommended a follow-up scan after 2 days. As expected , on the next scan the baby’s heartbeat had stopped completely , and she did a D&C to terminate the pregnancy.

The patient came to me for a third second opinion , and had lots of questions. She wanted to know if her first doctor had messed up by not providing her with progesterone support . If he had given her progesterone support , would she have been able to stop the miscarriage from occurring ? Was it her low progesterone which had caused the miscarriage ? She was understandably upset and agitated and I did my best to explain the facts to her.

From a medical point of view, the treatment which the first doctor had advised was absolutely appropriate. With the help of the ultrasound scan , he had made the right diagnosis of a nonviable pregnancy . Since the commonest cause of a non-viable pregnancy is a genetic problem in the embryo, no amount of medical treatment or progesterone support can change the outcome . If the baby is genetically normal and is going to die , it will , no matter what we do. It's not like he didn't know this , but he did not take the time and trouble to explain this to her. The second doctor knew this and could have explained the facts to her, but was mature enough to realize that what the patient needed was handholding . She therefore provided her with medical treatment , which she knew would not change the outcome in any way , but would help to clam the patient , because of the semblance that something was being done . In one sense this was unnecessary medical intervention , because it was not going to change the outcome, but the fact that the doctor did something meant that the patient felt a little more reassured and comfortable.

Patients need to understand that sometimes doctors do things which are clinically correct but which may seem hard hearted and cold-blooded, because they have not been able to achieve emotional rapport with the patient and are not able to explain why they are  advising a particular course of action. This was the problem with the first doctor , who was clinically competent, but emotionally incompetent.

Doctors often need to make a judgment call , based on their own gut feeling , as to what they feel the patient in front of them needs. Sometimes , VIP patients end up being harmed , because they're often overtreated , without any clinical benefit at all.

The best policy for most doctors is to sit down and explain to the patient what is likely to happen – and the limits of our ability to be able to influence the course of the disease. Unfortunately, time is a luxury which most doctors do not have enough of , as a result of which they are  forced to short resort to shortcuts  - not all of which can be right.

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