With patients, fair play requires the right approach
By Michael Kirsch, FACP
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In tennis, the overhead smash is the most dramatic shot on the court, but it is not the most important. Rather, it is the approach shot that precedes the overhead smash that makes the real difference. Similarly, a dramatic slam dunk in basketball or a power spike in volleyball depends on well-placed approach shots. In other words, outcome depends on the setup.
While we physicians are not athletes, there is an analogy. We have several medical approach shots stashed in our black bags. Our patients' decisions largely depend on how we "set up" the situation. Consider a hypothetical example.
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"We need to be mindful that in medicine, there is often no single correct answer."—Michael Kirsch, FACP |
A 50-year-old smoker has a cough and a fever. A chest X-ray shows a right middle lobe infiltrate and a small lesion in the left upper lobe. After antibiotic treatment, the infiltrate has resolved, but the left lung lesion persists. The radiologist and the pulmonologist suspect that the lesion is benign. Nevertheless, the patient is anxious because his grandmother died from lung cancer.
Several physicians offer their approach:
- Doctor A: the conservative
"Because the lesion is probably benign, I wouldn't pursue an aggressive approach. While we could arrange for a biopsy, the procedure has risks and may not be definitive. A 'benign' biopsy result does not guarantee that the lesion is truly benign because the biopsy may miss a cancerous portion. For now, I suggest that you return in three months for an X-ray so that we can monitor the lesion. At that time, we'll review our options again." - Doctor B: the moderate
"Let's arrange for a biopsy. If the result is benign, then we can be even more confident that we are dealing with an innocent lesion. A lung biopsy is a low-risk outpatient procedure. Why jump right into major surgery if we can avoid it? If the biopsy result is negative, then we can monitor you with periodic chest X-rays." - Doctor C: the radical
"I'd strongly suggest an operation to remove the entire lesion. This is the only option that will eliminate diagnostic uncertainty and give you piece of mind. Biopsy results can be misleading, and checking X-rays every few months has the risk of letting cancer spread. What if an X-ray in three months shows that the lesion is questionably larger? Would we get another X-ray three months later? Why take a chance? If the lesion is cancerous, then surgery now is our best opportunity to cure you." - Doctor D: the academic
"Our research department is studying a new technique to differentiate benign tissue from malignant lung tissue. While this is experimental, our initial results have been very encouraging. So far, we have correctly identified 90% of truly benign lesions. If your result from this new test is negative, then a biopsy may be unnecessary. Unlike surgery or a lung biopsy, our noninvasive test has no risk of complications."
Each of these physicians has used a different approach shot to coax the patient toward a decision. Every one of us has steered patients to a course that we deem proper. When this occurs, score one for medical paternalism.
Surgeons, for example, may be more inclined to consider an operative solution because they are trained to solve problems with scalpels. Internists, more cautious by nature, may favor a different approach. Academic physicians, under pressure to recruit patients into experimental studies, may have an agenda that influences their recommendations.
We can't eliminate our personal biases, but we can restrain them. We need to be mindful that in medicine, there is often no single correct answer. What seems "right" to us may be wrong for a particular patient. The truly "right choice" is whatever informed decision the patient makes. I recall many intelligent, informed patients who rejected my medical advice for various reasons. We must respect this right of refusal. We doctors, after all, don't always know best.
It is not enough for medical advice to be true; it must represent the whole truth. Rather than setting patients up to choose what we think is best, we should present all the reasonable options fairly and allow our patients to make their own decisions. For patients, this approach is a slam dunk.
Dr. Kirsch is a practicing gastroenterologist and freelance writer in Highland Heights, Ohio.
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