Thursday, September 10, 2015

Primum non nocere

It’s a well-known and long observed fact that the treatment you receive as a patient has as much to do with the particular physician who treats you as much as any other single factor. If medical evidence was — or even could be — uniformly and reliably interpreted, it wouldn’t matter what physician you saw; you should get the same recommendation regardless.

But evidence in medicine is anything but uniform and reliable, either in interpretation or performance, as evidenced by the pediatrician’s unhappiness with my treatment plan. The entire field of meta-research, which identifies weaknesses in and suggests improvements of scientific research, has grown in response to this problem.

But although it is (almost) universally recognized that there is significant error in the general medical literature, medical decision making does not seem to reflect this problem. There is a general attitude of “we just have to do better.” Although laudable and certainly a goal all physicians should share, this reaction does not address the idea that there is good reason to think that most of what we recommend as physicians simply does the patient no good, and that by committing to “doing better” while continuing with treatments that have never proven of benefit, we most likely are doing harm...

So really, the problem that the pediatrician had with my management of her patient is that people want to believe in control. Patients — and doctors — want to be told that everything is under control and that, although the path to health is potentially a difficult one, they and their children will be safe. It’s a basic agreement that lies at the base of the surgeon-patient relationship — I’ll do what you say as long as you keep me safe.

But when a preponderance of evidence, as is the case with vesicoureteral reflux, indicates that doing something, or actively treating, does not change the patient’s outcome, the logical conclusion would be to not do anything. Occam’s razor, in short.

Yet when, as a treating surgeon, I say that there really isn’t anything to be done, I’m calling into question the possibility of control, or the idea that if we can identify a disease process like reflux or cancer, we can intervene to stop it in its tracks. But this idea many times is simply not supported by the available evidence, regardless of how appealing to intuition it may seem.

A famous rejoinder to the problem of evidence I am discussing is that there are no randomized controlled trials proving the efficacy of parachutes, either. Yet no one would suggest jumping out of an airplane without one. But this obscures what most of medicine, and virtually all of pediatrics (I’m a pediatric urologist) is based on, which is managing outcomes that are years in the future...

Most would assume that a parent would be happy to be told that their child doesn’t need surgery, but that assumption is complicated when there is a possible bad health outcome at play. It’s one thing to tell a patient that they don’t need surgery for the lump in their breast because it’s not cancer – it’s another thing to be told your child has a condition that may be related to kidney disease, but there is nothing I can do to prevent the kidney disease from developing.

Luckily, in the case of reflux, the odds of anyone developing significant kidney disease with normal kidneys at first diagnosis are very small, but the fact remains that there is at least the perception that there is a risk. But to recommend surgery to eliminate the reflux, or treatment with antibiotic prophylaxis, in this setting is equivalent to recommending a haircut. The evidence for both in terms of preventing a bad outcome is exactly the same.

I no longer recommend treating, or even diagnosing, vesicoureteral reflux. I explain to the patients I counsel, as I explained to the parents of the freckled two year old, that this puts me outside of majority pediatric urology opinion, and almost certainly outside of what is considered standard of care. As a physician, it is difficult to admit to a lack of control. But we owe it to our patients to do so, instead of offering them an illusion.
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