Bone of Contention
Medicine is a science of uncertainty and art of probability
- Sir William Osler
I am part of a crazy group of runners, and we do long runs, sometimes a couple of half marathons a month. We don't run in silence; we tend to talk, and talk a lot about all the topics under the sun. We need to get over boredom and pain you see. It was a gloomy Sunday morning; we had just finished our run and it started to rain heavily.
One of them bought up the topic, a relative, had had an angiogram done and was advised cardiac bypass surgery. On taking a second opinion, he was told he could be treated by using a stent, which is a much simpler procedure from patient perspective, he had his stent done and has been doing well for the past 6 years. Why this disconnect in opinions between doctors was his question.
Medicine is an uncertain science, it's possible for two people to see a certain result and interpret it in completely different ways. Logic doesn't always explain everything in medicine and that's the reason it's still called the art of practicing medicine. The reason being that there are many variables, in how an individual's body will behave and react to a particular intervention, and what is the weightage to be given for these differences is impossible to predict. Two grossly similar people can go into a critical surgery, operated by the same surgeon can have vastly different outcomes, without us being able to explain why, as we don't understand the effect of these variable in total.
There is also a problem when different specialties can provide similar results, to a given problem, very commonly seen for example in prostate cancers. The results of intervention by urologist, medical oncologist and radiation oncologists can be nearly the same, but there is a bias towards your own specialization, and so the doctors claim to have better results, in their own domains. I do understand that it is difficult for patients to make an informed decision without all the information. In such a scenario, the patient should be allowed to meet all the specialists and on understanding the pros and cons should be allowed to choose the intervention.
This phenomenon should not be confused with errors made by doctors. Again, the distinction should be made between errors versus negligence. Negligence is a topic for discussion on some other day. Why doctors make errors. Most of the run of the mill diagnosis and treatments will not run into wrong paths. There are clinical decision-making algorithms to help doctors now adays and evidence-based medicine is the buzz word. Problems arise when the signs and symptoms are vague, or multiple and confusing, with equivocal test results. It’s in these times we will need a thinking doctor. The clinical algorithms will also fail as these are statistical averages and cannot discern individual variations. Even with all the support available from databases, algorithms and also the latest innovations in diagnostics, when decisions have to be made subjectively based on experience and knowledge, errors tend to creep in.
These uncertain times are taxing for the doctors, who most often are used being able to diagnose and treat with certainty. These uncertainties can be due to limitation in available medical knowledge, or a lack of knowledge by the doctor, a third scenario can be a combination of both, limitation and lack. Doctors react to these uncertain situations in different ways. The most common being, not admitting to the patient about the lack of certainty, which is seen as undermining themselves in the eyes of the patient. As of now this uncertainty has a negative connotation in the medical as well as patient community. Patients tend to disregard doctors who are unable to give them a confident diagnosis. Eventually it is detrimental to both the groups.
There is a need for the doctors and patients to embrace and acknowledge this phenomenon, only then effective way and means to overcome this will become available. Medicine is not a science in the truest sense, there are too many exceptions and variables to a given scenario, its more interpretative. In attempting to describe it as a science, people tend to equate it with newtonian science which is certain. A given law tends to stay true under a given set of circumstances.
So how much does medical science know about human body? Since we don't know what we don't know, we at present can only guess what is lacking in our knowledge. Some wise persons are only willing to wager that we know less than what we don't know.