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Ignoring the gray areas of medicine

September 11, 2010

recent article in the New England Journal of Medicine* lays bare the harsh reality of modern medicine–despite an unrelenting pursuit of medical knowledge in recent decades, gray areas still pervade clinical medicine.  Unfortunately, we (both physicians and patients) often ignore these gray areas.  Uncertainty is uncomfortable.  As physicians, charged with the care of others, we want to have a clear path to providing for the health and well-being of our patients.  As patients, we are navigating unfamiliar and complex territory.  Cognitively, we need simplified choices with clear consequences.  However, such clarity is rare in medicine.  Medical decisions carry risks and benefits that exist in probabilistic terms.  All too often we ignore this fact and frame choices as dichotomous options.  As the authors of this article remind us, we can recognize the inherent uncertainty of medicine and incorporate this into our decision making or allow ourselves to fall prey to overly simplistic conceptualizations of care.

*I highly recommend reading this entire article.  It is well-written and has important themes outside of the uncertainty of medicine.  I also recommend it because I think it will generate some interesting replies in the coming weeks, since the authors basically called the Society of Breast Imaging and American College of Radiology avaricious blockheads (I’m paraphrasing here).

2 Comments leave one →
  1. September 16, 2010 10:59 am

    Thanks for the link to the article which was interesting. It is always good to hear the uncertainty and probabilistic nature of medicine being highlighted, it is one of the first and hardest lessons one learns about clinical practice and often a tough discussion with patients.

    I’m afraid I don’t share the authors’ idealism about the future of clinical guidelines however. They advocate an ‘independent’ review panel but the thing about medicine is that such a panel does not exist and never will. I subscribe to Popper’s view on science and understanding reality, that no one looks at anything including scientific evidence with a blank slate of thinking- we can only understand evidence through applying theories and hypotheses which we already hold, these are the scaffolding of our thoughts without which interpretation is impossible. The key is not to complacently call yourself ‘objective’ or ‘independent’ but to recognise your own underlying biases (hypotheses), interpret the evidence while humbly acknowledging them, and then try to interpret the evidence with as many other hypotheses in mind as you can- especially those of your opposition in the argument. This is of course extremely difficult and taxing to do properly.

    It’s ironic that the authors highlight the importance of recognizing gray areas in medicine while supporting the idea of an ‘independent panel’ producing a guideline of utopian rationalism. How good a clinical guideline is is just as gray a question as how good the management of an individual case is. It is better to encourage any and all to publish guidelines for any purpose, and welcome the vigorous sort of discussion that this mammography issue has engendered.

    As for the breast surgeons et al, I can accept the authors’ contention that their arguments are unfounded or irrational. However it is too glib to invoke financial interest as the source of their bias. Surely more bias would come from their clinical practice, from seeing and dealing with cases of missed cancer and cases of cancer detected early with good outcome. This personal experience, which would be a poor foundation for a clinical guideline, is surely more likely to lead to an emotionally-derived bias in their interpretation of the evidence than anxiety about whether they will starve, or not be able to afford another Porsche. Adam Smith should be invoked with more respect.

  2. November 19, 2010 10:38 am

    Good find. I’ve written and reflected upon this theme many times. And am always reminded of Feynman’s quote on uncertainty and not knowing things.

    When looked at honestly you quickly realize that there’s quite a bit of bogosity in medical “science”.

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