Saturday, October 28, 2017

Simple Questions--or Not--At Harvard Medical School

The Billy Rubin Blog went mobile this week, as I gave a talk at the Harvard Medical School Academy's annual Medical Education Day. The theme of the day was medical uncertainty, which given my work in Snowball seemed to the organizers to be a perfect fit. Hopefully it was enough of a match that I didn't embarrass myself completely.

The talk is here: The talk proper starts at 30 seconds. Apologies for the stops and starts; it felt much more fluid in the moment than the slightly herky-jerky quality the address has on playback.

One exchange at the end is worth meditating on--and I include it here as a meditation, a sidenote, for I don't mean for it to indicate that this was anything approaching the most important moment of the hour. But it does allow a second for a departure on the philosophy of medicine.

When I was taking questions at the end, at about the 51:30 mark, a senior clinician wondered about the process of advice from doctors. Here's the exchange (in raw transcript form--the dead-ends make a little more sense as you hear it in the moment):

MD: There's a very specific prime question that I think is legitimate for patients to ask: "Well, what you you do if you were in my shoes?" And this is a very different question from an erudite but simple discussion of a problem, and they are asking for a very specific answer. And I wondered if you give this, believe in it, and if you do, what do you tell your students about answering such questions?

Me: When they [patients] ask, "What would you do if you were me?"

MD: Yes.

Me: So, I know we have one of my former students here who's a psychiatry resident; I would bounce the question right back and say, "Well, I'm not, um, I'm different. I come with certain, you know, fears, hopes...and then you open up a discussion about, really--because when they ask you that question, they're not asking you that question. They're trying to figure out how to prioritize things. That's my sense."

MD: I think they're asking, very specifically, that question. [Audience laughter.]

Me: I don't...I don't agree. I actually think that question is a good deal more complicated than it looks on the surface.

What's fascinating to me about this exchange, in a talk on uncertainty, was the unequivocal confidence this physician had that patients just want to know what their docs would do in the same situation, no further question asked.

My reply in the moment was not perhaps as quick-witted as I would have liked, but I'd add here that medical decisions aren't the same as car repair decisions. I trust what my mechanic tells me, because a car is an expensive but not priceless piece of machinery, important to my life, worth something but something finite. Thus, I can have a straightforward discussion about whether it makes sense to rebuild the engine for $3000 in a twelve-year old Toyota that has 180,000 miles on it and has a reasonable chance of breaking down in other ways, or just trade it in for a new model. Maybe it's more expensive in the short run to get another car, but that comes at the benefit of fewer headaches induced by repeated trips back to the garage.

A good mechanic can lay out the risks versus benefits in a clear way, and based on what they've seen over the years (the number of 12 year-old Toyotas that make it to 15 without constant servicing, for instance), they can say, "it's a good car, I'd hold on to it, but there's a risk," or alternately say, "I'd be rid of the headache." That kind of advice in that kind of situation is genuinely helpful, and more importantly, the terms being discussed are reasonably clear and equivalent to both parties.

But a doctor just casually dropping advice to a patient's family asking a similar question about a loved one struggling for life on the vent in the ICU, and whether the doctor would request to have all lifesaving measures stopped, presupposes any number of areas of understanding that may not be so. What value does the family place upon religion and ethical precepts about the value of life no matter the struggle? Have they had good or bad experiences with the medical system? Are there life events on the horizon that might make a patient or family try to subjugate themselves to the frequently tortuous procedures and treatments medicine can provide, in order to reach such moments? Does the patient or family have regrets about saying goodbye, of having fights years ago in which no reconciliation has ever been broached?

Don't these questions seem rather more important than, "Well, doctor, what would you do?" as if the subject could be so easily compressed to a singularity of physician wisdom?

And if those questions are explored between doctor and patient, or doctor and family, then what need of such an absurd and possibly dangerously oversimplified question?