Bioethics Discussion Blog: Is There Certitude in Medicine?

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Saturday, April 26, 2008

Is There Certitude in Medicine?

Just in case there is anyone out there that believes that with all the current technology there is certitude in the practice of medicine, I wrote the following crude poem to express my understanding. Any comments to the contrary would be appreciated-- in a poem format might be interesting ..Maurice.

Is There Certitude in Medicine?
By Maurice Bernstein, M.D.

As a doctor, I know
What I should know
But is that knowing enough?

As a doctor, I see
What the disease might be
But there is uncertainty

Since I wonder do I really know
That what I see, is what I know?
My patient wants to know

Do I know what I see?
What the disease might be?
Should I tell the uncertainty?

Unlike mathematics which has a unique conclusion
Unlike physics which points to a principled conclusion
Medicine may provide only a confused conclusion

Truly, medicine is still rather crude
Surely, let’s tell that there is a lack of certitude
But to the patient, would that honestly be understood?

6 Comments:

At Saturday, April 26, 2008 6:20:00 PM, Blogger Maurice Bernstein, M.D. said...

As a teacher of medical students, I think the students in most of their years are fully aware of how much they don't know and how uncertain making a diagnosis is to them or predicting the outcome of a treatment that they learn more about in their later years. I think, as time goes on, and with additional knowledge and experience, the pain of uncertainty they had in earlier years gives way as they go into residency into some sort of a compensatory certitude regarding the practice of medicine. "I've seen this.. I've done that" becomes a hallmark for these later years and yet is it realistic? There are still patients, particularly the elderly and on polypharmacy whose cluster of symptoms may represent more than one pathologic process or disease, however it is part of that certitude psychology that the doctor decides as per the consideration of Occam's Razor that but one disease exists and may avoid considering that the same cluster should be looked upon in terms of the Saint's Triad, that indeed two or more diseases are simultaneously represented. I think that the need for certitude is the basis for this intellectual behavior and the possible missing of a mixed diagnosis.

Do you think that it would be in the best interest of the patient to allow the patient to understand a doctor's doubts about certitude? ..Maurice.

 
At Saturday, April 26, 2008 8:14:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is the view of a surgeon on this topic. A surgeon ethicist writing to a bioethics listserv today after I had written about certitude in medicine there gave me permission to post his view here. I agree that there could be a difference in the assumption of certainty by the different disciplines of medicine. ..Maurice.


Maurice,
As you know, the old line about surgeons is “Often wrong; but never in doubt.” I think the need to feel certain increases with the risk or invasiveness of the proposed therapy (or lack thereof). It’s easy to be uncertain about whether the patient has bacterial bronchitis, but to start the patient on antibiotics anyway; it’s much more difficult if one is telling the patient, based on clinical history and exam alone, that they have a rupturing aortic aneurysm, must undergo emergent life-threatening or life-saving surgery, and don’t have the time for further diagnostic tests. The patient, on the one hand, deserves to know (must know in order to give informed consent) how certain you are of the diagnosis, what else it might be, what will happen if you’re wrong, etc., and on the other hand is putting his life literally in your hands, and so needs to feel confident that you’re pretty damn certain of what you’re proposing. I often feel that my residents are much more certain than I, but then they aren’t the ones holding the bag if “we’re” wrong. Michael

 
At Sunday, April 27, 2008 2:08:00 AM, Anonymous Kacy said...

It has you thinking in a scary sort of way about all the uncertainty. Now on visits to my doctor her diagnosis is never made without consulting the Internet first.

 
At Sunday, April 27, 2008 7:00:00 AM, Anonymous Mike said...

Medicine is a kin to an investigation of a crime scene if you will. Typically providers are called in after the onset of symptoms where we have to rummage through the evidence to make a believable story. Sometimes it is simple based on the evidence before us to put the puzzle together and be certain of a diagnosis. Other times the evidence is less convincing, this is where experience comes into play to raise the level of certitude.

I would agree with your surgeon's opinion though, with invasive workups and treatments a provider better be very sure of their diagnosis and have gone through the laundry list of differentials before they start making holes and pulling out the wires.

In the end I think the only certitude that exists in medicine is that there isn't any on a consistent basis. There are too many subjective variables, too much complexity of the human body, and way too much for any one provider to reasonably know.

Some days all you know is that the "check engine" light is on but you don't know why. That is why we have second opinions, consults, and do a lot of hoping we didn't miss something.

 
At Sunday, April 27, 2008 7:57:00 AM, Blogger Maurice Bernstein, M.D. said...

Kacy, a bit of clarification here:
Did you mean that it is your doctor who consults the Internet first to establish her diagnosis or that you go to the Internet before going on your visit to your doctor? But, I wouldn't be surprised if it were your doctor who did the Internet research. In years past, we would leave the patient in the exam room for a few minutes with some excuse and go in our office and look things up in our medical books and the PDR drug manual. That was when we all had time for this little excursion away from the patient. Nowadays, we have much medical information stored on our Palm hand held device or easy access to the Internet with a computer system in the exam room. Those, patients and doctors, however, who look up diagnoses on the Internet must have confidence that the source is providing valid information without any conflict of interest.

Memory based on experience or previous reading is important in the practice of medicine but so is documented factual information. The doctor needs to make a diligent effort get information and things right despite all the uncertainty.

Yes, Kacy.. it is scary, and even at times for the doctor. ..Maurice.

 
At Friday, May 30, 2008 3:55:00 PM, Blogger Maurice Bernstein, M.D. said...

To give the layperson some additional insight regarding the uncertainties that physicians face, read the Perspective article in the May 29 2008 issue of the New England Journal of Medicine (full free text) by clicking on the link. ..Maurice.

 

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