Dr. Michael Wilkes: Less is more
11/14/2013 12:00 AM
11/13/2013 5:35 PM
One of the hardest lessons for a medical student to learn is the power of doing nothing. It seems so counter to everything else we teach in medical school – the drugs, surgery, and much more.
At its core, the lesson is really about the art of medicine – to improve the quality of life. Sometimes it is easy to forget that what drives medicine are not the scans, ICUs and laser-guided procedures, but rather the person who is often scared, anxious, and confused.
Each person comes to the doctor with his or her agenda. The doctor also comes into the room with an agenda. Sometimes the agendas coincide, but often they do not. Too frequently, the doctor is clueless about what the person really wants.
Of course, the solution is for the doctor to simply ask. But, given pressure to see more patients, fill out more forms and use more computer programs, it is hard to put all that aside and simply ask and listen, both to what is said and what is not said.
When a doctor feels uncertainty, we order stuff supposedly to reassure the patient that all is well. It turns out that the stuff we order often does more harm than good. There seems to be no end to the number of “major medical advances” that only later are shown to be no better than, or even worse than, doing nothing or doing something simpler or less expensive.
There are many examples from every field in medicine, but a few include the complicated insertion of a tube (stent) into the blood vessels of the heart to improve blood flow. Billions of dollars were spent on this “life-saving procedure” until it was shown years later that for most people the risky procedure is no better than taking pills.
Based on early studies, hormones were given to hundreds of thousands of women to prevent heart disease. Later we learned that taking the pills was worse than doing nothing.
Not long ago we gave certain drugs to people with irregular heart rhythms with the hope of preventing sudden death. Those pills ended up causing more deaths than they prevented.
In each of these examples, once better studies could be completed that involved more people, over a longer period of time, and with better study designs, we were forced to change clinical practice.
A recent report examined 363 medical studies published in the New England Journal of Medicine over a 10-year period. Nearly half (40 percent) of these studies examined a current recommended medical practice. It turns out that one-third of these reports contradicted the original published findings suggesting that the original practice was less effective than originally reported.
My students would tell you I am a believer in “systemic doubt,” but I believe it has benefited my patients. We need to teach doctors to be highly skeptical, and that less is often more. These are hard lessons unfortunately not found in modern textbooks.
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