'Medical Principles: Part 4'

CAERS SUBSTACK ARTICLE #55

‘Medical Principles: Part 4’

CAERS Substack Article #55

In my previous articles I spoke about the potential for harm from treatments. One way to avoid harm, as difficult as it may be, is to do nothing rather than rush in prematurely. The famous physician, William Osler, said: ‘The art of medicine consists in amusing the patient while nature cures the disease’. There is often tremendous pressure to prescribe antibiotics for viral infections, or to do surgery when physiotherapy would be just as good and less risky. In fact, the opioid crisis in part arose from the desire to help ease patients’ suffering; unfortunately, too many physicians used a sledge hammer when a fly swatter would have been sufficient.

Using the right treatment is of course important, but we often forget that the best way to avoid harm is to go right back to the beginning: make the right diagnosis first. Errors of omission, where we forget to consider a diagnosis when we develop the differential, are perhaps even more common than errors of commission, where we use the wrong treatment. So, we have to be careful not to hurry unnecessarily into making a final diagnosis, or avoid considering one that is too scary for the patient or the physician. Taking the time to re-evaluate a situation, rather than forcing a diagnosis to fit, may be frustrating but is good medical practice.

Because common things are common, we should consider those first; too often we are looking for rare and exotic diagnoses (referred to as ‘canaries’) right off the bat, and we miss the obvious, more mundane diagnosis. We usually try to find the diagnosis that explains as many of the symptoms and signs as possible, because it is far more common for patients to develop one new disease than several new diseases simultaneously.

In medical practice we look for patterns, and when things don’t add up, then we need to look deeper and wider because canaries, though uncommon, do exist. And although individual canaries are rare, there are a lot of them out there and no doctor will ever see all of them. We look for what are called ‘red flags’, warning signs of something serious or highly atypical. That is when we enter ‘tiger country’, where we have to be alert to the potential dangers lurking around the corner. Sometimes the toughest part is distinguishing the signal from the noise; identifying what is relevant from what isn’t.

More than anything else, we must never let a patient leave our care until we have ruled out any illness that could seriously harm or kill them before they would have time to seek follow-up. Missing a mild problem is annoying, but missing a potentially life-threatening one can literally be lethal. In fact, often we cannot provide a specific diagnosis and the best we can do is simply rule out all of the serious ones. Frustrating yes, but reassuring nonetheless.

One of the biggest dangers is that sometimes we don’t know what we don’t know. Experience can help minimize that, but remaining open-minded and humble are the real keys. Recognize your assumptions, be as explicit as you can and re-assess the situation, going back to square one if necessary. Asking for help is crucial; another pair of eyes with an alternative perspective and a different catalogue of experiences is invaluable.

Once the diagnosis is made, explore the full spectrum of possible therapies. At one end there are therapies that are safe but minimally helpful, and at the other end ones that are very efficacious but risky. Helping patients to find their ‘sweet spot’, where the balance of effectiveness and safety lies for them, is the goal of our care. As well, sometimes an aggressive treatment may offer what seems to be an advantage in favour of its use; but if the improvement is only statistically significant but not clinically significant it may not be worth it. For example, a surgical procedure that improves function by 20% in studies or laboratories may be of much less value in many real-life situations.

And finally, although it is always desirable to have a definitive diagnosis, there are times when it may not help as much as you would think. In fact, not uncommonly medical diagnoses sound more impressive and helpful than they really are. Dermatitis is a good example. ‘Derma’ is Latin for skin, and ‘itis’ means inflammation. The use of Latin makes the diagnosis of dermatitis sound sophisticated, but most of us can recognize inflamed skin without having a medical degree. ‘Nummular dermatitis’ is skin inflammation that has a coin-like pattern (notice the similarity to numismatics, the study of coins?). The diagnostic name does not necessarily tell us the cause of the illness (etiology), nor does it always suggest a curative treatment.

So, what do you think? Is it helpful to know these medical principles? Is it clear to you that these principles guided the pandemic management? Although data and expert opinions are useful, principles that provide a better understanding of a medical situation are often necessary to make the best decisions for ourselves and our society.

J. Barry Engelhardt MD (retired) MHSc (bioethics)

CAERS Health Intake Facilitator