Welcome to the world of medicine and medical testing.
I am responding
to a discussion on the List about trusting doctors. It is perhaps not appropriate
to say that you should not trust doctors, but more that
(1)
you should understand what is behind a physician's opinion, and that
(2)
you should take responsibility for your own health.
I am a 63 year old
diagnostic radiologist on WW (Watchful Waiting)
with Gleason 3+3. PSA is slowly rising and I am probably going to opt for Cryotherapy.
Like pathologists, radiologists look at diagnostic images (our images
are not slides but instead are X-ray, CT, ultrasound, MRI, Nuclear Medicine, Mammograms
and the like) and generate a report that constitutes our opinion as to what is
important on those images, and what is the significance of such findings.
It is a traditional joke, sort of, that if you line up any 10 radiologists
and they all look at the same diagnostic exam, you will get 10 different opinions.
If you can any two to agree, it is a miracle.
A second traditional joke
regarding our profession is that the "national flower of radiology is the hedge."
e.g. well....it could be this, or ......it could be that.
What does this
all mean to you, the patient?
If you are dissatisfied with the above
situation (i.e. physician variation), you might take an aggressive approach and
study and learn what is known about medical testing, but this, I believe, will
be an exercise in frustration if not futility for you. If you pursue such an activity,
you will learn concepts related to screening vs. diagnostic tests, specificity
and sensitivity, true positives and false negatives, negative and positive predictive
values, etc.
You will learn that two universities can do the same clinical
study and come up with conflicting data. You will learn that some folks fudge
data in order to get it published first, and then, later on, get a second publication
out that negates the first, and thereby add two articles to already padded curriculum
vitae. Sad but true. This is reality. It happens not infrequently.
Back
to the real world. If ten bystanders witness an accident, you may get ten different
accounts from each observer as to what each saw. However, you may respond, people
on the street are not "trained observers" and this is to be expected. What about
"trained observers?"
Variations in physician "trained observer" opinions
exist and will always exist. Each physician possesses a background of training,
experience, and knowledge that is unique to that physician. Each physician is
looking at your medical test, not with their eyes, but with their mind. What the
physician sees in that diagnostic images is different that what other physicians
see, and also different than what that same physician will see 6 months to a year
later, because of 6 months of additional experience, knowledge, etc. We look with
our minds, not with our eyes.
Add to the above differences (i.e. training,
experience etc) additional differences in values and philosophies plus differences
relating to previous and current malpractice suits, current financial needs, etc.
One radiologist may look at an image and say this is life threatening and must
come out immediately, the other will say not to worry, a third will say I am not
certain and therefore it is up to the patient.
How to respond to this?
Each patient must be armed with some basic information.
Medicine deals with statistical probabilities related to groups. However, each
cancer is a different disease in each patient. I have seen patients dead from
the most benign cancer in less than a year and patients alive from the most aggressive
and malignant cancer 10 years later. These events are rare but they do occur.
That is why most physicians, if wise, will not answer the patient question "how
many months do I have left to live?" For each patient, it is different.
A second fact is that the
relationship between experience and dogmatism in a physician is fragile at best.
That relationship is a philosophical matter.
A highly experienced physician may be dogmatic or flexible (i.e. appear uncertain).
Some may interpret such uncertainty as inexperience, but this conclusion is erroneous.
Another physician with limited experience may be dogmatic or flexible. Some may
interpret such dogmatism as representing excellence, but this is also erroneous.
I repeat, dogmatism in a physician is a philosophical matter.
I might
add the often dogmatism is found more frequently in those who are insecure, but
this is a generality and not always applicable. After 30 years in radiology, I
have chosen throughout most of my career to avoid being dogmatic. Although I am
rarely wrong in my opinions regarding diagnostic images, I am wrong on occasion.
I personally choose not be dogmatic in good conscience. I just state my opinion
and justify it and then leave it at that. I do not argue with others who possess
a differing opinion.
A third consideration is that patients differ in their ability to live with uncertainty.
An experienced physician will try to find out what a patient's tolerance for uncertainty
is, and then instruct a patient such as yourself to act accordingly. What this
means is that a physician may recommend biopsy in fairly benign situations to
those patients with a low tolerance for uncertainty, but may recommend WW in similar
cases to someone else. For those on WW, particularly younger patients, such patients
must follow a fairly rigorous protocol and keep on top of things.
A fourth generality amongst most physicians is "I'd rather be lucky than good".
Not infrequently, we make a mistake and yet the case comes out right for the patient.
Conversely, we do that "right" thing, but unexpectedly and unfortunately, the
result is not good for the patient. Medicine is not the same as manufacturing
cars or other products. That is what makes it interesting and challenging for
us.
This is a lengthy piece, but I hope it helps. Just like being a parent
is "on the job training" so, in reality, is medicine "the practice of medicine."
We are always practicing and trying to reach perfection but we physicians know
we will never get there no matter how hard we try.
To conclude, physicians'
opinions will always differ. Understand why. Accept it. Act accordingly. Such
variations do not constitute lack of excellence or bumbling, such variations reflect
the reality of life.
When a physician becomes a patient, we each pursue
the truth until we are comfortable with our understanding of such truth. Unfortunately,
but in a similar fashion, it is up to each patient to pursue the truth until that
patient reaches satisfaction with his /her own level of understanding.
Good luck on your journey.
Wesley Root
