predicting the future

Tuesday, October 23, 2012

On occasion, the legal system can be very strange, but perhaps not as strange as the decision by an Italian court that found six seismologists guilty of manslaughter for not accurately communicating the risk of the 2009 earthquake that killed more than 300 people in L’Aquila. Should the verdict, doctors in Italy may be left quaking in their boots. Predicting the future is more than inexact and if scientists are required to efficiently predict nature disasters, what standard will doctors need to meet when caring for patients.

The body is as tough to predict as the weather. Most illnesses have common presentations but there is enough variation of normal to make diagnosis a potential minefield. Injury patterns have just as many pitfalls, so that doctors, using guidelines to help order the proper test, have to remember that they are playing a game of probability when it comes to their patient’s care. Nothing it seems is black and white in medicine and yet, when a patient is given advice as to the alternatives of care, the usual response is to have the doctor choose. While patients and families want to be informed about the benefits and risks of each step of the diagnosis and treatment process, there can be decision paralysis because of too much information. The same paralysis afflicts medical students and new residents who lack the experience component to supplement book knowledge. It also doesn’t help that guidelines change faster than most people realize.

When new technology arrives, doctors are like everybody else; they like to play with new toys. Such was the case for CT scans and the ability to peer inside the body. This is especially helpful when the history and physical exam is hard to come by. Think of children and how hard it is to get a reliable story from them. Add worried parents and the kid who presents with belly pain can be a challenge when it comes to diagnosis. The parent’s major worry is usually appendicitis and the need for surgery, but there are other alternatives that can weigh on the doctor’s mind, like intussusception and Meckel’s diverticulum, all equally serious. Missing appendicitis is one of the major causes of malpractice lawsuits and CT is helpful in decreasing the miss rate, as long as the test is ordered in the right patient at the right time. Too often, CT scans are used indiscriminately and the child is exposed to unneeded radiation. New protocols are being developed based on blood tests and ultrasounds that may limit the need for the CT, but their use depends upon the doctor listening to the story and performing a solid physical exam. Observation is also helpful, with time being an ally for watching the disease process develop, but doctors are also being pressured to decrease waiting times. Even with normal tests, the most a doctor can say is that the child does not have appendicitis at the time of the visit, but there is no guarantee that the appendix won’t become inflamed tomorrow, in a week or in a month.

CT has also become the gold standard for head injury evaluation but so many normal scans were being done that guidelines were developed that could predict who would need a brain operation after getting hit in the head and who could be watched. The problem was in the semantics. The guidelines did not say that there wasn’t any bleeding in the brain, only that there was no need for surgery. Imagine trying to explain to a patient or their family that a CT scan wasn’t necessary based on the Canadian or New Orleans CT head rules, but there was a possibility that there was a small amount of blood or swelling in the brain. Should the head scan be done showing the minimal bl0od, it almost always results in a consultation with a neurosurgeon and a discussion about observing the patient at home instead of the hospital. Admit the patient to the hospital and they might be exposed to any sort of potential infections. How can the patient understand the benefits and risk of a medical decision when the doctors involved are hard pressed to know all the potential complications.

Once advice is given, it is up to the recipient to decide what to do. In the case of the seismologists, the courts found that they were too reassuring to the residents of the town of L’Aquila. But what was their advice to be? Sometime in the next few days or weeks, there might be an earthquake and we’re uncertain as to the magnitude or extent of potential damage. And the population’s response? Shall we evacuate for an unknown amount of time or stay realizing there is potential danger? Perhaps they should take a cue from people who live in hurricane prone areas who decide with each storm, based on a meteorologist’s forecast, whether to stay or leave.

In medicine, it’s much more personal. There is no herd mentality and patients tend to trust the advice their physician gives them. But if predicting the future is a standard of care, Italian doctors may be much less likely to offer that advice.

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