Can experience make it tougher for doctors?

You have probably read that experience makes for better doctors.

And of course this would be true–in the obvious ways, like with the hand-eye coordination required to do complex procedures, or more importantly, with the judgment of when to do them.

There’s no news here: everyone knows you want a doctor that’s been out of training awhile, but not so long that they have become weary, close-minded or physically diminished. Just the right amount of experience please.

But there’s also potential downsides struggles that come with experience. Tonight I would like to dwell on three ways in which experience is causing me angst.

But first, as background…

It was the very esteemed physician-turned-authors, Dr Groopman and his wife, Dr Hartzland, who wrote this thought-provoking WSJ essay–on how hidden influences may sway our medical decisions–that got me thinking about how I have evolved as a doctor. They were writing from the perspective of the patient. But in the exam room, there are two parties: patient and doctor.

# 1) The sobering view that experience brings:

Looking back at the history of a medical treatment is intensely sobering. It’s distressing to think how sure you were of a treatment that turned out not only to be ineffective, but downright dangerous. (Seldane, Vioxx (all NSAIDs?), and stenting non-symptomatic coronary blockages leap to mind; there are many more.)  Living through the history of medical folly forces experienced doctors to present patients a more measured outlook. (Perhaps it’s why many doctors run so far behind in the office.) But at the same time, doctors also see the benefits of the fury of medicine. Patients come back to the office better; their lives enhanced (or saved) by new catheters, new medicines or even an implanted device. What’s more, over-thinking a problem gives masters-of-the-obvious acid reflux. The dilemma: don’t over-think it, but don’t oversell it either.

# 2 ) How much science is needed?

New medicines and procedures are emerging rapidly. (Which is a very good thing.) Many of these advances boast striking statistical advantages but have yet to be tested in the real world. Complicating this struggle–new versus old–has been debacles like the Multaq story: where paid consultants continued to tout a drug that doesn’t work and may not be safe. Though far from the rule, this outlier case gives both doctors and patients pause about the validity of science conducted and funded by industry.

But on the matter of science: does every therapy require a prospectively-detailed evidence base?

Take the angioplasty story:

Older doctors can tell you the story of acute angioplasty (squishing open an occluded artery) during a heart attack. Years before randomized controlled clinical trials or outcomes research showed that physically opening a blocked artery during a heart attack was better than giving a clot-buster–that failed 20% of the time or caused catastrophic brain bleeding–heart doctors were saving lives with angioplasty. They treated patients as they would want if it were them–to get that artery open, pronto. Their common sense was spot on. The moral of the story: not everything that is good for people, or favorably reimbursed, can be vetted first by mountains of evidence.

Another example of a successful treatment without an outcomes evidence base is AF ablation:

Patients with AF that isn’t controlled by medicine or lifestyle change(s) face a tough choice. They can, of course, live with the disabling symptoms of AF–resetting (lowering) their wellness barometer. Or they can reach for the treasure that AF ablation holds: freedom from AF and the need for taking drugs. This treasure, however, comes with a cost: the risk of the procedure and the untested long-term results of AF ablation. For instance, we cannot tell an AF patient that burning the left atrium reduces their risk of stroke or extends their life. Right now, all we can honestly say is that ablation is more likely than drugs to control AF symptoms. (The CABANA trial—which is currently enrolling patients–compares AF drugs to ablation. This trial seeks to answer these outcomes questions.  But the answer is many years away. And even when the data comes out, the ablation tools used today will surely be outdated.)

#3) We can…but should we.

This struggle, my friends, grows harder by the day. As people live longer (and get sicker), the benefits of treatments reach an asymptote: the point where the benefits of aggressive treatment become neutralized by the risks. A few years ago, I thought of this plateau as the point where we say uncle. Enough.

But isn’t this kind of thinking wrong-minded? Would not a more enlightened–albeit far more time consuming and emotionally draining–way to approach this intersection near death be to ask people to consider their goals of treatment. Where are they on this curve?  Why does the default mindset hold that death is something that can be beaten? Or, why do many patients (and doctors) consider the human costs of delaying death as minimal; they are not.

In a recent JAMA appendix, I saw that there were thousands of residency slots for interventional radiology and cardiology, but only a mere hundred (or so) for palliative care.

It seems highly relevant to at least offer patients the choice of comfort-focused care rather than continued life-prolonging care. Paradoxically, earlier adoption of palliative care may sometimes actually prolong life. What was a kid to think when he saw his 89 year-old grandfather live another 5 years after throwing his pills away?

Suffice it to say, that many of us are evolving the way Dr Groopman has: toward at least considering the option of no treatment, or to use big words: towards minimalism.

We can, but should we?  I surely don’t know the answer. That bothers me.

You see…

Experience complicates things.

JMM