7:30 am, morning rounds: port
placements, PICC lines, drains, and biopsies with the occasional thrombolysis,
stenting or tumor ablation thrown in for good measure. I have watched for three
weeks the members of the interventional radiology (IR) division at New York
Presbyterian Hospital discuss the same types of procedures for patient after
patient. After a while, one has to ask:
why the repetition? Surely after years, or in the case of some of the attending
physicians, decades of performing the same type of procedures they no longer
need to discuss them.
The problem
with this seemingly logical conclusion is that no matter how many times a
physician performs the same procedure each patient is different and each
necessitates his or her own special considerations. I witnessed a debate among the IR physicians
this week about the best way to treat a particular patient with a thrombus. One doctor was of the opinion that two days
of anticoagulation (blood thinner medication) would be more effective than just
a single day as was more standard. All
recognized that longer anticoagulation increased the risk of bleeding
complications, but the physician in favor of longer anticoagulation believed
that the risk was no longer particularly high for this patient despite a
previous hematoma. Upon hearing this
conclusion, another physician responded “famous last words”. He was clearly concerned that despite
precautions taken against bleeding, the risk was too high. In an otherwise perfectly healthy individual,
the doctors would likely have easily agreed that two days of anticoagulation
would be better, but the history of hematoma in this particular patient raised
doubts.
Besides
history of previous disease, the age of a patient can drastically alter the way
certain treatments are applied. I
watched a resident fellow put a peripherally inserted central catheter (PICC)
into a 6 month old. This otherwise routine procedure became extremely complex
due to the age of the patient. What is a small needle to an adult appears a
deadly weapon next to such a young baby.
Wires and sheath’s had to be downsized, drugs diluted, and x-ray dose
minimized. Fellows and nurses from the
neonatal department stood by to give advice.
Particularly complicated was the anesthesia. Obviously, for one so young, general
anesthesia rather than simple sedation was needed, yet even after the patient
was completely asleep her continued movements necessitated the use of
paralyzing drugs. Although the main procedure
lasted perhaps half an hour, the process of anesthetizing the patient and
prepping her for the procedure took over an hour.
Shadowing
my mentor at the clinic, I saw that patient lifestyle also influences
therapeutic decisions. For an athletic patient who made running, biking, and
tennis a big part of his life, Dr. Sista considered a more aggressive treatment
than he might otherwise in order to avoid the possibility of post-thrombotic
symptoms that would interfere with this lifestyle. When considering a particular treatment
regime, he and others doctors carefully weigh a multitude of factors specific
to that patient before deciding on the most optimal therapy.
However, if
the same patient sees two different physicians it is far from certain that they
will receive the same treatment. Much of
medical decision-making is based on the physicians judgment, and just like
their patients, every physician is different. As a Ph.D. student, I have been trained to
think objectively about everything. Experiments
must be carefully designed, decisions well supported by evidence and results
reproducible. At first the lack of
uniformity and the unknown aspect of medicine jarred me. Unfortunately, sufficient evidence is not
always available for a fully scientific decision to be made. Furthermore, clinicians do not have the
option for waiting for more data; they have to make a decision when the
patients need it.
The
differences between clinicians and researchers became more obvious as I spoke
to some of the visiting medical students.
As trainees in the medical field they seemed world’s ahead when it came
to understanding medical procedures and diagnostic decisions, yet our roles
completely reversed when it came to research.
As I worked on my summer research project I realized that the techniques
that I took for granted and applied without thinking were foreign to them. To each his own: while the medical students delve into the
complex world of clinical diagnosis, I will hopefully be researching new medical
tools, techniques and therapies. Perhaps
together we can find cures for many human diseases.
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