Saturday, May 07, 2016

Your expectations, our limitations!

Saturday, May 07, 2016

Your expectation.

"Doc! I am travelling with family day after; can you give my daughter medicine so that she is free of fever when we travel?"

My limitation!

I honestly do not know in a given patient when the fever is actually going to go away. Or, I do not have luxuries to choose from various treatment regimens to suit one or the other social obligations.

Another example.

Your expectation.

You wish to know and rightfully so, when your unconscious patient is going to gain consciousness?
Probably you have heard a doctor in a movie saying that a patient will regain consciousness in 24 hours!

My limitation!

No neurologist worth the salt can make a prediction. There is no way to know how long it will be?
There is no way to know when a failed kidney is going to resume its function, if at all!
There is no way to know if a failed liver is going to restart functioning, and again, if at all!
The truth of the matter is whenever a body organ fails to perform its functions, we have to keep supporting and supplementing, sometimes substituting its function (Dialysis is called kidney replacement therapy, it does not cure kidney disease). With the hope that in due course of time it starts functioning, it may or it may not!
Often times, especially in critical illnesses we are confronted with questions like when he will be off ventilator or when will he stop needing supplemental oxygen, we do not have numbers to give it to you. You expect us to come out with a number, and as we do not, you find it unacceptable, and increasing number of people see it as a sinister design of a commercial mind.

Your expectation.

You shove a report under my nose (you haven’t even got the patient) and wish to know all the answers to your patient’s illness! You may be right in your assertion because you have in black and white a report that should tell me all!

My limitations!

It does not (Tell me all!)

Blood tests are not done to first diagnose and then fit the patient to conform to the test results, they are (or should be) ordered to confirm or refute a clinically made diagnosis. How do I explain to a patient something I have learnt assiduously over years, and still grappling to come to terms with, what is a pre test probability of a test coming positive, what is a false positive, what is a false negative, what is positive predictive value, what is negative predictive value. How do I explain to you that prevalence of a disease in given community affects the positive predictive value of a test?

I can ad nauseam cite innumerable examples of difficulties and limitations of interpretation of a test, when a test is positive in certain percentage of normal population, when a test may come positive in more than one disease, when a test can continue to be positive despite adequate treatment and clinical cure (and patient continues to repeat the test in a hope to get rid of the disease report wise). This is beyond the scope of this blog and is wisely left enshrined in medical curriculum! The idea is to convey 2+2 do not make 4 in medicine! Not always! Sounds too complicated? It is!

Everything in medicine does not come in such sharply divided black and white, there are more often than not, grey zones and that’s what makes medicine interesting and challenging. Medicine is not mathematics, it’s a dynamic science, ever evolving, resulting from a host of interactions.

I have a known treatment modality, I have a standardized treatment guideline to treat your patient, yet I have absolutely no way to know how your patient is going to respond. And I have no modalities to govern or modulate an individual’s response.

You will be surprised to know that even in this 21st century when medical science is expected to know everything, it does not. In a child with pneumonia the choice of antibiotics is largely a calculated risk, you hazard a guess and often times you are right, but before hand you do not often have a bacteriological proof to guide your treatment!

You vaccinate a child and you expect him to be 100% protected, but the limitation is that we do not know how his body is going to respond in terms of producing the desired protective antibody! If he fails, you can always cry foul, and say the doctor did not give the injection properly!

Often, one thing which scores in minds of many patients and to some extent propagated by practioners of other systems is the “propensity” of allopathic medicines to cause side effects. The beauty of our science is that we know what the side effects are, if you have to adequately control fits, you may have to cope up with some initial sedation and that is the side effect. But there are effects which are based on individual’s response to a given drug. Such idiosyncratic response are unpredictable and come to fore only after the patient takes the drug! Sometimes the side effects may be advantageous to the patient. A drug used to control tremors may cause dryness of mouth and may be advantageous to a drooling octogenarian!

A patient often equates my science’s limitation to my individual ignorance. The science does not and cannot have answers to each question life throws at it. That science progresses to limitless boundaries which is aware of its limitations and these limitations constantly nudge and urge to go beyond. My allopathic science is a vibrant kicking science, tries as much as possible to be evidence based, and is in constant search of answers which are elusive and evasive.

Too many expectorations are truly the cause of too many heart burns and unrealistic set points will cause them more!

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