Most concepts within early medical education are presented in black and white, a dichotomy that assumes a definitively correct and incorrect decision at each crossroad. On tests and board exams we are rewarded for memorizing the knee-jerk associations: Diabetic? Give ACE-inhibitors. Isoniazid treatment? Supplement with vitamin B6. Roth spots? Think bacterial endocarditis. As we move to the wards, we find residents and attending physicians alike enjoying the game of extracting knowledge, pimping us for factoids and giving a pat on the back when we deliver. We are praised when our plans are decisive, as one attending put it: “It’s better to be certainly wrong than uncertain!” So we rejoice for the patient plans that fit the mold—penicillin for the child with strep throat, yearly mammograms for a 50 year-old woman, an SSRI as a first-line agent for depression. Clear-cut answers for clear-cut questions. The thinker in us must give way to the doer, because after all, only one correct decision can be reached and action must be taken, or so it seems.
In the midst of this “reflexive” medicine that we are taught and see during our clinical clerkships, it is easy to come under the false belief that the practice of medicine is not the “thinking man’s game” some of us imagined. Has the fierce debate surrounding the “best plan of action” given way to a system that demands that some plan, any plan, be implemented and implemented quickly?
In a recent evidence-based medicine conference, two of our school’s experts, a seasoned geriatrician and a neurologist specializing in memory and cognitive disorders, debated the merit of pharmacotherapy in treating dementia. Each came to the conference armed with their stack of recent literature and bolstered by their own clinical experiences.
The first to present, the geriatrician, confidently made his case that the data did not support use of the therapy in question in our patient with dementia. His case was convincing.
The neurologist disagreed, stating that drug therapy was indeed indicated in dementia. He based his argument on a reinterpretation of the same data and, more importantly, his own clinical experience. Again, the case was convincing.
“I’ve seen it work…. My patients get better!” he said.
“But the data don’t support it,” the geriatrician returned.
As the conference continued and the conversation intensified, it became clear that what was being debated was more than the simple utility of a specific drug for dementia. They were debating methods of “doctoring,” vying for the philosophical allegiance of the young doctors-to-be. To be sure, both relied on evidence, but the synthesis of evidence with their experiences differed. One relied almost entirely upon the clinical trial data while the other tempered this evidence with that of clinical experience … and both were convincing. But who was correct? They offered different methods, each with merit, for clinical decision making, and were encouraging us to follow them.
The disagreement was refreshing. It served as a welcome reminder to us and our classmates that medicine, at its core, is not reflexive, not algorithmic, not black and white. Instead it is the debate between reasonable options that drives our patient care and determines the types of physicians we are to become.
When we walked out of the conference, we had not gotten a single “correct” answer to the question of whether pharmacotherapy was appropriate for our demented patients. We will have to decide that for ourselves as we interact with our patients. But this much is certain: regardless of the answer, the decision is worth taking the time to think about.
Daniel L. Fox
Mr. Fox is in his final year of medical school at the University of North Carolina at Chapel Hill School of Medicine and is a participant in the University of North Carolina’s Howard Holderness Distinguished Medical Scholars fellowship; (firstname.lastname@example.org).
Mr. Ferrell is in his final year of medical school at the University of North Carolina at Chapel Hill School of Medicine and is a participant in the University of North Carolina’s Howard Holderness Distinguished Medical Scholars fellowship; (email@example.com).