At the heart of medicine is a never-ending stream of difficult conversations. We can try to simplify it with guidelines, targets, and protocols, but as Ben Goldacre is fond of reminding us: ‘I think you’ll find it’s a bit more complicated than that.’ My persistent neurosis in general practice is whether I’m doing more harm than good in over-medicating the elderly. Follow all the guidelines and chase all the QOF points, and you will soon have every patient over 70 years on ten tablets a day. But no one ever does trials with patients on so many tablets. How do I know they’re not all interacting in ways that, if not catastrophic, just give you a feeling of constant muggy headedness and a propensity to fall over in the garden?
The trouble is, the evidence just isn’t there to tell me what the likely effect is of so many tablets all at once, so when patients ask me if they really need to be on 15 a day, my difficult (and oft-repeated) conversation is to admit that I really don’t know. This daily act of staring into the abyss is what doctors get paid for. There will always be uncertainty and doubt, no matter how hard we stare. We could try staring into the abbess, but I doubt if even a Mother Superior has the answers to the complexities of healthcare.
This was beautifully illustrated in an excellent BBC documentary, Great Ormond Street (BBC 2, Tuesdays, 9 pm). I usually avoid medical documentaries, but my daughter vaguely mentioned she might want to be a heart surgeon (via a marine biologist and America’s next top model), so we all sat down to watch what I assumed, would be a series of triumphant and heroic surgical procedures. In fact, it was a brilliant portrayal of the dilemmas facing clinicians, patients (if old enough), and parents when deciding whether to ‘do something’ for rare conditions when all else has failed.
Very little surgery was shown, and most of the hour was a series of very difficult conversations facilitated by doctors with truly excellent communication skills, carrying the weight of worry that they might not be doing the best thing. Some of the illnesses were so rare that there simply wasn’t an evidence base beyond ‘there are only three cases like this in the literature.’
But what impressed me most was that they didn’t shy away from things not going as well as hoped. In the first episode, one child died, another was damaged by renal failure, and one was denied surgery because it was felt to be futile until other opinions were sought from across the globe and a new method was tried that was successful in the short term, but … .
It took me back to working on a special care baby unit, the most stressful six months of my life, not just because I’m not very good with my hands, but I was never sure if the 26-weeker we were attempting to save would end up thanking us for it.
At Great Ormond Street, they somehow have to get informed consent from parents who may not be in a position to understand the illness, let alone the statistical probabilities of death, organ, and brain damage. One mum had a wonderfully, bright, bubbly daughter with a terminal vascular disease. As she poignantly observed: ‘I was prepared for her to die and optimistic that she would be returned to us bright and bubbly with a good life expectancy. But I wasn’t prepared for her to come back blind and unconscious.’
You could write a whole ethical textbook on just one of the children featured, and didn’t the staff know it. As one surgeon reflected: ‘I worry sometimes that we spend so much time and money trying to treat the untreatable that the treatable get overlooked.’ But then he consoled himself. ‘Even when a patient dies, I think that the expertise and experience we have gained trying to perform the procedure will help others in the future.’ Maybe the most difficult conversations we have are the ones inside our heads.G
Phil Hammond is on comedy tour
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