Hem > Uncategorized > There are very few things in medicine that I know for sure

There are very few things in medicine that I know for sure

This is my second post in three days. Again it is about something Rob Orman said on his podcast on suicide risk assessment. He said that when it comes to suicide risk assessment, there isn’t a clinical decision aid to lean on, only a structure to go by. There are no binary, yes or no answers, that can say with certainty if the patient will commit suicide or not in the future. Patients are different and you just have to rely on whatever information you get out of them and weigh it all together.

This is all well. What surprised me, however, was that the above statement was made with reference to the literature. It more or less sounded as if he had expected to find a study that showed Yes, all depressed patients who are male, in their late sixties with suicide ideation end up killing themselves and No, borderline females who slice their wrists from time to time never ever actually complete their suicide attempts.

Of course Rob Orman knew he wouldn’t find any studies of that kind. What he did find was studies showing that old patients with suicidal ideation were more likely to complete suicide than young ones, indicating that old age is a warning flag, or studies showing that a lot of hospitalized patients deny intent, but still kill themselves, indicating that your assessment has to be more detailed than just asking the patient if they are suicidal.

But, and this might be why I sometimes find myself lost in the EBM community, Rob Orman said that this is something that makes the risk assessment of a potentially suicidal patient different from the risk assessment of a patient with e.g. chest pain. And I can’t see that difference.

Let me give you an example.
A junior doctor presents the following case to you:

A 54 year old man presents to the ED with a diffuse feeling of not being well. He has no known risk factors for CAD and has never experienced chest pain at rest or on exertion. His physical capacity has been reduced over the last few months, but he hasn’t noticed any deterioration during the week previous to this visit. There are no pathological findings on the physical exam, except for a BP of 165/95. His ECG and cardiac enzymes are within the normal range. He is now symptom-free and wants to go home.

How likely is it that this patient has an acute coronary syndrome? I dislike the usage of percentages, since it gives a false sense of certainty where there is none. Instead I like to use very low, low, medium, high and very high. Make your estimate.

Since it’s an unusually quiet day in the ED and you feel an overwhelming urge to show off your history taking skills, you decide to take the history all over again. You grab two chairs for your young colleague and yourself and start from the beginning.

Twenty minutes later, this is the patient’s history:

He is 54 years old. Since he was adopted as a child he doesn’t know if heart disease runs in his family. He dislikes hospitals and hasn’t seen a doctor for the last 40 years. A friend with hypertension checked his blood pressure on her device ten years ago and told him it was high, but he never followed up on it. He has never checked his blood sugar or cholesterol levels. After a while he reluctantly admits that he smokes a couple of packs per week.

A few months ago he experienced a burning sensation in his jaws when he was running to catch a bus. This was the first time it happened. At first he didn’t think much of it, but there were recurrent episodes. Gradually it got worse and he had to stop at first once, then twice when walking up the stairs to his office. It wasn’t just the pain, in fact he doesn’t even want to refer to it as pain, he also felt nauseous and a bit dizzy. Since walking up these stairs is the only exercise he gets, he stubbornly kept going. But a week ago he sprained his ankle and had to start taking the elevator. During this week the jaw sensation has been more or less absent, until today when it suddenly came back as he was limping back to the office after a heavy lunch. It was much more intense than he had ever felt it before and he got scared enough to go to the hospital for the first time in his adult life. The sensation subsided almost immediately once he got here and he is very pleased with your younger colleague’s assurance that all is well and he can be discharged home, without having to wait all day for a second round of that non-high-sensitivity troponin that you still use in your emergency department.

Does this additional information change your estimation of this patient’s risk of having an acute coronary syndrome? Of course it does! Does it change his TIMI score? No! The boxes still have to be ticked the same way.

Emergency physicians preaching evidenced based medicine sometimes give the impression that science, in the form of research, gives us exact answers. As if there were an absolute truth and the more you standardize medical practice, the better your outcomes will be.

The patient, with a strong family history of thromboembolism, who presents with a swollen lower leg, measuring 2,5 cm more than the other leg, who was curatively treated for testicular cancer 7 months ago and who has now been immobilized for two days, is not at a very low risk of having a DVT, just because his Wells score is 0. The scientific evidence suggests that all these circumstances increase the risk of a DVT. In order to make a clinical decision aid, there had to be cutoffs for continuous variables. The collective body of science, including all kinds of studies on all different aspects, is what gives us the knowledge needed to decide how to treat our patients.
A drug which is commonly used and works well in one setting, may be less beneficial in a setting where it is only prescribed by a few specialists and the rest of the medical community doesn’t know what side effects and interactions to look out for.

To practice evidence based medicine is not to uncritically apply even the most prominent researchers’ recommendations, based on excellent randomized controlled trials. EBM doesn’t obviate the need for critical thinking. I think most doctors agree with that statement. But I wonder how many agree when I say that a fair amount of humility is needed in the discussion on what’s to be considered best practice and evidenced medicine in a setting you know nothing about.

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