For the clinical residents, does medicine even make a significant difference

[deleted263296]

As a radiology resident, I just see the worst manifestations of disease on a daily basis - late stage cancers, cancer progression (vast majority of cases), devastating iatrogenic injuries. I am so detached from the world of clinical medicine, I don't even know if this is the norm. I am completely disillusioned with the profession, like we are perpetrating fraud, highly educated deceivers exerting herculean effort to prolong life for what? Just for patients to suffer longer? I have thought multiple times that if I were as sick as these people, I wouldn't even go to a hospital because I'd know the treatments are pointless and dangerous and the fight isn't worth the non-existent reward.

Of course, doctors can help treat pain and infectious disease quite well. But I am just wondering, are patient's outcome as bleak as they seem from the radiology reading room?

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[BoardingDoc]

Nope. Let me relate my similar experience from the ED and why that view changed. After a few years, I started thinking less of humanity because of all the frequent flyer drunks/heroin addicts/malingerers that kept coming in week after week. I saw people get joint infections coming back through the ED for their 7th infection/3rd joint revision/amp whatever. I saw more spine surgeries go bad than I can recall to the point that when a family member was considering having spine surgery I wanted to scream at them not to do it. Same goes for the recurrent CHFers, COPDers, cancer patients who are constantly neutropenic and febrile despite ongoing therapy etc etc etc etc etc.....

It got really depressing.

Then I realized that for every patient I'd seen 20 times in the ED, there were a half dozen others with the same presentation who simply never came back. All those hip infections / heroin addicts / back pain patients? Unless they all dropped dead, a lot of them probably got treatment, got better, and never had to come back.

The family member I mentioned? Got the surgery. He's not hunched over and in constant pain all the time now. His life is measurably better now. Yeah, that's an n=1, but lots of these n=1 are starting to add up.

The problem is this: in your field (and in mine, and in much of medicine in general) you will see and remember the ****ty cases. Do you remember the last few clean PET-CTs you read? You know, the ones where you wrote that the patient likely did NOT have cancer? Probably not. But I'll bet you can quickly remember the last few unexpected peritoneal carcinomatosis scans you read.

What I ultimately realized is that yes, we routinely see and deal with the worst that can happen to people. But if you can take the time to followup on a chart or two of someone who had a clean scan, who had a negative hip arthrocentesis, etc etc etc, you begin to remember that some of this **** actually does work, and it can vastly improve the lives of our patients. It's easy to remember the failures and forget the successes. Just remind yourself about that from time to time.

 

[mvenus929]

It's sample bias. We see really sick kids with cystic fibrosis when they get admitted. But for every patient admitted, there's 20-30 who are managed completely outpatient that we never see. We remember the kids with cancer that are always in the hospital, but a good number of them are admitted for initiation of chemotherapy, and are then managed in the clinic for the remainder of their treatment course.

For radiology, I saw a scan the other day of a girl with a huge mass in her abdomen. She went to surgery, and it was a simple ovarian cyst that just got gigantic. She needs an GYN consult, but is otherwise doing quite well.

 

[northernpsy]

As a psychiatrist: I find it refreshing to see someone asking this about medical fields OTHER THAN psych for a change.

As a psychiatrist who often deals with palliative care patients and has personal experience with a loved one dying of cancer: Even in those cases where a patient can't be cured, being able to make them more comfortable or make the time they have left more meaningful does matter. If your read of a CT scan helps someone make decisions about how to spend the rest of their finite time in this world, then you made a difference for that person. Sometimes the people who are closest to dying are a lot more grateful and understand what is really important better than the rest of us do.

 

[yeasports]

agree with mvenus as a sample bias. I often told my med students while in residency that when considering a field of medicine they need to think about the big picture. I found many would have tunnel vision on procedures/money/status. Think hard about what type of patient will be in your waiting room. If you are a vascular surgeon it most likely won't be a happy mostly healthy soccer mom/dad in your waiting room. (no offense to vas surg)

 

[nidusiamnot]

Calling physicians highly educated deceivers is a little much. It holds some truth that a lot of physicians wouldn't take the same course as their patients, i.e. prolong life no matter what the cost but that thinking is tempered by experience and in depth knowledge of the disease process. Unless we are expecting all our patients to be as well versed with their pathologies as we are, their decision to prolong life will be based on societal norms, mores and expectations. It's not as grim as it may seem. Some want closure and enough time to say goodbye, others want to beat the odds and manage to do so.

As for pointless and dangerous treatments, medicine progresses due to those willing to try. The very patients who go in for risky procedures become evidence in support of a new therapy or evidence against it. Without them, we will be stuck in a situation akin to when the church outlawed cadaveric dissections. The defeatist attitude that we're working to prolonging life only in the worst possible way is an antithesis to the spirit of modern medicine.

The only thing I'm disillusioned with is the financial aspect of healthcare, where the adiposity of one's wallet determines their options. While not everyone will choose the same treatment for a particular condition, the fact that there are treatments available to some more than others really gets to me. This increase in inequality, without intervention on our part, is the bleakest outcome for any patient.

 

[operaman]

Some of these efforts nearing the end of life seem Herculean and uneccessaey until you see the disease's untreated natural course. Sometimes it's not pretty. We typically do some pretty big whacks on some older folks that routinely nets us some eye rolls and whispers from the peanut gallery, but most of these people do very well and certainly do better than if they went without treatment. I don't think we are deceiving people by treating their disease when we have a reasonable chance of curing it. My PD speaks of a patient he did a big whack and free flap recon for about ten years ago when she was in her mid 80s. One of the daughters ripped him a new one post op saying he should have just let her go peacefully, but now she's in her mid 90s and doing great and has had 10 years of extra time with the people who matter to her.

The other issue is that QOL is relative. The thought of getting ye olde trach/peg and being vent dependent sounds like the most awful existence to me a healthy young man. But to someone who was already pretty much bed and chair bound, it may not feel like such a leap. Some people also just feel differently about these things and really truly want those things done. I saw a dude last week for a trach and after reading his chart expected to find some old guy gorked out of his mind surrounded by family who just couldn't face the inevitable. Instead I found a dude with a tube in his mouth who was flirting with his nurse and watching sports center and 100% on board with the surgery. I had another a couple months back who was actually gorked out of his mind - long icu course, lots of family meetings. Post op after trach his sedation weaned to the point he woke up and was crying and thanking everyone for going forward with it because he wanted a little more time.

I know the big picture view argues the futility of such things, but the individual view is quite different. I would also imagine that most of us who say we would eschew heroic measures would carry a different tune were we on the receiving end of a terminal diagnosis and suffering the effects of the disease itself.