Crozet Annals of Medicine: Sharing Uncertainty

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May is my favorite month in the hospital. All of the interns have survived intern year (usually). When they started last June they were tentative and nervous all the time. They were wrong more often than they were right when making treatment decisions. Now after a long year made harder by the toughest type of learning of all—learning from their mistakes—caring for patients correctly is ingrained; they do it almost reflexively. They are becoming physicians in the true sense of feeling it as their identity. They have earned a bit of swagger but they carry it lightly, as they should, still fearing the many mistakes ahead. My job is to let them come as close to the edge of those mistakes as possible before nudging them back onto safe ground.

By May the second year residents have completed two years of intensive training and are right more often than they are wrong. They do not appreciate much correction from me. The swagger has turned into skepticism. My guidance is no longer accepted simply on my authority. Less willing to accept my judgments at face value, they demand sources and studies and citations to support my pronouncements of fact. I enjoy this intellectual chess match and learn continually from my residents’ challenges and burgeoning knowledge base.

By May my third year residents are ready to graduate, ready to go make their own mistakes. They know what is in store for them, and so I feel them watching me, trying to absorb one last thing. They want to know how to cope with the two certainties of clinical medicine, the certainty of error and the certainty of doing harm.

There are many ways practicing physicians try unsuccessfully to protect themselves from these two certainties. Some order lots of tests. Some ask for lots of consults from other specialty physicians. Some limit their practice hours and see fewer patients. Some pursue treatments long past any expected benefit.

While these strategies may occasionally benefit a patient, they are essentially focused on protecting the physician. This is not a formula for long-term practice satisfaction or good patient care. It is also expensive.

I recently treated a 98-year-old man who had fainted at home while watching Dancing With the Stars in his recliner. He had been unconscious for about 15 minutes but was back to normal by the time he arrived in the ER. Normal for him was slightly demented. We ran some tests on him to be sure he had not had a heart attack or a stroke and he had not.

His son was with him and wanted to know what we thought had happened to him. There was no way to really tell for sure, but the most likely thing was that his heart had had an abnormal rhythm. In his age group, this carries a high one-year mortality rate.

This is a difficult condition to diagnose and treat. Standard therapy is admission to the hospital for overnight monitoring and consultation with a cardiologist. Study after study has shown that the rate of definitive diagnosis with this strategy is very low but not zero. Some few patients’ lives are saved or prolonged with this strategy.

Hospitalizing a 98-year-old, though, is not without significant risks. Away from the familiar surroundings of home, the elderly can become disoriented, delirious and agitated. This happens to anywhere from 20 to 55 percent of elderly hospitalized patients. They can also fall, they can get hospital-acquired infections, and they can get complications from the therapies and IVs and tests.

The resident was explaining all of this to the son and his father. Shared decision-making, the resident told me, and the family was very important in these situations. Basically, the patient and the physician mutually come to a treatment decision after carefully weighing the risks and benefits and factoring in patient preference. In this case, the decision was over whether to hospitalize.

By now it was late evening and Dad just wanted to go home and sleep in his own bed. His son, however, wanted everything done, hospitalization, further testing, whatever could be done. They could not agree. They needed to do some shared decision-making of their own.

I left them to work it out somehow and went back to my desk. The resident hustled over to further discuss this new concept of shared decision-making and the latest studies on the benefits to patients, families, doctors and health systems.

I listened with some interest and admitted that I, too, had been taught shared decision-making back in residency. But the concept was slightly different back then.

“I’ll make the decision and then I will share it with you,” I growled at her, doing my best curmudgeon impression.

“Come on, I’ll show you how it works” I said, and I got up and went back to the old man’s bedside.

“Well, what do you want to do folks?”

More arguing ensued. The dad refused to stay. The son refused to drive him home. The resident went over the risks and benefits again. It did not change anyone’s mind, including hers and mine.

Finally the son asked the very best question in health care. He looked me in the eye and asked me what I would do if it were my father? And I told him.

So, my dear residents, as you go forth into the hurly burly world of emergency medicine practice, let that be your guiding question. You may still err, harms will still befall your patients, but you will be able to go on knowing that you answered the right question.

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