Treatment and Prognosis
First do no harm.
If all treatment were simple and without potentially adverse effects, deci- sions about treatment would be easy. For example:
• The treatment for an upper respiratory infection, the common cold, is nothing more than some medicine for comfort. Untreated, the patient may be uncom- fortable for a few days, but she will suffer no long-term adverse effects.
• The treatment for a strep throat is penicillin. Untreated, the patient may develop rheumatic fever or glomerulonephritis, an inflammation of the kidney.
• The treatment for a skin laceration is sewing it up. Unsutured, it will heal poorly and may become infected.
• The treatment for appendicitis is appendectomy, usually a simple operation of low risk. There are no good alternatives. Anything other than appendectomy may lead to serious complications and premature death.
• The treatment for a compound fracture of the femur, where the bone fragments have broken through the skin, is reparative surgery. The choice is usually simple for the patient and the patient’s family, for untreated, the fracture will be unsta- ble and the patient will develop a severe life-threatening infection.
The treatment for S.M., Case 3 in chapter 10, is more complex, for there are many problems to consider concurrently. For the patient with coronary heart disease in chapter 1, the issues are complex also. Recall this part:
The next day the surgeon arrived and said that surgery was an option and that he could do it. With the cardiologist, I examined my choices. Treatment with med- icine alone would not improve the long-term outlook. Angioplasty, using a bal- loon-tipped catheter to enlarge the areas of narrowing, might be a possible remedy but had its risks. Surgery, though also risky, seemed the best choice.
Most of the time, there are several treatment choices to consider in a pa- tient with significant coronary artery disease: medication, bypass surgery, angioplasty, or combinations of them. Medication alone is least traumatic. Angioplasty, with or without a stent (a supporting structure inserted in the angioplasty site), often involves no more recovery time than that required for the angiogram. Bypass surgery is by far the most traumatic, for it in- volves surgery and anesthesia, a long recovery period, and potential com- plications of the surgery. All three, alone or in combination, may fail. The arteries treated with angioplasty or bypass may close, and drugs may be inef- fective. Then how do we decide about treatment? What enters into the de- cision? Not all turns out well, and a primary value in medicine is, “First do no harm.”
Consider first the treatment and the options available for this patient. The cardiologist decides about the best treatment by considering the out- come and the risks of treatment. He asks himself, “What is the course of this illness, coronary heart disease, with the patient’s specific coronary ar- tery anatomy, treated and untreated? What are the benefits and risks of treatment?” A good physician applies these questions to every treatment decision. Defining and declaring the prognosis have importance to the phy- sician and to the patient. Unless both are convinced that the treatment will improve the outcome, there is no good reason to choose it.
A more precise way of framing the cardiologist’s question is: “On the ba- sis of the coronary artery anatomy, how much muscle would be injured were he actually to have a heart attack?” If the amount of muscle at risk is small, usually when only a small branch of a major artery is narrowed, then the risk of surgery or angioplasty is unwarranted, and medication is the best choice. But suppose the affected artery is a major one, serving a large vol- ume of heart muscle. Then the choices may be different: angioplasty or by- pass surgery. The technical details of the procedure enter into the choice between the two; some are best handled by one or the other.
Sometimes a “trial of therapy” serves as a method of diagnosis. For example:
• A confused patient who has diabetes and takes insulin may be given a glucose injection without a confirmatory blood sugar test if hypoglycemia is suspected. If the confusion clears promptly, then hypoglycemia is the likely cause of the confusion.
• A patient with episodes of chest pain may be given nitroglycerin. If the pain is relieved promptly, he may have angina.
• A patient with hoarseness may be told to “take aspirin, gargle with salt water, and call me in three days if you’re no better.” If the hoarseness has resolved, the symptom requires no further investigation. If it persists, the physician must look for serious causes.
Prognosis, the prediction of outcome, affects the choice of treatment, but that is not all. Anyone who has been through a difficult illness knows that the process of care is an important dimension of the treatment. To the patient with heart disease and to his wife (chapter 1), the cardiologist said, “Here is what I think and here is how I think we should proceed.” Then he defined for them the issues and the coronary artery abnormalities, de- scribed the choices and potential benefits of each, explained that there were risks to each and also risks of doing nothing, and provided opportunity for questions. Having outlined the choices, he said, “Here is what I think is the best choice.” He expressed his understanding and empathy, “I know that this is a lot to absorb all at once. What are your thoughts?”
He did not say, “Here are the choices, take your pick,” because most pa- tients are unable to make such complex choices without the physician’s wisdom. While most patients will ultimately participate in the decision, it is the physician’s responsibility to provide sufficient information and ex- planation, weight the choices on the basis of his knowledge and cumula- tive experience, and then make a recommendation.
Then there is the human side. Which treatment is best also has to do with the patient’s values. Consider the case of the 75-year-old patient with major narrowing of his carotid artery. When his physician urged him to have sur- gery to lessen the risk of stroke, she also told him that the surgery itself could precipitate a stroke, though that was less likely. The patient said, “I’ve lived a good life. I’m ready to die. I’ll take my chances without surgery.”
The treatment choice also has to do with the patient’s experience. What may seem like an obvious, easy choice to the physician may be unaccept- able to the patient, who fears hospitalization or has a friend whose outcome from similar treatment was poor. “No, thanks!” was the patient’s response to her physician who suggested back surgery for a ruptured disc. “My friend had that surgery and hasn’t been able to walk since.” “No, thanks!” was an- other patient’s response to a proposal for chemotherapy for breast cancer. “I don’t want to lose my hair. I don’t want to spend my last months vomiting.” Inquiring about that patient’s experience and her knowledge of other pa- tients’ stories provided the opportunity for the physician and the patient to talk further and reach a more informed decision. Cost may influence the patient’s decision. If the patient can afford neither the cost of treatment nor its follow-up visits and tests, she may decline.
The physician’s own experiences often influence what she recommends. If, despite the statistics, the physician has had a bad experience using a spe- cific drug or treatment, she will be reluctant to recommend it. For the phy- sician, the important step is to identify all the issues in the use of a specific treatment: Was the adverse effect even rarer when seen in its broader com- munity use? Did it happen because it was used inappropriately?
Most decisions regarding diagnosis and treatment are simple. Those that deal with several concurrent illnesses and treatments are more difficult. The more complex the illness, the greater the likelihood that the physician will need help from others, for medicine is a collaborative profession, the subject of the next chapter.