Why doctors say ‘it depends’.

She looked harassed. She flung herself into the chair.

I’ve just about had enough. This cold is driving me mad. I’m coughing all day. Nothing helps. I’m still working for that pig of a man and we are short staffed this winter. I’m not sleeping at night. The kids are all down with this bug and my husband is on night shift. I can’t go on like this.

She left with a prescription for amoxycillin and a seven-day course of hypnotics. She also agreed to come back the following week to report on her progress. The consultation included a conversation about the natural history of viral illnesses and advice to defer the antibiotics, a discussion about her job as a reluctant telemarketer who left school without any qualifications and how to promote restful sleep. The only part of the consult that could be easily audited were the prescription data. The ‘real’ issue was not a microbe it was the milieu.

It is possible to publish papers in prestigious journals demonstrating that clinicians deviate from the evidence base. The list of misdemeanours is not insubstantial:

If you were a clinician you might say:

I never do that.

In which case you might reasonably be asked to outline your goals for consultations. If we accept that it is to be celebrated that people are free to make choices good or bad then we must accept that people smoke, eat more than they need, work in occupations that make them miserable or under bosses who are tyrants. They may choose to remain in abusive relationships or be addicted to drugs, alcohol, pornography or gambling. They are free to make choices but they must also live with the consequences of those choices. Eventually in most cases people will consider alternatives. The role of the clinician is to try to make that sooner rather than later whilst keeping channels of communication open.

The clinician advocates for the patient. In which case the answer to the question ‘would you do this’ is more likely to be:

It depends on the circumstances

You aim ‘never’ to cause harm. To avoid that which will diminish the patient’s choices by engendering physical or psychological adverse outcomes. Technological medicine can and does harm. However what is seldom reported is how the practitioners of the art of medicine help people to cope with life, not just today or tomorrow but in the longer term. That precludes slavery to ‘evidence’ that was never indicated for the very specific circumstances in which a person presents on one occasion. Compassion is not weakness. There is a narrative behind decisions in practice and simply reporting data does not present the whole story.

Picture by Vishweshwar Saran Singh

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