March 2014

The Medicine

The biggest decisions

By Karen Hitchcock
Why doctors second-guess themselves

Researchers relate “decision fatigue” in executives to the degradation of sound judgement and to poor impulse control after hours. Nearing the end of a weekend of dealing with a ward full of sick patients, and faced with a particularly challenging case, I recognise I have it by my own sudden irritability and my desire to decide anything, for a bit of relief. Rather than start saying stupid things in an authoritative tone and driving a Maserati I don’t own 200 kilometres an hour down some freeway, I tell my registrar I’ll be back in 15 minutes and walk to my office.

Each year, medical errors cause hundreds of patient deaths in Australia. Decision-making processes are therefore interesting to educators and researchers seeking to reduce avoidable harm. You see your GP and your blood pressure is elevated: whether you will be prescribed a drug or not depends on your “risk profile” – whether you smoke, have diabetes, have cardiovascular disease – and also on your doctor’s threshold for prescribing. The doctor will hopefully include you in the decision-making process, but he or she still needs to recommend a particular course of action and tell you why. The drug must be chosen from one of dozens on the market. Each decision is made through a mix of scientific methodology, pattern recognition, probability and personal opinion.

National consensus guidelines offer basic treatment algorithms for all the common diseases. If a patient has a chronic lung disease, you can check these guidelines and prescribe what is considered to be best current practice. There are websites with “consumer decision-making tools” where patients can type in their own data and get a computer-generated recommendation. There are also equations and scoring systems, far too many to remember, so we carry them around in apps. The Wells score determines the likelihood that a breathless patient has a blood clot in their lung; the CHA2DS2-VASc score guides the prescription of anti-coagulants by determining the risk of stroke from a fibrillating heart; the Child-Pugh score (based on tests for blood albumin, bilirubin and clotting, fluid in the abdomen and degree of brain malfunction) is used to work out how long a patient with a failing liver has to live. Should a drug be prescribed for osteoporosis? Type in the patient’s data and get an answer. There are protocols in hospital for the treatment of disasters like heart attacks, catastrophic haemorrhage and community-acquired pneumonia. These are designed to guide decision-making and reduce human error, and are helpful if the patient’s body follows protocol. But if I followed the guidelines for all of the diseases afflicting my typical elderly patient, she would be on 21 medications and I would be killing her.

Hippocrates said that it is more important to know what kind of patient the disease has than what kind of disease the patient has. You’d think the body would be more straightforward; we don’t have that many organs and only five of them are vital. Sometimes you just don’t know exactly what to do: you study the form, consult your mates and the major online encyclopaedias, take an educated gamble, then sit back and watch the race, sweating bullets. Maybe that’s why some people hate doctors, those culpable, imperfect decision-making machines.

As a trainee you pass the difficult decisions to the boss, with relief. But now I am the boss, and I have a young patient with pneumonia and 2 litres of bacteria-filled pus collecting outside his lungs, making him septic and delirious. The treatment is intravenous antibiotics and surgical drainage. But the patient’s liver is failing after a decade of serious drinking; it no longer makes clotting factors, so his blood is thin and he may bleed to death if the surgeons cut into his chest. His heart is straining; his brain is faltering in a bath of blood-borne toxins. He will likely die without the operation. He will likely die with the operation.

The patient laughs and pulls his blanket over his head when I outline his options. His only living relative tells us to do what we think is best. The surgeons say it’s my call. So do the infectious diseases physician and the gastroenterologist. The anaesthetist says he’ll intubate him but estimates that he has a 70% chance of death. My team of junior doctors look at me expectantly, trusting that I have the answer. There is no protocol, no app that can share the responsibility.

All day I have that feeling you get when you take a step and think you’ll hit pavement but your foot falls unexpectedly into a gutter. No sooner have I convinced myself that it would be futile to put him through surgery than I think, “Well, why not put him through the surgery? What have we got to lose?” Even Hippocrates knew that “when the entire lung is inflamed … he will live for two or three days”.

He could die on the table, but then again he might wake up with a clean chest cavity and say thanks. According to his Child-Pugh score, he could last three more years. You can do a lot in three years.

My other patients, with simpler combinations of pneumonia, dehydration, intoxication, and heart and kidney failure, recede in their crisp white beds. Their treatments are settled; all they need for today is time and medicine.

I tell my registrar I’ll be back, go to my office, and pick up a book about a journalist and a doctor who may or may not be a murderer. I never wanted to be a lawyer, because laws are just made-up rules. I never wanted to be a gambler, because I don’t believe in luck. I drink a glass of water and walk back to the ward. I take the patient’s file – that poor sick man – and write a summary, each of his vital organs listed and followed by its narrative of failure. It is useful, to see the facts reduced to a story in a format that approaches an equation that ends with a decision.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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