Friday Reflection 47: Patients Make the Hardest Decisions

MM is a 55-year-old man with recurrent pneumonia. He initially presented with a fever, chills and a lobar infiltrate. Symptoms resolved with antibiotics but recurred a week later. During his second course of treatment, further evaluation with a CT scan showed the infection to be post-obstructive, occurring distal to compression of a secondary bronchus by severe scoliosis. Following a third course of antibiotics, bronchoscopy, and consultation with spine and thoracic surgeons, a lobectomy is recommended.

If you write enough of these reflections, you end up constructing a few 2X2 tables.¹ The types of management recommendations we make easily fill one of these tables.

Some clinical dilemmas are associated with straightforward recommendations. Data, clinical experience, and science all point toward one course of treatment. These recommendations might be for minor problems – a urinary tract infection or strep throat – or for life-threatening ones.

Other clinical scenarios do not lend themselves to obvious recommendations. When the problem is minor, a patient may choose either course, knowing she will likely do just fine, or can change course if she wishes. When the problem is major, even life-threatening, patients are left with the most difficult decisions.

Patients faced with ambiguous choices for severe problems often see multiple physicians on their way to a management recommendation. During this journey, they experience all the complexities of medicine, replete with anxiety and uncertainty at a time they are not well. Frustration is common, especially when their doctors disagree about the best way forward.

For doctors, these “cases” are humbling. They put in stark relief the uncertainty of medicine. No article or textbook or AI bot will give “the answer.” Experienced, dedicated, and informed physicians might recommend different courses. I have been in situations when my recommendations are at odds with doctors I trust, respect, and referred the patient to. Usually, I understand why the other doctor is recommending what she is.

In the end, the decision will be the patient’s.

She must choose a single path from the multiple ones suggested by doctors.

He must choose between the risky plan the doctor recommends, or the conservative one the doctor thinks is even riskier.

She must commit to the one path that is right for the only person who will have to live with—or die by— that decision.

In hopes of avoiding surgery, MM requested an additional 8 weeks of antibiotics. He reasoned this might prevent another infection, maybe giving the obstructed bronchus a chance of opening. He was willing to accept the possibility of antibiotic side effects, bacterial resistance, and requiring surgery in an even more weakened state.

MM never underwent surgery, and, five years later has had no recurrent infections.

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TS is a 60-year-old woman admitted to the hospital with painless jaundice. She was feeling well when she noted yellowing of her sclera. The following day, her husband noticed the change and brought her to the emergency room.

MRCP revealed a bile-duct stricture. Interventional gastroenterology placed a stent across the stricture during an ERCP. Pathology from brushings showed atypical but non-malignant cells. The differential diagnosis included early cholangiocarcinoma or a benign stricture, a late complication of a cholecystectomy decades earlier.

One month later, TS had the stent removed. Repeat imaging and biopsy were unchanged though genetics on the pathology were concerning. A surgical oncologist recommended a pancreaticoduodenectomy (Whipple procedure). TS declined surgery. She felt that undertaking such a radical treatment for an uncertain diagnosis was extreme.

Six months later, she began having abdominal pain. Cancerous tumors were found in her bile ducts and liver. She died six weeks later.

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WB came to see a new primary care doctor after his doctor of 30 years retired. He has asthma, which he doesn’t think is perfectly controlled, and notes about six months of increased shortness of breath. He admits he has a hard time keeping track of his symptoms. On his physical exam, the new internist hears a loud mitral regurgitation (MR) murmur. WB does not remember being told about the murmur, but says that his previous doctor had not really examined him recently.

A transthoracic echocardiogram shows moderate to severe MR, a finding verified on a transesophageal echocardiogram. Given the severity of the MR and the progression of the dyspnea, the cardiologist recommends surgical repair or replacement of the mitral valve.

WB seeks a second opinion, which was also for surgery. A third opinion recommended monitoring.

WB is now 6 years out from this third opinion and has stable shortness of breath.

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All healthcare should be collaborative care. A doctor makes a recommendation, explaining her rationale, and the patient considers it, thinks about what he knows and wants, and makes a decision. Many decisions are straightforward, and many that are not are relatively trivial.

Then there are situations when stakes are high and the correct path unclear. As a doctor, your patients may choose to follow a different path from the one you suggest. You know there is a chance their decisions will prove correct. When they do, you are humbled but happy your patient made the correct choice. When things go poorly, you wish you could have been a more persuasive, or better, guide.

Doctors often get credit (or blame) for having to make difficult, life-and-death decisions.

But really, it is all of us, when we are patients, who make the bravest decisions that carry the highest stakes.

1. Both Friday Reflection 34: Disagreement and Chagrin in Therapeutic Decision Making and Friday Reflection 44: Diagnostic Enigma featured 2X2 tables.

Photo Credit: Jens Lelie