A Certainty of Medicine Is That Caregivers Will Forever Wrestle With Uncertainty

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COVID-19 has brought this into sharp relief as we confront an illness that we are just beginning to understand. Even as we make significant strides in treating the sick, a host of basic questions remain: Why does it affect the elderly far more than the young;? Why do some people who seem similar based on their age and medical histories suffer no symptoms while others remain ill for months on end? Why have a tiny handful of recovered patients become reinfected?

Although some of the mysteries can be attributed to the sudden and unexpected emergence of this deadly virus, the questions highlight a more profound truth of modern medicine.

An irony of our high-tech age is that even as breathtaking discoveries and wondrous machines allow us to improve care, these advances have raised almost as many questions about the human body as they have answered.

Our growing understanding of cancer, for example, has revealed that it is not a single illness but a complex set of perhaps 200 diseases known by a single name, each of which presents its own challenges to treatment.

Perhaps even more daunting – and inspiring – are the questions raised by the mapping of the human genome. This dramatic breakthrough has shown that even those 200 types of the cancer are just the tip of the clinical iceberg because each disease can take a slightly, or sometimes radically, different course in each unique individual.

This discovery informs the concept of precision medicine, which combines the patient’s genome along their personal and family medical histories, social and physical environments, and lifestyle, to tailor treatments that are most effective for them.

Precision medicine is promising, but it is still in its infancy. It remains, today, more an aspiration than a reality. This creates a Catch-22 for caregivers: We know that the most effective treatments are personalized but we don’t yet have the capacity to deliver customized medicine in the vast majority of cases. Thus our growing certainty about the limits of the general approach we often take adds uncertainty regarding the care we are delivering.

Make no mistake, this awareness is an important advance. It is just as empowering to recognize what you do not know as what you do.

Still the Catch-22 abides. In response physicians must embrace what we might call radical uncertainty. Through this approach, we recognize that the standard form of care is both necessary and yet may also be inadequate. It urges us to constantly monitor patients not only to see that our treatment is working, but with a focus on how it may be less or more optimal for each individual case.

Radical uncertainty urges us to seek answers not only in the data generated by essential new technology, but by placing even greater emphasis on the foundational and eternal core of medicine: the doctor-patient relationship.

This is the argument Kenneth Brigham, MD, and Michael M.E. Johns, MD, make in their illuminating new book “The Good Doctor: Why Medical Uncertainty Matters.”

In it, these distinguished physicians and academics observe that, “The traditional authoritative doctor-obedient patient arrangement no longer serves to make us healthier. The truth is that the doctor isn’t always right and the patient always brings critical information. What we need is an equal partnership between the person seeking medical care and a doctor who knows and thoroughly understands the current data and as a result, has a firm grips on the uncertainties.”

As the authors note, this approach updates the famous wisdom of one of the giants of early modern medicine, Sir William Osler (1849-1919), who taught: “Listen to your patient, he is telling you the diagnosis.”

Brigham, Johns and Osler were not arguing that doctors should become 50/50 partners with their patients. Trained physicians possess knowledge and experience that cannot be acquired through Google searches. But patients with an illness often possess insights into the course the specific disease in their unique bodies that can elude the machines we tie them to.

The paradox is that even as digital medicine underscores the fact that human beings can never be reduced to numbers – that precision medicine tailored to each patient is part of the future – we must not rely on machines to provide every answer.

 “The tragedy and the paradox that we may be courting is that dehumanizing health care, trusting the whole thing to gadgets and machines, would severely limit the potential of the science and technology,” Brigham and Johns write. “The real power of science and technology to make us healthier and happier is the power to enhance the critical functions of the doctor-patient partnership.”

Of that we can be certain.

Marschall S. Runge, MD, PhD, is Executive Vice President for Medical Affairs and Dean of the Medical School for the University of Michigan.  He serves on the Board of Directors for Eli Lilly and Company.

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