The Concept of Sober Second Thought in Medicine


Perhaps it is the vain attempt of Age to maintain its relevance in a time of incessant, dizzying innovation, but it seems to me there is something to be said for reflection before action.

We have here in Canada, a now much-derided political institution called the Senate whose members are appointed, not elected, and whose purpose is supposedly more to reflect regional differences than voter preferences (as in the other institution, the House of Commons). Approval of both institutions is required for legislation, although the Senate rarely rejects Bills passed by the more powerful and voter-elected House. Its purpose, at least according to Canadian myth, is to be a chamber of ‘sober second thought’, unsullied as it were by recent fads or the evanescence of events that might unwisely sway popular opinion.

While in practice, there is much to criticize about the Senate as an institution, the concept of ‘second thought’ is worthwhile.  And I see this as nowhere more important than in Health Care.

Our concept of health has evolved over the years as have our expectations. We no longer tolerate the intolerable with the equanimity of a century ago; at least in more affluent nations, we don’t expect children to succumb to infectious diseases, or women to die in childbirth. We assume there will be ever more sophisticated approaches to diabetes, treatments for autism, preventative strategies against heart disease… Knowledge conquers all.

But sometimes in our headlong rush to cure, we engender unrealistic -even unnecessary- goals. We unwittingly foster an assumption that living through life’s vagaries needs to be asymptomatic -or at least should be. And while I’m sure most of us understand the need for priorities in health care, its boundaries are, at best, often vague, and usually personal. This is to be expected: we enter the world of medicine only when there is a need, a worry -a symptom.

Symptoms are puzzles waiting to be solved, questions as yet unanswered. They do not always bespeak disease, of course; many point to an underlying concern, an anxiety that needs as much exploration as the condition feared. But the solution -the diagnosis and subsequent management- is not always as straightforward as it might seem. Not all symptoms require intensive investigation; not all conditions require treatment. And while all symptoms require explanation, most conditions also require options -and that is different.

The rush to cure leads down different roads, and not all of them pleasant -not all of them even necessary. An example from my specialty, gynaecology, might be illustrative. Let’s say a 48 year old woman is discovered to have fibroids (benign overgrowths of muscle tissue in the wall of the uterus) during a routine physical examination when she has her pap smear. She didn’t know she had them, had no symptoms that concerned her, and would no doubt have carried on her with life blissfully unaware of what lurked so silently just underneath her skin… But she is told she has some uterine tumours by her well-meaning family doctor. She is then told she needs an ultrasound -just to be sure they are fibroids- and is referred to a specialist for management.

The woman is understandably concerned about the ‘tumours’ growing inside her, and has probably talked to those of her friends who have had problems with fibroids, researched the issue online, and then arrived at the office primed for treatment. And there are many treatments -or at least, many variations on the theme of the need to treat. The usual approach has traditionally been a surgical one -with all the usual permutations and combinations that depend on the prevailing wisdom of the medical center or the research project currently underway. And then, of course, there are the medical and other non-operative methods -some new and sparkled with hope, some castigated online for the side-effects. As I have said, the need for cure can be all-pervasive, all consuming. And perhaps an imperative: anything less is a disappointment -a failure.

And yet the problem -at least in the case I have outlined- is not so much the fibroids, as the attitude attending them. They were, after all, aymptomatic, aproblematic, and indeed a concern that needn’t have been. Most will shrink after the menopause when there are no longer any stimulating hormones -and at 48, that time is not likely to be in the too distant future. Doing nothing, in other words, is acceptable; a ‘cure’ is unnecessary…

Yes, they could be treated -and heaven only knows they often are- but in her case, why? She needs an explanation, reassurance, and a promise of follow-up should any new questions or issues arise. You might think I have chosen a special case, an anomaly whose rarity shouldn’t really affect our exciting and ever-evolving management strategies. And it shouldn’t -there is much to learn, much to improve. We need cures for cancer, better and more effective vaccines, more inclusive and affordable Health Care… And yet sometimes we need to step back and decide what is truly worth pursuing and to what end; decide whether our goals have blinded us to the value of perspective. Knowledge without perspective is not wisdom; it is detail… It is Hope unsummoned.

The Senate may have something to teach us after all… despite itself.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s