2.3 The doctor as watchmaker - appraising options

'I trust my lawyer more than my doctor; at least my lawyer sets out all the facts to me.'

An American Patient

Dr M diagnosed his own acoustic neuroma. He looked this up in the textbooks and accepted their advice that referral to an expert surgeon was necessary. He arranged an appointment and when he saw the surgeon, the surgeon told him that there was no-one more experienced in operating on the disease than himself. The operation was a success, so far as the removal of the tumour was concerned, but it permanently damaged the facial nerve.

Years later Dr M discovered that 50% of acoustic neuromas do not grow quickly and that they can be safely monitored for a year or two after diagnosis to check the rate of growth. Thus an alternative to surgery would have been active surveillance with an annual MRI examination. Unfortunately the surgeon, although an expert at action, was poorly informed of work on the natural history of the disease and the option of not intervening was not considered.

A British doctor's tale

The doctor as watchmaker who has made a diagnosis has three questions to answer.

2.3.1 Active surveillance or active intervention?

Having made a diagnosis, there is often pressure to act. This is not always in the best interests of the patient, and the desire to act sometimes results not simply from a desire to please but from inadequate understanding of the natural history or prognosis of the untreated disease. This has led to a new slogan developing in medicine - 'don't just do something, stand there' as an antidote to decades, and perhaps centuries, of well-intentioned intervention without adequate understanding of natural history.

However, when intervention is necessary, the clinician has to appraise different options.

2.3.2 Option A or Option B?

Having decided that the condition should not be left untreated, the best treatment option has to be identified, and to do this the clinician has to:

• find all the relevant evidence by searching Medline or by using purified distillates of knowledge such as The Cochrane Library
• appraise the evidence found, using standardised checklists

2.3.3 Am I asking the right questions?

All this sounds very neat and logical but the treatment does not necessarily follow the diagnosis as night follows day because each patient is unique and may present a combination of risk factors and disease complications not covered by the research literature. Furthermore, in very rare diseases there may be no standardised treatment that can be followed or modified, as Jerome Groopman outlines in Second Opinions in his story called 'Don't just do something, stand there' in which he describes an argument between himself and another highly esteemed physician, one of whom believes the patient should have a transplant, the other wanting to try to stimulate the bone marrow. The language is often strong and direct, as, for example, when one expert says to the other, 'It's madness just to sit and wait for the next catastrophe.'

2.3.4 Tailoring research evidence

Evidence is derived from research, almost always based on the study of groups of patients. When the watchmaker is handed an Omega Seamaster he knows it will be identical to all other Seamasters. However, when the clinician sees a patient with stomach cancer or migraine, he can be equally sure that the patient in the consulting room will differ in many important ways from the patients in the research on stomach cancer or migraine. The clinician has to tailor the information to ensure that it will fit the needs of the particular patient.

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