When a doctor is confronted by serious doubt , what will be the outcome for the patient ?
Can doubting be beneficial for a patient ? . It seems so , according to EBM which stresses about statistical outcome at every turn of events in a patient who is critically ill .
Is something , always better than nothing ? Our limbic system tends to think so . It may not be true. But in dire situations , many things (Proven , unproven) need to be tried however doubtful it ‘s efficacy may be .This is akin to an emergency in an airplane. Even here there need to be a logic.
Then ,this question arises . How do we make sure , we have a dire situation on hand ?
This is the key issue , in the decision making for the critically ill patients . It needs experience , only experience ! Though the principle of uncertainty is the fundamental rule in medicine , EBM aims to bring some degree of certainty in medical therapeutics.
Benefits of doubting in coronary care unit.
In a sinking patient with cardiogenic shock , try the maximum treatment . Even if , the patient is in severe shock , take him to the cath lab , try open the coronary artery . Give the benefit of doubt to him even though the chances of reviving him is less than 10%.
Risk of doubting in Coronary care unit.
A.Elderly STEMI with SHT,(Arriving late , with an unknown time window after an MI ) To thrombolyse or not ? . There is no benefit of doubt here. Do not thrombolyse. Here , apply the benefit of doubt against thrombolysis .
B. Chest pain with LBBB (Thought to be new onset LBBB ) don’t ever rush to thrombolyse. Wait for the enzyme result . Don’t try to thrombolyse your doubt , instead thrombolyse the confirmed thrombus !
C. Patient with persistent ST elevation following thrombolysis ,in an otherwise asymptomatic and stable patient. Don’t pass on ” your doubt ” of salvaging at least some myocardium by rescue PCI .Rescue should be done before death. You can not resuscitate dead myocytes.
Final message
The concept of giving the benefits of doubt to the patient is a widely prevalent practice in medicine .This concept is alive and popular , not because it has proved effective, but because of the primitive human perception and cognition , namely “Something is better than nothing ” !
Common sense and logic would suggest , whenever there is a benefit for doubting there would be a equal ( or even more ) unmeasured hazards and risks . This becomes especially true , when a physician makes a therapeutic move based on doubting than on conviction .
Dr.S.Venkatesan MD 