About the same time, another commentary discussed the appropriateness of treating some patients with stable coronary artery disease with intense medical therapy and avoiding referral for coronary stenting. It discussed the findings of many trials demonstrating the effectiveness medical intervention alone, summarizing data from the COURAGE, ORBITA, and ISCHEMIA clinical trials.
The argument of this second paper is based on an important ability of a good physician; the capacity to recognize when potentially indicated medical intervention shouldn’t be pursued. This ability to recognize the lack of need for action and then withholding a specific therapy requires the integration of the above qualities, empathy, kindness, and knowledge; plus, it requires something more. Reflecting on my experiences in over 40 years in medicine, I realize that not acting by not doing the more aggressive intervention, even though others might, is very difficult. This applies to any intervention including those that are mundane like adding a medication, to those that are very dramatic, like coronary artery stenting. A very current issue concerns trying to avoid endotracheal intubation in COVID-19 patients with respiratory failure, which has potential benefits, but is not without risk.
Understanding why the conscious act of appropriate inaction is so difficult to perform is worth discussing, because it is not easily understood nor often discussed. This could be helpful for both physicians and patients. Interestingly, although there is significant literature on the general topic of the process of medical decision making, I could only find limited information on the specific topic of why deliberate appropriate inaction is difficult.
When discussing this topic, I am reminded of an asymptomatic patient who was very upset when I told him that his nuclear perfusion stress test which revealed good exercise tolerance, an old infarction with no ischemia, and a normal ejection fraction, didn’t warrant proceeding with cardiac catheterization. I simply could not convince him no matter how hard I tried. I finally told him something like, ‘OK, I give up’, and started to consent him for cardiac catheterization telling him all the reasons why it was easier for me to do the procedure while clearly pointing out the potential risks and apparent lack of any clear benefit to him. Fortunately, after a while, he was finally satisfied with medical treatment. And I’m sure he did well as I’m certain I would have heard if he hadn’t!
I would say that there are emotional reasons why it is hard to turn down cases. In general, performing procedures, for which one believes are beneficial and one is well trained, is enjoyable and fulfilling. We believe, hopefully correctly, in the benefit of what we do, and this causes an inherent bias. In the 1960s, Abraham Maslow wrote about the long-standing theory that people are motivated to act in a certain way by what they know how to do. He is quoted as paraphrasing a time-honored phrase this way, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”
One can see this bias in other areas of medicine.
With respect to cardiology, it has been demonstrated that some cardiologists minimize the risk and overstate the benefits when discussing cardiac intervention with patients.
This doesn’t appear to be the result of physicians trying to deliberately be misleading, it appears to be an inherent bias.
Physicians appear to be following human nature, which is why the time-honored saying above exists. I also wonder if a myopic view is necessary in order to perform or prescribe higher risk interventions, as they can be anxiety provoking. I remember the transition that I underwent, when I was trained in performing cardiac catheterization. I no longer felt the procedure to be as dangerous as I had thought of before. I did, however, never forget what the general surgery chief resident told me on my surgical rotation in medical school, “A chance to cut, is a chance to kill.”.
Physicians face more inconspicuous incentives for performing procedures. One needs to perform enough procedures per year to maintain one’s skills. And doing more procedures keeps the hospital busy which ensures the hospital staff, who are generally friends, have jobs. I don’t think these have a significant impact on physician decision making, although I couldn’t find that this has been studied.
We live a in world were “medical miracles” occur frequently and have often become expected. I have seen many patients over the years present with illnesses that were not well treatable in the past, become treatable today such as an acute myocardial infarction was before reperfusion. Reperfusion can extend a patient’s life decades. However, this doesn’t mean that all interventions or simply intervening without reference to the timing of the intervention is beneficial. Not all patients are ill enough when seen or are seen at the appropriate time to warrant intervention. And some patients are just too frail to warrant advanced treatment as the harm can out weights the benefits.
It is important that we remember that there are situations “when less is more”. Maybe this commentary will help other medical professionals understand better why appropriate inaction is difficult emotionally and become more comfortable with it. And maybe, if practitioners share this commentary with their patients, patients might understand that when physicians don’t do something that might be expected, it is often harder than doing it. Patients might understand that their physicians are often putting themselves at risk for criticism and are taking on this risk because they do care. In the practice of medicine, appropriate inaction can be arduous. In order for good physicians to be able to this, I believe another quality in addition empathy, kindness, and knowledge is necessary; it requires “courage”.
Conflicts of Interest
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