Making sense of changing treatment approaches

The practice of Medicine is truly a humbling experience. And it doesn’t matter how long you’ve been practicing. That’s why sometimes, when friends or relatives whom I haven’t seen for a long time ask me if I’m still practicing, I would answer in jest, “Yes, I’m still practicing because I can’t seem to master it.”

Well, Medicine is probably one profession wherein practice never makes perfect.

A week ago, my 91-year-old patient who was a former  school principal told me, “Doctor, you can’t seem to make up your mind. Several years ago, you told me that my blood pressure should be less than 140/90 and my blood sugar level should be well within normal range. Now you’re telling me that it’s OK for my systolic BP to be higher at 150 and for my blood sugar level to be slightly higher than the normal, too.” She fixed her thick eyeglasses as if to make sure we had good eye contact and blurted out, “You’re being fickle-minded.”

I felt like one of his vacillating and nitpicky pupils four or five decades ago who wasn’t sure of his answer in a graded recitation. I had to compose my thoughts well before explaining to her that Medicine is such a dynamic and sometimes mysterious science that despite all the advances, there are still a lot of things we don’t know or aren’t sure of. And as we get more scientific evidence, we have to revise the way we treat our patients.

Treatment guidelines

The practice of Medicine is also not a one-size-fits-all  approach to treatment. Medical organizations, composed of experts in a particular field, come out with treatment guidelines from time to time, and these are supposed to guide practising physicians, which may be applicable to most but not all patients. If the physician does not tailor-fit or individualize his treatment strategy, it can spell disaster for some patients. They’ll get worse instead of getting well from their illness.

Sometimes, it’s true that side effects from the treatment can be worse than the original illness for which the drugs were intended.

For our 91-year-old patient, she would have dizziness on standing when her blood pressure is brought down to theoretically normal levels. She would also experience frequent hypoglycemic episodes (excessively low blood sugar) when her diabetes is aggressively treated.

Some middle ground has to be arrived at which is considered safe for her, in terms of preventing heart attack, stroke and other serious complications due to excessively elevated BP and blood sugar; and at the same time, not too low that could cause equally serious side-effects and complications of bringing down her BP and blood sugar to the theoretical normal levels. An individualized or what some call as a customized approach is still best for most patients, rather than an off-the-rack, one-size-fits-all  treatment strategy.

Best standard approach

While treatment guidelines can be a boon for practising physicians to guide them in the best current, evidence-based, standard approach, these can also be a bane if they think that all they need to do is memorize them and do as these guidelines dictate for all the patients they see in the clinic. If that were so, then we don’t need doctors anymore. Patients, who have already been previously diagnosed, can just follow up with anyone who has a modicum of knowledge about Medicine for so long as he knows by heart all the published guidelines and can write prescriptions based on them.

But Medicine, as a science and art, is a lot more complicated than that. No two patients can ever be the same. That’s why some patients who think they’re smart and can save on doctors’ professional fees by just asking a relative or friend, who has the same illness, what his/her doctor prescribed to him/her and taking the same medicines, are committing a grave mistake. It is a mistake which can cost them much more in the long run. For some, it can even cost them their lives if they develop serious reactions to the treatment or take a wrong dose of the drug.

I enjoy talking to this 91-year-old patient of mine. At her age, it’s a marvel how she can still recite verses from “Hamlet” and other Shakespearean plays—word-perfect and with such theatrical flair. I figure, she must have really been a strict and no-nonsense principal in her prime.

She still speaks her mind without mincing words. She didn’t speak a word during my lengthy explanation on why treatments change and why we need to individualize our treatment approach for every patient we see. But as her nurse helped her get up from the chair at the end of her last consultation with me, she said without looking at me, “You still don’t make sense to me.”