Looking back, some of my biggest medical mistakes have been times when I was reactive rather than proactive when faced with a clinical problem. A doctor may have to be one or the other depending on the circumstances, but knowing when and which approach to take is one of the harder skills of medicine, taking time and experience to master.
What do I mean? Here are some examples from my field.
Treating acute otitis media (AOM) with antibiotics is proactive doctoring. Withholding antibiotics for AOM, and having to treat acute mastoiditis a week later as a result is reactive and unsatisfactory doctoring. Antibiotic use for AOM is still a wide open topic, and the literature remains full of debate on one of the commonest of clinical decisions.
A patient with a unilateral sensorineural hearing loss may have an acoustic neuroma. Proactive doctoring means doing a contrasted MRI scan if funds permit. If no funds, a cheaper but far less sensitive investigation is a CT scan, which will show a large tumor but not a small one. Reactive doctoring means making the diagnosis by MRI scan if hearing deteriorates or when brainstem compression or facial weakness sets in.
Treating unilateral sensorineural hearing loss, as with Bell’s palsy, with cortisone and antiviral drugs is proactive care. For idiopathic facial palsy (Bell’s palsy) the jury is still out as to whether either treatment is more effective than placebo. Conservative treatment, i.e. nothing, is reactive.
For these and the many thousand other issues of medical protocol, there are strong arguments to support all approaches, many based on sound research.
So why have I made an issue of it?
The answer lies in my own experience of being at the sharp end of the decision process, when a family member developed sudden visual field defects in both eyes. A highly respected ophthalmologist diagnosed optic neuritis, did the appropriate investigations to exclude multiple sclerosis, and then discussed treatment. His opinion was that high dose cortisone had not been shown to be of benefit in management, and that most cases resolved spontaneously anyway with restoration of the visual field defects. On that basis he recommended against using cortisone. Against the odds, the visual field defects never did get better.
We are well over that issue now, with life back to normal and very little subsequent disability, but this question still bugs me. Would the outcome have been different if we had insisted on the cortisone? Even just for the placebo effect. Would that have tipped the balance towards complete resolution? We have no way of knowing. There is no reactive doctoring option open to us.
I don’t want to have those clouds of suspicion hanging over the decisions I make for my patients. I try to be as proactive as I can within the bounds of safe and sensible evidence-based medicine. One way is to discuss all the options and let the patient decide. This takes time, and effort. One approach may be good and right for one patient, and not appropriate for the next. Another is to practice preventative medicine wherever possible, i.e. encouraging parents of children with recurrent upper respiratory tract infections not to smoke. This is proactive medicine at its best.
I think I have had better outcomes being proactive, with fewer complications and adverse events as a result, than being reactive. But time constraints on doctors work against these ideals, and being proactive under time pressure may mean more medications and more investigations.
All of which needs to be kept in mind when you’re running late, and filling out your next lab request or prescription.
Martin Young is an otolaryngologist and founder and CEO of ConsentCare.
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