Don’t be foolish enough to think you control outcomes


Let’s be honest. If you are bold enough to hit the “publish” button, it’s normal to care what readers think. I write about medicine: I like doctors, I respect doctors. So it matters how colleagues react to my words.

I was both proud and concerned when the Greater Louisville Medical Society decided to republish my “Changing the Culture of American Medicine” piece in their monthly journal, Louisville Medicine.

The reaction of my colleagues has been interesting.  And, in my humble opinion, worth telling you about.

Recall that the main point of the essay was to amplify the issue of medical reversals. Researchers from the NIH looked at a decade of NEJM studies in which an established medical practice was evaluated by current evidence. They discovered that 40% of the time prevailing medical dogma did not hold up to rigorous scientific inquiry.

Examples included ear tubes for middle-ear infections, hormone replacement in women and aggressive therapy for advanced breast cancer. The paper listed 146 recent examples of medical reversals. No branch of medicine was spared.

Here are some excerpts of (in-person) feedback I received. A bigeminal pattern emerged.

A senior cardiology partner: “I read your pontification … [long pause with a facial grimace] … we aren’t that bad.”

A surgical oncologist: “I read your piece … [again a long pause] … we have learned a lot in surgical oncology over the years.” Then he said nothing else and walked away.

A cardiac surgeon sent a text message: “The aprotinin studies were flawed.”  That’s it.

A few doctors simply congratulated me. One of them is an avid New York Times reader. That felt especially good.

The best reaction came from one of the most senior and respected doctors in the city. He’s practiced in Louisville for more than 40 years. He carries the distinction of being universally loved and admired by everyone. He’s soft-spoken and wise — and a true gentle man. If you were angrily stomping around a unit, mad at something you couldn’t control, and he walked onto the unit; you would stop misbehaving. He’s that kind of person.

“I read your article,” he said.

I stopped in my tracks and focused. Here was feedback that interested me greatly. Wisdom does that; it makes me tingle with delight.

But then the same pause came. (What’s up with these pauses?)

He thought for a moment. Soon, wisdom rushed out:

John, this is old stuff. You know they killed George [Washington] with blood-letting. One voice of reason at the time dared suggest it wasn’t a good idea, but they pushed on. They killed old George.

We went on talking more about the history of medicine and other failed therapies. He reminded me that when he started practice there wasn’t even an effective diuretic. The conversation steered to my thesis that awareness of reversals made it tougher to practice medicine.

The wise doctor disagreed. He countered with this beautiful nugget:

One guiding principle that has served me well over 40 years, one that allows me to sleep well at night, is this: We don’t control outcomes. All we can control is making the best decision possible at the time. Many times over, I’ve been sure a patient would die, and then she lived. And there have been times when I expected the patient would do well, but he died.

John, there’s something else that controls outcomes; we don’t.

I love this philosophy. Patients sometimes say I saved them. But this isn’t really true. Biology, luck, or perhaps fate, saved them. I just succeeded in not mucking it up. The same decision in the same situation can work well on Monday, but terribly on Tuesday.

My wife Staci says she sees this principle in the hospice care of veterans. The message goes something like this. You come to understand that, in most cases, veterans are going to live or die despite what you do.

Make the best decision possible at the time. Don’t be foolish enough to think you control outcomes.

John Mandrola is a cardiologist who blogs at Dr John M.


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