When experience trumps evidence

December 23, 2013

Experience-based medicine is a personal and dynamic learning process based on the everyday experiences in the life of every clinician.

This essay is part of Medical Economics' 2013 Physician Writing Contest. Click here to enter the 2014 writing contest.

In the real world of treating patients, diagnoses are complicated and apparent risk factors sometimes amount to nothing. But after a patient dies of a complicated medical issue, the physician’s soul searching begins: Did you see the signs?

Did you interpret the symptoms correctly? One physician’s story about the death of a long-time patient has lessons for all providers about the value of experience, and what doctors learn along the road of their career.

It was around 3 p.m. when my office nurse pulled me out of my exam room.

“Doc, I’ve got Vern’s wife on the line and she sounds pretty worried. Can you talk to her now?”

“Martha, what’s going on with Vern?” I asked Vern’s wife.

“I don’t know, but he says his pain is getting worse and he doesn’t want to get out of bed,” Martha said, her voice attempting to conceal her anxiety.
I told Martha that I would come by their house and check on Vern in a couple of hours after I was done with office appointments.

A patient with chest pain
Earlier in the week Vern was in the office complaining of what he thought was a spider bite on his lower left chest. A few days earlier he had noted a red spot on his skin and he felt some tenderness in the area of his left chest wall but attributed it to a pulled muscle. Otherwise he said he was feeling okay.

When I looked at Vern’s chest I saw a bunch of tiny blisters on a streak of reddened skin overlying his left six rib. The diagnosis in my mind was straightforward: Herpes zoster.

The year was 1982 and medical science had little to offer the shingles sufferer other than pain relief while waiting for the condition to run its course. I explained this to Vern as he left the office with a prescription for pain medicine and advised him to follow up if needed.

The phone call from Martha was a little disquieting since neither she nor Vern were alarmists.

As I started off on my house call my thoughts turned to wondering what possibly could be the cause of Vern’s decline. Aside from occasional exacerbations of his emphysema Vern’s health was reasonably good for a man in his mid-70s. His only cardiac risk factor was his history of heavy cigarette use, but he’d thrown out his cigarettes at least 10 years earlier. Blood sugar and lipids were normal as was Vern’s blood pressure.

Probably all that was needed was some reassurance and a readjustment of his pain medication with a possible addition of steroids.

Martha met me on the walkway up to the house, her face seized with fear.

“After I covered him with a blanket he seemed to quiet down and I thought he went to sleep,” she said.

“That was about an hour ago. Just before you came I looked over at him and he didn’t seem to be breathing. I thought it was just my imagination because I’ve been so worried about him. Come in here. He’s in the bedroom.”

 

Questions that come after
I followed Martha into the dimly lit room, hesitating for a moment hoping to see Vern breathing. I could detect no respirations.

I rushed to his bedside to undertake a more detailed examination finding Vern’s eyelids half open and motionless. Pinkness had left his face and there was no pulse.

“Vern is gone,” were words I wish I never had to say and I’m certain were words that Martha dreaded to hear.
Martha, sobbing, threw herself into my arms saying, “It can’t be true, but I know it is.”

In a soft voice I said to Martha, “Let’s just lift the blanket over Vern and you can sit next to his bed while I call the corner. They will help take care of everything.”
Within about half an hour the people from the coroner’s office arrived and gently removed Vern’s body.

I asked Martha if I could help her with anything. She said no, but she accepted my offer to stay with her until she called her children. I also added that I had no explanation for Vern’s death, but the coroner’s office should be helpful with an answer.

The answer came a week later. The coroner’s office told me that Vern’s death was due to a massive heart attack because of extensive coronary arteriosclerosis.

Experience vs. evidence-based medicine
Never to be answered adequately were the questions: Was some of Vern’s chest pain due to pre-infarction angina? Did I overlook doing something that could have prolonged Vern’s life? The soul searching has never ended.

If Vern had presented without an apparently obvious cause for his chest pain, would I have undertaken some kind of cardiopulmonary evaluation? Yes. I would have at least listened to his heart and lungs. Had oversimplification of Vern’s condition prejudiced my clinical decision-making? Probably so.

A fine line exists between arriving at a timely treatment decision based upon reasonable evidence versus delaying important management while on a fishing trip for red herrings. How can I apply my experience with Vern to help me be a better doctor?

A part of my 10th grade curriculum was world history-a class with the reputation for monotony but a necessity for that high school diploma. A part of each homework assignment was the memorization of dates, events, places, and so on. In addition our teacher, Mr. Wayne Jones, required each student to be prepared to discuss a principle underlying a particular historical event-nurturing the habit of critical and analytic thinking. Mr. Jones taught that a principle is a general belief that you have about the way you should behave. I’ve learned to apply these lessons to the practice of medicine and treating patients.

What I call experience-based medicine differs from evidence-based medicine in that it expands decision-making beyond mathematical estimates of the risk of benefit and harm, derived from research projects of many people on multiple population samples.

I perceive experience-based medicine as a personal and dynamic learning process based on the everyday experiences in the life of every clinician. It involves the personal discovery and application of principles necessary for improving patient care as well as encouraging physician humility and integrity.

With the help of Mr. Jones and Vern I’d like to share with you a couple of principles I have adopted based on experience-based medicine. First, always remember that completely unrelated, coexisting disease processes can share similar signs and symptoms.

The limits of risk factors
Second, the presence or absence of measurable risk factors does not infallibly predict future health.

The story of Adele illustrates the second point. A few years before she died, Adele was noted to have a cholesterol of 360.

“I don’t like pills and I’m not going to take any. I feel pretty good so put your prescription pad away,” she replied when I advised her to begin a statin for what I considered to be a worrisome cholesterol level.

 “OK, but be very careful with the fats in your diet,” I told her, thinking to myself: Hey, it’s a free country.

Adele did go on to die-from pneumonia the day after her 101st birthday.

Well doc, what do you think of that?

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