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In medicine, every decision matters

Every Tuesday at noon, the pediatric oncology team skips their usual lunch plans and gathers for tumor board. Unfortunately, it’s as grim as it sounds — a discussion around a large conference table on the previous week’s most complicated and often sickest patients. In this case, the patients are children and most of them have been diagnosed with late stage cancers with poor options for therapy and poorer prognoses.

Involved is a multidisciplinary team of doctors, from pathologists to oncologists to surgeons, offering differing second, third, and fourth opinions on the best way to treat their patients until a consensus is reached. The discussions are intense and emotions can flare, a testament to the team’s dedication to their patients. The decisions are gut-wrenching and are only complicated by the fact that many of the patients have yet to reach puberty.

But not all cases are put up for discussion by the tumor board. In fact these days, many treatment decisions are made easily — and perhaps too easily. Science and technology have streamlined the process and removed much of clinical ambiguity (or at least we like to think). Many of our medical decisions aren’t even made with the patient in close proximity but instead made in front of the computer or on the phone with the nurse or the senior physician.

And this can happen because only recently has medicine finally fully embraced scientific evidence. We now know which hypertension drugs should be used for which patients at which age or which blood thinner would most effectively reduce their risk of a future stroke. We know when to take a patient to the operating table and when medications would suffice. There are now websites and phone apps within a finger’s reach that allow us to reduce a patient into a few numbers, spitting out directions telling us precisely what we need to do. And thanks to the thousands of trials (and the many more thousands that are ongoing), a large potion of medicine has been distilled down to algorithms.

There’s no doubt that science has made for better physicians, but it has also forced a wedge between patients and their physicians, distancing us from the weight of our decisions and their consequences. Medical decisions can now be made so swiftly and almost without a second thought and yet still have the most profound and lasting changes on the patients. And if, god forbid, the treatments fail, science can give us a reprieve -- we tell ourselves that we’ve done the best that is science has to offer, and so, we convince ourselves that we’ve fulfilled our Hippocratic duties.

But for some questions, science can’t give us the right answers or even offers us a hint. For those patients at noon tumor board, the parents and their doctor will have to decide whether to send their child back to the OR when another lesion appears on their chest CT. They'll have to decide whether going through another round of chemotherapy is worth the few extra months of life or if the patient even has enough strength to survive it. Even the most rigorous clinical trials won’t help them choose.

As medical students, we have yet to bear the burdens of our decisions. We have the luxury of a safety net: residents and attendings who check, double check, and triple check our recommendations. But when that day comes and our orders are finally carried out by the nurse, we can only remind ourselves that behind every computer screen and iPhone app is a human being who will have to live with whatever choice -- no matter how seemingly inconsequential and fleeting -- we make for them.

Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

Steven Zhang is a fourth-year medical student at Stanford. When he’s not cramming for his next exam, you can find him on a run around campus or exploring a new hiking trail. 

Photo by Pexels

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