Correspondence
Criticism of Clinical Problem-Solving
N Engl J Med 1993; 329:1743-1744December 2, 1993
- Article
To the Editor:
In the April 1 issue,1 your experts recommended and implemented an extensive, unnecessary cardiologic diagnostic and surgical course of treatment for a hopelessly ill 87-year-old woman; and in the June 3 issue,2 your experts put a 71-year-old patient through an extensive workup, including antinuclear-antibody testing, protein electrophoresis, measurement of total complement, and ultrasonography of the left kidney, all before examining the chest film of a patient with obvious peripheral edema and a 50-pack-year history of cigarette smoking.
I suggest that you send your experts back into clinical practice. I think that any second-year medical student who did not order a chest film before ordering all the above-mentioned tests would be in deep trouble. At least, I hope he or she would.
2 ReferencesJerome S. Reich, M.D.
16800 N.W. 2nd Ave., North Miami Beach, FL 331091
Thibault GE . Too old for what? N Engl J Med 1993;328:946-950
Full Text | Web of Science | Medline2
Pauker SG ,Kopelman RI . Hunting for the cause: how far to go. N Engl J Med 1993;328:1621-1624
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Dr. Reich raises two points: one reflects a misconception about the Clinical Problem-Solving series, and the other a basic disagreement about the goals of medical care for the elderly. The series is designed to highlight strategies and difficulties in medical practice with the use of real case reports. Each article contains three distinct parts. The case description presents the actual clinical report in digestible chunks. For example, the 71-year-old man with nephrotic syndrome had a clear chest on physical examination and did not have a chest film until the nephrologist undertook the search for secondary causes of nephrotic syndrome. Interleaved with the clinical report are the thoughts of an experienced clinician, who sees the case description, chunk by chunk, in retrospect. In this case, the discussant mentioned the possibility of nephrotic syndrome caused by a malignant condition as soon as the patient's history of smoking became evident, but given the retrospective nature of the exercise, the discussant could not affect the order of the workup. The Commentary presents the opinions of the editors about the patient's course, the clinicians' approach to the problem, and the discussant's approach. We selected this example because nephrotic syndrome, with its myriad secondary causes, exemplifies diseases that can lead to seemingly endless and often fruitless workups. The thoughtful clinician must decide how to order and when to abandon the search.
Clinicians increasingly care for the elderly and other patients with limited life expectancies. Dr. Reich would sharply limit the diagnostic and therapeutic options offered to such patients, but many clinicians (and perhaps many patients) would strongly disagree. The 87-year-old woman was not hopelessly ill; after surgery, she returned to an active life. Our analysis suggests that aortic-valve replacement in the elderly provides benefits in terms of both quality of life and survival that are comparable to and perhaps greater than those provided by some procedures commonly applied to younger patients.1 As limitations in available resources force us to be more selective in the care we deliver, we must establish fair and rational mechanisms for making such choices, as a profession and as a society. Such approaches should be based on the potential benefits of treatment and not on the physician's arbitrary and perhaps capricious beliefs about who is “hopelessly ill,” how old is too old, and who deserves the benefits of modern medical care.
1 ReferencesStephen G. Pauker, M.D.
New England Medical Center, Boston, MA 021111
Wong JB ,Salem DN ,Pauker SG . You're never too old. N Engl J Med 1993;328:971-975
Full Text | Web of Science | Medline
To the Editor:
Dr. Reich has raised questions about the course of treatment for a patient presented in one of the Clinical Problem-Solving cases. The expert discussant does not determine the patient's care. As Dr. Pauker explains in the accompanying letter, the case report is presented as it actually happened, reflecting the decisions made by the clinicians caring for the patient. Sometimes the discussant disagrees with the decisions made or with the interpretations of data, but he or she cannot change what was done. Some cases are selected because they are likely to generate disagreements or differences in interpretation. In the case of the 87-year-old woman who underwent cardiac surgery, the clinicians and the discussant agreed on the course of action. As the accompanying commentary, editor's note, and companion articles1,2 indicated, this is a complex decision about which reasonable people might disagree.
2 ReferencesGeorge E. Thibault, M.D.
Veterans Affairs Medical Center, West Roxbury, MA 021321
Wong JB ,Salem DN ,Pauker SG . You're never too old. N Engl J Med 1993;328:971-975
Full Text | Web of Science | Medline2
Abrams FR . The doctor with two heads -- the patient versus the costs. N Engl J Med 1993;328:975-976
Full Text | Web of Science | Medline
- Citing Articles (2)
- Letters
