Saturday, August 3, 2013

To Treat or Not To Treat: Medical Uncertainty

One of the most challenging things about being a doctor is that medical science is so often uncertain. This was brought home very vividly to me this week. One of the psychiatric residents I work with, a doctor who I deeply respect as a compassionate, dedicated and thorough physician, raised an outstanding question. She asked if we should be more proactively treating delirium with antipsychotics than is the current practice in our hospital. Delirium is a medical condition in which the brain is functioning but in a disorganized way due to another severe medical illness. It has been termed “brain failure” and compared with heart failure or kidney failure in that a critical organ is malfunctioning and there are many different pathways that can cause the syndrome. I was taught that the mainstay of treatment is addressing and reversing the initial medical illness causing the problem. Antipsychotics might be used to manage agitated behavior that was endangering the patient (for example pulling out catheters and lines) or staff (hitting or biting, both of which I have witnessed) but I had always been told (and had read) that antipsychotics did not have any particular beneficial effect on the delirium itself.

However, my resident had seen things done differently in another hospital. So she sent me four different articles she had found suggesting that treatment of delirium with antipsychotics in general and haloperidol in particular has beneficial effects for delirious patients in terms of time to resolution of symptoms and longer term cognitive outcomes. This was very interesting and important information, because delirium can’t always be completely reversed and significantly complicates medical care. If we were able to directly treat it many people could recover more quickly and with less long-term debility. It’s also interesting because I don’t use haloperidol very often. It’s an older medication and has some acute unpleasant side effects for many people, and I have greater familiarity with some of the newer medications. Which of course also have unpleasant side effects but seemingly less so in the acute setting. So I read her articles with interest and checked a few other sources and was giving thought to revising my current practice. And then I read another article.

I subscribe to several email services that send important medical articles and headlines directly to my email inbox. There is a lot of medical news happening all the time and I want to keep up as well as possible. One of the articles in this week’s email from Current Psychiatry caught my attention immediately, as it was an editorial entitled “Haloperidol clearly is neurotoxic. Should it be banned?” ( In the editorial the author, the editor-in-chief of the journal, cites numerous articles from neuroscience journals that describe neurotoxic effects of older antipsychotics in animal models, cell cultures and post-mortem human brain studies. The author states that he no longer uses the older antipsychotic medications and opines that these medications should no longer be used at all.

And this is what makes medicine difficult. In one week, I have read articles suggesting I should be using haloperidol more often as it protects the function of the brain during severe illness and another article suggesting the same drug is a neurotoxin that should be banned. Obviously there is some missing information here. This doesn’t particularly surprise me; in medical school one of my professors told me that about 50% of what I would learn would be eventually turn out to be wrong, it’s just that they didn’t know which 50% it was. But it does leave me with a bit of a challenge for my own practice. I’m not quite sure what to do, so I will probably consult with some colleagues and most likely will end up treating delirium more proactively but perhaps using some of those newer antipsychotics. 

This is often the case in medicine. I have trained and practiced in an era of medicine in which “evidence based medicine,” meaning medical decisions supported by numerous randomized controlled research studies, is considered the holy grail of good clinical decision making. And yet I find that often the evidence is incomplete, contradictory, clinically irrelevant or altogether missing. I end up doing the best I can based on what evidence I can find, supplemented by experience and advice from trusted colleagues. Which is not to say that evidence based medicine is wrong or bad. I believe in practicing according to the best scientific information available. I think it is important though, for medicine as a field and doctors as people to be humble enough to say – “I don’t know. I'm sorry, but I just don't know." I think that might actually go a long way to restoring some trust in our profession.