Monday, 1 January 2018

The induced gray areas

From scientific points of view, one tends to think that the clinical practice is binary. That is, it’s thought that the medical actions are either effective or ineffective. The reality of the practice teaches, however, that on the ground, the gray zone is much broader than one would hope because many clinical practices are neither clearly effective nor clearly ineffective. In an article in The New England Journal of Medicine, "Addressing the Challenge of Gray-Zone Medicine," Chandra and colleagues claim that due to the dazzling effects of new drugs and technologies, the gray area is expanding and therefore, these authors claim strategies to reduce the phenomenon.

Stenting as an example 

Stenting is a tremendously effective technique when practiced in patients with early stages of myocardial infarction but, when indicated in other clinical circumstances; such as in patients with low risk of infarction, or when the infarction is already too evolved, its beneficial effects disappear but the risks inherent to the test persist. Now, thanks to a study, it’s possible to estimate the ejection fraction of the stenosed coronary artery and determine which patients with stable angina could benefit from stenting and which ones could not, which should, in theory, serve to reduce the gray area, but the social prestige of this intervention is already so great that, according to experts, it seems that this last refinement has arrived too late. 

Gray areas induced everywhere

Uncertainties in clinical practice will always exist as they are part of the nature of the profession, but one of the major emerging problems of modern medicine are the gray areas induced by the fascination of certain tests and treatments. There’s no need to scratch a lot to select some practices with gray areas induced by their social prestige. See the following selection as an example: 

a) Drugs: antibiotics, antidepressants, proton pump inhibitors, anticoagulants. 
b) Diagnostic tests: preoperative in healthy people, CT, MRI, PET. 
c) Screening: health screenings, PSA, mammograms in women under 50 years of age.
d) Interventions: caesareans, hysterectomies, tonsillectomies, arthroscopies.

Clinical practice guidelines focus on the degree of adequacy of each step (appropriateness). However if an act is deemed appropriate it doesn’t necessary mean that it’s also necessary. The adequacy is theoretical, while the need is real, understanding that a necessary activity is only that which, if left undone would lead to worsening of the clinical results of a specific patient. Therefore, only by persisting in obtaining greater clinical effectiveness, is it possible to battle the induced gray areas.

Jordi Varela

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