Evidence-based medicine is a topic about which we as medical students hear lectures, have workshops and complete written assignments. What is it really? Is it just keeping up with the most recent literature in the field of medicine and practicing medicine based on evidence? The reason I bring up these questions is because I recently scrubbed in on a surgery during which I was not entirely sure if I was witnessing evidence-based medicine in practice, and this made me feel distinctly uncomfortable.
I had been invited by an attending to scrub in on a hysterectomy, which I appreciated as the clinical site I had been assigned to provided somewhat limited gynecologic surgery exposure. I had not been working on this attending’s service, so I did not know anything about the patient, let alone having met her. As we walked, I asked the attending more about the case. What was the indication for the hysterectomy? Bleeding, caused by a large fibroid. How old was the patient? 50. Would this hysterectomy be open or laparoscopic? His response to my last question was something like this: “I am not trained in laparoscopy, and besides, this is not the university hospital. Everyone there is on salary but working here, I am running a business. I do not have five hours to spend doing a hysterectomy.” This response was, I think understandably, a little off-putting. The principles my attending seemed to be using to make this decision did not appear to be the right ones. I wondered if he was making a sound business decision rather than what might have been a better clinical decision.
Let’s give my attending the benefit of the doubt. He is not trained in laparoscopy and it would be unsafe for him to attempt a laparoscopic surgery. Although there is good data which shows that laparoscopic hysterectomy relative to abdominal hysterectomy is associated with shorter hospital stays, fewer wound infections, less blood loss and a faster return to normal activity, it is by no means the standard of care. We did not even discuss vaginal hysterectomy as an option even though there are benefits to this approach as well. It is likely that my attending considered that route but decided the fibroid was too large (and it was quite large) and that an abdominal hysterectomy was the best, safest surgery he could provide. Perhaps he also considered that continuity of care is valuable to both patients and providers, and that was why he chose not to refer her to someone who does laparoscopy. Additionally, one could make the argument that physicians have a duty to provide care to as many patients as they are able and if doing abdominal hysterectomies allows a physician to maximize the number of patients he is able to treat, then he should do so. These were the rationalizations that I came up with in the absence of a more thorough explanation from my attending.
We completed the surgery with the assistance from a second attending and as we were leaving, I asked my attending why he had made the decision to remove the ovaries. I vaguely remembered hearing from a resident that the ovaries continue to produce hormones for ten to 15 years after menopause and that removing them at the time of hysterectomy was no longer routine. His response was along the lines of “they have the potential to get cancer and she’s 50, so they’re not doing much anyway.” By his tone, I could tell he was not especially interested in discussing the case any further. I read about oophorectomies when I went home that night. I learned that there are several indications for an oophorectomy in a fifty-year-old woman at the time of hysterectomy, including the reason my attending had cited. However, the benefits of oophorectomy in these women, especially women without known ovarian pathology or family history of ovarian cancer, must be weighed against the risks. These risks include an increase in all-cause mortality, cardiovascular disease and neurologic disease. The degree of risk is dependent on the age of the patient at oophorectomy and whether or not the patient takes supplemental estrogen after the procedure. I chose to believe that my attending was well aware of all of this evidence and that he had had a lengthy discussion with the patient about the risks and benefits of oophorectomy prior to the surgery.
In this situation, what is my ethical responsibility? Much of the onus lies on us as medical students to educate ourselves about our patients and the therapies we provide. We need to know the evidence. If I had known more about the procedure my patient was undergoing, I could have asked better questions, questions like, “Did you and the patient decide on what you were going to do regarding estrogen supplementation after the surgery?” or “Does the patient have any risk factors for cardiovascular disease?” Some of the responsibility also lies with our residents and attendings to help us understand why they make the clinical decisions they make and how they integrate the evidence into their own practice. The patient demographics and individual patient preferences that a clinician encounters may influence his or her recommendations in ways that are not necessarily readily apparent to an observer. It is the harmony of evidence, the patient’s needs and a clinician’s judgment that truly makes medicine both a science and an art.