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In the podcast I just posted that involved a discussion with Dr. George Blumenschein, medical oncologist at MD Anderson, Dr. Wally Curran, radiation oncologist at Emory University, and myself, we spoke a bit about the challenge of the art vs. the science of medicine. GRACE member David Fourer added a comment highlighting the importance of this acknowledgment, and I think this merits further discussion.

There is a fundamental difference between discussing a person’s situation in the abstract and actually working closely with the patient in the exam room, part of a patient/doctor relationship. The issues that I and the other faculty discuss focus largely on the evidence and the prevailing standards of care, but that only gets you so far. What strikes me is how much every oncologist I know, myself included, deviates from the data-driven standards — but that’s not a bad thing. It’s just that it’s not fair for one physician to comment impartially about the evidence while another is managing the actual patient and situation. That’s apples and oranges. We (oor patients) sometimes try to bridge the gulf by ending a case presentation with, “What would you do if it were your wife/sister/mother?”, recognizing that the evidence only takes us so far.

I run an annual lung cancer conference for cancer professionals in which I and my colleagues at my own institution present challenging cases that don’t have an obvious right answer to other experts. We describe what we did, which may not have a lot of evidence to support it, although it’s fair to say that in oncology we are faced every day with situations that don’t have any evidence and that require us to use judgment (what chemo to give someone with lung cancer after a kidney transplant? There’s never been and never will be a trial that gives us any insight.) Often, our guest colleagues from another institution may pontificate about what the evidence does or doesn’t support, but that can’t limit the real practice of real patients in the trenches. I happen to know that many of them (us) get very, very creative in their (our) own patient management, regardless of how cerebral we might all sound in discussing what the evidence demonstrates.

When I’m serving on the panel at a conference or sitting in on the tumor board at another institution, I’m the one making judgments in the abstract about the management of patients who have messier real life situations for the doctors working with them. It’s easy for any of us to get haughty about what the evidence does or doesn’t show when we’re looking from 20,000 feet. In fact, I’d venture to say that if we were to review the clinic charts from the actual clinic patients of any oncologist, whether generalist or academic expert, we’d find that they do plenty of cancer management that deviates from any evidence and is based on judgments by the doctor, by the patient’s perspective, or both. Of course, this isn’t a bad thing (except that I can’t just review other people’s charts, because that’s a HIPAA violation).

Everyone considers themselves a better than average driver, and most oncologists fancy themselves to very evidence-based, but that’s based on our abstract view of what we’re taught that we should be. Of course, the evidence should inform our recommendations, but I think it’s very important to realize that the abstract idea of what the data tell us is no substitute for managing patients in the real world.

By the same token, of course this also means that anyone reading our recommendations here should take them with a grain of salt, because there is always room for individualizing and good judgment on a case by case basis.