Medical Decision Making !

When a doctor tells a patient "You have Cancer "  those may be the most terrifying words they will ever experience, but when the doctor goes on to say that the only treatment for that condition is  "Chemotherapy " the terror deepens.

Chemotherapy has an evil reputation in the minds of many people.   They envisage the total loss of all body hair and reports from those who have experienced such therapy are accounts of misery and endless vomiting.  It is an imprecise science.  Some people achieve a miraculous cure - and others simply die.

How much and how often chemotherapy treatment is applied to each patient is in the hands of a specialist oncologist.  As with most medical treatment, the final balance is decided in the mind of the treating doctor and that is a skill we recognise by the reputations earned by those in the medical profession.

Some men and women go on to become legends because they develop a degree of skill in treating patients that delivers outstanding results.  Very often, this is because they dare venture beyond the widely accepted guidelines for treatment and often they are the pioneers of what goes on to become the accepted standard.  Whenever they depart from normal practice they risk their professional reputation.   Medicine is an unforgiving science.

A parliamentary enquiry in New South Wales is examining the chief oncologist of a leading Sydney hospital who also had outreach clinics at Bathurst and Orange.   This senior doctor is accused of ordering under-dosing of over a hundred patients and that this under-dosing caused them actual harm.  Some of these patients have since died.

The crux of this enquiry is that the oncologist varied the dose from the guidelines suggested for chemotherapy use.  In giving evidence, the senior oncologist testified that in his opinion giving the guideline dose would have had a negative impact and may have discouraged the patients from accepting further treatment.

Clearly, this is a matter of questioning the judgment of a treating physician who adjusted the degree of chemotherapy by taking into account the advanced stage of the disease coupled with the patients ability to withstand treatment.  There would be little point causing huge distress to those at the terminal stage by delivering a massive dose just to satisfy the guidelines concept.

What is becoming clear is the rush of colleagues to deny any knowledge of guideline variations because to do so would put their reputations at risk.   This senior oncologist claims that his guidelines departures were widely known and accepted in Sydney medical circles and were also practised by others.   He reports that his superiors suggested he consider early retirement to avoid what was termed "a coming shit storm "!

The most likely outcome from this enquiry is that this oncologist will be criticised for using his judgment to vary dosage.  As a result, the profession will adhere more strictly to the rules and less mercy will be shown in adjusting the chemotherapy dosage to the patients age, condition and likely outcome.

As with such enquiries, the final outcome is much more likely to reach a political conclusion than advance the practice of medicine  !