Doctor: what would you do?

Many of you will have seen Bill Murray’s star performance in the 1990’s comedy classic, Groundhog Day, the story of a man who is forced to re-live the same day over and over again. In clinical neurology, Groundhog Days can occur once in a while but we are particularly blessed in having a wide variety of clinical conditions that we can now successfully treat all of which present in so many varied and interesting ways. Not for us the humdrum of recurrent chest pain or incessant presentations of dyspnoea!

However, there is one question that I am being forced to answer on a near daily basis, which after the 10th iteration for the day makes me feel somewhat Bill Murray-like. It starts with a simple question from the patient, “Doctor, what would you do if you had (insert name of condition)”.  This question is most frequently raised in relation to multiple sclerosis, the neurological condition in which we have had the most significant therapeutic advances in the last decade. Phase III trials in MS continue at a rapid rate, but instruments for patient selection and disease monitoring are still unable to provide an individualised method of assessing treatment response. However, this question also rears its head in relation to neuropathic pain treatment, ways of managing back pain and whether or not treat a first seizure. Yesterday, I was asked by a well-meaning 75 year-old man whether or not I would have a shunt if I had normal pressure hydrocephalus.

How should we respond to this? It is easy to say that the decision is the patient’s and that everyone is different. Patients generally understand this and we are then able to move on from this question to other matters. However, the question remains as to how impartial we can really be. During my time at Queen Square, I was told that the Prof Anita Harding would say in relation to genetic counselling that the family should never know what you really think. How feasible is this in current practice, where the options for treatment have not been matched with the same level of advances in development of clinical biomarkers or measures of treatment response? It used to be said thought that interactions with Pharmaceutical companies may have unduly influenced prescribing practices? Is this still an issue or should we side with recent studies that suggest that pendulum if anything may have shifted the other way, towards increased suspicion and scrutiny of studies involving or subsidised by pharma 1?

We all know about disclosures in research papers, but do we need to ‘disclose’ in daily interactions with patients? Let us know what you think.

  1. Kesselheim et al., 2012. A Randomized Study of How Physicians Interpret Research Funding Disclosures. N Engl J Med 367:1119-1127.

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