The Certain Nature of Uncertainty in Medicine

The Certain Nature of Uncertainty in Medicine

I looked at my office schedule and questioned why Mr. Jones was back so early. I had seen him in the office about six weeks before and he was doing well at that time. Mr. Jones, who has a history of coronary artery disease, had a heart attack several years prior. He had minimal symptoms, but given his history we decided to proceed with a stress test to evaluate his heart. He passed with flying colors!

When Mr. Jones came in previously for his test results, I explained to him that his exercise tolerance was excellent and that his stress test showed no sign of any abnormality. Mr. Jones had previously been on medications for his cholesterol, but he had experienced severe side effects with multiple different medications and therefore he was doing his best to manage with lifestyle changes. I advised him see a lipid expert to discuss any further options for management of his cholesterol.

So, all of this said, I was very surprised to look on my schedule and see Mr. Jones was back in so soon. I flipped through his chart to understand that he had been in the hospital. He had a heart attack exactly four weeks after his normal stress test. He required several stents to be placed in his left coronary artery. He had done well in the hospital and was discharged to follow up in the office.

I sat there in the office with Mr. Jones and his wife both frustrated by the uncertainty of medicine. I had told him just several weeks prior that his heart was doing fine, as he had passed the stress test. We knew that he was at increased risk because of his history; however there had been no warning that this heart attack was going to occur. In fact Mr. Jones was very active and was biking regularly to and from work without any symptoms at all!

During our visit, I explained the physiology of coronary disease and how many heart attacks occur when arteries that are only partially blocked become vulnerable and an unstable plaque ruptures. This causes the artery to thrombose or clot off. The arteries, which go on to become unstable, often do not show as abnormal on a stress test.

Despite understanding how this type of discrepancy can occur, it’s still disheartening and scary for all involved. I was grateful that Mr. Jones had the confidence in me to come back for his follow-up visit. Despite knowing I had done my best, I couldn’t help but feel disappointed. Clinical medicine is an imprecise tool... a tool that at times allows suboptimal outcomes to be experienced.

I accept that I may not be able to predict that next heart attack. Medicine is an inexact science. Despite our best efforts, sometimes things do not go as planned. I encourage every patient to live well. Studies suggest that for many, atherosclerotic heart disease can be prevented with lifestyle changes. Perhaps in the future we will have better tools to predict when a patient is at highest risk for unstable coronary syndrome. But for now patients and doctors alike will need to understand and accept the uncertainty that exists in modern medicine.