Abstract
A paradox describes the clash between 2 seemingly reasonable prepositions whose joint occurrence appears impossible. Like any other human endeavor, medicine is also filled with paradoxes that await resolution. This editorial lists several common paradoxes frequently encountered by clinical gastroenterologists. These examples illustrate the interplay between risk and benefit, cost and effect, disease and cure, and escape and exposure. It is hoped that addressing these paradoxes and trying to resolve their underlying contradictions will ultimately lead to a more efficacious and rational delivery of healthcare.
A paradox describes the clash between 2 seemingly reasonable prepositions whose joint occurrence appears impossible. The coincidence of 2 mutually exclusive facts contradicts our expectation, yet when such phenomenon occurs, it amuses us and awakens our curiosity. Groucho Marx famously quipped that he would not want to belong to any club that will accept him as member. By the same type of logic, in choosing a new Gastroenterology Division Chief, we are quite skeptical of anyone and their motives who really wants to come and join us. The attempts at resolving paradoxes of mathematics and physics have resulted in ground-breaking insights and opened new avenues for research. Like any other human endeavor, clinical medicine and gastroenterology also seem full of paradoxes that await their resolution.
Although diagnostic workup is supposed to result in a therapeutic consequence, a group of patients find comfort and relief by the diagnostic process itself irrespective of its therapeutic outcome. These patients enjoy being the focus of attention and being taken care of, as well as the entertainment provided by interacting with medical staff. A lengthy process of ruling out feared and fancied imaginary diseases of the intestines provides a secondary gain that is more important and meaningful to them than any therapy that would end the comforting or even pleasurable interactions with the medical profession. This paradoxical behavior where the journey matters more than the destination characterizes some of my patients with vague abdominal symptoms, functional bowel disease, or repeated ingestion of foreign objects.
As a general principle of all medicine, the benefit of healing or curing a given disease should be greater than the costs associated with its treatment. In essence, the cure must not be worse than the disease because otherwise treatment does not make sense and becomes paradoxical. Why would physicians nevertheless deviate from this seemingly elementary tenet of medical practice? Sometimes, the risks and adverse effects of workup and treatment are unknown or difficult to estimate beforehand. Their probability of occurrence is unknown or becomes affected by a patient's history or characteristics that are ignored or forgotten at the time of decision-making. Physicians may be biased by or so focused on the beneficial aspect of a given therapeutic intervention that they become too distracted to pay attention to its potential risks and costs. In other instances, simple cost-benefit analyses become confounded by the physician's own cost-benefit considerations that are separate from those of the patient. An interventional endoscopist may enjoy performing a highly complex and challenging endoscopic procedure that is also well remunerated. In other instances, physicians may order additional diagnostic tests and procedures primarily to protect themselves from future lawsuits and claims of negligence or to satisfy their own curiosity but that have little benefit to the patient. Such cost-shifting and benefit-mixing between physician and patient perspectives can easily invalidate any cost-benefit analysis.
In trying to escape danger, occasionally, we increase rather than reduce its probability of occurrence and find ourselves having caused greater damage than the one we intended to avoid. This occurs especially if the means of avoidance harbor some hidden risks of their own that may assist or even hasten the occurrence of the anticipated danger. Many young patients seen in gastrointestinal outpatient clinic are overly concerned about vague and benign abdominal sensations. In trying to cure minor or imagined sickness, they expose themselves to unnecessary endoscopic procedures and surgical interventions that carry a much higher risk to their overall health than the feared disease itself. All means of medical prophylaxis are also prone to such paradox. For instance, a single-minded focus on colon polyps and exaggerated cancer phobia can lead referring physicians wanting to subject elderly patients with serious comorbid conditions to low-yield screening or surveillance colonoscopies. The endoscopist herself may become so preoccupied with removing all polyps that she may underestimate the risks of bleeding or perforation. This applies not only to colon but also gastric and duodenal polyps. Such complications may ultimately result in the same type of surgery one was initially trying to prevent.
Training to become a general gastroenterologist currently takes more than 14 years, including 4 years of college, 4 years of medical school, 3 years of medicine residency, and 3 years of gastroenterology fellowship. Eventually, most gastroenterologists end up diagnosing a limited number of medical conditions and performing a handful of common endoscopic procedures. There is a paradoxical discrepancy between the lengthy, meandering path of education and the limited number of requirements to perform the actual job.
To protect themselves from litigation, medical institutions have implemented countless rules and regulations to guide and improve medical practice. Each endoscopy at my institution is now accompanied by filling out 8–14 forms associated with its completion. The time it takes to perform any gastrointestinal endoscopy is dwarfed by the length of time spent sitting at the computer before and after the endoscopic procedure, filling out forms and documenting one's actions. The endoscopy has also become prolonged by a detailed informed consent and preprocedural timeout. Outside the endoscopy suite, gastroenterologists are required to renew their medical license, hospital credentials, and procedural privileges every 2–3 years. Each year, they also need to accumulate continuing medical education credits and undergo innumerous sessions of mandatory training. All such efforts seemingly devoted to quality assurance have reduced the amount of time available to take care of patients. It is a paradox of current clinical practice that the vast amounts of measures to increase quality of healthcare and ascertain patient safety have made medicine far more expensive and far less accessible to many patients who need it. Similarly, with its tight oversight, abundance of forms, rules and regulations, academic research offices, and institutional research boards have contributed to its overall demise at academic centers in recent time as well, despite the fact that they were originally designed to foster clinical research and assure its quality.
As a common feature of the paradoxes listed above, the choice of a beneficial measure results in its own negation. The examples illustrate the interplay between risk and benefit, cost and effect, disease and cure, escape and exposure. A paradox ensues when the means to an end becomes more important than the end itself. Instead of looking at competing alternatives as absolutes and therefore irreconcilable alternatives, they ought to be considered as relative values that can be quantified and then decided upon based on their comparative merits. Such analyses would need to be conducted separately for each individual patient because different types of risks and benefits apply to different case scenarios. Ultimately, cost-benefit analyses could also be applied to resolving the general paradoxes that affect the healthcare system itself aside from individual patients, although a satisfactory resolution would be far more difficult to achieve because of the number and the complexity of the many factors and stakeholders involved.
CONFLICTS OF INTEREST
Guarantor of the article: Amnon Sonnenberg, MD, MSc.
Specific author contributions: conception, design, and writing: A.S.
Financial support: None to report.
Potential competing interests: None to report.