Medicine is an Imperfect Science

A doctor can not promise what can not be known.
July 28, 2015

The knowledge of my limited power became clear to me early in my career, and I recognize it each time I treat a person who has sustained an acute trauma that causes a spinal fracture and sadly, a spinal- cord injury.

I walk to the emergency department or intensive- care unit bed to meet the patient, who may be only minutes or hours from an awful fall, an accident, or some other trauma, and I am ready for the worst, knowing only the victim’s medical-record number, basic story, and CT scan findings. I prepare a game plan and think about what I will discuss. I try to imagine what the patient and family are going through. I quickly obtain a history and perform an exam.

The patient and family eagerly and nervously wait for me to say anything that pertains to a cure, or a treatment, or a prognosis. I can see in their eyes and in their expressions what they really want me to say: Everything is going to be all right. I’ll do this and that and another thing, the spine and spinal cord will be fixed, and you will walk out of the hospital. I efficiently but thoroughly review the extent of the damage, exploring the surgical and medical options, including surgery to stabilize the unstable spinal structures with rods and screws and the removal of bony structures pinning into the spinal cord. And then I admit I can’t fix the injured, struggling spinal cord. Before my words are registered and processed, the person (or loved one) asks, “But will I walk again?”

That question never fails to grab me. I hear it in every communication before and after surgery. Its duration depends on the patient’s ability to comprehend the role of science, their denial, and their faith in the natural healing process. My answer is always the same: “I don’t know.” My review of the imaging, my vision of the spine at surgery, and my observations of recovery of some sensation or strength after surgery may help me formulate better odds with time. But honestly, I don’t know.

Odds don’t make people heal more quickly, but a positive attitude may. I hope for a miracle just like the family does. For me, a miracle means one’s ability to defy the odds of what the medical literature says the past 10,000 patients in the same situation did. I believe outliers exist in all spheres, and I believe there is more to healing than science. I have treated people who appear to have a complete injury of the spinal cord with no residual function and yet who recover.

I cannot promise something I don’t know, and there isn’t a test to prove who will be lucky or who won’t. In truth, neither I, nor any other spine surgeon, currently can repair the injured one-centimeter- wide tube that carries all signals between the brain and the body. I cannot empower the patient and the family with my hands or physical skill to reconnect and revitalize the injured tube. But I can give them positive and accurate information. I can relay that if I can stabilize the spine and remove any additional insults to the spinal cord, I can provide the best chance of recovery and limit more damage. From there, I can share the positive outcomes I have seen in many of my other spinal-cord injury patients after months of rehabilitation, what they have achieved, whether they are completely or partially paralyzed.

Regardless of the natural and surgical response of the injured cord, functional recovery of many roles is possible. I can’t use my hands to fix that small, important tube, but many patients can have a realistic optimism that with time, commitment, and hard work, they can in many cases achieve independence and improved quality of life, and continue as productive members of their family and society.

Medicine is an imperfect science. Sometimes there are no good options, or a perfectly planned and executed treatment fails or leads to complications or death. All I can do is never overstate my abilities or skills or show confidence that is not based in the reality of my experience.

Gottfried is an associate professor of neurosurgery and spine surgery and is the quality leader of the department of neurosurgery. He is a medical consultant to several hit TV shows.