Leilani Valdes, MD, FCAP
As a first-year medical student, once a week my small group would meet with an attending physician to learn how to talk to patients respectfully and document that conversation in the history and physical examination. In those early years of medical school, my time was mostly spent in lecture halls, gross anatomy and microanatomy labs, and the library studying, so these weekly meetings held all the promise and anticipation of what practicing medicine and actually treating patients would bring. In one of those meetings, our leader made a comment that had a lasting impression: the words “always” and “never” have no place in the dialogue of strong science and the practice of good medicine.
Always and never. Two words at opposite ends of a spectrum that imply absolute certainty. But that is the point—in the practice of medicine, no matter how convincing the patient’s history, the physical exam, the laboratory findings, or the imaging, there needs to be room to consider what we don’t yet know and how that might change a diagnosis or treatment plan. Science and medicine are constantly evolving, so to say that a tumor never metastasizes, or a particular lab result is always normal is misleading and unreasonable.
Or of late, attesting that a vaccine will always work or never have side effects is untruthful. Interpreting and understanding outliers and clinical subtleties is the art of medicine and is at the heart of physician and laboratory professional training.
Many of my COVID-19 conversations during this past year with concerned patients, colleagues, and friends have revolved around this discomfort of uncertainty. In normal times, our medical knowledge and understanding are so close to “always” and “never” that patients feel like they can trust their physicians and scientists when they make recommendations. A pandemic can highlight the lack of complete certainty in medicine by introducing a new medical problem we’ve never quite encountered before.
Our acquisition and processing of knowledge around the COVID-19 disease need to happen at a speed generally uncommon in medical research—we are literately learning as we go. So we, as physicians, use our past research knowledge and experience to help guide diagnostic algorithms and treatment plans, constantly revising our paths as we gather data and learn more. But always, we are weighing the risks and benefits of clinical choices.
Relating the “always and never” understanding to vaccination for any illness, we are aware that choosing to vaccinate does carry a small level of risk, but the benefits of preventing death, severe disease, and disability outweigh that very small risk and benefits the health of our community. As in the case of the recently paused Johnson and Johnson vaccine, we are applying the principle of understanding new knowledge and interpreting outliers. Vaccination, with any COVID-branded vaccine, is a safe choice and will provide significant gains in controlling the spread of this disease.
In the medical laboratory, we understand that outliers are part of any test. Here again, “always” and “never” do not apply when it is possible for a patient result to be normal for a particular patient but not fall within a normal range. Partnering with physicians in the quest of understanding and interpreting data and pivoting when challenges occur in medicine are the medical professionals in the lab.
During April we celebrate Lab Week nationally, and as a pathologist, I am privileged to work with knowledgeable and dedicated resources that are our constant gatekeepers of quality data—they investigate the outliers as part of their jobs. It’s estimated that 70 percent of medical decisions are based on information provided by pathology and the laboratory, and it is with a high level of confidence that I applaud laboratorians in the crossroads area. Their daily service to health care and their journey with us during COVID-19 is appreciated.
Happy Lab Week.
Leilani Valdes, MD, FCAP, is a pathologist with Regional Pathology Associates. She may be reached at [email protected].