Drs. Hartzband and Groopman in the August 6^th issue of the New England Journal of Medicine fret about the inevitable clash between the medical humanism movement, which promotes understanding the patient as a person, and evidence based practice. The Obama administration has invested $1.1 Billion in acquiring the badly needed best evidence for a slew of therapeutic situations. (Some have attacked this as inserting the government between doctor and patient which is untrue.)

Drs. Hartzband and Groopman are concerned that getting improved scientific evidence for a particular form of treatment and formulating clinical guidelines for that treatment will allow individual doctors to impose their will on the patient thus overriding what the patient believes is in his best interest. But there is a field of medicine that is tightly governed by clinical guidelines that has deferred to patients’ individual needs for over a decade. I can illustrate this with an experience from my years as a trauma neurosurgeon in the third busiest trauma center in Florida where we saw 1800 patients per year.

No area of medical practice has been more rigidly evidence based than the management of head trauma. In the early ‘90s a pioneering group of academic trauma neurosurgeons reviewed exhaustively all the relevant literature and assimilated their findings into a set of guidelines for managing seriously head injured patients. Where we can, we follow these guidelines to a T.

One night a 90 year old man dying of aggressive metastatic prostate cancer was brought to the center where I was the on call neurosurgeon. He was accompanied by his daughter. He had shot himself in the forehead. I rushed in and checked the CT scan first. The bullet was imbedded deep in his brain. There were the expected bone fragments lying within the brain close to the wound of entry. He was breathing on his own but very sleepy and not responding to the spoken word. He would not open his eyes to a pinch of his pectoral muscle near his armpit but would mumble incomprehensibly. He was a potential survivor but a long shot. I advised his daughter that I would take him to the operating room to debride the wound of entry to reduce the risk of meningitis and put a monitor in his brain to measure intracranial pressure. This was all according to the best medical evidence. Like a typical surgeon, I was all set to go. Moreover, I was chief of neurosurgery and it was my job to see that head injury patients were managed in accordance with the guidelines.

She declined, saying he was miserable and had suffered enough. She went through the whole history of his illness and how nothing seemed to control his pain. “All right,” I said.”You’ll just have to excuse me if I seem frustrated because now I can’t do what I do, but your dad’s wishes come first.” He died two days later. It turned out that his urologist and the urologist’s office nurse who’s also his wife are close friends of mine. The next day Mary called me to thank me about how I had handled their patient and the family. I think just about any doctor with at least a couple of years in practice would have done the same. Not to worry.