Clinical Judgment: Balancing Evidence-Based Medicine and Patient Self-Determination

Clinical Scenario: You are seeing a patient, Henry Jones, in your faculty clinic with a second-year otolaryngology resident. Mr. Jones is a 78-year-old gentleman who was referred by a neurology colleague for the evaluation of an incidental finding seen on an MR scan obtained during the course of a late-onset Alzheimer’s disease workup. The neurologist sent both the scan images and the neuro-radiologist’s report, which stated that, in addition to some early changes suggestive of neurodegeneration, there is a 3-mm presumed acoustic tumor in the right internal auditory canal.

The resident evaluated and examined the patient prior to presenting him to you, and you confirm the history, signs, symptoms, and examination findings with your own evaluation. Mr. Jones and his wife explain that he has had some hearing loss that has been present since his discharge from the military, where he completed 21 years as an aircraft mechanic. When pressed, he indicates that perhaps his hearing is worse in the right ear, but not substantially so. The tuning fork tests at 512 Hertz were normal. The neurological examination, including neuro-vestibular, facial, and oculomotor tests, was unremarkable. The patient states that he has had some occasional imbalance, but no falls and no vertigo. His neurology consultation was primarily for memory loss. You feel that he appears to be competent in his judgment. Before the patient is escorted to the audiometry suite, he emphatically states that he is not interested in any surgery or radiation at this time, which is what the neurologist had mentioned to him.

You and the resident return to discuss the findings with the patient, and review the MR scan, the audiogram, the history, and physical findings. An onsite audiogram demonstrates bilateral noise-induced hearing loss with a downward slope from 1000 Hertz, slightly worse in the right ear. When queried about what should be the recommended course of action for the patient, the resident excitedly tells you that, with a small tumor, either surgery or radiation therapy would be indicated. He further shows you printouts of several systematic reviews that support early intervention to lessen the effects of the mass on auditory and vestibular function. You remind him that the patient stated he did not want surgery or radiation treatments, but the resident makes his case for intervention—“We’re here to cure disease, aren’t we? And, we know much better than the patient what treatment is called for.” It is clearly time for a teaching moment.