As an actively practicing hospitalist, physician, professor of Medicine in a low resource rural setting , I face these nodes very often when I do have to provide (very often it's my team of residents and on call attendings who make these decisions) overtreatment.
Can recently recall a young boy with multisystem inflammatory response syndrome with hemolysis, liver failure, covid antibodies and coma who received antimalarials (cerebral malaria is very common here), hepatic coma regime and even n acetyl cysteine because residents pulled out a paper that showed a small trial displaying dubious benefit in non paracetamol related liver failure but the course of treatment and the boy's sudden remarkable recovery from coma even convinced our residents (especially when we later reflected on it in a central clinical meeting) that the recovery couldn't be correlated to any of our interventions.
Yet we are also convinced that because we continued to offer one new drug after the other, it kept his parents hope and faith alive in us and made them stick with our hospital (also the coma lasted just a few days and didn't drag) , else very often patients in India have the option of leaving for another hospital if they can afford the fee for service the other hospital with a better name commands (the system is slightly different here and not yet insurance driven).
So is it eventually as deep as faith based medicine that lurks in the shadows of our profession?
"Is it not possible to offer hope -- and more importantly, relieve suffering -- in ways that do not assume the only alternative to abandoning a patient is to give them something that you know is useless or likely to be so?" (SB)
A solution to the problem statement shared above is "rational minimalism" as opposed to the previous examples of "rational maximalism" that were shared as a part of our current medical industrial complex training and upbringing.
One way to implement rational minimalism is to first identify the "parachute" intervention (the one that hasn't been tested in an RCT and yet every physician knows they can't do without, for covid recently, it was oxygen) and then decide about the other interventions keeping wishes of all the stakeholders around the patient in mind rather than aim at covering all therapeutic targets with rational but marginal efficacies, all the while remembering that it's the trillion cells in the body that would be responsible for 80% of it's healing with time rather than the chemicals or molecules we deliver.
In all this process the role of the doctor is very much like the man in this video
who strapped a 100 year old US citizen onto his shoulders and jumped out of the plane along with him till he landed safely.
Rational minimalism may drastically summarize the three goals of medical care into one, which is to "be with the patient" till he lands safely. It would rely on strong and well designed complex empathy straps to hold the patient, doctor (and the family) together all through the plunge in regular best case scenarios.
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