Introduction
A recent perspective piece in the New England Journal of Medicine explores the challenges of "gray-zone medicine," ie, when the available medical evidence doesn't offer guidance for treatment decisions a doctor faces.[1] The authors challenge "the misguided perspective that healthcare is a binary world in which interventions are either effective or ineffective, appropriate or inappropriate."
The gray zone, they say, is where treatment choices do not fit into these neat, black-and-white categories, presenting dilemmas to the clinician and risks for overuse of nonbeneficial treatments.
"Most of medicine is in the gray zone, where benefits are not known or are small and valued idiosyncratically," said Amitabh Chandra, PhD, lead author of the NEJMarticle and professor of public policy at Harvard Kennedy School. It's not just that randomized controlled trials (RCTs) have failed to address the effectiveness of major treatments for all patient populations with common conditions. "If I come in for treatment and you are my doctor, even if there is a relevant RCT, you may not know how that evidence applies to me. The RCT may have been done in a different group of patients than the one in front of you," Dr Chandra explains.
When people say that trials will show us the way, it sounds crisp and neat, he says, but it assumes that clinical trials are quick, cheap, and easy to do. "In fact, they are very expensive and take 5-6 years to get an actionable result." For hospitalists, another illustration would be the wide variation in hospital length of stay. "When should this patient go home?" The evidence doesn't answer that, so the doctor makes an arbitrary decision using rules of thumb. "We'll never be able to do trials on the length of hospital stay," Dr Chandra added.
Vineet Arora, MD, MAPP, a hospitalist and assistant dean for scholarship and discovery at the University of Chicago Medical Center, agreed that the decision about when to discharge a patient, particularly in the era of readmissions penalties, is one of the biggest gray zones for hospitalists. "For some conditions there are clear studies, like community-acquired pneumonia and stability at discharge. But for a lot of patients, we just don't know—would they benefit from one more day of inpatient therapy or not? This is one of those really tough calls that experience helps with. But there is always some level of uncertainty."
David Meltzer, MD, PhD, chief of the Section of Hospital Medicine at the University of Chicago, said, "There will always be gray areas in medicine, but it is also important to recognize that some gray areas can be made clearer over time. One reason to be aware of gray areas is to recognize when they occur frequently so that answers to the most important questions can be found."
