By Steve Schlozman, M.D.
When tragedies hit, it is in our nature to ask why. The co-pilot in the horrific Germanwings crash had serious mental health problems, according to reports. How could no one have known how serious his challenges were? How could no one have predicted this terrible outcome? On its surface this line of questioning seems even a bit ludicrous. After all, even in the murky face of mental illness, the potentially deliberate and fatal nose-dive of a commercial aircraft seems impossible to imagine. Nevertheless, this is exactly the question that we’re seeing over and over in the coverage of the crash.
How could we not have known?
The fact is, however, that this particular question glosses over a profoundly uncomfortable quandary that is by no means unique to psychiatry. For all of modern medicine, predictions are surprisingly fraught with difficulty. For all of medicine’s miracles, for all of its technological wonders and advances, medicine remains a quintessentially human endeavor. You might even argue that phrases like “medical miracle” are indeed part of the problem. This more we grant medicine undue and mystical prowess, the more resistant we grow to the grueling trial and error that characterize everyday medical practice. Doctors are wrong all the time. That’s a fact.
Nevertheless, physicians are asked to prognosticate. That’s the verb form of “prognosis.” As patients and families, we look to our doctors daily for prognostic estimates. (Emphasis on estimates.) These estimates are really hypotheses necessarily based on incomplete data. Rare complications and twists of fate befuddle even the best.
For psychiatry this truth can be especially hard to swallow. A neurologist might not be able to predict every migraine, but it is the rare migraine that results in tragedy. Still, remember that psychiatrists cannot read minds. Like all physicians, psychiatrists will try their best to understand what is the cause of suffering. And, as with all clinicians, psychiatrists will sometimes be right and sometimes not. Medicine remains an art even as the science continues to improve.
The fact that someone suffers a psychiatric disorder, even a recurrent psychiatric disorder, is not remarkable when compared to the rest of medicine. The same occurs with ulcers, asthma, allergies, orthopedic injuries, sinus infections and so forth. Most medical illnesses are chronic and many are intermittent. No medical professional can predict with absolute certainty when an episode is going to occur or how severe it may be. To be fair, physicians can and do identify triggers, but the intensity of a presumed reaction is outside anyone’s ability to predict.
And this is where society gets especially flummoxed. No one would argue that the art of medicine is infallible. No one would suggest that medical practice is right 100% of the time. But faced with tragedy, we are much more comfortable as a species pretending that our predictions are foolproof and that our mishaps are exceedingly rare.
Why can’t we always know? Medicine is post-modern. We cannot know because we can’t. Continue reading