Medical Challenges: Jumping to Conclusions and Medical Uncertainty
"A DOG'S STORY
The man dressed all in white quickly raised the dogs over the flames. Fortunately they were neither burned nor damaged. Covered with the yellow emoliment, he bedded them to rest for now but not for long. Every dog lover must know that
Nathan's on the Coney Island boardwalk is famous for their dogs."
When you read A Dog's Story, you are presented the perfect example of what all physicians face when confronted with a patient's medical story without sufficient time because of scheduling or where an action must be taken quickly and that is--jumping to conclusions and, in fact, the wrong conclusion.
And if the challenge of "conclusion jumping" is not enough for the physician there is also the "fog of medicine", the certainty that there is uncertainty in medicine.
Patients may unrealistically expect their doctors to uniformly overcome these challenges. But it really is difficult. Robert Lowes writes about this issue in the October 24 2003 Medical Economics: "In fact, The doctor-on-a-pedestal model of medicine also makes it hard for doctors to voice their doubts. Patients naturally prefer comfort and reassurance to any talk about percentages. Many physicians assume that anything less than supreme certitude on their part will discourage them and set back their progress. In the end, doctors have no choice but to live with unease."
How do you expect your doctor to respond to these challenges? How would you feel if your physician expresses personal doubt about his or her diagnosis or prediction of the outcome of any treatment? Would you be willing to face the uncertainty together or would you expect to be transferred to another physician who would be able to provide you with all the answers to the questions you are asking? But is there such an "other physician"? ..Maurice.
posted by Maurice Bernstein, M.D. @ 8:51:00 AM
5 comments
5 Comments:
I have learned over the years that I am equally as intelligent and research-able as my physicians -- in fact I probably do more research on a regular basis than my physicians, because research is my job. If my doctor has any doubt or concern about their diagnosis or choice of treatment, I expect them to share that with me, so I might read the literature and partner in the necessary decisions to be made. This may make for a longer time to diagnosis or time to treatment, but if a physician were to treat me the way 'House' does, for example (name a disease, treat, and then get it wrong...repeat until patient has been tortured for a whole episode and never involved in their treatment because "all patients lie"), they would not be my physician for very long. I will no longer deal with a physician who is not honest with me.
Having said that, I am aware (without sounding like a conceited jerk) that I am of above average intelligence, and I have much more research training than most people will ever have -- I am fortunate in this respect. Not all patients are like me, and some will expect to be referred to a doctor who "knows what they are doing". I think this really means they want a doctor like 'House' who has no better idea than the next doctor what he is doing, but who is so blind to his own failings that he cannot doubt himself. In that case, they are better off with a less confident doctor who kept quiet about their doubts, in my opinion.
Robert Lowes writes about this issue in the October 24 2003 Medical Economics: "In fact, The doctor-on-a-pedestal model of medicine also makes it hard for doctors to voice their doubts. Patients naturally prefer comfort and reassurance to any talk about percentages. Many physicians assume that anything less than supreme certitude on their part will discourage them and set back their progress. In the end, doctors have no choice but to live with unease."
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This is all assumption on Robert Lowes part. I resent when doctors lump patients all together and assume we all think the same way.
I do not put doctors on pedestals.
I do not "naturally prefer comfort and reassurance to any talk of percentages"
I am not discouraged by lack of "supreme certitude"
Frankly, since I know medicine and science are uncertain, always changing, I know there are risks, I know that medical studies are often ambiguous, I become incredibly distrustful of doctors who do not express doubts. When they speak so confidently and narrowly about something, I really question their expertise.
I suspect there are many patients like me. Ideally, but probably difficult to do in the rush to get the patient out of the office, doctors should treat each person as individuals who have a variety of perspectives and reactions to their health care. All they have to do is ask the patient for their perspective, instead of assuming.
Dr. Bernstein, I always prefer a physician who is honest - whether he feels certain of what he's doing, or wonders if he's doing the right thing. I've always respected a clean, simple "I don't know."
If the physician is unable to make a decision, or effect any changes, but knows of other physicians who could, then yes, I would expect him to refer me to one of them.
If no such physician exists, then I would want to know that, too.
It's amazing what a person can endure when they know they're not going to have to do so alone.
Personally, I prefer a physician that is confident enough to say s/he doesn't know. I don't expect him or her to know everything on the spot. I would much rather have them say they'll look into it and get back to me rather than act like they know something they don't. A doctor like House would be a pain in the neck... I would never trust their judgement.
Dr. Bernstein. Like most of your readers, I'm intelligent and well read so I expect to be treated as a partner in my care. I have complex medical issues -- so I fully expect to sometimes stump doctors. It may frustrate all of us, but I find myself suspicious of doctors who think they can see me for 5 min. and crank out a result.
I have encountered doctors who have an attitude of "I am the doctor and you know nothing." I convinced my spouse to leave a neurologist who made it clear that he didn't appreciate my doing research and asking intelligent questions. I used to think doctors like this were mostly older, "old school" docs -- but this was a 20 something doctor!
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