Sunday, November 3, 2019

What Makes a Good Doctor. You Be The Judge

I’ve delved into the issue of medical judgment more than once on this blog.  I have argued that sound judgment is more important than medical knowledge.  If one has a knowledge deficit, assuming he is aware of this, it is easily remedied.  A judgment deficiency, per contra, is more difficult to fix.  Who doesn’t think he has good judgment?

For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up.  If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined.  Medical judgment is a murky issue and often creates controversies in patient care.  Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently.  Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families.  This is one of the dangers of seeking a second opinion, as this opinion may be different, but not superior to the first one.  Patients have a bias favoring second opinions as they harbor dissatisfaction, or at least skepticism, with the original medical advice.  

Whose Advice Carries More Weight?

Here are some scenarios which should be governed by medical judgment.
  • A 60-year-old woman with severe emphysema uses an oxygen tank.  She has never had a screening colonoscopy.  Professional guidelines suggest that screening begin at age 50.  Does a screening colonoscopy make sense for her considering her impaired health?
  • A 40-year-old man has had 1 week of stomach pain.  This started 10 days after he took daily ibuprofen for a sprained knee.  The physician suspects that he might have an ulcer.  Should this patient undergo a scope examination to make a definite diagnosis?  Should the doctor prescribe anti-ulcer medication without determining if an ulcer is present?  Should the ibuprofen be stopped if the patient states he has significant pain if he does not take it? 
  • An 80-year-old woman had some recent dizziness and nearly fainted.  The doctor sees her in the office two days later and questions her carefully.  He suspects that the patient was simply dehydrated.  Should the doctor simply reassure the patient or arrange for a neurologic evaluation to make sure that a more serious condition is lurking? 
Of course, you want your doctor to know a lot of stuff.  More importantly, you need a physician who can give you sound and sober advice.  Knowledge and scholarship are important physician attributes, but practicing medicine demands more.  At least, that’s my judgment.  What do you think?


2 comments:

PICU MD said...

I agree. Especially in the modern era where on my smart phone I can access journals, references etc, having and encyclopedic knowledge of medicine is not as necessary as it once was. I think having good decision making skills is more important. This is especially true for patients that did not read the textbooks. I worry that the trainees these days want a guideline for everything. However, I think we display our real skill in the patient who does not fit these guidelines.

Michael Kirsch, M.D. said...

@PICU, thanks for your comment. I agree. In addition, increasingly 'guidelines' are regarded as mandates. Much of what we do is deep within the gray area, beyond the reach of formulaic medicine.

Add this