Sunday, June 29, 2014

Are Your Medical Priorities Straight?

The world is asunder.  As I write this, Iraq is sinking into a sectarian abyss.  ISIS, a terrorist group, now controls a larger territory than many actual countries.  Russia has swallowed Crimea and has her paw prints all over eastern Ukraine.  China is claiming airspace and territories in Southeast Asia increasing tensions with Japan, Vietnam and the Philippines.  The Israeli-Palestinian peace process is in another deep freeze.  Terrorists in Sudan and Nigeria are kidnapping and murdering innocents with impunity.  The Syrian regime has resulted in 160,000 deaths and has displaced over 6 million people.   The Taliban continue to destabilize and terrorize in Afghanistan and Pakistan.  Disease and hunger claim millions of lives in the developing world while other world regions have a surplus of food and medicine.  We have an immigration crisis in this country that gets worse by the day.  Several million Americans are still out of work.

Let’s not be distracted by these trifles.  A looming apocalypse exists that dwarfs the above issues and demands our overriding attention.

Should the Washington Redskins change their name?

Sometimes, folks have difficulty deciding what’s important.   

Weigh the priorities

Assigning rational priorities is an important professional and life skill.  Collectively, we all waste an incalculable amount of time, energy and resources pursuing ventures that should be left for another day.  All of us do this.   Sometimes, we do so deliberately when a lower priority activity will deliver some pleasure or entertainment.   In these instances, at least we are aware that we are dipping down on our priority list.
An important physician skill is to judge which medical issues and tests should have a priority status.  Hmmm, a patient suffering a heart attack also has athlete's foot.  Which issue do I address first? We would recognize that a patient recovering from a severe pneumonia in an intensive care unit should not undergo a mammogram or a screening colonoscopy.  Often, it is not so easy to determine the medical priorities and different physician specialists on the case may disagree on what should be the next step.

Here are a few hypothetical scenarios.

A surgeon insists that an operation is urgently required, but the cardiologist counters that stabilizing the patient’s congestive heart failure must be done first. 

A gastroenterologist advises stopping a blood thinner as the patient has a bleeding ulcer, while the pulmonologist disagrees as the patient has a new pulmonary embolus and argues that the blood thinner cannot be interrupted.

A patient comes to his internist very anxious over 3 days of rectal bleeding.  He wants a colonoscopy as soon as possible as his father had colon cancer.   The physician advises instead evaluating the patient’s recent episodes of chest tightness, which the patient dismisses as anxiety.

Knowing how to do something well is not nearly as important as knowing if and when it should be done at all.  Who wants to have his gallbladder flawlessly removed if it didn't need to come out?  You can substitute any surgery, medical procedure, diagnostic test or treatment in this example.  

Medical knowledge is important.  Technical procedural proficiency is necessary.  Communication skills are a distinguishing asset.  But, medical judgment is paramount.

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