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.
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 or taught.
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 not be superior
to the first one. Patients have a bias favoring
second opinions as they pursue them because they harbor dissatisfaction, or at least
skepticism, with the original medical advice. If the second opinion differs from the original, it reinforces their belief that the first advice was inferior.
Second Opinions Can Cause a Tug of War
Here are some scenarios which should be governed by medical
judgment.
A 70-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 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
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 still present? Should the ibuprofen be stopped if the
patient states he has significant pain without 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 want a physician who
can give you sound and sober advice. Knowledge
and scholarship are important physician attributes, but healing demands
more. At least, that’s my judgment.
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