Why Smart Doctors are not Enough

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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