Necessary is a word best defined when looking back in time

How do you define a “good” doc?  I was reading the patient responses to an article here on KevinMD.com and was saddened by how many of the patients were angry with their docs.  Anger is an unhealthy emotion!  One of the respondents was particularly angry about the “unnecessary” tests her doc performed on her and her family.

I have written about the vagaries of the term “unnecessary” in the past.  What makes a doc brilliant?  What makes a doc lousy?  How can the same doc be perceived as “brilliant” by some patients and “lousy” by others?

When I order a test that saves a man’s life, I’m brilliant. That patient and his family tell all their friends that I made a brilliant, lifesaving, diagnosis.  “Go see Dr. Segal; he’ll take good care of you.”

When I order a test that fails to shed light on a diagnosis, I’m a lousy doc.  “Don’t see Dr. Segal, he orders too many tests.  He never did come up with a diagnosis for what is making me sick.”

No matter how many brilliant diagnoses a doc makes, there will be diagnoses he can’t make (or misses) and patients who will be unhappy.  So, what’s a doc to do?

Docs formulate a list of differential diagnoses.  Based on the list of possible causes of a particular problem, docs order diagnostic tests and procedures.  When I started in medicine over 30 years ago, we called the process ”rule out,” meaning we ordered tests to narrow the list of possible diagnoses until we found the right one.  The more complex the disorder, the more tests are ordered.

In reality, docs don’t own a crystal ball.  If they did, they would know which tests were going to be positive (necessary) and which were going to be negative (unnecessary).  Since docs don’t have the ability to see into the future accurately, diagnoses and test ordering boils down to an educated guess.

To make matters worse, diseases are dynamic, forever changing.  An eighteen year old comes in with a severe tonsillitis.  Her mono test is negative.  Obviously, the test was not necessary since the test is negative. Right?  Wrong!  Ten days later she is seen again by another doc.  Her mother states, “I took her to Dr. X 10 days ago and he didn’t know what he was doing.  He wasted my money on a negative mono and strep test.  Can you help her?”  After explaining that a negative mono test is meaningless (as Dr. X had previously warned her), the new doc orders a repeat test which is now strongly positive.  Diseases are dynamic and our ability to diagnose them correctly often improves with time as the disease evolves and changes.

In “You’re Damned If You Do and Damned If you Don’t,” I review the dilemma docs face on a daily basis.  Going back to the original question, What makes a doc good, I think the answer is a caring attitude.  If your doc cares about and for you, he will do what he feels is in your best interest.

As a doc, I am acutely aware that I spend your time and money in pursuit of good health and I try to spend it as wisely as if it were my own.  Sometimes, what I think is necessary turns out to be unnecessary.  Sometimes, I like being wrong!  If I think you have a life-threatening disease and you don’t, I actually rejoice in being wrong.

Do I do too many tests?  “Too many” is in the eyes of the beholder.  Necessary is a word best defined when looking back in time.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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  • sFord48

    Clearly, tests are used to rule out possibilities.  that doesn’t make them unnecessary.  I had an unnecessary CT scan because the doctor who ordered it didn’t understand the circumstances or maybe thought it would reduce her chance of getting sued.  It was an urgent situation and if I had been given time to think about it, I would have refused the CT.

    Another post suggesting the a doctor must care about you to give good treatment.  What do you do with those patients you don’t like, give them lousy medical treatment?

    • http://twitter.com/livewellthy Stewart Segal

      May 20, 2012

      Today, KevinMD
      published an article entitled, Necessary is a word
      best defined when looking back in time, 
      I wrote the article early in the month in response to a comment made on
      KevinMD by an angry reader.  The comment
      had to do with doctors ordering unnecessary tests.  In response to my article, a reader posted, “Another
      post suggesting that a doctor must care about you to give good treatment. What
      do you do with those patients you don’t like, give them lousy medical
      treatment?”

      The answer
      is NO!  However, often I have to work six
      times as hard to give them excellent care. 
      Yes, just as patients have the right to dislike their doctors; doctors
      have the right to dislike their patients. 
      When a patient is unhappy with, or dislikes his doc, he simply transfers
      his care to another doc in the community until he finds a medical home he can
      be comfortable in.

      When a doctor
      is uncomfortable with or dislikes his patient, the situation is much more
      complicated.  The doctor-patient
      relationship is governed by both medical ethics and law.  Doctors are supposed to be clinically detached
      from their patients, making medical decisions based on scientific fact and
      evidence-based medicine.  I have never
      understood how to care, yet be detached. 
      I believe that caring for the patient comes before science and
      evidence.  So what do I do when I find it
      hard to care?

      First, I
      analyze the situation, diagnosing why the patient makes me uncomfortable.  Why is it so hard to care?  Sometimes, the patient’s illness makes it
      hard to care for an individual.  Imagine
      a patient who has a personality disorder. 
      He hates people, is rude to the staff, verbally abusive at times, and on
      occasion, is physically threatening. 
      It’s hard to care for the above mentioned patient, yet his illness
      requires care and understanding.

      Caring for a
      person who does not care for himself is hard. 
      Patients often abuse themselves, drinking too much, eating too much, and
      smoking.  Caring for a patient who asks
      for help and then refuses to help you help him is difficult.  Non-compliant patients fall into this
      category.  Many non-compliant patients
      have passive-aggressive tendencies.

      “Another
      post suggesting that a doctor must care about you to give good treatment. What
      do you do with those patients you don’t like, give them lousy medical
      treatment?”  I work hard to find what the
      patient needs to succeed.  I work to find
      the best in my patients.  When I can’t, I
      tell them that I am not the right doctor for them.  I try to help them find a doctor more suited
      to their personalities or who can reach them when I cannot.  Just as patients have the right to change doctors;
      doctors have to have the right to change patients.  In my opinion, if you can’t care for a patient,
      you should not treat him.

      Yes, the
      doctor-patient relationship is a sacred one. 
      It should encompass mutual care and respect, be grounded in good
      communication, and mutual goals.  When
      that relationship is flawed and beyond repair, it should be severed for the
      sake of both parties.

      • sFord48

        As a professional, I do my job to the best of my ability and it doesn’t matter whether or not I “like” the person.  I have worked with drug addicts, prostitutes, lazy, and rude people and I do my job.  Some people have difficult personalities or have difficulty communicating and I don’t tell them to go away because I don’t like them.

        You imply only likable people should have a relationship with a doctor.  I have a friend whose son whose son has difficulty in social situations.  He is often abrupt and many people don’t like him.  According to you, you would dismiss him from your practice based on whether you like him?

        • JannyPi

          I read the same article, and then the same response to your comment that you did.  Both were well thought out and carefully written so as not to offend. Unless someone is looking to be offended, which seems to be the case here.

        • http://twitter.com/livewellthy Stewart Segal

          I do not “imply that only likable patients should have a relationship with a doctor.”  I am honest with my patients and if the patient and I cannot establish a healthy relationship, I help them find a doctor they can work with.  I cannot be all things to all patients. No doc can!  There are patients that work really well with my personality and practice style and those that don’t. 

          The doctor-patient relationship is a two way street and is critical to the patients wellbeing.  Patients need to find medical homes that fit their core beliefs and docs need to help them be at home.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

     Well written and well said. You enter this profession to try and use your education and experience to help people. Most of the time you are correct and it works. Sometimes it does not and as a physician you take those situations to heart and always remember them. If you are in the public eye there will always be situations where you were brilliant in others eyes  and others where you are a bum. The problem is that the public does not realize that we never want to be wrong and we do expect ourselves to be perfect. When we correctly recognize a situation as non complex and we are correct or when we make a brilliant diagnosis and execute a successful care plan, we feel no true additional joy because we expect ourselves to be correct 100% of the time. It is important to not do any harm. Most of my colleagues want to be correct because they really care about their patients. They respect the trust put in them and are more disappointed than the patient when they are unable to successfully help.

  • Sophie Zhou

    There can be clear definitions of “unnecessary.” Perhaps, the definition is not a definite number – say two or three, but there is a definition. When doctors go overboard to cover themselves in terms of malpractice and order too many tests – some of which may pose unjustified risk for the patient – then it is unnecessary no matter if you’re looking back in time or seeing it in real time. Perhaps the unnecessary burden of too many tests is not the fault of the doctors, but the pressure from the patients. Perhaps we should be looking at guidance for malpractice suits. Perhaps if doctors were not UNNECESSARILY scared of their own patients, then maybe all doctors would be a “good” doctor.

    - alittlehappi.blogspot.com

  • petromccrum

    I think that Doctors can overcome this “too many tests” if they would explain in lay terms why they are necessary. In some cases patients and/or caregivers are so overwhelmed they don’t know what questions to ask.   But you are also correct about the caring attitude.  Too many doctors do not seem to really care about their patients.

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