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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