What If I'm Wrong?

I was supervising the residents yesterday afternoon.  Most of patients had typical run-of-the-mill issues that any family doc should be able to handle.  However, a few of the patients hadn't responded quite the way the residents had hoped.  What if they were wrong?  An article appeared in the Wall Street Journal on Tuesday asking just that question: what if the doctor is wrong?  The hairs on the back of my neck stood on end as I read the article and reader commentary.  But was that because I had been wrong?  After all, I'll readily admit that I'm not the brightest lightbulb in the room.  Nor am I the sharpest knife in the drawer.  You get the idea.  But is it enough to mean well?  

Now I can't comment about other professions and lines of work but in medicine, we can't afford to let the moss grow beneath our feet (much less be wrong too often).  What I mean by this poorly chosen metaphor is that we need to continually learn about advances in science and medicine.  We need to learn about new medications & techniques, yet not be so enamored that we prescribe and recommend the latest just for the sake of being the newest.  As I noted yesterday and in other posts, never be the first, neither be the last, when it comes to new medications & techniques.

Never?  Well, never say never, but I suspect that if you're presenting with common symptoms which all point towards a common diagnosis, and you respond well & quickly to common treatment modality, chances are pretty good that we (you & I) got it right.  Sure, we may have to adjust the dose a little up or down.  Perhaps we'll need to change the medication entirely while staying within the same class (kind of like switching from Chevy to Dodge to Ford).  But the point is that you're getting better.

But what if your symptoms don't clearly point to a single diagnosis?  What if the tests are equivocal?  What if you don't respond as expected to the initial regimen, nor the succeeding ones either?  What if your symptoms (and tests) point to a diagnosis with greater potential for loss requiring major intervention, eg surgery, radiation or chemotherapy?  That's when I think it's perfectly reasonable to consult someone at a major teaching & research facility for a second opinion.  After all, these guys in the ivory tower fashion their careers around finding zebras when they hear hoof beats.  Those of us in primary care mostly find horses when we hear hoof beats.  

And what of the residents?  Family medicine is all about developing relationships with your patients.  It's all about listening closely to what they're saying (and not saying).  It's following up closely so that if the patient doesn't respond as expected, we help expedite their search for a second and even a third opinion.

But here's where health care is a two-way street.  You have to be open to us (your family physician).  You have to tell us everything.  You have to follow through with our recommendations or explain why you couldn't.  You have to keep your follow up appointments with us so that we can monitor how you're coming along.  Remember that your health requires a team effort.

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