Tuesday, July 15, 2014

What "I Wouldn't Worry About That" really means when it comes from your doctor

Nearly all the patients that come to one of our practices have done so after leaving another primary care physician with whom they were unsatisfied.  Among the many complaints fairly or unfairly directed at their former physician, one that I hear frequently after explaining some lab or result is: "My last doctor just told me not to worry about that.  They didn't care about me."

Not to worry... is there a more dismissive, potentially condescending way to explain something to a person who is in fear for their health?  What a terrible, uncaring and hurried physician.  But here is the kicker, contained within that phrase is the essence of what primary care, and all honest medicine is all about--balancing risk.

What their quite astute doctor thought, and meant to say was probably something like, "Based on what we know about the uncertainties of diagnostic testing, and the differential diagnosis of that particular abnormality, and the risk associated with further exploring and/or treating those possible abnormalities, the risks of harm, misery, cost, side effects and complications by proceeding on this issue far outweigh any potential benefit."

That is a much longer sentence, and worth breaking down a bit:

1.  Uncertainties of diagnostic testing: Every test is imperfect with possibilities for human, chemical or interpreter error anywhere along the way.  Even performed perfectly (which is the norm), there are still built in margins of error in every test (think presidential election results).  No test is perfect, and even though it looks like a beautiful, meaningful, significant number, it is not.  It is one of a range of numbers, some of which imply doom, some of which imply nothing.

2. Differential diagnosis:  Medical speak for all of the things this could be.  This is the essence of practicing medicine.  Patients come in with symptoms and want to know what they are.  It turns out that our bodies have a limited vocabulary and lots of things look similar.  It is why googling your cough on WebMD is so dangerous.  Colds cause cough, cancer causes cough--so which is it?  The differential diagnosis is a method we use to determine all of the likely diagnoses that explain your symptoms or lab results.  The more a physician creates but whittles that list down quickly by probability, the more blood (and parts) you get to keep.  Here is a hint-- some type of cancer is always on the differential, but its persistence & rarity only make it a major player in special circumstances.

3. Risks associated with further exploring and/or treating: Everything doctors do can be dangerous.  That is why we go to school.  If it isn't dangerous (or if not doing it isn't dangerous), you don't need doctors.  You need parents, friends, family, herbalists, physical trainers, coaches, yoga instructors, health coaches, smoothie makers, cooks, grocers, etc. etc.  It is why we are bad at recommending diet and exercise.  We are trained on judicious use on the dangerous stuff, and that is what you want us doing.  You don't want doctors rigorously evaluating what you should eat, because self experimentation is really useful and really safe--until you start to add in multiple medical conditions and medicines (which are dangerous) and then our input matters. Therein lies the key.  Our work is dangerous, and we work hard to minimize the danger and maximize the benefit.  It is why we don't want to give narcotics and antibiotics for everything, because it is dangerous.

And remember, our promise is to first do no harm.

So now you see why your doctor said not to worry-- it was an unfortunate attempt at time savings.  When I take patients through the above, I find that we are better connected, I can understand their values and preferences, and they see how (and that) I think.  To the docs out there, next time you tell someone not to worry, think about taking them through the above and see the magic that happens.

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