Wednesday, November 23, 2011

Doing "nothing" is still something

I've been struck lately by how often I don't do what my patients are hoping I'll do.  A few examples:
  1. Anyone with <10 days of common cold symptoms (patient wish: antibiotics)
  2. Young, healthy people with chest pain, a normal exam and EKG, and a whole lot of anxiety (patient wish: more heart testing)
  3. Middle-aged men with no risk factors terrified of prostate cancer because a friend was recently diagnosed (patient wish: PSA test)

For those three scenarios, here's why I wouldn't follow my patient's wishes:
  1. Antibiotics do not help viral cold symptoms to be less intense or resolve faster.  They do contribute to a lot of antibiotic resistance, though, making it harder for us to treat legitimate bacterial infections. http://bit.ly/uhpDfi
  2. If I am confident that the patient is not having a heart attack (low pre-test probability), then testing is just unnecessary expense.  Not to mention that no test is perfect, and the risk of a false positive (meaning showing there was a heart attack when there wasn't), can lead to a whole lot more unnecessary and progressively risky testing and interventions.  http://bit.ly/uYFRBm
  3. Unfortunately, the PSA blood test to screen for prostate cancer is just inaccurate; again, a false positive screen can lead to unnecessary biopsies (which, gents, can occasionally cause impotence and incontinence.  I'll wager that's a high price to pay for a false positive screening test).  http://bit.ly/qcsI5X
Despite our robust knowledge base of medical evidence, the temptation to go ahead and do that something* anyway can be very strong when a distraught patient is sitting across from you.  Some of the hardest patient situations for doctors to navigate are the ones when we choose not to intervene, even though we could (albeit with an intervention that goes against our best judgment).

I was taught what I call "the Balint principle" by a mentor: I, the physician myself, am the most powerful thing I can give to my patients.**  My positive regard, along with my attitude of caring and diligence for them, importantly affects their well-being.  I have learned that exploring patients' concerns and fears related to their issue is terribly important, and I am transparent with them regarding my thought process about why I don't believe their desired intervention is necessary.

So, even when I do nothing, I still do something.  I listen.  I share.  I verbalize and demonstrate my caring.  And, when after our conversation we still fundamentally disagree, I respect their viewpoint and offer them the opportunity to get a second opinion.

After all, as physicians, we always have something to offer - even if that something is just us.

* I can't resist: http://www.youtube.com/watch?v=SMTDQZzQMKk "Do something!"
** For more on Drs. Balint:    http://www.balintinternational.com/downloads/Balint_in_a_Nutshell.pdf , http://americanbalintsociety.org/http://www.jfponline.com/Pages.asp?AID=9167&issue=December_2010&UID=

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