- Anyone with <10 days of common cold symptoms (patient wish: antibiotics)
- Young, healthy people with chest pain, a normal exam and EKG, and a whole lot of anxiety (patient wish: more heart testing)
- 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:
- 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
- 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
- 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
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=