Monday, March 5, 2012

Doctors should trust their clinical judgments

A physician reader of AFP submitted the following post.


Many doctors have lost, or never acquired, the ability to make decisions based on clinical judgment after a detailed history, physical examination and basic laboratory tests. Instead, they substitute expensive diagnostic tools for clinical competence.

A case in point: a friend recently asked my opinion after her primary care physician noted a moderately elevated eosinophil level on a complete blood count. I remembered the common causes of this abnormality (allergies and parasitic infections) and asked some questions about recent changes in diet, use of herbal products, and travel. I also recalled seeing eosinophilia in patients with Hodgkin's disease and systemic vasculitides, but she was completely asymptomatic and had been told that her physical exam was normal. In reviewing the topic online, I read about other rare causes of eosinophilia, but told her that in my judgment the chance that she had ovarian cancer or any of these other conditions was extremely low. This was, after all, a healthy 35 year-old woman who regularly ran marathons.

Our job as physicians should be to educate patients so that they can make informed decisions. Based on the information I gave, my friend seemed comfortable with a "wait and see" approach. She was not particularly concerned, as she recalled an aunt having been told for years that she had an elevated eosinophil count. However, her doctor pushed her to see a hematologist. After she endured CT scans of her chest, abdomen and pelvis, followed by a bone marrow biopsy, she wrote again to ask my opinion. It seems that the hematologist had found nothing and now wanted her to see an infectious disease specialist.

What drives doctors to order tests that, in their hearts, they must know have a remote chance of being helpful? For some, it may be medical-legal considerations. For others, there is a financial incentive. But at a deeper level, I think it is that too many doctors are unable to live with medical uncertainty. They want a definitive answer, even when it is unlikely that it would alter the patient's long-term well-being. We must learn to trust our clinical judgments, and to educate our patients and involve them in decision-making, if we ever hope to rein in health care costs.

Robert G. Brown, MD
Lovettsville, VA