Choosing Option A

He was an athletic healthy-looking young man.  His symptoms were transient and had occurred a while back.  He was sent in for a “heart check-up.”

We met, and something old-fashioned happened.  A history was taken, an exam performed, an inexpensive ECG reviewed and then I said this:

“You know what…I think you are OK…I don’t see the need for any other tests.”

And then I received a compliment that made me feel as good as I do after a successful ablation.

“Good…That’s what my family doctor predicted.  He sent me to you because you wouldn’t order unnecessary tests.”

It was Bryan Vartabedian’s recent post on how pediatricians handle worried parents that got me thinking about one of doctoring’s most pressing challenges: the decision to reassure, or as some patients might say, “do nothing.”

On the surface, doing nothing seems easier, less complex, less risky.   This thinking would be wrong.  The paradox is that doing ‘nothing’ really means doing way more. (Ask any primary care doc who is tasked with treating viral bronchitis without antibiotics.)

When talking with patients, I call the choice to do nothing further: Option A.

For US doctors, choosing Option A is tough because it requires a fair number of enoughs:

Enough savvy to distinguish whether symptoms or signs indicate a disease or a variation on normal.  Examples here are infinite; for pediatricians–as @Doctor_V notes–there is benign spitting-up, and for electrophysiologists, there are the benign palpitations of middle-age.  The acumen to distinguish normal variations cannot be extracted from memorizing books and acing multiple-choice tests.  Nor can it be measured by present-day “quality” metrics, which use spreadsheets and checklists.

Enough mettle to risk an error of omission—a missed diagnosis. You might think it takes guts to poke a needle across a beating heart (trans-septal), but this pales in comparison to choosing “no further testing.” It’s true, talking about defensive medicine gets tiring, but such is the reality of the current healthcare system in the US.  I am not complaining, just stating the facts.  As an example, look at the practice of Emergency Medicine, where diagnostic tests are used (in vain) to eliminate the inevitability of human error.

Enough skill to tactfully explain why nothing further is needed–something more than statements like, you are fine, there’s nothing wrong, live with it. Though these sorts of dismissals make a doctor more efficient, and they don’t show up as a black mark on a quality report, they represent doctoring at its worse.

Enough time to explain what normal is, or that the symptoms will pass with time, or that there is danger in willy-nilly testing, or that available treatments are worse than the problem. Such thoroughness requires time and patience, a service that our current compensation system doesn’t value very highly.

For patients, hearing Option A can also be a challenge:

They are not used to hearing that some symptoms may be part of life—not everything is a disease. For instance, it comes as a surprise to many that not all joint aches indicate auto-immune disease or are easily fixed, that not every palpitation means heart disease, and that not all mood swings are related to hormone alterations.

Patients are also challenged by the notion that many ailments stem from less than ideal lifestyle choices.  Again, infinite examples abound, but I like this one: it’s much easier for an obese man with shortness of breath, fatigue and low sex drive to accept a prescription, than a frank statement that his fat cells are making too much estrogen.  That his fatness is turning him into a woman is an awfully bitter elixir to swallow.

Some patients find it disconcerting to leave the doctor’s office with no more than words of expertise—no toothbrush, no X-ray request, no procedure scheduled.  The intangible feels less valuable than the tangible.  Maybe that’s just human nature.

Good doctoring is about having the time, patience, savvy and mettle to make hard choices.

This often means choosing Option A: nothing further.

It ain’t easy.

JMM