Is it nothing, or could it kill you?

Posted Feb. 14, 2013, at 1:06 p.m.

If patient symptoms were bees, a typical day as a family doctor would produce an entire hive swarming around my head. Bleeding, bloating, belly pain, back pain, chest pain, chunks of something coughed up, discomfort, fatigue, fever, limp, lump, ringing, tingling, weird smell, weird taste, weakness and wonkiness are but a few of the problems my patients and I must sort through.

The challenge of distinguishing buzzing that’s a bother from buzzing that’s a brain tumor is what sometimes makes our work scarier than crashing a convention of killer bees. Every one of those complaints could be caused by a problem that’s trivial, or one that could ultimately kill the patient.

Take dizziness — is it just an irritated inner ear, or is it the warning sign of an impending stroke? Diagnostic dilemmas require a decision in the exam room as to whether it should be pursued, ignored or watched carefully over time. That requires a rapid filtering for red flags of dangerous disease, and rapid processing of the many options for answering the dilemmas. All options must factor in patient and caregiver preference and paranoia, ability to delay the search for an answer, ability to pay for a search for an answer, and much more.

Do we watch it and wait, or stick some whats-its in your whoozits chasing down something that might turn out to be nothing? Since many symptoms will just go away with watchful waiting and no specific tests to see what’s causing the problem, waiting may be just the right “test” to show us the problem was not important. With that approach we might avoid a CAT scan and the increased risk of cancer down the road its radiation causes. Or that way, we might miss the chance to catch a problem early, when it might be more treatable.

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If there was lots of room for error, we could watch and wait in every case. If there was no room for error we would not watch or wait in any case, just CAT scan every patient from head to toe every time they came to see me. Neither approach is tenable as the only way, so how do we — patient and physician or other caregiver — walk this tightrope of timing about when to test for what? How do we find that balance between working up every ailment to the nth degree and ignoring every one until disaster identifies the dangerous ones?

If we are to be successful walking this tightrope with the bees buzzing about us, we need a better partnership between patients and caregivers. This cannot be a solo sport where the savvy physician savior scans for the damned among the dizzy and discomforted. It takes a savvy patient-caregiver team.

Such a team would have careful agreements about follow up of symptoms and signs, and who is doing what to make sure the follow up happens. Computerized systems would be used by both of us to remind us when follow up was due on a specific problem. It would have a patient who thought more like a physician (a bit detached and methodical in pursuit of answers), and a physician who thought more like a patient (in touch with the symptom and fear of the possible cause).

Such a team would understand the patient’s tolerance of cost, paying out of pocket for the diagnostic pursuit of certainty that nothing bad is going on, and each team member’s tolerance of risk. It could talk comfortably about patient paranoia that I might miss something, and physician fallibility because I do miss things.

Those and other efforts would make us more effective diagnostic partners in a world where certainty only exists for the dead.



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