Lee A. Resnick, MD, FAAFP
Carl Jung said, “We should not pretend to understand the world only by the intellect. The judgment of the intellect is only part of the truth.” In medicine, reliance on intellect alone is a significant danger. Ignorance of cultural, social, and even psychological context can mislead the clinician and risks misdiagnosis and error. Yet the very basis of medical decision-making is rooted in the rule of intellect. Evidence-based medicine is, after all, the accepted rule of law in clinical circles these days, and it has become the rallying cry of everyone from healthcare reformers to physician colleges. But sometimes, the evidence can mislead. We fall victim to the bias of intellectual facts and past experience, and ignore the power of context and nuance. To understand how, we must first examine the roots of medical decision-making.
The decision-making process is fed by a steady stream of facts and calculations learned through study and experience and filtered through the evidence-based guide of the scientific model. The scientific model is a rather rigid premise and leaves little room for speculation. It is not based on hope or belief, nor is it fond of irresolute thinking. The scientific model creates the framework for “answers” in medicine. It generates judgments, and while there may be debate over the “strength of evidence,” it is nonetheless a path towards relative certainty of thinking.
In practice, the scope of knowledge derived from the lifelong pursuit of the most certain and relevant of these judgments is what drives our medical decision-making. With each encounter we attempt to lump presentations into neat and factual compartments in an effort to bring definition and appropriate action. The longer you practice, the better you get, and after a while you feel like you can efficiently compartmentalize with ease and confidence. The result is a very systematic and productive machine that can generate conclusions and their associated interventions with minimal risk of error.
Consider the 30-year-old postpartum female with leg pain, swelling, and shortness of breath; the patient with runny nose, congestion, and cough for 4 days; or the man with non-traumatic back pain for 2 days with no neurologic symptoms. The decision-making machine will accurately and reproducibly determine the appropriate diagnosis and intervention for each of these clinical scenarios. Assessment is swift and painless.
And yet, despite all my calculated certainty, every day in practice reveals cracks in the scientific armor. I see patients who can’t give me the history I want; patients with their own agendas; patients with conclusions drawn from the Internet and Aunt Susie; patients who present irrelevant clues that lead me down the wrong diagnostic path.
Consider these common presentations:
- A 26-year-old male on his third visit for a back problem who is visibly, albeit “dramatically” in
- Anxious, 34-year-old female with dizziness and tingling in her fingers
- 45-year old-female, seen on multiple occasions for migraines and well known to staff as “challenging and difficult,” presents her usual sunglasses and pajamas complaining of worsening
In the middle of a busy day at the urgent care, all three of these patients run the risk of falling victim to judgments deemed factual by virtue of the certainty of our past experiences. At risk of falling victim to the drug seeker,the panicky worrywart and the “borderline” migraineur, we quickly compartmentalize and don our emotional armor to protect ourselves and our staff.Odds are that our judgments are right. But what happens when we are wrong? What opportunities did we miss to help someone in need? How many epidural abscesses, acute MIs and sub arachnoid bleeds will we miss if we rely on the certainty of our judgments and experiences?
When we remove all that armor and dispense with our prejudgments, we expose ourselves to risk and uncertainty,but we also unveil nooks of opportunity. Within these exposed cracks lie the real joys of medicine. These are the encounters you remember. These are the motivational stories from everyday practice. For all the emphasis on“calculation” in medical decision-making, and despite all the pres- sures to be productive and efficient, it is ability to defer judgment and challenge our intellectual biases that makes this profession so special and worthwhile.