There's an episode of Parks and Rec in which the main character, Lesley Knope, encounters a recalcitrant voter during her political campaign for city council. The voter, a blue-collar man from her town, just doesn't like her, despite her crazy antics to win him over. I felt like that today.
One of my patients this morning was new to our clinic and came in with abdominal pain of rather sudden onset. I reviewed her chart before her visit. I took a careful history and updated her medication list. I did imaging and appropriate lab work. Once I had the diagnosis, I discussed it with her and prescribed medication, even discussing a couple of different treatment options. I left the visit feeling confident that we had a good visit and the patient felt well cared for.
Ten minutes later, the patient was at our clinic's front desk, reporting that I had misdiagnosed her. I offered to have her come back to the exam room to address the concerns or to see a colleague if she wanted a second opinion. Opening the electronic health record, I re-read my notes and double checked the imaging results. I took a mental inventory of the visit to make sure that I didn't miss anything. The patient ultimately decided to try the treatment I prescribed and "see what happens." Needless to say, I probably felt as uncomfortable as my patient.
Truthfully, these are the moments I hate being a doctor. There is a level of uncertainty in many of the patient cases I see. I have become comfortable with that over time, as I recognize that medicine is an inexact science. Patients are generally less comfortable with this, a point I very much sympathize with, especially when I am a patient myself. Enter the art of medicine – working with a patient in a way that you convey confidence amid uncertainty, being honest without causing undue concern. I believe that I usually do this well, but not always.
I had another patient today in which I was pretty sure of the diagnosis, but not 100percent sure. I recommended that we do a lab test that, while not diagnostic, would be additional information to help me make the diagnosis. I ended up confusing the patient who couldn't understand why I needed to do a lab test that could be normal even in the presence of disease.
I have found over time, as I become more experienced with medicine, that I spend an increasing amount of my time with patients carefully considering not just the diagnosis and treatment but how to explain it to the patient in a way that is neither paternalistic nor overly familiar, informative without being too complex, and decisive without inhibiting dialogue.
Sometimes I do a great job. Sometimes I don't. Sometimes I'm aware that I haven't done a good job, but I am not sure how to remedy it. Sometimes trying to remedy it makes the situation worse. And sometimes, I just have to accept that I am an imperfect provider of an imperfect science.