I’m about 35,000 feet up en route to the American Society for Reproductive Medicine (ASRM) conference in Denver. For some reason I always feel bad for myself when I fly. My mind says things like “well if you have to be crammed on a plane you should treat yourself.” My treat is trashy magazines and silly TV shows.
When I got to the airport this morning I went magazine shopping but somehow I no longer recognize any of the celebrities on the cover of magazines. I think because I don’t watch YouTube, The Voice or shows like Gossip Girl I don’t know whose personal life I should care about anymore. I used to eat up stories about Jennifer Aniston, Justin Bieber, Johnny Depp, etc. Now I don’t even know who the woman is who lost 400 lbs and while her husband was in Iraq and her daughter learned to walk after a car crash. So, I started to look in the other magazine section.
I grabbed Esquire and the Walrus. Might was well read what smart people are thinking these days. In the Medicine section of the Walrus an article titled “Uncommon sense “ discusses a doctor’s clinical intuition. I’ve been interested in this concept since medical school. I remember being on my nephrology rotation and two nephrologists were arguing about the diagnosis in a shared patient on a hospital ward. It was heated - one a part battle of egos and one part a deep concern that if the other person “won” and got to treat the patient under their incorrect diagnosis, the patient might suffer. Well my preceptor lost and as we were walking off to the next ward he said “that’s called diagnostic anchoring and it is very dangerous to patients.” What he meant was if a physician makes a diagnosis and sticks to it as evidence to the contrary mounts the patient can suffer. I saw it a lot in my training and it does not come from bad physicians it comes from bias and it comes from being rewarded for fast decision making. There is no doubt we are rewarded in medicine by coming up with a diagnosis fast and being right. Family doctors, ER doctors and many other physicians have to see a lot of patients quickly. If they get the diagnosis and treatment right, the patient is helped. Most of the time doctors do get it right, but sometimes the first answer isn’t the correct one. Most estimates are that doctors are wrong 10% of the time. The more information the doctor has and the more time a disease has to evolve the more likely the doctor is correct. If a doctor sees someone with a 1 day history of a sore throat they might dismiss it as a viral throat infection. If they see the patient on the 5th day after the sore throat has gotten worse, become associated with a fever, neck stiffness and lethargy they are more likely to get the diagnosis of meningitis. The doctor who diagnosed the throat infection seemingly missed the diagnosis of meningitis but they just didn’t have the whole story yet.
This is very true in fertility. We try to have patients get testing before they see us for the first visit so we have more of the story to piece together. Then, electronically and in person, we ask questions to try to sort out the diagnosis and then it comes down to our clinical intuition. Good intuition is a combination of good training, experience, humility and smarts. I think my clinical intuition is pretty good (doesn’t everyone think they have good intuition?!). I also know my patient’s intuition is also good. I frequently ask “why do you think you aren’t getting pregnant?” People often know. So, we make a diagnosis, often more than one, but don’t anchor to it - as we see patients on treatment we learn more - diagnoses and treatments evolve with information.
So, what is good physician care? I think the Walrus article says it well “when decisions are made with humility…. taking an analytic approach whenever possible.”
Going to watch Portlandia now. I will post Facebook updates about the meeting and blog about the events of the day at the conference.