Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments (2)

Over-Reliance On Tests: Why Physicians Must Learn To Trust Themselves And Their Patients

I met my newly admitted patient in the quiet of his private room. He was frail, elderly, and coughing up gobs of green phlegm. His nasal cannula had stepped its way across his cheek during his paroxsysms and was pointed at his right eye. Although the room was uncomfortably warm, he was shivering and asking for more blankets. I could hear his chest rattling across the room.

The young hospitalist dutifully ordered a chest X-Ray (which showed nothing of particular interest) and reported to me that the patient was fine as he was afebrile and his radiology studies were unremarkable. He would stop by and check in on him in the morning.

I shook my head in wonderment. One look at this man and you could tell he was teetering on the verge of sepsis, with a dangerous and rather nasty pneumonia on physical exam, complicated by dehydration. I started antibiotics at once, oxygen via face mask, IV fluids and drew labs to follow his white count and renal function. He perked up nicely as we averted catastrophe overnight. By the time the hospitalist arrived the next day, the patient was looking significantly better. The hospitalist left a note in the EMR about a chest cold and zipped off to see his other new consults.

Similar scenarios have played out in countless cases that I’ve encountered. Take, for example, the man whose MRI was “normal” but who had new onset hemiparesis, ataxia, and sensory loss on physical exam… The team assumed that because the MRI did not show a stroke, the patient must not have had one. He was treated for a series of dubious alternative diagnoses, became delirious on medications, and was reassessed only when a family member put her foot down about his ability to go home without being able to walk. A later MRI showed the stroke.

A woman with gastrointestinal complaints was sent to a psychiatrist for evaluation after a colonoscopy and endoscopy were normal. After further blood tests were unremarkable, she was provided counseling and an anti-depressant. A year later, a rare metastatic cancer was discovered on liver ultrasound.

Physicians have access to an ever-growing array of tests and studies, but they often forget that the results may be less sensitive or specific than their own eyes and ears. And when the two are in conflict (i.e. the patient looks terrible but the test is normal), they often default to trusting the tests.

My plea to physicians is this: Listen to your patients, trust what they are saying, then verify their complaints with your own exam, and use labs and imaging sparingly to confirm or rule out your diagnosis. Understand the limitations of each study, and do not dismiss patient complaints too easily. Keep probing and asking questions. Learn more about their concerns – open your mind to the possibility that they are on to something. Do not blame the patient because your tests aren’t picking up their problem.

And above all else – trust yourself.  If a patient doesn’t look well – obey your instincts and do not walk away because the tests are “reassuring.” Cancer, strokes, and infections will get their dirty tendrils all over your patient before that follow up study catches them red handed. And by then, it could be too late.


You may also like these posts

Read comments »


2 Responses to “Over-Reliance On Tests: Why Physicians Must Learn To Trust Themselves And Their Patients”

  1. Asha Padmanabhan, MD says:

    Dr. Val, you raise a very good point. The over-reliance on testing results while not actually looking at the clinical picture can lead to serious issues and in the cases you have reported, unnecessary pain and suffering for the patients. I cannot tell you the number of times I have had to tell an anesthesia resident, a CRNA or a Student nurse anesthetist “treat the patient, not the monitor.”
    Maybe it is time for medical education to put more emphasis on actually looking at the patients and not rushing to order tests.

  2. sumithra says:

    I totally agree with this—lab numbers-x ray reports are far more denials at time when u look at the patient—how a x-ray can tell u about dehydration—
    bein gin North america many times when dr,s prescribe medicines to the patients with out having a look at them concerns me alot—
    many incidences have proven wrong—-I question the physicians here–how are u ready to priscribe medicine with out looking at the patient—-
    simple blood pressure check up straight with the stethescope will not tell u miss beats,,arrythymias untill unless we feel the pulse—-
    patient physical examination by palpation -auscultation is the best method instead of looking at numbers & priscribing medicines—-

Return to article »

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »