What Matters I

Family medicine is the lightest third year rotation with no call and little work outside the outpatient clinics. I was advised to leave this for the middle or end of my third year when burn out is a large factor. But because I'm not tired or burned out, I've been doing a lot of thinking. Much of this is stimulated by talks given by the residency director Dr. Kopes-Kerr.

What matters? Why are we doing what we do? These two questions are really changing my paradigm of medicine. For example, why do we listen for bowel sounds in anyone except post-surgical patients? To say there are no bowel sounds, you have to listen for a significant period of time. Let's say I don't hear bowel sounds in an asymptomatic patient. How does that change my management? It really doesn't. Even if someone came in with constipation and I heard no bowel sounds, I don't think it would change what I did at all. As far as I know, it's not sensitive or specific enough of any symptom to really change my thinking. It's just a variable. Who cares?

Another thing taught to us is that a patient with stable angina (substernal chest pain radiating to left arm exacerbated by exercise, relieved by rest) should get a stress EKG. But why? The history is strong enough (high enough predictive value) that you would treat this as stable angina regardless of what the stress test results show. Thus, the test is just a waste of money. Really, if something doesn't change management, then is it worth doing?

Last week, I saw a patient who was extraordinarily reluctant to accept treatment for her diseases. She didn't want to take any medications (even OTC medications), she didn't want to try physical therapy, and she didn't want psychiatric counseling, yoga, relaxation, or anything. Really, she just wanted a miracle to cure her (and we'd give it if we had it). So even though we diagnosed her with deQuervain's tenosynovitis, it made no difference. It just put a name to a problem she refused to treat. We could have diagnosed anything and the outcome would be the same.

This is frustrating to me. I completely understand the patient's reservations in avoiding medical treatment. That's fine. But then what can we do for her? Really, not much.