Putting Judgment to the Test

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Don Mason / Corbis

A doctor examines an x-ray

Tim was a reasonable-looking guy, neatly dressed in his mid-40s. He showed up for his office appointment with a brief full of papers, a bag full of X-rays and a face full of exasperation. This was obviously a second or third opinion. I could anticipate his response to my first question.

"So what's bothering you Tim?"

"Well, Dr. A sent me for tests for a blood clot, but they couldn't tell, so he sent me to Dr. B for electronic muscle tests and they think it might be coming from my spine, so I have the MRI and it shows bulging discs. They've been doing laser treatments in physical therapy, but we haven't been able to work it out, and Dr. C is going to start acupuncture but if you could just take a look at this scan..."

"But what's bothering you?"

"The MRI, you see, found a bulge and the electrical test says..."

Patients like Tim might eventually tell you why they went to the doctor if you keep on asking long enough.

"Hold on Tim. Let's forget about all the tests and the other doctors. What happened to you? What hurts? When did it start?"

A little shaken, he finally established that about a month earlier he was standing in his office, having just come up a flight of stairs, when he felt a sudden pain and a bit of a pop in his right calf. The calf was sore and it made him limp so he went to a commercial chain's urgent care center nearby (a "doc-in-the-box" in hospitalese) and thus began his saga. The story made me groan.

What Tim had, at least by his history, was a true classic — a common problem. His physical exam was also classic — tender at a certain spot on the inside of the calf, pain here when he tried to stand on tip toe. It's called "tennis leg" because it often happens on the tennis court; it feels like you just got hit with a ball. In the days before MRI we thought it was caused by rupture of an unimportant little muscle in the leg called the plantaris. Now we know it's actually a small tear of a part of the big calf muscle called gastrocnemius. These tears get better in about six weeks. The treatment is easy — just a high-heeled shoe like a cowboy boot and sometimes a cane. That's it. Patients ask for physical therapy but I won't give it until they're healed. Stretching a muscle that has just torn isn't usually a good idea. So why the big work-up with Tim's case?

It is possible they just didn't know. Small things we take for granted can be enormous problems in the absence of a little knowledge. Take cholera. My gastrointestinal colleagues tell me that although it will make you sick and miserable for a couple of weeks, cholera won't kill you if you simply drink enough water and salt to combat the dehydrating effects of its severe diarrhea. But millions have died from it just because they didn't know. Or how many horrible, slow deaths have there been from scurvy, which a bite of green pepper would have cured? How many poor kids in our parents' generations suffered years in splints, braces and weird, painful shoes treating "flat foot" that was no problem at all if ignored? So the doc-in-the-box might not have know about tennis leg; they're not specialists, they're usually moonlighting docs in their fellowships — someone going into cardiology might know a lot about heart attacks but very little about muscle tears. Tim's subsequent referrals did make this innocence less likely. But it's hard to point the finger of blame.

Consider first the vascular test: All orthopedic surgeons have a great respect for phlebitis. Thrombosis (clotting) in the big veins of the legs is among the top killers of orthopedic patients. And calf pain is one of the signs. I never faulted anyone for getting a Doppler, the test for the blood clots. I have seen patients with barely any calf pain at all fall over dead from the things — you can't be too careful. A recent scare about Vice President Dick Cheney's calf clots showed how seriously doctors take them. Tim was a little tender (albeit at just one spot) and this is — vaguely — a sign of clots. The test is non-invasive. And Tim was the nervous type. Scared patients can get doctors scared too.

Then there were the MRIs of his lumbar spine: Here the docs-in-the-box might have been simply playing the odds. Patients who complain of leg pains often turn out to have what we call radiculopathy, which affects the spinal nerve roots. Sciatica is a well-known term for one type of this. Although caused by pressure on a nerve in the back, there might be very little or no back pain. Patients sometimes just cannot believe there is nothing wrong in their leg. Tim could have been vague about his story, or he might have been so wound up that the pain seemed to involve the whole leg, not just the one spot. In any case, the chain that owned the doc-in-the-box also owned a diagnostic center. So the MRI was done pronto.

EMGs and NCVs (electrical nerve tests) could have been justified as well considering the weakness — or what seemed like weakness — of Tim's calf muscle. These rather unpleasant examinations measure the electrical activity in nerve and muscle. The torn calf muscle would hurt to use and so would appear weak. And its reflex would be inhibited by the pain and swelling, further implicating a nerve issue. Certainly one could justify these tests as well by the findings on Tim's exam. Right?

Absolutely not. This is a primrose path; no good orthopedist would actually buy any of this. I would blast any resident out of the water if they did this kind of work-up on a tennis leg — the same as my teachers would have blasted me. We train hard in medicine is to develop good clinical judgment: a feel for things. It's a lot like what tells a good cook the roast is ready, or a good teacher that the kid nodding in back doesn't really understand. Clinical judgment often makes a doctor do things the "objective tests" do not support. Trusting what you see in the patient more than what you find in the chart is a common exercise of medical judgment. You see it used by the doctor starting antibiotics on a sick child with a negative culture, transfusing a patient whose blood count isn't that low (yet) or putting a cast on when it's clear the bone hurts but the X-ray doesn't show a fracture. (The machines might actually trump us on these — an MRI will usually show up these "invisible" breaks.)

An enormous effort is now made applying business methods to American medicine — making money by reducing what doctors and nurses do to flow charts. Thousands more business people every year make money "reducing costs" in medicine. It has worked out well for many; the CEO of one of our larger HMOs took home over a billion dollars last year. These people know they can slice up and squeeze the money out of the doctor-patient relationship only if it's reduced to a lifeless, mechanical emulation — an algorithm. But it's more complex and beautiful than those without feeling and judgment can know, and sometimes, like in Tim's case, it's simpler.

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area