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‘Are you sure, doctor?’ Well no, I wasn’t sure, actually. The truth is, in this job, it’s often hard to be absolutely sure.
I’d been asked to review a patient who had become a bit drowsy. He had come in a few days before with shortness of breath, hoarseness and difficulty swallowing. The team looking after him were worried about a cancer, and he was waiting for a scan to confirm this.
When I examined him I found him sleepy, but I couldn’t find much specifically the matter. I heard a few crackles in his chest, but his oxygen saturation levels were normal and his breathing okay.
His blood tests showed he was dehydrated, with a high sodium level. His CRP was also raised above a hundred, but the white cell count was normal. He had had one ‘low grade’ temperature of 37.6. The dehydration and hypernatraemia could certainly explain why he was drowsy. But the high CRP might also suggest a developing infection.
So should I start an antibiotic? Did I have enough evidence to justify it? Should I wait and see what his chest x-ray and urine screen would show? Or should I just go ahead? It was nearly the end of my shift – if he was developing an infection, might he have deteriorated further by the time the night-team reviewed the x-ray?
‘Better safe than sorry’ one voice was saying in my head.
‘You don’t just treat a blood test’ another argued back.
In the end I had told the nurse we would hold off. But she had evidently caught a note of indecision in my voice. (Or perhaps she’d overheard me thinking out loud as I reasoned my way to a plan of action.)
It was hardly the biggest decision I’ve ever had to make. In fact it was perfectly routine. But as doctors almost every decision, whether big or small, has the potential to be similarly challenging.
Medical education, where you get the exam question right or wrong, leads you to expect things to be more straightforward. But the problem is, when you get to actually practising it, medicine is fundamentally uncertain. Whether it’s estimating prognosis, balancing risks and benefits of treatments, or deciding when to send a patient home, things are rarely clear cut.
For those of us prone to overthinking things, it can be difficult. The feeling that in this mess of real-life uncertainties and grey areas there is a course of action which is clearly the right one, if only you could see it, can be unsettling. At worst it leaves you paralysed with indecision, reaching for the phone for the reassurance of senior advice even when you know you probably do know what to do. Especially at the beginning.
But as time goes on you see more senior doctors, all of them good doctors you look up to, do different things faced with very similar situations. And you start to realise, often there is no ‘right’ answer.
There might be wrong answers, like ignoring that central crushing chest pain, or giving Tazocin to the patient with a penicillin allergy. But there are often a range of reasonable, justifiable courses of action, and in the end it’s about picking whichever of those seems the best and being prepared to re-evaluate if something changes. And then sounding decisive when you tell the nurses.
By the Secret Doctor. Read the blog and follow on Twitter @TheSecretDr
When assessing human (patho)physiology and human behaviour in relation to ill health, one is often faced with uncertainties.
Although we must all strive towards a "certain diagnoses" and comprehensive assessments of our patients, we may often be compelled to make clinical decisions even when one is "uncertain".
Thanks for this - I think this summarises a lot of what I'm currently finding hard about my job (year 3 junior doctor). I often come to conclusions that are just as reasonable as my colleagues, but I seem to "over-think" more than others, and therefore take longer and feel more stressed and exhausted by the end of a shift