17 June 2012

Medicine by-the-book

I saw a patient who had injured his knee. I performed a handful of physical exam tests that I was familiar with: pulling on his leg to check the integrity of the anterior cruciate ligament (ACL), twisting his joint in a particular way to check some other ligaments known as the collateral ligaments. Still, I wasn't sure of a diagnosis. There were a handful of other tests that I wanted to perform which I had never done before. I didn't remember how they were done, and I didn't want to guess for fear of injuring the patient. So, with the patient in the room, I pulled out Sapira's, my gem of a physical exam textbook, and read for a bit of its section on the knee. Thanks to the exams it described, I was quickly able to pinpoint his injury to the posterior horn of his medial meniscus, without needing to take an X-ray or an MRI.

The patient seemed fine with my consulting a textbook mid-examination. "After all, you're just a student," he had said. But it felt uncomfortable. Bringing out the book was a tacit acknowledgment that I am falliable, that I don't know everything I need if I'm to help the patient. Most primary-care doctors I shadow excuse themselves from the room when they want to look something up. They don't mention to the patient that they're consulting other sources. For that matter, most primary-care doctors rarely consult outside sources when assessing and treating patients.

Should it be such a bad thing to consult a textbook with the patient present? Using a textbook conveys humility and demonstrates that the doctor cares. Double-checking against the textbook helps the doctor confirm that they're providing the most up-to-date and appropriate care.

I'm not sure that that's how patients feel, though. Patients want their doctors to be smarter than their textbooks. I'm willing to concede that, in some respects, the textbook knows more.