by Danielle Ofri
Los Angeles Times
Is the quality of a judgment call determined only by the outcome? Or does it stand alone, with the outcome irrelevant?
On a late Monday afternoon Mr. Miah [not his real name] came to my clinic and announced that he had pneumonia. As a pharmacy assistant, he had some medical knowledge and, as usual, the patient was right. He told me that he had a fever of 102 at home and pointed to the right side of his chest, which hurt when he coughed or took a deep breath. When I listened to his lungs there were indeed crackles at the right base, suggesting a pneumonia at that spot. His temperature was now normal, and he was breathing comfortably. A community-acquired pneumonia in a healthy 41-year-old male.
First judgment call: which antibiotic to prescribe. Most private practice doctors prescribe the newest and fanciest antibiotics, but these cost 10 to 20 times more than older ones, with no clinical data to show that they are any better.
Erythromycin, one of the reliable old workhorses, I decided.
But, Mr. Miah had diabetes. Every doctor knows that infections can be more serious in diabetics, so I reconsidered my erythromycin decision. Perhaps I should give him the stronger antibiotics, despite the cost. But he was a young, healthy man, with a normal vital signs and no signs of a serious infection.
I stuck with my decision to prescribe erythromycin. It was 4 p.m., and I sent him for a stat chest X-ray before the radiology department closed. I’d heard crackles on his lung exam, and I thought it would be worthwhile to see what was on the X-ray, even though I probably wouldn’t change my antibiotic decision based on the results. Of course the X-ray result wasn’t ready by the time I left that evening.
Tuesday. I called Mr. Miah at home and he said he was feeling better. Hurrah. My decision to prescribe erythromycin had been the right one. If the patient does well, then the judgment call was correct, right?
I checked my computer all day, but Mr. Miah’s chest X-ray remained “in progress.”
Second judgment call: should I leave work that evening without getting the results of the X-ray? Given that Mr. Miah was already clinically improving, it was hard to imagine that there would be anything on the X-ray that would change my management. And if there was something terrible there, he wouldn’t be feeling better after one day of erythromycin. Right?
I went home.
Wednesday. The X-ray report finally appeared on my computer screen. “Right-sided pleural effusion, but no obvious evidence of consolidation.” That is, a fluid collection, but no consolidating pneumonia. Hmm I would have expected to see a consolidation, not fluid, for a typical pneumonia.
Had I made the right decision about the antibiotics? I reminded myself that the No. 1 cause of a fluid collection is, in fact, pneumonia, so the X-ray was still consistent with the clinical picture. And the patient was getting better on antibiotics, so the fluid was probably from his pneumonia.
Had I been remiss, I wondered, in waiting two days to obtain the X-ray results? The patient was clinically improving – that was the most important thing. Knowing that there was fluid instead of a consolidation wouldn’t change anything, as long as he was getting better. But if it were a very large fluid collection, it would need to be drained. However, if it were such a large fluid collection, he wouldn’t be getting better. Right?
It was already after 5 p.m. and the radiology department was closed. Tomorrow I would physically track down the X-ray and look at it myself.
Thursday. My top priority was to get my hands on the X-ray. and look at it. Then I would call Mr. Miah to see how he was doing. I checked my voice-mail, and there was a message from him saying that he was feeling worse and was on his way to the clinic.
Now I second-guessed all my previous decisions. Had I done everything completely wrong? Had I been too cavalier about the antibiotic and the X-ray?
I raced down to Radiology and extracted the X-ray from the morass of files. Thrusting it up against the light-box I could see there was a little fluid around the right lung, but not too much. I probably wouldn’t have rushed to drain it in someone with ordinary pneumonia. He did have ordinary pneumonia – I was still sure of that: he was a young, healthy guy who didn’t smoke, didn’t have HIV and his diabetes was mild.
Mr. Miah arrived and I was relieved to see he wasn’t doubled over or gasping for breath, though he did look like someone who had the flu. Even though he’d felt better on Tuesday, he told me, his fever had gone up to 103.7 on Wednesday.”
103.7? My heart sunk.
But the pain had lessened, he informed me; he was able to take deeper breaths and cough without wincing. His temperature this morning was 101.
Maybe he had turned the corner, I thought. Maybe my judgments had all been correct.
I sent Mr. Miah for another chest X-ray, and I had him wait while I took the X-ray, by hand, to show to a radiologist. Only the bone radiologist was available, so I gave her the chest X-ray. She was concerned that the fluid had now partially solidified, and might be holding a pocket of pus. That would require admission to the hospital for a chest tube to be inserted. She told me that I’d need a CT scan to figure this out. Given the vagaries of a city hospital, it could take up to two weeks to obtain an outpatient CT, but if I admitted him to the hospital, he would get the scan tomorrow.
Other than the fever, Mr. Miah appeared relatively well – certainly not like someone who was about to clinically decompensate.’ He didn’t even look sick enough to be admitted to the hospital; it was only the X-ray that looked worse.
Final judgment call: should I just admit him to the hospital immediately? Obviously, it would be the safest thing — and it would certainly ‘cover me.’ But did Mr. Miah truly need it? Since Monday, he had gotten a bit worse, but now was feeling a bit better.
Hospitalization is not a benign thing– there are risks of getting sick from other patients, infected IV lines, blood clots from lying in bed all day. And it would be a severe disruption for Mr. Miah’s family and job. Not to mention the $10,000 bill at the end of it all.
Luckily, Mr. Miah made the decision for me: he didn’t want to stay in the hospital. Of course, I could have applied all of my powers of persuasion to make him stay, but I wasn’t so convinced that he really needed this. I gave him my beeper number and a prescription for a stronger antibiotic. We scheduled the soonest outpatient CT scan for next week. “I will call you tomorrow, Friday morning,” I said, “but feel free to page me if you get worse.”
Friday. It’s 11:45 a.m. Noon is the time I set for myself to call Mr. Miah, but I’ve decided that I need to write down this story before I know the outcome. I want to think about my judgment calls without knowing the result.
All of medicine is probability. If 80% of people with ordinary pneumonia get better on erythromycin and Mr. Miah turns out not to be one of them, does it mean that my decision was wrong? If I call Mr. Miah and he feels fine, would my decision, then, have been the right thing?
I wonder, though, if the outcome is truly relevant. Obviously, in cases of utter negligence or gross error it is important, but what about in the gray areas of everyday medicine? Could a decision about whether I made good or bad judgments in this case be rendered in the absence of knowing the outcome? Can a judgment call stand on its own legs, irrespective of the consequences?
As I am writing, my beeper goes off and my heart lurches into a frenzy. I am sure it is news that Mr. Miah is intubated in the ICU. I chew down my breaths as I wait for the maddeningly slow operator to transfer my call. But it’s a colleague who only wants to know if I can give a lecture to the interns next week. I say yes and slowly exhale.
It’s noon. I dial Mr. Miah’s number with jittering fingers.
And now it’s finally done. I’ve called, we’ve spoken – the suspense is over.
What, you want me to tell you what happened?
No. You’ll have to make your judgment without knowing the outcome. I wouldn’t want to bias you. (from the Los Angeles Times)