How can a family physician send home from clinic an 18-year-old woman who reports she’s been having chest pain? Couldn’t she be having a heart attack? Absolutely.
How can a family physician reassure a person with hand tingling and numbness without ordering any tests? Couldn’t this be a stroke? Of course.
From the results of our recently published study on the ways family physicians deliver better care at a lower cost than a multi-ologist approach, we next consider comfort with applying probabilities to individual patients.
All physicians, ologists included, know that it is extremely unlikely that an 18-year-old woman with chest pain who shows up to a clinic is having a heart attack. The issue isn’t one of knowledge, it’s one of psychology on the physicians part. It’s a difference in the culture of family medicine vs. the body part fields of what defines the best way to deal with this situation.
In our interviews, the family physicians actually expressed a lot of sympathy for the position the ologists were in. If a patient went to a nephrologist with a possibility of having kidney disease, the nephrologist felt obligated to absolutely prove beyond a shadow of a doubt whether the patient has kidney disease, and if so, what kind and how bad it was. Family physicians said they didn’t feel that pressure, either internally or from the larger society.
But I believe these differences in approaches relate also to the personalities of the physicians, not just societal pressure. Ologists are more prone to be Type A personalities, which is selected for and then reinforced in the medical school and ologist fellowship environment. This ties in to the ologists’ obsession with finding the zebra, or rare disease as the definition of professional success.
The larger question is what is the best approach for patients with rare likelihoods of bad disease, no matter which physician sees the patient? We’ll get into this issue more in the next post.