Treat the Patient Not the Number – A Short, Nuanced Perspective on a Traditional Teaching

 

 

 

 

Traditional clinical teaching tells us to treat the patient, not the number. 

At face value, you could interpret this old teaching as “only treat if there are symptoms”. When applying this teaching, we should include some nuance, namely see how the number fits into the big picture.

Good examples include abnormalities in asymptomatic patients that may not be causing a problem right now, but have consequences in the future. Such abnormalities could include: 

• Elevated Hemoglobin A1c 

• Decreased glomerular filtration rate 

• Elevated blood pressure

In an asymptomatic patient, these types of measures are analogous to someone walking towards a cliff’s edge. They are not falling yet. However, the closer they get to the edge the more at risk they are of falling.

When you take the big picture into account, you understand “the number” in the context of the overall, clinical situation. So what is this big picture then? The big picture includes information from the history, physical exam, test results, response to treatment, etc. These are like pieces of a puzzle that fit together  to make the big picture     

Without this greater context, ”the number” can have many different meanings, and can lead you down many, different paths.

You can certainly treat “the number”, but you should do so as part of the big picture that is the patient. 

If you are interested in this and further topics regarding clinical decision making, please check out my book: A Guide to Clinical Decision Making 

 

 

All Your Tests Are Negative. Now What? - A Lesson On Thinking A Step Ahead

You’ve ordered a slew of tests for your patient. You hope that one of them comes back positive, giving you guidance for the next step in the patient's care. However, your tests all come back negative, leaving you wondering what to do next.

This is a common scenario whether you work inpatient, outpatient, or a combination of both.

Most of the time, it’s easy to know what to do if the tests are positive. It’s much harder to decide what to do if the tests are negative.

We cannot discuss every single scenario, but it’s important to bring up the following concept:

When you order a test, consider what you will do if the result is negative.

Do this and you find yourself one step ahead in many clinical scenarios.

Ask yourself questions like:

·         Should I expand my differential diagnosis?

o   If so, what other diagnoses should I check for?

o   If not, am I sure that I have enough information to proceed with treatment?

·         If I need more information, how will I get it?

o   More tests? more History? More physical exams?

Experienced physicians often get to the point that they internalize these processes. However, even experienced physicians can still get stuck when they unexpectedly get negative test results. To be more ready to adapt to these situations, it is good practice for all physicians, from brand new to well-seasoned, to  explicitly ask themselves what their next step will be if the tests they order are negative.

Clinical practice is a tricky thing, and events do not follow the textbooks and guidelines. If you think a step ahead and plan out the next steps for when your tests are negative, you will be more ready when your tests results are unexpectedly negative.

If you are interested in learning more about this and other topics in clinical decision making, check out my book A Guide to Clinical Decision Making.