When doctors don't see eye to eye

Parikh, a Walnut Creek, Calif., physician, writes the Vital Signs medical column for salon.com.

I was more than a little concerned about Pete, age 11. His mother had brought him to see me one Friday afternoon; he was limping and complaining about a few days of bad ankle pain.

Examining him, I found that his left ankle was tender, swollen and warm, but he hadn't remembered injuring it. I ordered an X-ray and blood work, trying to ascertain whether he had developed septic arthritis -- an infection deep in his ankle joint -- the worst-case scenario.

An hour later, I looked at the X-ray (which showed no fracture) and his lab results. The complete blood count didn't show an elevation in his infection-fighting white blood cells; it was normal, in fact. But another test that helps mark inflammation -- called an erythrocyte sedimentation rate -- was moderately elevated.

I had done what I could at my end, so I called one of my colleagues, a surgeon. I asked him to do an arthrocentesis -- put a needle in the ankle and get a sample of the suspicious fluid causing the swelling.

Later that evening, I received a short message from the surgeon. Yes, he had seen the patient. But, no, he hadn't performed the procedure. Instead, he sent Pete and his mother home with a plan to see him again in two days.

I was concerned, but it was too late for me to contact the surgeon to ask him what he had been thinking. I called Pete's mom with strict instructions: If he gets worse, see a doctor -- day or night.

The following Monday, Pete's mother left me a message: He was being admitted to the hospital and was going to need surgery to open and clean out his ankle. He, indeed, had septic arthritis and would end up spending the better part of that week in the hospital receiving intravenous antibiotics.

Two days of waiting had, at best, only delayed the inevitable and, at worst, would leave Pete's ankle more mangled than it would have been had the surgeon gone ahead with the procedure. I wondered what would have happened if that surgeon had said to come back in three to five days instead of two. Would Pete still have had a foot to walk on?

Disagreements between doctors happen much more often than we care to admit to our patients.

"No colleague will accuse by name another either of ignorance, malpractice, or an ignominious crime . . . ," states the 17th century statutes of the Royal College of Physicians of London. It's an ancient rule that has been perpetuated into the 21st century. We assume that openly disagreeing with colleagues will destroy our patients' confidence in us.

Still, there are legitimate reasons for disagreement.

Clear medical decision-making is often blurred by a variety of factors, including discrepancies in what a patient tells the doctor, how test results are determined and even economic pressures. Two doctors may get histories from a patient that emphasize different symptoms or events. That may be enough to drive each doctor to make different decisions.

There can also be a great deal of variation in how doctors interpret findings. A recent University of Virginia study had emergency room doctors review several hundred electrocardiograms (EKGs) looking for signs of a heart attack to see how often the physicians agreed on diagnoses. It turns out that doctors disagreed on nearly a third of all the EKGs they reviewed.

Medical economics plays a role in why we disagree as well. In an ethics case published in Canadian Family Physician in 2006, a patient was admitted to the hospital with a kidney infection. After she was treated with intravenous antibiotics for two days, her fever was gone and she was able to drink fluids, though she continued to have back pain and occasional vomiting. The resident taking care of the patient pushed for discharge; the cost of keeping her would have added up, and discharging her would have freed up a hospital bed. The patient's primary-care doctor, worried about the vomiting and pain, advocated that she stay longer.

So if we disagree more than we admit, how do most of us work it out? We don't. Too many times, we tolerate it, condone it and we fake that we're in control.

Having initially been upset the way the surgeon handled Pete's case, I could have taken some action. As medicine comes under more pressure to improve quality and reduce errors, there are more formal ways to handle major disagreements between doctors. I could have asked for a third opinion, for example, by paging the surgeon on call and having Pete come to the ER. After we knew Pete's diagnosis, I could have referred his case to a committee of the surgeon's peers to review it and determine whether he mismanaged Pete.

On the other hand, does it have to come to that? Maybe if we stopped trying to brush our disagreements under the carpet, and openly discussed them with each other, we could solve them on the spot. Better yet, we could stop hiding our differences from our patients and instead tell them we have an honest disagreement that we'll work out. It's hard for me to believe that anybody still views doctors as infallible, so why are we trying to perpetuate that myth?

In retrospect, given all the inconsistencies of Pete's case, I've come to believe that the surgeon did what he thought was best. Pete didn't have a fever, that harbinger of infection. His blood work suggested inflammation in the joint, but it certainly wasn't impressive enough to make us certain of anything. In the surgeon's mind, the decision on whether to test further came down to weighing the risks of a not-entirely-benign procedure against watching him. The surgeon also had a clear plan of action for Pete: See him again -- and take further measures if he wasn't better in 48 hours. Most important, he sensed what I did: that Pete's mother was reliable and would bring her son back.

Monday-morning quarterbacking isn't easy in medicine. There are obvious cases of right and wrong, but most disagreements settle somewhere into a large, nebulous zone of uncertainty. We can't always cite studies or order tests. And despite what you may see on an episode of "House," those "a-ha" moments are all too rare. Thus, the art of medicine -- we rely on our instincts, feelings and luck to guide us through ambiguity. And we hope, in the end, that it works out. As it did for Pete, who went home in great shape.

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www.rahulkparikh.com.

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