Practicing medicine in shades of gray

Mrs. Jones delivered several weeks ago and now presents with brief periods of shortness of breath. Could it be a pulmonary embolism?

Mr. Johnson has had odd paresthesias in all 4 extremities and occasionally feels like his vision is “off.” Hmm. Maybe MS?

Mr. Smith has a history of diabetes, heart failure, and COPD, and now complains that he feels “wobbly” and can’t walk properly. A vascular problem? Stroke?

These are just a few of the patients I have seen over the past several weeks who have given me cause for concern.

Mrs. Jones doesn’t have leg tenderness or swelling; her spells last for just a second or 2. Mr. Johnson is always anxious. Mr. Smith decided to stop all his pills because he thinks he’s overmedicated.

The students and residents want the evidence, the pretest probabilities, the black and the white. Yet all I see are shades of gray.

It’s hard to tell our learners that the decision point is often clinical instinct—part educated hunch, part experience, and part an instantaneous weighing of the evidence. That child with croup can go home safely, this patient with abdominal pain needs an urgent MRI, and another with chest pain needs a cardiac workup.

Most of us in family medicine become comfortable with uncertainty; we’re able to tolerate ambiguity. And while we may worry, we can move on to the next patient with only a modicum of concern. Indeed, the ability to accept uncertainty is often a deal breaker in weighing a career in primary care—as much if not more so than the desire for a controllable lifestyle or the promise of a Porsche in the garage.

We come to recognize that not every patient with angina is on the verge of an MI, and that labels such as “atypical chest pain” are shorthand for “I’m just not sure.”

I still don’t have a diagnosis for the patients whose cases I’ve described. For now, what I can tell you is that Mrs. Jones’ D-dimer is elevated but her CT-PA is normal; Mr. Johnson has decided to talk to his oncologist and defer further evaluation, and Mr. Smith—and I—are expectantly awaiting the results of his MRI.

It’s all in the life of a family physician.

Mrs. Jones delivered several weeks ago and now presents with brief periods of shortness of breath. Could it be a pulmonary embolism?

Mr. Johnson has had odd paresthesias in all 4 extremities and occasionally feels like his vision is “off.” Hmm. Maybe MS?

Mr. Smith has a history of diabetes, heart failure, and COPD, and now complains that he feels “wobbly” and can’t walk properly. A vascular problem? Stroke?

These are just a few of the patients I have seen over the past several weeks who have given me cause for concern.

Mrs. Jones doesn’t have leg tenderness or swelling; her spells last for just a second or 2. Mr. Johnson is always anxious. Mr. Smith decided to stop all his pills because he thinks he’s overmedicated.

The students and residents want the evidence, the pretest probabilities, the black and the white. Yet all I see are shades of gray.

It’s hard to tell our learners that the decision point is often clinical instinct—part educated hunch, part experience, and part an instantaneous weighing of the evidence. That child with croup can go home safely, this patient with abdominal pain needs an urgent MRI, and another with chest pain needs a cardiac workup.

Most of us in family medicine become comfortable with uncertainty; we’re able to tolerate ambiguity. And while we may worry, we can move on to the next patient with only a modicum of concern. Indeed, the ability to accept uncertainty is often a deal breaker in weighing a career in primary care—as much if not more so than the desire for a controllable lifestyle or the promise of a Porsche in the garage.

We come to recognize that not every patient with angina is on the verge of an MI, and that labels such as “atypical chest pain” are shorthand for “I’m just not sure.”

I still don’t have a diagnosis for the patients whose cases I’ve described. For now, what I can tell you is that Mrs. Jones’ D-dimer is elevated but her CT-PA is normal; Mr. Johnson has decided to talk to his oncologist and defer further evaluation, and Mr. Smith—and I—are expectantly awaiting the results of his MRI.

It’s all in the life of a family physician.

Mrs. Jones delivered several weeks ago and now presents with brief periods of shortness of breath. Could it be a pulmonary embolism?

Mr. Johnson has had odd paresthesias in all 4 extremities and occasionally feels like his vision is “off.” Hmm. Maybe MS?

Mr. Smith has a history of diabetes, heart failure, and COPD, and now complains that he feels “wobbly” and can’t walk properly. A vascular problem? Stroke?

These are just a few of the patients I have seen over the past several weeks who have given me cause for concern.

Mrs. Jones doesn’t have leg tenderness or swelling; her spells last for just a second or 2. Mr. Johnson is always anxious. Mr. Smith decided to stop all his pills because he thinks he’s overmedicated.

The students and residents want the evidence, the pretest probabilities, the black and the white. Yet all I see are shades of gray.

It’s hard to tell our learners that the decision point is often clinical instinct—part educated hunch, part experience, and part an instantaneous weighing of the evidence. That child with croup can go home safely, this patient with abdominal pain needs an urgent MRI, and another with chest pain needs a cardiac workup.

Most of us in family medicine become comfortable with uncertainty; we’re able to tolerate ambiguity. And while we may worry, we can move on to the next patient with only a modicum of concern. Indeed, the ability to accept uncertainty is often a deal breaker in weighing a career in primary care—as much if not more so than the desire for a controllable lifestyle or the promise of a Porsche in the garage.

We come to recognize that not every patient with angina is on the verge of an MI, and that labels such as “atypical chest pain” are shorthand for “I’m just not sure.”

I still don’t have a diagnosis for the patients whose cases I’ve described. For now, what I can tell you is that Mrs. Jones’ D-dimer is elevated but her CT-PA is normal; Mr. Johnson has decided to talk to his oncologist and defer further evaluation, and Mr. Smith—and I—are expectantly awaiting the results of his MRI.

It’s all in the life of a family physician.