Page 4 - Mecklenburg_Medicine_July-August-2017

President’s Letter

The Art of Restraint

By Stephen J. Ezzo, MD

W e live in a world of excess. “You want fries with and function. Early on in physical therapy he complained of knee
that?” “How about making that a combo meal?” pain (hey, I am 34 years younger and my knees hurt after a day of
“We have three sizes of beverages: large, extra- bending down to examine children), with no external findings. This
large and gargantuan, where we put a nozzle in triggered a new cascade: X-ray, ultrasound, Doppler and consultation
your mouth and pour until you are filled.” with a vascular surgeon, who had the good sense to leave alone
an asymptomatic popliteal aneurysm that was probably decades
We also reside in a world where deviation from, and embellishment old. He was cleared to return to PT after missing several sessions.
Side note: The care he received everywhere was professional and
of, the standard is au courant. Consider our national anthem. How compassionate. His physicians promptly returned my calls and texts,
and the therapists fell under his charm like everyone else. He’s back
often do we hear versions with over-extended syllables and even home now, continuing PT, getting stronger and gaining weight. We
are fortunate we can keep both my parents in the home they have had
the musical notes being changed? (Now, before you chalk this up to for more than 50 years. A silver lining in the end was out there — the
path to it, though, had numerous switchbacks.
just another of my patented rants, this time against artistic license,
The art of making a diagnosis includes hundreds of options we
know this: My CD collection includes a Bluegrass Beatles, as well as have at our fingertips. Oftentimes, a good history and a physical exam
are all that are needed. One of my medical school professors who
Michael Bolton, whose style never has been confused with subtlety, taught physical diagnosis was fond of saying in his heavy German
accent, “Listen to zee patient! He eez telling you zee diagnozees!” We
swinging Sinatra tunes.) Still, some things should remain sacrosanct. have to factor our confidence, not just in our own knowledge, but also
our ability to allay the concerns and fears of our patients.
I have nothing against excess/embellishment, as long as it is done
We must ask ourselves: Will the test(s) we order change our
in moderation. The problem is, the opportunity to go overboard approach and treatment plan? (Do I really need to know what virus is
causing this respiratory illness?) Will performing a test inadvertently
is everywhere, and lead to more angst from the patient? Is there potential harm to the
patient in ordering tests? (Radiation exposure, for example, is not to
The opportunity to go if you are like Oscar be taken lightly.) Are we afraid of missing something that could have
overboard is everywhere, Wilde in that you can both medical and legal consequences?
resist everything but
We will answer these questions differently, depending on our style,
and if you are like Oscar temptation, then issues our training, our experience and our relationship with each patient.
Wilde in that you can can arise. But these are important questions to ask.

This dilemma extends Remember, less care is not equivalent to bad care.

resist everything but into the practice of “Restraint and discipline are examples of virtue and justice.
temptation, then issues medicine. Technology These are the things that form the education of the world.”
has provided us with
— Edmund Burke
can arise. the ability to measure
almost anything Trivia question: The fourth oldest medical school in the country is
named after a doctor who never treated patients but made millions
contained in our body’s of children and adults feel better. After whom was the school
named? Answer on page 8.
humors. Likewise, we seemingly can image the internal organs six

ways to Sunday. As our options multiply, so does the need to choose

our care course with prudence.

We know the old saying about never ordering a test of which

the result we do not want to know, lest it unleash a cascade of

more testing that leads us further and further away from our initial

diagnostic task. Another pitfall we encounter is going against

our better judgement of close observation in exchange for tests to

reassure us.

Let me give you a close-to-home example. Several months ago,

my father was admitted to the hospital for a presumed pneumonia,

following a solitary episode of coughing/spitting up some blood-

tinged mucus, which most likely was post-nasal drainage from his

chronic allergic rhinitis. The CXR was inconclusive, the white count

neither here nor there. During his hospital course, he never coughed,

ran a fever, needed oxygen or had any resemblance of respiratory

difficulty. The uncertainty of the CXR led to a pulmonary consult

and CT of the chest, which showed nothing, including pneumonia.

While that was reassuring, the unintended consequence of severely

limiting the mobility of a 91-year-old man resulted in a transfer

to a rehab facility upon discharge, in hopes of regaining strength

4 | July/August 2017 • Mecklenburg Medicine