The Trouble with Disagreements in Medical Diagnosis

Lately I’ve run into a number of cases in which two providers have a difference of opinion on the right treatment for a patient and the patient is caught in the middle, wondering who to trust. As physicians, we recognize that there are many gray areas in medicine in which great doctors can disagree. Evidence-based medicine doesn’t cover all (or even most) areas of medicine which keeps doctoring a skill that requires knowledge, skill, and creativity. Additionally, even when evidence exists, it can be interpreted in many ways.

However, it is difficult to explain this to patients. There is a degree of comfort in certainty, so when a doctor confidently declares the diagnosis and treatment plan, patients often assume that truth has been proclaimed. When a second doctor changes the diagnosis or the treatment plan, a patient can be left wondering about the competence or knowledge of the first physician. We are not always good at informing our patients that sometimes there is no “right” answer, but rather a multitude of possible answers. Sometimes, we neglect to mention that some diseases declare themselves with time, which can make all the difference between a suspected and confirmed diagnosis. Finally, physicians can inadvertently throw a colleague under the figurative bus by arriving at the correct diagnosis which eluded a previous physician. They fail to acknowledge that the diagnostic investigation and failed treatment undertaken by the first physician were the building blocks upon which the final diagnosis is found. And, of course, there are legitimate disagreements that fail to reach a conclusion.

Medicine traditionally is viewed as a field in which the expert (the doctor) pronounces a diagnosis with certainty and uses his vast knowledge to arrive at the single appropriate plan of care. Since medicine does not actually operate that way, save for a few conditions such as strep throat or poison ivy, patients can easily become alarmed by the seeming lack of expertise with which they are confronted. So, our challenge as good doctors and good colleagues, is to support each other’s opinions, ideas, and thoughts without feeling obligated to continue a treatment plan we do not support. Interestingly, we, as a profession, have historically had a very difficult time policing ourselves and bringing bad doctoring to light, even as we struggle to explain that while we may disagree with a colleague, both approaches can be considered reasonable.

It is a tricky balance to reassure a patient by providing a clear explanation of the suspected diagnosis and proposed plan of care, while also disclosing that medicine is an inexact science with many competing ideas, opinions, and even conflicting evidence. However, our failure to do so undermines patients’ care by introducing confusion, distrust, and fear.