When Physicians' and Patients' Perspectives Differ

A 42-year-old woman came in to see me recently complaining of some mild diffuse abdominal pain that coincided with constipation over the last couple of weeks. She had been completely symptom free before that point, and lacked any alarm signs that would suggest a serious medical condition.

“My sister has a friend who developed constipation and it was because of a large tumor in her colon. I am so worried about cancer that I haven’t been able to sleep for the last few days. I would like a colonoscopy to sort through this.”

In my medical opinion, there was no reason for a colonoscopy, but this was by far most likely simple constipation that could easily be resolved with laxatives and/or increased water and fiber intake. But it brings up a point that we experience nearly every day: How do we (should we?) handle patients who use anecdotal evidence to jump to unlikely conclusions?

It’s important to remember how we are trained to think versus how the typical person thinks. To this woman who heard a story of colon cancer, she thought this very likely could mean the same for her based on “similar” symptoms. From our perspective, the N of 1 for an unlikely outcome means almost nothing. But this is how people tend to think and approach problems - anecdotally, with personal stories.

As physicians, we have been taught to look at population-based studies to influence our decision making. We will look for sample size and power to ensure that enough people of the appropriate demographic and variable risk are included in order to ascertain a valid outcome. Oftentimes thousands of people included in a study are not enough to fit the need for a study.

We also tend to think in a probabilistic manner. Based on the history and exam that I performed on my patient with constipation, I may assign roughly a 90 percent chance of standard constipation without any complications, and maybe about a 1 percent chance or less of a malignant colonic mass.

The odds are strongly against anything serious, but at what point would you consider a colonoscopy? What if you determined a roughly 5 percent chance of cancer, is that enough for a colonoscopy? Ten percent? Would it need to be more? These are difficult questions and require patient input, as well as oftentimes input from other physicians.

Because of this, when we hear from a patient these anecdotal stories of one person, we are not too inclined to believe it and may then discount the patient and possibly our relationship with him. The trick comes in properly communicating our thoughts to the patient while keeping in mind his concerns spurred on by the anecdotal story. Specifically stating that this is what we think and why tends to go a long way toward understanding.

As we all know, sometimes this isn’t enough and the patient continues to request a test that is not indicated. This is obviously treacherous territory. Compromise is often needed with the hopes of not wasting resources and putting the patient in danger. Risks and benefits need a serious discussion to hopefully ensure the patient will be willing to follow evidenced-based recommendations.

Is there enough time in our brief visits to have such discussions? Not always, which tends to lead to dissatisfaction, and even malpractice suits. Hopefully newly recommended payment models based on value will assist in improving this problem, but that is yet to be determined.

One of the most crucial aspects of patient relationships is understanding the different ways in which we have been taught to think as compared to how patients tend to think about medical problems. This awareness will lead to much improved care and relationships with patients.