The hardest thing in Medicine today

I can’t imagine how difficult it was to practice medicine in the “dark ages”. I would feel helpless.

In the pre-antibiotics era, I can’t imagine how difficult it was to care for a patient with an infection.  Without rapid high fidelity imaging, I wouldn’t know how to manage patients with acute abdomens, strokes and many other conditions. 

There’s a lot modern medicine affords us that we take for granted. With relative ease, I can prescribe potent antibiotics and order expensive imaging without putting much thought into it. Such cavalier “easy” medicine would seem unfathomable to our physician forefathers and our current colleagues who struggle caring for patients in the 3rd world. 

Recently, in our office one of our bright conscientious resident physicians discussed a case about an elderly demented patient whom he suspected had pneumonia.  He wasn’t sure the patient had pneumonia because the history and physical exam wasn’t convincing. Because the patient was frail and elderly, and the diagnosis was uncertain, he wanted to send him to the hospital for further diagnostics, monitoring and management. An ER visit would guarantee blood work, imaging, IV antibiotics, an admission to our medical service and more importantly a clear conscious. In my opinion this was the easy way out. 

After discussing a few academic issues related to risk benefit ratio of the different ways we could have managed this case and also taking into account patient and family preference, we decided to send the patient home with an attempt to manage him as an outpatient. 

I explained to the resident, who is extremely intelligent, compassionate but also lacked confidence (understandable for a trainee) the easiest thing in medicine today, is to do. It’s very easy to do anything or everything. But he didn’t go through years of education and training, to make easy decisions. As doctors we are counted on to help make the difficult decisions. In modern medicine, the difficult decisions are not related to what we can or should do. The hardest thing in medicine today is the decision to do less, or sometimes nothing at all. 


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