When the Doctor Says "I Don't Know"

Q:  I have a comment and a question. It has been my experience that doctors always have a ready diagnosis of a problem when you first see them, and then, if that diagnosis proves wrong, they give up. For example, I have been to five different doctors (family, dermatologist, eye (2) and otolaryngology) for my problem. Each told me a diagnosis but wanted it confirmed with a biopsy, blood test or CT scan, and each time this follow-up investigation proved the diagnosis wrong. Then they gave up.

One doctor actually said to me, "Maybe if I were smarter, I could figure this out, but I can't." This has obviously cost me and my insurance company thousands of dollars and lots of time, and we have absolutely nothing to show for it.

Don't doctors collaborate anymore? Shouldn't they say, "I'll ask a few of my colleagues about this," or, "Let me read up on this and check for the latest information"? It seems that if an individual doctor today does not have the answer, it is up to the patient to find someone who does. What training are doctors given regarding this?

A:  First, many times, specialists, especially when consulted for a second opinion, anticipate that their role will be an initial evaluation (hearing your story, a physical examination and tests), possibly a procedure (such as surgery) and then follow-up specific to a focused medical problem.

On the other hand, generalists, such as your family physician, anticipate many repeat visits about the same or different problems. When the clinical situation calls for a different role, such as a specialist repeating a comprehensive evaluation, it's harder to do because it's not routine. (The specialist may not be practiced at it, the clinical schedule may not allow time for it, and insurance companies may not easily reimburse for it.)

Second, I think doctors do collaborate. I know I often bring a colleague to my clinic room when I don't know how to interpret a physical finding or I stop a subspecialist in the hall to chat about a clinical dilemma. I'm sure I'm not alone in this. I send letters to specialists I refer to, and more often, specialists send me letters about patients I referred.

As an educator at the Medical College of Wisconsin, I can also tell you there is a new effort at all levels of medical education to teach collaboration. The Accreditation Council of Graduate Medical Education wants all doctors to be team players, understand health care systems and practice patient-centered care, and so it only accredits training programs that demonstrate they teach these things.

The truth is that there are still many parts of medicine that all doctors, including "Milwaukee's Best," still don't understand. Your doctor who admitted he couldn't figure out a treatment for your problem was being honest. And I don't think he said it lightly, I think he said it knowing that he had exhausted his options (i.e., reviewing the literature and consulting colleagues). I bet he also intended his comment to reassure you, hoping you'd see that he takes you seriously, and although he wasn't able to diagnose the problem, he knew at least it wasn't anything to worry about.

What doctors frequently do poorly and do not receive good training in is continued management of the enigmatic complaint. It's easy to think, "I don't know what's going on with this patient, but I know it's not serious" - and then brush it off. Patients often need to know that doctors will continue to help them, even if they don't have all the answers.

Julie L. Mitchell, MD, MS, is an Assistant Professor of Medicine at the Medical College of Wisconsin. She practices internal medicine at the Froedtert & Medical College General Internal Medicine Clinic - East. Her column appears in the Milwaukee Journal-Sentinel.