Judgment

“Today, Jaded Julie, we’re going to talk about judgment.”

“You mean Judgment Day like in church with singin’, shoutin’, and wavin’ my arms?”

“No Julie, I mean personal and professional judgment, as in making important decisions. Consider a veterinarian who specializes in small animals. Her good judgment tells her not to go out to a farm to treat a sick draft horse.”

“How about some examples in human health care, Curmudge? I bet that’s where you were heading all along.”

“Let’s start with primary care and the ED. Most of the illnesses and injuries that patients come in with are low acuity. As they say in the ED, ‘treat and street.’ In these situations, mid-level providers like NPs or PAs are just what the patients need. I have a physician friend who is delighted with the NPs in her practice. She says they can do 90% of what a physician does.”

“That’s great, Curmudge, but where does judgment enter the story?”

“It’s the other 10%, Julie. It’s the NP’s judgment of when the patient needs to be seen by a physician. Of course she is limited by her license and state regulations, but I would favor good judgment any day.”

“Some people call NPs and PAs ‘physician extenders,’ but that sounds demeaning. ‘Advanced practice’ or ‘mid-level’ are more appropriate terms.”

“It isn’t just the NPs who need good judgment. The primary care physician needs to judge when a specialist must be consulted, and sometimes the specialist determines that the patient should see a subspecialist. In rare cases the patient must go to a world-class medical center for diagnosis and treatment. Excellent judgment by the providers and the patient is critical at each step along this pathway. If the patient has compelling concerns about her diagnosis and proposed treatment, she should seek a second opinion.”

“But Curmudge, doesn’t the patient stop when she reaches a physician whose credentials match her illness?”

“Ah, Jaded Julie, here is where judgment enters the picture big time. Credentialing cannot guarantee the best of all possible outcomes for every patient. I would personally have reservations about a provider who might be near the lower limit in relevant experience and would want to push the envelope of his proficiency. Examples of this have appeared in recent news articles about poor outcomes from robotic-assisted surgery, presumably performed by physicians with inadequate experience with the specific device.”

“So who makes the judgment about the best path forward for the patient?”

“The patient does, but not without help. She should go back to her primary care physician—hopefully in a medical home where she is well known—and review her diagnosis, proposed plan of care, and provider. Of course, she can use her computer to find evaluations of hospitals in CheckPoint and physicians in HealthGrades. In addition, she should get advice from people she trusts, including retired health care professionals and their spouses. It seems that every senior has a health care story to tell; Ms. Patient should listen. After careful consideration and the best judgment she can muster, she should make her decision and proceed with confidence and faith.”

Affinity’s Kaizen Curmudgeon