How well does an abnormal rectal examination help in diagnosing appendicitis? Does the presence or absence of exudate in a person with sore throat help in diagnosing a strep throat infection? In this issue, Gilbert et al (p 37) guide us through a clear approach to clinical reasoning, starting with a child who presents with fever and a petechial rash but who appears otherwise well. The authors ask how reliable is the observation that the child looks well? They then walk us through a practical step-by-step approach to answering the question. Applying their approach to our clinical thinking not only can help us become better clinicians, but it will go a long way toward decreasing unnecessary testing and the resulting health care costs. But the process takes time and depends on the ability to ask clear questions that can be used to search the literature. Then it depends on the clinician taking the time to pull the articles, read them, and digest their recommendations. All the while, the patient is sitting and waiting—and other patients not yet seen are sitting and waiting. What we need are reliable, searchable databases of predigested information that can be accessed while the patient is in the office. Until that time, Gilbert et al's approach teaches us how in an ideal world we can arrive at the best diagnostic plans for our patients.
Once we arrive at a diagnosis, how can we help our patients make the best, most appropriate treatment decision based on their own values? In the first of a 2-part series, Heller et al (p 35) describe what information an otherwise healthy person with a moderately elevated cholesterol level might need to decide whether to begin pharmacotherapy. This simple, easy-to-understand example pits the “proven” benefit of cholesterol reduction against data that allows the patient to understand the magnitude of benefit and the costs—both actual and theoretical.
Once diagnosed, our patients depend on us to help them pick the best treatment plan. Too often, the “best” treatment plan needs to be altered, not by scientific information but by the realities of economics. Becker (p 19) provides sound data suggesting that being uninsured leads to poorer control of chronic illnesses. Although this may not be shocking, it reminds us that in the country with the best medical care in the world, millions lack access to simple interventions that have proven benefit. Further, simple interventions provided by primary care physicians (beta blockers, anticoagulants, asthma medications, and the like) not only can improve the quality of life but can extend life at little or no cost relative to the costs of untreated illness, which results in costly interventions and hospitalizations.