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The Second Opinion

Sep 27, 2017
by Dr. Michael Trapani

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Let’s imagine for a moment that you are the smartest human being who ever lived. Imagine that you are a student, and a stellar learner, who soaks up information like mad, understands it, and commits it all to virtually perfect memory. Imagine that you take a immensely difficult final examination ten times a day, five days a week, week after week, and you consistently get 99 out of 100 questions right on every test.

You’re amazing! You’re beyond A+.Your performance is super-human! No one could ever be asked, or expected, to achieve such a phenomenal accomplishment. Yet stunningly, you do it, week after week after week. O. M. G! And every week, you make 50 mistakes. Uh-Oh! Now imagine you’re not a student anymore. You’re a doctor. And any one of those mistakes can be life threatening, even life ending. You’re not so super-human now, are you Bub?

Let’s play again: Let’s imagine that you have all of your knowledge available to you in a book that you keep on your nightstand. Just for fun, we’ll give it a title. How about “Googol”? Everything you’ve ever known is right there in the book and you can pick it up and think about anything you have ever thought because it’s all right there.

But you can’t think about the knowledge that sits on your stove in the kitchen, or gathers dust on a shelf in your garage, and you certainly can’t think about the knowledge written in your neighbor’s book - the one that sits on a different nightstand just next door. None of that stuff is in your book.

What to do? No one, however brilliant, can ever achieve perfect understanding or perfect memory. No human mind, however capable or broad, can ever contain all possible knowledge or synthesis. We are, all of us, limited and imperfect.

But when lives are at stake, limitation and imperfection are not acceptable. Yeah, it’s the human condition, but so what? Surely, there must be a way to cook the books and beat the system.

It’s really not that difficult. Let’s imagine that we have 50 amazing students taking 50 tests each every week and making 50 mistakes each. What are the chances they’re all go-ing to make the same 50 mistakes? Pretty much zero. The same goes for books of knowledge: Even when the books are 99% identical, the other 1% of the knowledge they contain is different, and that’s the difference that beats the odds.

When you have a problem that seems impossible to solve, seek help from another mind.

I do a fair number of second opinions. It’s not that the other doctors are in any way inadequate, it’s just that no one mind can possibly contain all knowledge or recognize all possibilities. When reviewing a case, I look at the assumptions that have been made (because we all make assumptions) and I ask whether those assumptions are necessarily true, and what it might mean if they were not. I look at what has been done, and try to identify what has not been done (because there are holes in the knowledge of every case) and consider whether there is benefit to be had from filling in those gaps in knowledge. Most of all, I look at what has been tried and did not work, trying to discern the thing by look-ing at the shadow of the thing.

When the patient has a problem that is known and the second opinion concerns how to best manage that problem, I consider patient factors and whether they support the “con-ventional wisdom” or not. The most difficult recommendation to make is “do nothing,” but nothing is sometimes the very best choice. Often, the solution to these problems lies in reconsideration of the problem itself. For example, an arthritic patient has problems moving around, not because of their arthritis, but because of their pain.

What do I do when I have a problem patient whose troubles defy understanding or resolution? First, I forget everything I think I know about them and give myself a second opinion. If that doesn’t shed new light on the trouble (and generate better results), I send them to someone else - another mind with different eyes to see the trouble, a different mind to consider what is best, and a different skill set to provide new options to make that patient better.

The old saying is wrong: Every man is an island. By understanding that no one person can see everything, know everything, or think of every possibility, we open the door to others who might help when we cannot.

The Family Pet by Dr. Michael Trapani

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