We all use heuristics in medicine—shortcuts that help us get where we're going. A master of the heuristic was Yogi Berra, the great Baseball Hall of Famer and quipster. Below are a few of his adages that, looked at a certain way, have clinical applicability. His characteristic "Berra-isms" speak perfectly to the situations we clinicians find ourselves in daily, in our efforts to diagnose and treat patients in a world every bit as prone to mishap and serendipity as baseball.
When You Come to a Fork in the Road, Take It
Indecision is a plague in clinical medicine. We order tests and imaging in order to advance our understanding and direct our management. If we look at results and they do not point to a clear differential diagnosis, then we may end up in a cycle of testing and be no better off than we were at the beginning.
For example, vague interpretations of results may occur in radiology or pathology. Such phrases as "clinical correlation is recommended," or the instruction to order a repeat film or other imaging studies "if indicated," are sometimes the beginning of a road to nowhere: recommending a CT if an MRI was done, an MRI if a CT was performed, or an ultrasound if both CT and MRI were done. Granted, some findings are ambiguous (eg, artifact vs pathologic), but lack of clarity and commitment is not helpful to a clinician. Physicians, including radiologists and pathologists, should be willing to put their money down and offer an expert opinion; waffling is costly and wasteful and increases the chance of error.
I have ordered tests to image a cystic lesion in the kidney with the hope of determining whether the patient had a benign or simple cyst or, instead, a malignant cyst. I have also read reports where detailed findings were repeated verbatim in the impression section, avoiding an interpretation that would have clearly stated a diagnosis and recommendations for follow-up.
By contrast, a good interpretation can make all the difference. A patient of mine had agreed to a kidney biopsy because she wanted to know whether she had a hereditary disease, but unfortunately, the biopsy was complicated by bleeding, and in the specimen sent for electron microscopy, only half a glomerulus was sampled. To my great relief, however, this was not a nondiagnostic biopsy. The pathologist took that one half of a glomerulus and gave his impression: After performing morphometrics, he determined that it had a thin basement membrane consistent with hereditary nephritis. Thus, although I had a poor sample, I had a good pathologist.
An expert consultant should be clear in recommendations to a referring physician. For example, in a patient with acute kidney injury, providing such suggestions as "avoid nephrotoxic substances" or "would manage hyperkalemia" without giving specific recommendations amounts to stating the obvious more than being helpful. A good clinician is willing to make a decision and stand by it. Over time, it becomes apparent whether that clinician has good judgment—which is the best skill anyone could have.
Those forks in the road? Take them.
Medscape Nephrology © 2016 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: The Medical Wisdom of Yogi Berra - Medscape - Jan 05, 2016.