Prersonal view: going around in circles -- circuitous medical management plans.

Abstract

Physicians occasionally embark on a work-up that, after a lengthy path, leads them to a clinical situation similar to that from which they started their original pursuit. This article aims to describe the characteristics of circular medical management and means for its avoidance. The underlying medical problem often presents itself initially as a bewildering array of consecutive outcomes similar to a complex decision tree. On closer inspection, however, few of the outcomes are associated with a high probability, and only one path stands out as the most likely one to take. This path usually ends in such options as expectant management, supportive measures or doing nothing, which are already available at the onset of work-up. If medical management is drawn out and takes a long time to complete, sight of its circular nature is easily lost. If many different specialists care for a patient, little appreciation for circular paths occurs. A prospective outline of the management plan and the elimination of paths with low a priori probability can help to prevent unnecessary medical interventions. The physician may then come to realize that standing still and waiting become as effective and less costly than a lengthy circular work-up.