In Reply…Credat Emptor

C ORRESPONDENCE In Reply. . .Credat Emptor Dr. Frei shines an important light on the potential ten- sion between the best interest of physicians and the best interest of our patients. And he is certainly right in suggesting that when these interests conﬂict, it is not surprising that we are tempted to put ourselves ﬁrst. In the case of ordering a test—no matter how “medically unnecessary” or potentially harmful to patients it may be—doing so is likely to have only potential beneﬁt to the ordering physician: we lessen our feelings of uncer- tainty, decrease the chance of blame that would come with “missing something,” and may even increase the amount we will be paid. 1 The only predictable potential for harm . . . is to some of our patients. This should remind us that the fundamental nature of a profession relates to an unwritten contract between its practitioners and the society that endows them enor- mous privilege—money, prestige, autonomy, and power —in return for an unspoken but central promise to put the interests of patients ﬁrst. We profess we have knowledge and skills that our society needs and that we will use such expertise in such a way that credat emptor (“let the buyer believe”). This is in stark contrast to the more familiar maxim of caveat emptor (“let the buyer beware”) that governs nonprofessional commercial interactions. 2 Patients offer us their trust, even when in their most vulnerable state; in exchange, our ﬁduciary relationship to them means that we promise to honor that trust. We are allowed to consider our own inter- ests, but as professionals we pledge that—if and when these interests conﬂict with those of our patients—we will put our patients ﬁrst. It is only human to look out for our personal inter- ests when inaction may do us harm. This is clearly rel- evant to test-ordering. As Dr. Frei articulates, there is little personal harm to the practitioner associated with getting a test. On the other hand, using clinical judg- ment and opting to forgo a test subjects us to risk if and when our judgment is faulty . . . as it will inevitably be, at least occasionally, for every one of us. Any potential solution to overtesting therefore must, as Dr. Frei suggests, address this psychological pressure ISSN 1069-6563 PII ISSN 1069-6563583 to test even when we believe that a study is not medi- cally indicated. But if we give in to this pressure, and overtest and overdiagnose and overtreat, we will inevitably cause important harm to some (small but real) subset of our patients. To the extent that our society recognizes we are violating our professionalism by putting our own needs ahead of those of our patients, we will ultimately lose the many privileges we now have. But that is not the reason to avoid unnecessary testing; the most important reason is because by doing so, we would voluntarily abandon the core nature of being a physician. doi: 10.1111/acem.12764 Hemal K. Kanzaria, MD, MSHPM (hemal.kanzaria@gmail.com) Department of Emergency Medicine San Francisco General Hospital University of California San Francisco San Francisco, CA Marc A. Probst, MD, MSHPM Department of Emergency Medicine Mount Sinai Medical Center New York, NY Jerome R. Hoffman, MA, MD University of California Los Angeles Los Angeles, CA Supervising Editor: Jeffrey Kline, MD. References 1. Hoffman JR, Kanzaria HK. Intolerance of error and culture of blame drive medical excess. BMJ 2014;349: g5702. 2. Hughes EC. Professions. Daedalus 1963;92:655–68. © 2015 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12764