As an ER doctor with 60 years’ experience and a missionary to third world countries for decades, I relate to physicians in the USA that are struggling with how to best treat their patients. Do we look for the most-serious cause of their symptoms or do we treat the most-likely? This is exactly the dilemma we face in either extreme on a daily basis.

For me, as a board-certified emergency medicine specialist, I had to come to grips with this dichotomy. For example, when a patient comes into the emergency room complaining of a headache, we automatically shift into our modus operandi, meaning, what is the worst possible diagnosis this could be? We think of subdural hematomas, hemorrhagic strokes, brain tumors, abscesses and temporal arteritis. It would be a critical mistake to miss any of these. So, we order all kinds of tests, such as CT scans, MRI scans, a bevy of laboratory tests, and maybe an ultrasound. We may even call in a specialist to help us on our quest to make a diagnosis. If we cannot make a definitive diagnosis at least we can reassure our patients that they do not have one of these sentinel events. The same goes for chest pain or abdominal pain.  There is a list of “never-to-be-missed” diagnoses that we must always consider and rule out before admitting the patient to the hospital or discharging them to home.  We cannot be short-sighted in our workup because that could be both fatal for our patient and the beginning of the end our careers. 

One time a 21-year-old woman came to our emergency room complaining of chest pain. Our ER doc, knowing that a myocardial infarct was a near impossibility for a young healthy woman, looked for other causes and reassured the patient. She was sent home only to return in cardiac arrest an hour later, dying of a heart attack. The doctor was wrong not to rule out the worst possible diagnosis, instead acting on his experience of other non-cardiac causes in this age group. In the US, our minds are always operating in the realm of the most serious, not the most likely.

 In missionary medicine, we do not have the luxury of CT scans, ultrasound, or laboratory diagnostics. We have to depend solely on our experience, training, physical findings and prevailing diseases in the area. Besides, we do not have time to consider or rule out every possibility for their complaint. We may only have 5 minutes per patient, because of the sheer number of patients we have to see per hour. So, when a patient complains of a headache, we give them Tylenol (or whatever medicine we happen to have) and wish them the best.  We know there is a 99% probability it is a tension or viral headache and will go away. We can’t even consider the worst-case scenario. In missionary medicine our minds are always operating in the realm of the most likely, not the most serious.

 Some would say, “That’s horrible. Don’t these people deserve the same level of care that our US patients expect and deserve?” 

The answer is unfortunately three-fold:

1.     Maybe they do deserve it, but there is no way that can happen. Resources are not available.

2.     They do not expect that same level of care. They are delighted for anything we can give them.

3.     We give them a level of care that is far above what they had before we came, by addressing the “Most likely” instead.

But, there is far more we can give our patients in these third world countries than what we can give them in the States.  That is the personal touch and caring of a physician. They can experience the love of God, intervening on their behalf through a caring physician, in their hopeless world. We listen to them, we pray with them, we hug them and let them know they are loved by us and by God. That is the best medicine of all.