Why Doctors Hate Science

[T.A.M.]

Sounds kinda like the 32year old guy who came in for heartburn...the guy looked ill. Didn't have single risk factor, normal vitals. Normal EKG. Normal vitals and was feeling better with good old morphine.

He says, "I feel better, just a bit more pressure. Can I go home?" I check one more EKG and it had converted to a fullblown ST elevation MI. Up to the cardiac cath lab and stented(Oh the horrible stents are anathema to Ivor) within 30minutes.

Yah the "heartburn" ones are tough. Even worse are the middle aged women that come in with some "stomach pain", and their Troponin is through the roof.

I miss the ER sometimes.

TAM

 

[kellyb]

Do not confuse paternalism with arrogance.

Arrogance is one of the primary symptoms of paternalistic attitudes.

That's not paternalistic, that's incompetent.

Well, I was assuming the relevant info making the prescription "not incompetent" was in the patient's chart.

 

[Skeptic Ginger]

I thought we were focusing on the role of the physician after a diagnosis has been made? If so, how is what I have said inaccurate?

Sometimes I think people are just looking to take offence in anything I say...

Right Ivor, it couldn't possibly be that some things you say are offensive, now could it?

As for your medical textbook citation in post #394 re patient autonomy, what do you suppose the result is that such discussion is in a medical textbook? Think it is possible this is part of one's medical education?

Combining these two thoughts, perhaps you are a defensive/offensive patient who creates a self fulfilling prophesy by the way you approach your doctors.

 

[Skeptic Ginger]

I think you are confounding diagnosis and treatment.

I agree that diagnosis should be left pretty much in the realm of the physician, since a typical patient will not have the expert knowledge to be able to perform the task. All I would add is that patients can help a physician avoid falling into cognitive traps by asking questions. Once a diagnosis has been made it tends to be resistant to conflicting evidence.

Once a diagnosis has been made and there are multiple courses of action to choose from, the physician should explain each one in an unbiased way and discuss with the patient which one is appropriate, which can be primarily determined by the patient.

I doubt you recognize the absurdity of your argument here. The doctor in your example can diagnose better than the patient but that same doctor isn't qualified to recommend the treatment?

Your first false premise is assuming a provider does not take into consideration a patient's needs when recommending a treatment. Your second false premise is assuming valid treatment options are not discussed with the goal of eliciting the patient's decision when there are optional treatments.

For example, if surgery or drugs offer different risk/benefit patterns, it may be totally patient preference that guides the decision. But that is not the case in the majority of treatment recommendations.

 

[Skeptic Ginger]

....

I am also aware that we naturally tend to look for evidence to confirm a hypothesis rather than that which would disprove it.

That is not how I make a diagnosis. And a diagnostic procedure which is definitive rules a diagnosis in or out. This is not consistent with your frankly naive view one is looking to confirm an hypothesis.


A health care provider usually merges the following considerations depending on the patient's problem.

First priority is to rule out anything critical or life threatening that you cannot afford to miss.

Second priority is to look for the most likely diagnosis on the dif, and work down the list.

And your third priority is to choose the least invasive tests/procedures to confirm your diagnosis.

 

[BillyJoe]

Well if Linda, high priestess of all of medicine says it, it must be true.

Someone earlier in the thread said that they often find Linda's posts opaque. I was going to respond but forgot, so thank-you for providing me with the opportunity now. What I was going to say to this person was:
If you find Linda's posts opaque, that it not a criticism of her.
And if you don't understand that sentence, that is not my fault either.

Anyway...

There are posters on this forum who are nearly always interesting and insightful and there are others, Ivan, who make me wonder why I even bother.

Humans have autonomy - the ability to reason, plan and make choices about the future. Respect for these attributes goes hand in hand with respect for human dignity. Doctors should respect the autonomy, and thus the dignity, of their patients. This respect for the autonomy of patients leads to two further rights - informed consent and confidentiality. Competent adult patients should be able to choose to accept proposed treatments and to control personal information which they divulge concerning such treatments. Denying patients such choice and control robs them of their human dignity.

There is nothing here to say that a patient's role in deciding what treatment they will have is anything more than an illusion.

The purpose of the doctor is to present the patient with the options for treatment, along with sufficient information in a form for them to be able to make a informed decision.

Only when there nothing or little to choose between the various options.
Note that the patient's decision in these cases amounts to no more than a coin toss. Some choice.
If you present to your doctor with a headache and he makes a diagnosis of meningococcal meningitis, unless you are stupid enough to make it completely impossible for him, he going give you an injection of an antibiotic and send you by ambulance to the nearest hospital, no matter what noises he might make to make it appear to you that you are taking part in the decision making process.

The purpose of producing statistics is to convert complicated information into a form which others with less detailed knowledge can use to make useful decisions with.

But, hold on, if you want to see the statistics supporting various treatment options, don't you also want to see how such statistics were arrived at? Whether they say what they seem to say? Does that not mean that you willl need to have knowledge about statistical methods used to evaluate clincal trials and therefore additional knowledge about clinical trials and how to evaluate them. If not, why not just stick with the doctor's recommendation in the first place.
How much information do you need to give you the illusion that you are participating in the decision making process?

Or your mechanic could say: "There's X mm left on your pads (mate), which is good for about Y thousand miles. Do you want me to change 'em now?"

I based this example on something that happened only a few weeks ago.
In fact, I was grateful that he did NOT interrrupt my busy work schedule to ask me that STUPID question. Going by mileage done, the break pads were due to be changed, but he didn't change them because, in his opinion based on his experience, they would easily last untill the next service, and he told me this when I picked up the car.
A truly professional approach in my opinion.

BJ

 

[Skeptic Ginger]

I looked into the engineer's anecdote Ivor brought up.

Here is the link Ivor provided. It is a typical news report making things look as sensational as possible.
Overconfident Docs Need Dose Of Reality

Misdiagnoses Occur Up To 15% Of The Time, Physician Overconfidence May Be Partly To Blame

The actual report was from The American Journal of Medicine; Volume 121, Issue 5, Supplement (May 2008); Diagnostic Error: Is Overconfidence the Problem?

The abstract

The great majority of medical diagnoses are made using automatic, efficient cognitive processes, and these diagnoses are correct most of the time. This analytic review concerns the exceptions: the times when these cognitive processes fail and the final diagnosis is missed or wrong. We argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors. We present a comprehensive review of the available literature and current thinking related to these issues. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.

Foreword by Paul Mongerson

After being misdiagnosed with pancreatic cancer in 1980, I founded the Computer Assisted Medical Diagnosis and Treatment Foundation to improve the accuracy of medical diagnosis. The foundation has sponsored programs to develop and evaluate computerized programs for medical diagnosis and to encourage physicians to use computers for their order entry. My role was insignificant, but as the result of much work by many people, substantial progress has been made. Physicians today are clearly more accepting of computer assistance and this movement is accelerating.

However, in 2006, I became worried after questioning my personal physicians as to why they did not use computers for diagnosis more often. Most explained that their diagnostic error rate was <1% and that computer use was time consuming. However, I had read that studies of diagnostic problem solving showed an error rate ranging from 5% to 10%. The physicians attributed the higher error rates to “other” less skilled physicians; few felt a need to improve their own diagnostic abilities....

...It is logical that physicians' overconfidence in their ability inadvertently reduces the attention they give to reducing their own diagnostic errors....

...The papers in this supplement confirm the extent of diagnostic errors and suggest improvement will best come by developing systems to provide physicians with better feedback on their own errors.

Hopefully this set of articles will inspire us to improve our own diagnostic accuracy and to develop systems that will provide diagnostic feedback to all physicians.

So the error rate is 5-10%, not 15%. (Perhaps there is a reference to 15% in the body of the paper, but I didn't see it.) While no one wants any errors in medical diagnoses, that's still a pretty low error rate when you consider the sheer number of possible diagnoses and patient presentations health care providers are confronted with. The emphasis on the "overconfidence" isn't quite as pronounced when you consider the studies suggest physicians estimate their own error rates as 1% when the average is 5-10%.

And the providers estimate their own error rates are less than other providers. Well, maybe they were, maybe they weren't. Individual estimates vs real error rates were not discussed. To get an average of 5-10%, some docs probably did have error rates of 1%.

It also depends on specialty. I practice in a very narrow specialty. It's easy to know a lot about a little.

I don't see that this research supports the implication here that most doctors are overconfident, arrogant and paternalistic. I remain confident that my assessment is some people in this discussion self fulfill their expectations as patients when they approach their providers with a chip on their shoulders.


Science Daily: Will You Be Misdiagnosed? How Diagnostic Errors Happen summarizes the supplement articles for anyone wanting the short version that is a bit more accurate than the CBS news version.



Mongerson started a foundation supporting the development of medical informatics. This is a marriage of biological sciences with computer programming science. It's a big focus these days especially in the field of genetics. BioInformatics is two fields of study. It doesn't turn computer programmers into doctors anymore than it turns doctors into computer programmers. Anyone can study dual sciences, but engineering is also not the same as medicine anymore than computer programming is. OTOH, we can all gain insights from other sciences.

A patient's perspective of medical informatics; P Mongerson

From my viewpoint as a patient, 1. Medical knowledge has expanded to the point that individuals cannot adequately improve quality without the assistance of computer programs. 2. The medical profession must concentrate on why and how computer program projects must be used, not on why they cannot be used. 3. The successful application of computer programs to clinical medicine is dependent mainly on the efforts of individual institutions and people at the local level.

But just as a reminder how complex decision making is in medical diagnostics, it's worth noting the FDA may need to regulate these programs to assure they provide proper assistance to medical decision making.

FDA Examining Computer Diagnosis

When Paul A. Mongerson of Marathon, Fla., had severe abdominal pains in 1980, a battery of tests showed he had an elevated blood level of the enzyme lipase, which could indicate cancer of the pancreas. Though the diagnosis was not confirmed by other tests, his doctor recommended surgery.

"I'm an engineer by training, so I made up a matrix, charting my symptoms and test results, the possible diseases that could cause my symptoms, and what other symptoms would be present with those diseases," Mongerson recalls. "My conclusion was that I could not have cancer of the pancreas, and the fifth doctor I consulted, at Mt. Sinai in New York, agreed with me."

Eventually the pain disappeared, and he was found to have a condition known as pseudolipase, which results in abnormally high readings for the enzyme in tests. Mongerson said he thinks he might have bruised his pancreas while working around the house.

"I said at that time, 'what I did is just what a computer would do.' Medicine has gone about as far as it can without computers. There's a limit to how much the mind can retain, even with the degree of specialization that we've seen in medicine," Mongerson said. "The field of knowledge is so big the human mind is incapable of grasping it all--but a computer could help."

So Mongerson formed a foundation that provided financial assistance to physicians working to develop computer diagnosis systems. Today, medical diagnostic software puts entire medical libraries a mouse-click away. The Food and Drug Administration already regulates some diagnostic software, and as the number of programs expands, so does FDA's review.

 

[paximperium]

Arrogance is one of the primary symptoms of paternalistic attitudes.

Yeah...was that suppose to have refuted my statement?

Well, I was assuming the relevant info making the prescription "not incompetent" was in the patient's chart.

A doc who ignores a patient's social situation and preference is incompetent. It is a definite way of not having your patient follow through with their treatment.

"Mr Soandso, you have strep throat. Here are some antibiotic pills for it that you have to take for one week. Bye." Mr. Soandso hates taking pills. He take 2 days of antibiotics before stopping because he feels better. Later on he comes back with a peritonsilar abscess. This could've been fixed by offering Mr. Soandso a single intramuscular shot of penicillin.

"Mrs. Soandso, you have a mild pneumonia. Here is some antibiotics for it."
She tries to fill the prescription but its costs $800 because her insurance does not cover that brand. She decide she won't fill it due to the price. This could've been solved by giving an alternate and cheaper antibiotic.

Tell me. Was any of the above not medically appropriate?

 

[paximperium]

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"I don't like it. I want it built up side down with laser beams."
"Uh...okay, I could do it this way."
"No, I want it with laser beams and Swiss cheese."
"But the bridge will collapse."
"Why are you so paternalistic? Why don't you respect my autonomy?"

 

[fls]

1. No, I am not pretending, or suggesting it.

2. Well for instance, patient presents with signs of generalized Anxiety.

Options:
(A) Psychotherapy/Counselling
(B) A + an SSRI
(C) A + a Benzo
(D) No treatment at all

TAM

Do you think those options are equivalent in efficacy?
Is a patient in a better position to understand how one chooses between these options than you?

Edit: I think our mis-connecting here, is based on "influence" and whether influence destroys "free choice". A good debate for sure, but I think it is a murky one.

Really? I think it's pretty clear that choices can be influenced.

I guess I'm asking why it is assumed that "free choice" is preferred over "physician choice" to the point where "physician choice" is synonymous with "paternalism" which is synonymous with "arrogance".

For instance, a drug rep will come in and try to influence you with studies indicating their drug is better at something then the competitors, or that they offer something the other versions do not. Now do you admit this influences you, and if it does, does that eliminate your ability to chose fairly what is best for the patient?

You admit that this influences you and you don't take information from drug reps.

Linda

 

[fls]

I think you are confounding diagnosis and treatment.

Yeah, I always get those two mixed up. It's because "drugs" and "diagnosis" both start with "d". Damn mnemonics.

And now that I think about it, I've never ever asked for informed consent for a diagnostic test.

I agree that diagnosis should be left pretty much in the realm of the physician, since a typical patient will not have the expert knowledge to be able to perform the task. All I would add is that patients can help a physician avoid falling into cognitive traps by asking questions. Once a diagnosis has been made it tends to be resistant to conflicting evidence.

Yeah, show me the results of the spiral CT and I'm still like "give him another dose of Lasix IV".

Once a diagnosis has been made and there are multiple courses of action to choose from, the physician should explain each one in an unbiased way and discuss with the patient which one is appropriate, which can be primarily determined by the patient.

I'm not disputing that it can be determined by the patient. I'm pointing out that it has been assumed that the result will be in the best interests of the patient when there is evidence that suggests otherwise. It seems that the perception of patient autonomy is valued more than maximizing health. I'm not saying that those priorities are wrong, just that we shouldn't pretend otherwise.

Linda

 

[T.A.M.]

Do you think those options are equivalent in efficacy?
Is a patient in a better position to understand how one chooses between these options than you?



Really? I think it's pretty clear that choices can be influenced.

I guess I'm asking why it is assumed that "free choice" is preferred over "physician choice" to the point where "physician choice" is synonymous with "paternalism" which is synonymous with "arrogance".



You admit that this influences you and you don't take information from drug reps.

Linda

1. I think that all of them can be relatively equal in efficacy, and that there are other factors besides efficacy to consider. For instance, maybe the patient does not want medication. Or maybe the patient does not want to take anything with addiction or abuse potential.

2. I never said that choices are not influenced. Your example, about Physician choice being synonymous with paternalism and arrogance, is (A) extreme, and (B) Not what I said, anywhere in my posting.

3. I admit that Drug Reps bring information and talking points that are MEANT to influence my decision making concerning drug choice. Yes I take the information, but what influences my drug choice (as I have told reps to their faces) is not their talking points, or a single small or medium study funded by their company, but metanalysis of many DBRCTs, as well as unbias expert medical opinion. Is it possible that they are influencing my choice in some small, unnoticed way...perhaps, I am not claiming to be perfect, but their influence is minimal.

TAM

 

[fls]

Sorry, I just can't resist:

http://www.cbsnews.com/stories/2008/04/30/health/webmd/main4058664.shtml

Overconfident Docs Need Dose Of Reality

(WebMD) Most of the time a medical diagnosis is on point. But misdiagnoses do occur, and an overly confident doctor may be partly to blame, a new review suggests.

The rate of diagnostic error is as high as 15%, Eta S. Berner, EdD, and Mark L. Graber, MD, write in a special edition of The American Journal of Medicine dedicated to understanding and addressing diagnostic errors.

Physician overconfidence and a lack of feedback following a diagnosis are two important contributors to the problem, they note.

"When directly questioned, many clinicians find it inconceivable that their own error rate could be as high as the literature demonstrates," Berner and Graber write. "They acknowledge that diagnostic error exists, but believe the rate is very low, and that any errors are made by others who are less skillful or less careful."

Berner says it is often the cases physicians perceive as routine and unchallenging that end up being misdiagnosed.

"With the hard cases, doctors generally seek out different opinions or turn to (computer-based) decision support tools," she tells WebMD.

I think this is the article that they are making reference to:

http://www.amjmed.com/article/S0002-9343(08)00040-5/fulltext#sec1

What is interesting is that the evidence they present contradicts what is written above. There is a good table of the error rates discovered through various methods within various fields. And I wouldn't dispute the error rate of 15%, although there is almost no precision to that number. What I would dispute is their claim of over-confidence. They seem to base this on these statements:

"When giving talks to groups of physicians on diagnostic errors, Dr. Graber (coauthor of this article) frequently asks whether they have made a diagnostic error in the past year. Typically, only 1% admit to having made a diagnostic error. The concept that they, personally, could err at a significant rate is inconceivable to most physicians."

However, it is plain that the results of this informal survey are wrong, since formal studies provide a far different answer, overwhelming biases (selection, recall, response, etc.) will form the results, and it is a different question from the one they claim to be asking. They summarize one study as "family physicians asked to recall memorable errors were able to recall very few", yet if you look at the results, 90% of the physicians recalled a memorable error and no conclusions can be drawn about the overall number of errors recalled, since each physician was only asked to recall one error. Berner and Graber grossly misrepresent the results of that study and the conclusions that can be drawn. The study actually shows that the overwhelming majority of family physicians are able to recall errors.

One of the studies they reference about over-confidence had physicians rating their confidence as 'low' in 2/3 of the cases and as 'high' in 1/3. This doesn't even remotely support their assertion that physicians rarely consider the possibility that their diagnosis is in error. They don't refer to any studies that support their conclusion, and the references they do provide actually contradict their claims.

A Missed Diagnosis

Retired engineer Paul Mongerson is all too aware of the problem of medical misdiagnosis, and he has spent the last 28 years addressing the issue.

In 1980, Mongerson was incorrectly told by four different doctors that he had pancreatic cancer, a highly deadly cancer that kills most people who have it within five years.

If you look at the details of the story (Skeptigirl already linked to a synopsis), you can tell that Mongerson would not have been told that he had pancreatic cancer. One does not make a diagnosis of pancreatic cancer on the basis of an elevated lipase - not even close. In 1980, the ability to rule-out pancreatic cancer would have been limited to exploratory surgery, and that would have been what the doctors were recommending. So it isn't even an example of medical misdiagnosis - merely a recommendation to rule-out an unlikely, but potentially serious condition.

Linda

 

[fls]

Aren't doctors who are paternalistic less likely to gather that relevant information?

Not necessarily.

Whereas TAM would discuss treatment options for generalized anxiety, the Bad Paternalistic Doc would take note of the symptoms and prescribe whatever he, in his clinical judgment, just thought was the most effective treatment.

But since being rushed and not gathering relevant information doesn't really have anything to do with paternalism, let's say that the paternalistic doc prescribed whatever she/he thought was the most effective treatment, taking relevant information into account. Is there anything wrong with that?

Linda

 

[fls]

1. I think that all of them can be relatively equal in efficacy, and that there are other factors besides efficacy to consider. For instance, maybe the patient does not want medication. Or maybe the patient does not want to take anything with addiction or abuse potential.

If no treatment is roughly equal in efficacy, why would you even mention other treatment options?

2. I never said that choices are not influenced. Your example, about Physician choice being synonymous with paternalism and arrogance, is (A) extreme, and (B) Not what I said, anywhere in my posting.

Oh no. I wasn't implying that you said that or that that was your implicit opinion. That was meant to be an indication of how paternalism was being presented in this thread - not by you, but by others.

Linda

 

[fls]

Someone earlier in the thread said that they often find Linda's posts opaque. I was going to respond but forgot, so thank-you for providing me with the opportunity now. What I was going to say to this person was:
If you find Linda's posts opaque, that it not a criticism of her.

That was Professor Yaffle, but I don't think the comment was meant as a criticism as much as it was an explanation for why she was attempting to restate my position.

Criticism is okay anyway.

But thanks for understanding.

Linda

 

[BillyJoe]

3. I admit that Drug Reps bring information and talking points that are MEANT to influence my decision making concerning drug choice. Yes I take the information, but what influences my drug choice (as I have told reps to their faces) is not their talking points, or a single small or medium study funded by their company, but metanalysis of many DBRCTs, as well as unbias expert medical opinion. Is it possible that they are influencing my choice in some small, unnoticed way...perhaps, I am not claiming to be perfect, but their influence is minimal.

The millions spent by pharmaceutical companies on Drug Reps, and through them, on doctors, would suggest that this is not generally true. I think it is also possible that you are being influenced far more than you realise. If their information is biased, why do you not just refuse to see them and spend your time more productively?

BJ

 

[fls]

3. I admit that Drug Reps bring information and talking points that are MEANT to influence my decision making concerning drug choice. Yes I take the information, but what influences my drug choice (as I have told reps to their faces) is not their talking points, or a single small or medium study funded by their company, but metanalysis of many DBRCTs, as well as unbias expert medical opinion. Is it possible that they are influencing my choice in some small, unnoticed way...perhaps, I am not claiming to be perfect, but their influence is minimal.

TAM

If you are getting something from them that is useful - samples for patients, reference material, food, eye candy - then even just a sense of reciprocity can lead to influence. If you are not getting something useful from them (and technically, the last two examples don't actually benefit the patient ), why are they even around?

Linda

 

[T.A.M.]

If no treatment is roughly equal in efficacy, why would you even mention other treatment options?



Oh no. I wasn't implying that you said that or that that was your implicit opinion. That was meant to be an indication of how paternalism was being presented in this thread - not by you, but by others.

Linda

Because what I determine as the best treatment, may not sit with the patient as the avenue they wish to go down.

I may suggest psychotherapy and an SSRI as the treatment option I think they should avail of, but that does not mean it is the one they wish, and if there are other options that will help them (psychotherapy alone, psychotherapy and a Benzo) then I have to at least provide them with those options as options, do I not? Perhaps we will have to agree to disagree on this one, but it is the way that I practice.

TAM

 

[T.A.M.]

If you are getting something from them that is useful - samples for patients, reference material, food, eye candy - then even just a sense of reciprocity can lead to influence. If you are not getting something useful from them (and technically, the last two examples don't actually benefit the patient ), why are they even around?

Linda

As I said, I am human, so of course there is SOME influence, but in my case, I feel it is minimal.

I love the eye candy reference, btw, as it is striking how much they try to make that play a role.

TAM