Why Doctors Hate Science

[Ivor the Engineer]

The doctor in Pax's example was playing a game, which is:

a) Disrespectful.

b) Risky, since one day the doctor will meet a better/harder player.

 

[T.A.M.]

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...

Ivor:

I do not know you, and I do not debate much with you, so I do not purposely take offense to ANYTHING you say...lol

Your comments do not seem to specify about at what point you consider us to be "user interfaces for medical technology" etc...

There is so much more to what a physician does, that to make grand, generic, and frankly insulting generalizations is not...well, very nice.

TAM

 

[fls]

In an earlier post of mine, I did stress that there is an "ER Doc" method, and then a "GP in the office" method. In the former I tend to ask relevant questions. I perhaps should have said, that in that setting, and depending on the nature of the illness, I might be more or less paternalistic.

However, if a patient were to present in my clinic with a headache, neck stiffness, coryza, and a fever, I would probably tell them this.

"You likely have an viral illness, a variation of the cold, but with your symptoms, and based on your physical, there is a possibility of meningitis. I strongly suggest we send you to the hospital for a CT and lumbar puncture, at the accepting doc's discretion, to rule this out."

If the patient is competent, and refuses to go, I will strongly urge he/she to reconsider, and then write in the chart that the patient was informed, competent, with a GCS of 15, and refused to take my advice.

TAM

Edit: so you, see this would be the ADVISOR part of the quote from me that you used.;D

So it seems like you agree that the choice isn't given to the patient - i.e. paternalism is appropriate and in the best interests of the patient. They may make the choice to ignore our advice, but that can happen under either system.

Linda

 

[fls]

The doctor in Pax's example was playing a game, which is:

a) Disrespectful.

b) Risky, since one day the doctor will meet a better/harder player.

Exactly!

And why does Pax have to play that game? Because he is forced to pretend that the patient is making an informed choice when he realizes that it is in the best interest of the patient for him (Pax) to make that choice.

Linda

 

[T.A.M.]

umm...here is what I would say.

There is a time when I advise STRONGLY (ie I strongly suggest) a course of action, but the patient is ultimately left with the final decision. There are other cases where more than one option is available, in which case I am much less paternalistic, and completely leave open the course of action to the patient.

TAM

 

[fls]

umm...here is what I would say.

There is a time when I advise STRONGLY (ie I strongly suggest) a course of action, but the patient is ultimately left with the final decision.

But that's irrelevant, isn't it? Unless we arrest them and strap them down, they are always free to act against their interests (the mark of a truly free society). You're not pretending that they are making a choice that is in their best interest, are you?

There are other cases where more than one option is available, in which case I am much less paternalistic, and completely leave open the course of action to the patient.

TAM

Could the choice be made by a coin toss?

Linda

 

[T.A.M.]

But that's irrelevant, isn't it? Unless we arrest them and strap them down, they are always free to act against their interests (the mark of a truly free society). You're not pretending that they are making a choice that is in their best interest, are you?



Could the choice be made by a coin toss?

Linda

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

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. 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?

 

[Ivor the Engineer]

Exactly!

And why does Pax have to play that game? Because he is forced to pretend that the patient is making an informed choice when he realizes that it is in the best interest of the patient for him (Pax) to make that choice.

Linda

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.

 

[Dr. Imago]

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.

That's just not true at all. That's the way the public THINKS and BELIEVES it works, but we actually work on a list of differential diagnoses. Sometimes it can actually take quite some time to pinpoint the etiology of a particular illness.

Ivor, I know you're only trying to keep your belief about how the medical system works and the medical profession in generall intact, but you are really reaching and making a lot of suppositions.

~Dr. Imago

 

[Ivor the Engineer]

<snip>

There is so much more to what a physician does, that to make grand, generic, and frankly insulting generalizations is not...well, very nice.

TAM

Well it looks like I'm the odd one out. I was discussing what I thought engineers and doctors provided the users of their services with an engineering colleague, and he was just as taken aback at the thought of being a human user interface for (in his case mechanical) technology.

I still don't get all the fuss, but I'll accept I have a minority and rather unpopular point of view.

 

[Ivor the Engineer]

That's just not true at all. That's the way the public THINKS and BELIEVES it works, but we actually work on a list of differential diagnoses. Sometimes it can actually take quite some time to pinpoint the etiology of a particular illness.

Ivor, I know you're only trying to keep your belief about how the medical system works and the medical profession in generall intact, but you are really reaching and making a lot of suppositions.

~Dr. Imago

Yes, I know how to perform differential diagnosis. I use the technique frequently in my line of work.

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

 

[T.A.M.]

Well it looks like I'm the odd one out. I was discussing what I thought engineers and doctors provided the users of their services with an engineering colleague, and he was just as taken aback at the thought of being a human user interface for (in his case mechanical) technology.

I still don't get all the fuss, but I'll accept I have a minority and rather unpopular point of view.

I think it is the general"ness" of your statements.

I will admit that there are certain aspects of my profession, that in this day and age of the internet, are becoming redundant. A good Physician adapts.

For instance, if someone wants detailed info on a particular condition, I will often tell them, at that time, to (A) go to the internet and do a search on it, (B) go to reputable sites, and (C) comeback if you have any questions and we can discuss it.

There are so many things, in both medicine, and engineering, that cannot be done by a computer interface, so to speak, that require the educated and experienced touch of a human.

In medicine:

The tenderness to know when to say something, and when not to. The understanding of context. The compassion, the empathy (where possible). The intuition.

For instance, on intuition, I'll tell you about a case I had a few weeks ago.

I had a man that came into me the other day in clinic. His presentation was as follows...

62 year old man, smoker, normal cholesterol, non diabetic, no significant medical history. Presents with left arm pain, worse with use, that awoke him last PM. Patient took Advil x 2 tabs, and settled within 2 hours.

HE comes to my clinic with mild left arm discomfort (at present time), no shortness of breath, no Chest Pain, No nausea/vomiting. When I examined him his vitals were normal, chest clear, CVS exam normal, and when I pushed on his bicep muscle, he told me "That's the pain".

I have sent a dozen of these presentations home as MSK PAIN, and they have done fine...but something struck me with this guy. He just didn't look well. He seemed "off". Something also alarmed me about the pain WAKING him at night.

I sent him to the hospital for an EKG.

EKG showed some mild ST elevations in the lateral leads. I called the ER doc and had him sent to him.

Cardiac Enzymes were up, and the ST elevations were now prominent. He was admitted and thrombolyzed...MI!

TAM

 

[Dr. Imago]

Yes, I know how to perform differential diagnosis. I use the technique frequently in my line of work.

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

Don't compare being an engineer with being a physician. They are not the same. Machines have causes that can, sometimes with difficulty, be definitively pinpointed and corrected. They are generally "binary" problems (e.g., some bolt is broken, find the bolt, fix it, and everyting is okay). Humans, OTOH, are "analog" and far more complex without a single, identifiable and treatable cause that will fix everything else downstream. There are magnitudes and shades of dysfunction, some being more important than others. Knowing that, we are often left to run tests to "rule out" diagnoses as much as to rule them in. Certainly, many times we use tests to confirm what we are thinking where it is important to quantify the problem. Yet other times, those tests will tell us something completely unexpected.

In my previous example, I used the echocardiogram to "rule out", among other things, critical aortic stenosis and significant left ventricular problems. Had it been aortic stenosis, as was a possibility, it would've completely changed my course of action. The patient did indeed have a valve problem, but it wasn't critical. Even just knowing that was clinically important. I could've "guessed" that it wasn't going to affect my planned care, based on other clinical findings. But, I wasn't willing to take that risk in this patient. Other clinicians might have. But, it seems that your core argument is based on whether or not there was a financial incentive to do a test, ie. if I'd somehow received some form of remuneration for ordering that test it would necessarily mean that I only did it because of some perceived financial incentive, or if I hadn't received some financial incentive (which I didn't) I wouldn't therefore do the test... and potentially put the patient at additioinal risk.

Data helps us understand. It is not used solely to confirm what we're already thinking, and I take umbrage that we necessarily "look for evidence to confirm a hypothesis" - i.e., that we only choose to do studies simply to reinforce what we already suppose, and subsequently ignore other possibilities. Everything in medicine is weighed in light of the inherent risk-to-benefit ratio of our planned intervention, which is unfortunately complicated by the fact that many patients can't or won't pay for the gold-standard care they expect. Doctors deal with these issues on a daily basis. For what you otherwise seem to be suggesting we already have a name for: fraud and/or malpractice.

You are being overly simplistic in your logic, which is understandable on an individual basis because you don't really understand how medicine works. But, it's not okay to use that simplistic logic to make sweeping generalizations and form firm conclusions about the field of medicine, and try to convince others a depth of understanding about a field of endeavor in which you are not initimately involved nor have real, working knowledge.

~Dr. Imago

 

[Ivor the Engineer]

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.

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.

Mongerson made up a matrix charting his symptoms and test results to help him assess the probability that his doctors were right.

"I determined from that matrix that I didn't have cancer," he tells WebMD.

Just two days before he was scheduled for cancer surgery, a fifth doctor agreed and Mongerson canceled the operation.

"I said at the time that if I survived I was going to see what I could do to help other people," he says.

What Mongerson did was form a foundation to fund the development of computer-based programs designed to assist physicians in diagnosing disease.

While such programs are being used in many hospital and educational settings, they are not yet widely used by private practice physicians.

Mongerson says performing more autopsies and having systems in place to crosscheck medical diagnoses would help address the issue of lack of feedback.

WTF do engineers know?

 

[kellyb]

You will notice that all of your (you and Professor Yaffle) examples of Paternalism Is Bad are about decisions made without all the relevant information. I'm suggesting that we should consider decisions made with the relevant information, and that we should be realistic about how that can be accomplished.

Linda

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

Although it's worth noting that almost any doctor who is too rushed for whatever reason, is probably almost indistinguishable from one with a paternalistic attitude.

 

[Ivor the Engineer]

Don't compare being an engineer with being a physician. They are not the same. Machines have causes that can, sometimes with difficulty, be definitively pinpointed and corrected. They are generally "binary" problems (e.g., some bolt is broken, find the bolt, fix it, and everyting is okay).

<snip>

Wrong.

Engineering is intimately connected with the natural world and dealing with all the randomness, chaos and complexity of it is what engineers do.

But I understand why you think the way you do about engineers; we have done a lousy job in explaining what it is we actually do.

 

[Dr. Imago]

Sorry, I just can't resist:

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



WTF do engineers know?

You quote an anecdote from 1980?

The proof, so to speak, is in the pudding. The guy didn't die. And, I hope you are the first to recognize that the body of medical knowledge as well as high-tech diagnostic tools at our disposal has changed drastically in the past 29 years.

I admit, we have occassionally have a problem with referrals sometimes, though. If Doctor X consults with Doctor Y about Patient Z, Doctor Y's initial approach to the patient will likely not include revisiting the primary diagnosis offered by Doctor X. The vast majority of the time this is not an issue, but occassionally someone will slip through the cracks as a result.

I'm not at all arguing that people shouldn't be involved in their own care. I'm not saying that you shouldn't know what's going on with your body and speak up if something doesn't make sense. However, on occassion, I will encounter patients who are "resistant" to the correct diagnosis and treatment offered because they believe the doctor(s) can't possibly be correct. The reasons for this resistance are often complex, and I think it speaks to a huge mistrust and misconception of out true intentions... which are, with rare exception by the sad and unfortunate practitioner who ineluctably seems to grab headlines, honorable and only looking out for your health and well-being.

Likewise, we just don't have the time to spend with everyone like my medical forefathers did. The insurance companies have put an end to that.

~Dr. Imago

 

[paximperium]

The doctor in Pax's example was playing a game, which is:

a) Disrespectful.

b) Risky, since one day the doctor will meet a better/harder player.

Bingo. Some people don't know what's good for them and some have this silly illusion that there is a choice when it comes to their care. Sometimes this is true when you can actually choose your care. This is if and only when I decide there is choice that is a viable option.

Impossible in many cases, if you have a meningitis/appendicits/pneumothorax/head bleed, you don't really have a choice, either do as I or the specialists say or you can take you life into your own hands leave, delay care and get a second opinion.

I offer people a service, they can either accept it or refuse it. You have a silly belief that I'm employee of the patients. No, they are hiring a service, an expert opinion. They have all the freedom in the world to listen to me or ignore me.

Call it patronizing or even disrespectful but I'm more than willing to manipulate people to protect their lives and health.

 

[paximperium]

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

Do not confuse paternalism with arrogance.

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.

That's not paternalistic, that's incompetent.

 

[paximperium]

For instance, on intuition, I'll tell you about a case I had a few weeks ago.

I had a man that came into me the other day in clinic. His presentation was as follows...

62 year old man, smoker, normal cholesterol, non diabetic, no significant medical history. Presents with left arm pain, worse with use, that awoke him last PM. Patient took Advil x 2 tabs, and settled within 2 hours.

HE comes to my clinic with mild left arm discomfort (at present time), no shortness of breath, no Chest Pain, No nausea/vomiting. When I examined him his vitals were normal, chest clear, CVS exam normal, and when I pushed on his bicep muscle, he told me "That's the pain".

I have sent a dozen of these presentations home as MSK PAIN, and they have done fine...but something struck me with this guy. He just didn't look well. He seemed "off". Something also alarmed me about the pain WAKING him at night.

I sent him to the hospital for an EKG.

EKG showed some mild ST elevations in the lateral leads. I called the ER doc and had him sent to him.

Cardiac Enzymes were up, and the ST elevations were now prominent. He was admitted and thrombolyzed...MI!

TAM

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.