Why Doctors Hate Science

[kellyb]

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

How could it? Your statement was a suggestion.

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?

"Incompetent" seems like a very harsh judgement, and I have a hard time thinking it's appropriate for physicians who prescribe evidence based treatments within the standard of care.

Those two examples do seem medically appropriate, just not ideal. Do you really think those are examples of incompetence?

 

[Ivor the Engineer]

Linda, TAM, Dr. Imago, Pax, Skeptigirl, DeeTee and any other medical professionals who wish to answer:

What do you think your error rate is?

 

[T.A.M.]

Define "error" for starters.

Are you asking me what % of the time I get the diagnosis wrong?

TAM

 

[kellyb]

Not necessarily.



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

Hmm...
I still think paternalistic docs are less likely to gather relevant information. If the doc does gather the relevant information, and communicates the rationale behind the treatment choice to the patient and the patient agrees, then it can't be paternalistic. That's just "patient centered care" coming from a very competent physician.
While I guess it's possible that a doc (in a non-emergent, PCP setting) could gather all the relevant info and not have an open line of communication with the patient about the prescribed treatment, it's difficult to imagine.
A doctor that communicates with their patient isn't paternalistic-seeming from the patient's point of view.

 

[Ivor the Engineer]

Define "error" for starters.

Are you asking me what % of the time I get the diagnosis wrong?

TAM

What % of the patients visits you have in a year do you reach an incorrect diagnosis?

 

[Ivor the Engineer]

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

<snip>

I didn't say you got them mixed up. I said you were confounding the two.

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

What evidence?

 

[T.A.M.]

What % of the patients visits you have in a year do you reach an incorrect diagnosis?

I would say about less than 5% for sure. Most of that comes from, however, a combination of correct diagnosis, and a fair few where I admit to the patient that their diagnosis could be a couple of things.

For instance,

Patient presents with headache, fever, maxilla pain, green nasal discharge, and cough.

So I will tell my patient,

"This is likely a case of viral rhinosinusitis. However, it may develop into a bacterial sinusitis. In that case you may need antibiotics."

Or, for instance,

25y male patient presents with daily epigastric pain worse with foods, and occasionally with nausea, no radiation of the pain no exertional pain. Exam reveals little to nil on that day.

So I tell my patient,

Your pain may be due to Reflux (GERD), but there is a chance it could be pain secondary to Gallstones. We can either try a week or two of a medicine for reflux, to see if it resolves, or we can proceed to Ultrasound, and wait and see...any further attacks, and to the ER for bloodwork and that Ultrasound.

So in the above cases (off the cuff examples), of course I might be incorrect, or I might be correct.

As I have said many times before, medicine is very grey.

for instance, roughly 40% of abdominal pain presenting to an MD will result in no definitive diagnosis.

TAM

 

[Professor Yaffle]

Quick question for Linda: If you had a patient with two different treatment options, with one option slightly superior, in your eyes, but the patient refused to take this option (for seemingly irrational reasons), would you refuse to treat them with the slightly inferior (IYO) option?

 

[T.A.M.]

Quick question for Linda: If you had a patient with two different treatment options, with one option slightly superior, in your eyes, but the patient refused to take this option (for seemingly irrational reasons), would you refuse to treat them with the slightly inferior (IYO) option?

This goes to the heart of my Generalized Anxiety example.

My preference for the "Optimal" treatment of GAD may be psychotherapy, the initialization of an SSRI, and a temporary dose of a Benzo, to be used for the first few weeks until the SSRI fully kicks in.

However, if the patient says they do not want to take medications at that time, while I might suggest that it is the better option, I sure would say it is fine for them to go with psychotherapy alone, and to come see me if it doesn't work out to their liking.

TAM

 

[JJM]

What % of the patients visits you have in a year do you reach an incorrect diagnosis?

You betray your ignorance of the difference considering the variability of biology, as opposed to the certainty of (properly analyzed) structural components. Medicine is more complex than anything you or I (a medicinal chemist do) despite your delusions of grandeur.

 

[Ivor the Engineer]

"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?"

Now either my communications skills suck, or your reading comprehension does. From what I have said the conversation would go as follows:

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"Could you explain the pros and cons of the 2 methods?"
"Sure. The first method has pros p11, p12 and p13, and cons c11, c12 and c13. The second method has pros p21, p22, p23, and cons c21, c22, c23."
"Hmm. I'm a bit confused by what you mean by p12 and c23. Could you explain those in more detail?"
<Ivor explains p12 and c23 in detail, translating the jargon into english.>
"Ok, I understand the differences between the two methods much better now, and I'm thinking I prefer method two, though I'm a bit concerned by c23. Is there another way to build the bridge which would remove it?"
<Ivor thinks hard.>
"I'm not sure. Let me have a look on the net."
<Ivor turns screen so customer can see it and goes to a reliable source of information on bridge construction.>
"You're in luck! Looks like there's a new version of widget X for option 2 which removes c23. It adds about 10% more on the price though."
"Ok then, I think I'm willing to pay a bit more to remove c23. When can you start construction?"

...

 

[Ivor the Engineer]

You betray your ignorance of the difference considering the variability of biology, as opposed to the certainty of (properly analyzed) structural components. Medicine is more complex than anything you or I (a medicinal chemist do) despite your delusions of grandeur.

Well given you know **** all about what I do, how can you say that?

 

[kellyb]

What evidence?

I'm looking around, and most of the evidence seems to suggest a positive effect of patient centered care.
I have found this, though:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1466873
Which seems to be saying that the effect might be some weird varient of the placebo effect. Which would explain why people who see naturopaths swear their quack brings them "better health than any allopath ever did."
I'm still looking for evidence that real MD's who deliver patient centered care have worse outcomes than those who don't.

 

[kellyb]

This goes to the heart of my Generalized Anxiety example.

My preference for the "Optimal" treatment of GAD may be psychotherapy, the initialization of an SSRI, and a temporary dose of a Benzo, to be used for the first few weeks until the SSRI fully kicks in.

However, if the patient says they do not want to take medications at that time, while I might suggest that it is the better option, I sure would say it is fine for them to go with psychotherapy alone, and to come see me if it doesn't work out to their liking.

TAM

That's quintessential "patient centered care", isn't it?

 

[kellyb]

Still looking for evidence that patient centered care might deliver worse outcomes than the alternative method...
Nothing yet, but this is interesting:

http://www.ncbi.nlm.nih.gov/pubmed/16356677

The moral nature of patient-centeredness: is it "just the right thing to do"?

OBJECTIVE: Patient-centeredness is regarded as an important feature of high quality patient care, but little effort has been devoted to grounding patient-centeredness as an explicitly moral concept. We sought to describe the moral commitments that underlie patient-centered care. METHODS: We analyzed the key ideas that are commonly described in the literature on patient-centeredness in the context of three major schools of ethical thought. RESULTS: Consequentialist moral theories focus on the positive outcomes of providing patient-centered care. Deontological theories emphasize how patient-centered care reflects the ethical norms inherent in medicine, such as respect for persons and shared decision-making. Virtue-based theories highlight the importance of developing patient-centered attitudes and traits, which in turn influence physicians' behaviors toward their patients. CONCLUSION: Different ethical theories concentrate on different features of patient-centered care, but all can agree that patient-centeredness is morally valuable. PRACTICE IMPLICATIONS: In order to sustain patient-centeredness as a moral concept, practitioners and students ought to examine these ideas to determine what their own personal reasons are for or against adopting a patient-centered approach.

Not that the paternalism advocates care what we patients think, but I'm going to go out on a limb here and guess that a vast majority of patients would say that yes, it is just the right thing to do on a moral level.

 

[paximperium]

Now either my communications skills suck, or your reading comprehension does. From what I have said the conversation would go as follows: AND THANKS FOR CREATING A COMPLETELY NEW SCENARIO THAT HAS NOTHING TO DO WITH THE ORIGINAL. Either your reading comprehension sucks or you're dishonestly changing your scenario from an unreasable customer to the most intelligent and well informed customer around so that you don't have to sound so silly. I wonder why?

Here's a modification to change it back to the original:
"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"Could you explain the pros and cons of the 2 methods?"
"Sure. The first method has pros p11, p12 and p13, and cons c11, c12 and c13. The second method has pros p21, p22, p23, and cons c21, c22, c23."
"Hmm. I'm a bit confused by what you mean by p12 and c23. Could you explain those in more detail?"
<Ivor explains p12 and c23 in detail, translating the jargon into english.>
"Ok, I understand the differences between the two methods much better now, and I'm thinking I prefer method two, though I'm a bit concerned by c23. Is there another way to build the bridge which would remove it?"
<Ivor thinks hard.>
"I'm not sure. Let me have a look on the net."
<Ivor turns screen so customer can see it and goes to a reliable source of information on bridge construction.>
"You're in luck! Looks like there's a new version of widget X for option 2 which removes c23. It adds about 10% more on the price though."
"Ok then, I think I'm willing to pay a bit more to remove c23. When can you start construction?"
"Hmmm...interesting plan but I still want lasers and I want it made with swiss cheese."
"But that's just silly."
"If you don't do as I say, you're disrespecting my autonomy.

"Civil Engineer Ivor, I need a bridge across this ravine."
"Okay, here are the 2 ways we can build it."
"So which is better?"
"So here are the pros and cons..etc."
"I don't get it."
"Well...blah blah blah."
"Uh...okay. Which do you recommend?"
"I suggest A."
"Uh...is it cheaper?"
"No it's actually more expensive."
"Why?"
"Well...blah blah blah."
"Uh...<blank stare> Are you sure we should go with A?"
So what are you going to do Ivor, is there autonomy here or informed consent or are you going to be paternalistic and choose for this customer?

 

[paximperium]

"Incompetent" seems like a very harsh judgement, and I have a hard time thinking it's appropriate for physicians who prescribe evidence based treatments within the standard of care.

Medically appropriate but ineffective and ultimately useless.
If I had a choice of using 2 antibiotics, one cheap but less effective and one expensive but marginally better, the medically appropriate treatment would be the second choice unless the patient can't afford it.

Those two examples do seem medically appropriate, just not ideal. Do you really think those are examples of incompetence?

Yes. Old joke, "I cured Mr X's stab wound but he died from an infection."
A dead or untreated patient due to the doctor's part is a failure. A doctor who does not maximize the success rate of his/her treatment from pure arrogance is incompetent.

 

[Ivor the Engineer]

Ah, I see, you believe most patients are unreasonable and/or thick, so the best strategy is just to treat everyone like a stupid child.

While I'm sure that works in ER, I doubt it would be very successful in family practice, or any place where you might have to interact with the patient for months if not years.

I think you should have a word with TAM, it sounds like you could learn at lot from him about how to treat people with respect.

 

[paximperium]

That's quintessential "patient centered care", isn't it?

There is a spectrum of medical choices that is "medically appropriate" and a patient can choose their treatment within this spectrum. It is the doctor's skill and judgment to pare down all the options available for a patient to decide.

Is it an impingement of autonomy? You betcha.
The Doc has eliminated a bunch of treatment options and will not even offer it to you. Now you have an "illusion" that you have some measure of choice but it is a controlled and already limited one.

So is your autonomy/free in this situation real or an illusion?

 

[paximperium]

Ah, I see, you believe somemost patients are unreasonable and/or thick, so the best strategy is just to treat someeveryone like a stupid child.

Ahhh...so much less straw. Ivor, you can have the straw mannequin back, I'm allergic to such nonsense.

Yes I do. Some people are in fact insane, unreasonable and downright stupid and I have little ethical problem with manipulating them and making decisions for their own good.

While I'm sure that works in ER, I doubt it would be very successful in family practice, or any place where you might have to interact with the patient for months if not years.

Beats me, I have a bunch of regulars who seem to love me. Maybe it's the narcotics I dole out.

I think you should have a word with TAM, it sounds like you could learn at lot from him about how to treat people with respect.

I treat all patients with respect. I'm working and am a professional. After a conversation with my patients, I can usually figure out who I can give reasonable options to(Would like an IV for your pain or would prefer to try out some pain pills?) or some which I will railroad into doing what I want(Your pain is improving but I'm really worried about an appendicitis. I'm going to do a CAT scan right now.-notice, no options offered?).

I'm also going to make decisions for some of my patients if they are unable to do so. I will not give the drug seeker narcotics just because they are withdrawing. I will not feed someone with a belly infection no matter how much they beg me for water. I will also get my Follow-up Care Nurse to call some of the stupid, demented and insane patients to make sure they are getting better and taking their meds like they are suppose to.

I actually care about the health and lives of my patients more than some silly illusion of autonomy. You can call it paternalism if you wish.

Patients deserve respect to a degree. Bigots on a forum the other hand actually need to earn it.