Why Doctors Hate Science

[fls]

I just asked a question, Linda, because you seem to be using the word paternalism differently to some other people in the thread and I was trying to clarify what it meant to you. You seem to be using it as a synonym of beneficience, whereas others on the thread (including some medical types) are not. For example Dr Imago said (my italics added):

My question was meant to apply under both uses of the term. Is a father expected to abandon their responsibility to a child at the first signs of misbehaviour?

So if you offer different alternatives, and the patient decides they don't want the alternative that you consider the best and would prefer a different (less good IYO) option, then you will prescribe their preferred option?

Why wouldn't I?

I think this goes back to what I mentioned earlier about the characterization of the patient's behaviour when they refuse. If that characterization is negative, then the model is paternalism. And we expect some sort of punishment or censure for negative behaviour. That was why I switched to talking about beneficence, since it doesn't seem to carry that same expectation.

If so, how on earth is that an "illusion" of the patient having a choice? Please explain it to me, as I am really not understanding you.

The illusion is that the choice is fully informed or that emphasizing patient autonomy over beneficence serves/protects the best interests of the patient. That is the major shift from pre to post-Nuremberg medical ethics. And I think that emphasizing patient autonomy does provide better protection against maleficence, which was perhaps the main impetus at the time. But if the only conflict is between beneficence and patient autonomy, then autonomy can only mean that the patient is free to act against their own interest. Whether or not this is 'best' is more of a socio-political discussion.

I see the emphasis on beneficence as placing a greater responsibility on the physician to make sure the patient isn't floundering - to ensure that any choices made adequately reflect the patient's interests.

Oh and by the way, I presume Ivor was using the word confound with the definitions "To fail to distinguish; mix up".

So did I, but he says that he wasn't.

Linda

 

[T.A.M.]

Regarding unneccery procedures/drugs.
My country have a sensibel/strict policy on antibiotic. (except in animalfodder)

I once showed up at the doctor with something that could be either flu or an infection of throut/head cavities. A nurse took a small blood sample, and I was told there were no infection, and I could not get a presciption for antibiotics.

Is that a common test, using a small glass pipe of blood to see if there is bacteria infections?

That is ridiculous.

1. The only test I could see he/she performing on your blood that would in any remote way help would be a WBC count. This would only tell he/she that your body was responding to something by producing an immune response (elevated WBC). It is completely non specific, and useless in this context.

2. Any doctor worth their salt will use their clinical judgement to determine the likelihood of you having a bacterial versus viral infection. Sometimes, in settings where the results are quickly and easily available, a throat swab can be done, but this is only an adjunct to clinical assessment.

eg.

If a patient walks into my office with a "sore throat" I tend to use a scoring system (a recognized, published one) to determine the likelihood of the infection being bacterial...it goes something like this:

Risk Factor= Points
-------------------
Fever= 1
Tender Lymph Nodes=1
Exudate on Pharynx= 1
Absence of coryza=1
Age < 14 = 1

You add up the points, and I do the following,

Score < 4, Sent home on OTC meds and counselled.
Score 4-5, Discussion about, and probable prescription of antibiotics.

The only exception, is the exudative pharynx, which I usually give more weight to. If someone scores a 3, but one of them is the exudative pharynx, I may suggest antibiotics.


TAM

 

[fls]

Regarding unneccery procedures/drugs.
My country have a sensibel/strict policy on antibiotic. (except in animalfodder)

I once showed up at the doctor with something that could be either flu or an infection of throut/head cavities. A nurse took a small blood sample, and I was told there were no infection, and I could not get a presciption for antibiotics.

Is that a common test, using a small glass pipe of blood to see if there is bacteria infections?

Maybe a white blood count plus differential or a CRP? I see both have been tested for utility as a clinical decision tool in related conditions, but I didn't see anything for upper respiratory tract infection. T.A.M. or Pax are more likely than me to know about this as it's a primary/urgent care issue.

Linda

 

[fls]

First of all, I don't think it's a cost saving to have a blood test before antibiotics.
Secondly I don't think a blood test can distinguish reliably between a viral and bacterial infection.
Thridly, whatever happened to clinical acumen.

Diagnostic test + clinical acumen = evidence-based medicine.

Linda

 

[Toke]

Is that a common test, using a small glass pipe of blood to see if there is bacteria infections?

That is ridiculous.

I have wondered about it, it sounds too usefull to be true without being used more.

It was not the nurse who took the decision, I was checked out by the doctor before being sent home. I just got the impression that the test was her main deciding factor.

Still wonder what the test was for.

 

[T.A.M.]

Maybe a white blood count plus differential or a CRP? I see both have been tested for utility as a clinical decision tool in related conditions, but I didn't see anything for upper respiratory tract infection. T.A.M. or Pax are more likely than me to know about this as it's a primary/urgent care issue.

Linda

I have not seen CRP used in this context in my province, EVER. Now I have been out of the ER for 4 years, so I suppose they might be using it there...but I highly doubt it.

WBC is so non specific, that it is useless in the context of a throat infection. Viral or Bacterial, the WBC might be up, or might not.

TAM

 

[Dr. Imago]

kellyb:

I think you are struggling a bit to understand concepts that we already utilize, most of us effortlessly and with aplomb after years of practice, everyday... or you (and Ivor) are trying to conflate the notion of the "self-aggrandizing, unwavering" physician onto the entire profession. That's why I suggested that we discuss the issues separately.

To (briefly) answer a couple of your points...

This "patient-centered care" stuff is redundant, in that (again) all care is patient-centered. It is touchy-feely buzzword nonsense. I already described the ethical principles that guide our patient interaction, and they are all patient-centered. Nobody used the words "patient-centered" in either med school, residency or on the wards. They would get laughed at (i.e., just like we would never use the layman term "partial-birth abortion" in our professional endeavors).

"Family-centered care" is something completely different, and a model (currently being pushed in the ICUs) that I think has a noble and admirable purpose, but that I don't necessarily always agree with. In many cases, this can cause sensory and informational overload for the family, along with added emotional stress, and can even result in interference with effective care. I've seen it firsthand.

Ethical principles which guide our care include doing no harm, trying to do what's "right" and best for the patient, allowing the patient (when possible) to decide what's best for him/herself, and trying to use all of the resources at our disposal in a manner that is fair and equitable. In other words, nonmalficience, beneficence, autonomy, and justice.

But, bottom line, this is a decidedly human endeavor, people are not machines where the problem can always be simply isolated and fixed, and to expect perfection - including perfect outcomes - every single time is unrealistic. As a clinician, I try to continuously gage the level of "what my patient needs" and give it to them, in whichever form that may manifest itself. And, that is more art than it is science.

~Dr. Imago

 

[fls]

I have not seen CRP used in this context in my province, EVER. Now I have been out of the ER for 4 years, so I suppose they might be using it there...but I highly doubt it.

Some references:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15353050
http://www.sciencedirect.com/scienc...serid=10&md5=ed4855d269c0352ae90a309f20ecd345
http://www.bmj.com/cgi/content/full/311/6999/233?view=long&pmid=7627042

WBC is so non specific, that it is useless in the context of a throat infection. Viral or Bacterial, the WBC might be up, or might not.

TAM

Yeah, it seems useful to rule-in some specific conditions (like bacteremia in a febrile child or appendicitis), but I wasn't aware of its use in URTI, even for ruling-out bacterial infections.

Linda

 

[Dancing David]

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

Well, I am sure this is true of most medications but it is very true with mental health.

The drug seeking is just tremendous. As a case manager and a crisis clinician, this is just a constant issue. And so when people start saying certain clues and present with a certain history you begin to wonder if it is efficacy of treatment or life style issues that predominate. requests for Ativan and Xanax were always warning signs.

Mental health treatment is very difficult at times and BOTH the doctor and patient have to show patience and resilience with each other. there are those treatment refractory cases that are just hard to treat, especially psychotic depression.

On the other hand getting clients to STOP using alcohol and street drugs was quite a challenge as a case manager.

 

[Toke]

Linda,
Thanks, that makes sense to me.
A blood sample as a help to determine whether a sinus infection is bacterial and would benefit from antibiotics or not.

I just remembered it as a straith yes/no answer to bacterial infection or not.
And wondered why it is not used more.

 

[T.A.M.]

Toke,

It is likely not used more often because it not that specific (the study says that CRP indicated Bacterial infection, but if you look at what CRP is, it goes up with an immune response in general, so I think it misleading to state that it has a high specificity).

That brings me to,

Linda;

The first link is not that much help (as it seems to be looking only at CRP), but the second one I find interesting. It seems the ratio of CRP to neopterin is of significance, and looks very promising.

The big questions

(A) How long does it take to get these results.
(B) What is the cost to the health care system to order these tests, for what amounts to in the vast majority of cases, a viral sinusitis.

Interesting though. I would like to know from pax if he uses it, or any of his colleagues. I would also like to know what % of ERs and what % of GPs are using it. Like I said, here in Atlantic Canada, I do not recall hearing of any of my colleagues using it.

TAM

 

[paximperium]

I have not seen CRP used in this context in my province, EVER. Now I have been out of the ER for 4 years, so I suppose they might be using it there...but I highly doubt it.

Nope. Nothing concrete in our ER literature for a CRP for strep throat.
BTW: Isn't the strep pharyngitis scoring system shown to be terribly unreliable? I like my Rapid Strep test.

 

[paximperium]

Yeah, it seems useful to rule-in some specific conditions (like bacteremia in a febrile child or appendicitis), but I wasn't aware of its use in URTI, even for ruling-out bacterial infections.

Uh unfortunately no. I believe the sensitivity and specificity for appendicits is only in the mid to high 50s and even in childhood bacteremia isn't all that good either, the blood culture is usually more useful.

 

[fls]

Uh unfortunately no. I believe the sensitivity and specificity for appendicits is only in the mid to high 50s and even in childhood bacteremia isn't all that good either, the blood culture is usually more useful.

Yeah, I shouldn't have said "rule-in". What I meant is that these decision tools help you decide whether to even bother performing more definitive tests.

Linda

 

[fls]

Nope. Nothing concrete in our ER literature for a CRP for strep throat.
BTW: Isn't the strep pharyngitis scoring system shown to be terribly unreliable? I like my Rapid Strep test.

I thought the scoring system helped you decide who to perform a Rapid Strep test on?

Linda

 

[paximperium]

I thought the scoring system helped you decide who to perform a Rapid Strep test on?

Linda

I use it that way, someone with 3 or more points gets a rapid strep.
I was just wondering if TAM uses solo.

 

[T.A.M.]

Nope. Nothing concrete in our ER literature for a CRP for strep throat.
BTW: Isn't the strep pharyngitis scoring system shown to be terribly unreliable? I like my Rapid Strep test.

When I was in the ER I used the rapid swabs a lot. Not the greatest of value for me in the clinic setting, or cost effective. Pay for the swab, then I would have to pay a courier to bring it to the lab, then once the lab processed it I would have to receive a call with the results, then I would either (A) get the patient back in again, or (B) waste my time on the phone calling the patient, and then the Pharmacy with a script (if positive). If you knew the number of sore throats I see in the clinic in the run of the day.

I use the scoring system alone, and I find it relatively reliable.

http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1239715&pageindex=3

This system is a little more complex (use more factors to arrive at a score) and they have a 71% sensitivity, 71% specificity.

I guess, in a perfect world, where easy access to the most effective test were inexpensive and at your fingertips, I would do as I did in the ER, which is pretty much as Pax does, swab those you suspect, and treat those that are positive.

However, in the real GP clinical world, where you pay for the swab, and you pay for the courier, and you pay for the time you are on the phone (you do not get paid to be on the phone with pharm or patient), one has to sometimes compromise.

On average, I treat with antibiotics, about 1 in every 10 cases of sore throat. That is about 10%, so I do not think I am doing too bad.

As soon as the provincial govt coughs up the money to order CRPs, and pay for Rapid Swabs and all the costs of processing it from the satellite GP clinics, then I am in...like Flynn.

As I am sure Pax will attest to, he can score them (and/or simply use his clinical judgement), swab the 3-5 scores, send them back into the waiting room, and in 30-60 minutes his answer arrives in front of him. He then treats and sends...not so easy here.

TAM

 

[Ivor the Engineer]

Exactly. There's no reason to hold lay-people exempt from those processes we have already documented with respect to decision-making in medicine when studying doctors. Except that it lacks those features which mitigate bias (experience, feedback, accountability, training, awareness of alternatives, etc.)

Linda

Experience: Familiarity breeds contempt. When a mistake is made and a patient dies, physicians can use the "but the patient would have probably died anyway" excuse to avoid having to examine what went wrong. None of their colleagues are going to rock the boat because they don't want other physicians looking too closely for and at their next cock-up.

Feedback: The feedback physicians get is biased by their belief what they do actually makes a significant difference in most cases. If a physician makes a diagnosis, prescribes a treatment and the patient gets better, the diagnosis and treatment are assumed to have been correct. This line of reasoning is subject to the following two facts:

i) Most people get better with no medical treatment for the majority diseases they get. (Ivor waits for someone to take this statement out of context)

ii) Many treatments have a wide spectrum of action. The diagnosis may be inaccurate, yet the treatment may still have a beneficial effect.

These make it highly likely physicians will be wildly overconfident in both their ability to diagnose disease accurately and in the efficacy of the treatments they prescribe.

Accountability: From the comments of physicians in this thread (exl. TAM and Dr. Imago) it appears that many of them think their patients are too thick and/or ignorant to know the good diagnoses and treatments from the bad, so it seems a bit of a stretch to then claim they also feel accountable to them when physicians can pull the wool over their patients' eyes whenever they want.

Training: This reinforces physicians' belief in the efficacy of medical intervention and the need to project confidence in the face of uncertainty, a.k.a “bedside manner”.

Awareness of alternatives: Given the enormous variety of medical conditions and treatments available, it is unlikely any physician is aware of all of the alternatives which would be worth considering, and so keep much shorter lists of treatments that have worked in the past.

BTW, I defined 'diagnosis' for you. Could you answer my question please?

And if any physicians are feeling brave they can answer the follow-up:

Of the medical errors you have made, what proportion resulted in the death or permanent injury/disability of the patient?

 

[paximperium]

Does anyone bother to read Ivor's strawmen filled rants anymore?

<snip nonsensical strawman>
Of the medical errors you have made, what proportion resulted in the death or permanent injury/disability of the patient?

None. Thanks for playing.

 

[T.A.M.]

Of the medical errors you have made, what proportion resulted in the death or permanent injury/disability of the patient?

zero.

I am 4 years in General Practice (private) and I have had 8 of my patients die. All of them died of illness they were being appropriately treated for, and none of them died of anything I misdiagnosed.

TAM