By Gerrit Van Wyk.
When I say “I thought”, I know I didn’t.
The word ”think” can mean many things. It can be a transitive verb, in other words used to do something about something else, such as having in mind, an opinion, to consider, to reflect, to anticipate, to remember, etc., it can be an intransitive verb, or used for doing something, for example to reason, a noun, or a thing, or an adjective, or modifier. One thing I learned late in life is when I say “I thought”, I didn’t. Also, sadly, when I was in medical school, they didn’t teach me to think things through, I learned that later on.
Jerome Groopman published How Doctors Think in 2007. He argued medicine is uncertain, hence doctors will sometimes make diagnostic and treatment mistakes, but we can reduce the risk if we understand how doctors think.
That is not a trivial issue since around 40% of diagnosis are wrong, which spills over into roughly a similar number of unnecessary tests, prescriptions, and procedures which has significant consequences. I read in a textbook the definition of a normal patient is someone who hasn’t had enough tests done yet; if we do an unnecessary test, we are likely to come across and treat something other than the presenting problem unnecessarily. Prescriptions and procedures have side effects and complications, which leads to more prescriptions and procedures. Patients get better despite an unnecessary prescription or procedure which leads to the placebo fallacy; the doctor thinks it happened because of a correct diagnosis, whereas it happened despite it being wrong, hence the wrong learning takes place. Last, but not the least, all this comes at a great cost to health care, hence, if we could eliminate 40% of unnecessary tests, prescriptions, and procedures, in one swoop the system may become affordable.
As Tversky and Kahneman pointed out, most doctors don’t reason through problems, but instead make decisions the way all of us do; because some condition is common, or because we remember a recent similar case. Before and after research on medical students shows a medical education does nothing to change that. In other words, doctors think the way we all do, and a medical education doesn’t change that.
We think of diseases as being on a spectrum from simple to complex, hence there are doctors who specialize in complex conditions and are more competent at managing them, which turns out to be wrong. Specialists make as many mistakes as generalists and for the same reasons.
We also think we can eliminate mistakes with better logic, which, today, depends on following protocols designed by experts based on pooled statistical evidence. That fails a lot of the time too, because of the complexity of the human body, our social world, and the technology we use at the same time. There are many variables you can’t know or control until you interact with the problem and must then adapt to. A treatment that to lawyers and experts seems logical may turn out to be wrong, resulting in complications or worse.
Physicians know about this uncertainty, which creates anxiety. What they need is the ability to adapt to incomplete information, but what they get at medical school instead is a formula, which, many times, lets them down. We need to teach a different approach to thinking about disease, diagnosis, and how to treat it, but, for our educational institutions, what was good for our fathers and grandfathers is good for us. It means we educate our doctors in a way that sets them up for failure.
Groopman also wrote about a colleague’s challenge to him to explain the problem of compassionate and caring physicians whose patients love them, but who are clinically incompetent (on the other side of that spectrum lies those with brilliant diagnostic ability and skills who rarely feature in online patient popularity contests).
As Kenneth Arthur pointed out, the health care product is knowledge, which means patients can’t judge clinical competency, and rely on a doctor’s social skills instead. Even physicians can’t tell until after the fact. Another problem is medical omerta; speak about a colleague’s incompetence, and you will be assassinated. Medical regulatory bodies are complicit in the charade and will not intervene until there is a complaint, which means affable incompetent doctors are unlikely to be scooped up in the net.
What can one do about this dilemma? Firstly, the medical curriculum must be rewritten to acknowledge and reflect the complexity of its subject matter, and we must teach medical students how to manage uncertainty and complexity. There are many excellent approaches they can use, but which they are not familiarized with now.
Secondly, medical registering authorities must pro-actively measure the pulse of what happens in the clinical world, and act before harm is done, and there are excellent ways to approach that as well.
Thirdly, patients must take ownership of the fact the tests, prescriptions, or procedures advised to them may not be what they need. As much as some doctors don’t like it, do your research, ask tough questions, and bring along an advocate as a second pair of ears. I was taught in pediatrics always listen to what the mother says, because their impression is never wrong, in the same way, listen to your gut before blindly accepting a diagnosis and treatment. Since mistakes are made, it is perfectly acceptable to ask for a second opinion. Doctors hate that, because it questions their ability and expertise, rather than embrace it to catch mistakes, but, ultimately, the patient lives with the consequences of the decision.
Finally, authorities and concerns paying for healthcare must reflect on what they pay for, and put systems in place to monitor that in a more sensible manner. There are good ways for doing just that, provided they are prepared to enter in a dialogue with the medical profession, which is likely to be difficult to begin with.
As always in our complex social world, there are small jackals that will destroy the vineyard. Some doctors may feel what I write is an attack on their integrity and professionalism, it is not, instead it is a genuine attempt at improving both. Medical educational institutions and regulatory authorities are monoliths isolated from the real world, and I don’t expect them to make any attempt to change their contribution to the problem anytime soon. Some patients, reading this, may completely lose faith in the medical profession, which is understandable but a complete overreaction, what they need instead is a healthy dose of skepticism without ditching the baby with the bathwater. Finally, the thinking of funders is dominated by managers at a distance from the battlefield. Only if they and doctors can see the problem from the same perspective is some sort of movement likely, In the meantime, business continues as usual as if nothing is wrong, although a lot is.