A fascinating and somewhat disturbing article at the New York Review of Books by Jerome Groopman looks at what counts for progress in medical diagnosis and finds it to be more of a mixed bag than most readers would assume. This won’t come as much of a surprise to those who know a bit about the field (one of my colleagues who worked at the National Institutes of Health called it “a medieval art”). But what is a tad disconcerting is that the efforts to make medicine more scientific may not in fact be a plus.
That may sound simply bizarre to readers. Isn’t evidence based medicine a good thing? Well, maybe not.
One of the reasons this piece struck a chord with me is that some of the efforts to make medicine more scientific parallel, in their negative aspects, the push to make economics more scientific. In medicine, this means developing more rules and tools for diagnosis; in economics, the course chosen was to impose more “rigor” which meant make greater use of mathematical exposition (proof-like theoretical papers) and to have “empirical” papers centered around statistical analysis of data sets.
Now while this all may sound well and good, in fact, both are methodological choices that limit investigation. For instance, evidence based medicine seeks to gather symptoms and then use that to determine what the ailment might be. Well, the problem is these protocols have been developed from people with only one thing wrong with them. Many people who show up in doctor’s offices have multiple pathologies. So a lot of effort is being expended to develop an approach that has limited value in the field, and worse, doctors are increasingly expected to conform to it.
An analogous problem in economics is the discipline has to ignore of finesse the role of uncertainty (unknown unknowns, as opposed to risk, outcomes that can be estimated with some precision). Frank Knight and John Maynard Keynes were both leery of undue reliance on math (and both were skilled in the art) for that very reason.
Another way that the desire to systematize medicine may not represent progress is that it limits doctors’ observational methods. Doctors look at a number of elements of a patients’ condition: skin tone, energy level, the quality of their breathing. Some of these do not fit neatly into diagnostic scoring methods and are thus discarded, resulting in information loss. There is in particular in medicine a distaste for seemingly old fashioned diagnostic methods even when they are more accurate than tests. My favorite pet peeve here is mammograms. A manual breast exam, whether done by the patient herself or by an experienced examiner, is far more successful at picking up the fast moving, dangerous cancers that pose a health risk. Mammograms are in fact a lousy test, good at picking up benign or slow moving growths (the ones patients will die with rather than of) and poor at picking up the deadly type. But women are hectored to have mammograms and they are falsely treated as a gold standard. Again, the analogy in economics is the preference for using data sets, and not having much interest in analyses that include hard and qualitative data (an author might include some discussion in a narrative section of his paper, as illustration or qualification, but there is not much receptivity to using qualitative analysis to supplement data sets with gaps).
Perhaps most important, Groopman stresses that the focus on methodology is dehumanizing medicine.
The ability to recognize complex patterns is one of our highest forms of intelligence, and one both disciplines seem inclined to devalue. Admittedly, as Malcolm Gladwell demonstrated in his book Blink, this faculty can be remarkably accurate or wildly wrong. Somehow, embracing technology too often leads to a rejection of older approaches, rather than figuring out how to use the best of both methods.
From Groopman:
Carrying the Heart: Exploring the Worlds Within Us
by F. González-Crussi
Kaplan, 291 pp., $26.95The Deadly Dinner Party and Other Medical Detective Stories
by Jonathan A. Edlow, M.D.
Yale University Press, 245 pp., $27.50Several months ago, I led a clinical conference for interns and residents at the Massachusetts General Hospital…
The subject of the conference centered on how physicians arrive at a diagnosis and recommend a treatment—questions that are central in the two books under review. We began by discussing not clinical successes but failures. Some 10 to 15 percent of all patients either suffer from a delay in making the correct diagnosis or die before the correct diagnosis is made. Misdiagnosis, it turns out, is rarely related to the doctor being misled by technical errors, like a laboratory worker mixing up a blood sample and reporting a result on the wrong patient; rather, the failure to diagnose reflects the unsuspected errors made while trying to understand a patient’s condition.[1]
These cognitive pitfalls are part of human thinking, biases that cloud logic when we make judgments under conditions of uncertainty and time pressure. Indeed, the cognitive errors common in clinical medicine were initially elucidated by the psychologists Amos Tversky and Daniel Kahneman in their seminal work in the early 1970s.[2] At the conference, I reviewed with the residents three principal biases these researchers studied: “anchoring,” where a person overvalues the first data he encounters and so is skewed in his thinking; “availability,” where recent or dramatic cases quickly come to mind and color judgment about the situation at hand; and “attribution,” where stereotypes can prejudice thinking so conclusions arise not from data but from such preconceptions.
A physician works with imperfect information. Patients typically describe their problem in a fragmented and tangential fashion—they tell the doctor when they began to feel different, what parts of the body bother them, what factors in the environment like food or a pet may have exacerbated their symptoms, and what they did to try to relieve their condition. There are usually gaps in the patient’s story: parts of his narrative are only hazily recalled and facts are distorted by his memory, making the data he offers incomplete and uncertain. The physician’s physical examination, where he should use all of his senses to try to ascertain changes in bodily functions—assessing the tension of the skin, the breadth of the liver, the pace of the heart—yields soundings that are, at best, approximations. More information may come from blood tests, X-rays, and scans. But no test result, from even the most sophisticated technology, is consistently reliable in revealing the hidden pathology.
So a doctor learns to question the quality and significance of the data he extracts from the medical history of the patient, physical examination, and diagnostic testing. Rigorous questioning requires considerable effort to stop and look back with a discerning eye and try to rearrange the pieces of the puzzle to form a different picture that provides the diagnosis. The most instructive moments are when you are proven wrong, and realize that you believed you knew more than you did, wrongly dismissing a key bit of information that contradicted your presumed diagnosis as an “outlier,” or failing to consider in your parsimonious logic that the patient had more than one malady causing his symptoms…
I worried aloud about how changes in the delivery of health care, particularly the increasing time pressure to see more and more patients in fewer and fewer minutes in the name of “efficiency,” could worsen the pitfalls physicians face in their thinking, because clear thinking cannot be done in haste…
Like all doctors educated over the past decade, the residents had been immersed in what is called “evidence-based medicine.” This is a movement to put medical care on a sound scientific footing using data from clinical trials of treatment rather than on anecdotal results. To be sure, this shift to science is welcome, but the “evidence” from clinical trials is often limited in its application to a particular patient’s case. Subjects in clinical trials are typically “cherry-picked,” meaning that they are included only if they have a single disease and excluded if they have multiple conditions, or are receiving other medications or treatments that might mar the purity of the population under study. People are also excluded who are too young or too old to fit into the rigid criteria set by the researchers.
Yet these excluded patients are the very people who heavily populate doctors’ clinics and seek their care…
At the conference, an animated discussion followed, and I heard how changes in the culture of medicine were altering the ways that the young doctors interacted with their patients. One woman said that she spent less and less time conversing with her patients. Instead, she felt glued to a computer screen, checking off boxes on an electronic medical record to document a voluminous set of required “quality of care” measures, many of them not clearly relevant to her patient’s problems…
During my training three decades ago, the team of interns and residents would move from bedside to bedside, engaging the sick person in discussion, looking for new symptoms; the medical chart was available to review the progress to date and new tests were often ordered in search of the diagnosis. By contrast, each patient now had his or her relevant data on the screen, and the team sat around clicking the computer keyboard. It took concerted effort for the group to leave the conference room and visit the actual people in need…
The two chief residents seemed deeply engaged by their patients’ lives and struggles, yet deeply frustrated, because that dimension of medicine, what is termed “medical humanism,” was, despite much lip service, given short shrift as a consequence of the enormous change in how medical care is being restructured.
What I heard from the residents at the Massachusetts General Hospital was not confined to that noon meeting or to young physicians. A close friend in New York City told me how his wife with metastatic ovarian cancer had spent six days in the hospital without a single doctor engaging her in a genuine conversation….no one attending to her had sat down in a chair at her bedside and conversed at eye level, asking questions and probing her thoughts and feelings about what was being done to combat her cancer and how much more treatment she was willing to undergo. The doctors had hardly touched her, only briefly placing their hands on her swollen abdomen to gauge its tension. The interactions with the clinical staff were remote, impersonal, and essentially mediated through machines.
Nor were these perceptions of the change in the nature of care restricted to reports from patients and their families. They were also made by senior physicians. My wife and frequent co-writer, Dr. Pamela Hartzband, an endocrinologist, reported conversations among the clinical faculty about how a price tag was being fixed to every hour of the doctor’s day. There were monetary metrics to be met, so-called “relative value units,” which assessed your productivity as a physician strictly by measuring how much money you, as a salaried staff member, generated for the larger department. There is a compassionate, altruistic core of medical practice—sitting with a grieving family after a loved one is lost; lending your experience to a younger colleague struggling to manage a complex case; telephoning a patient and listening to how she is faring after surgery and chemotherapy for her breast cancer; extending yourself beyond the usual working day to help others because that is much of what it means to be a doctor. But not one minute of such time may be accountable for reimbursement on a bean counter’s balance sheet.[5]
Still, I wondered whether my diagnosis of the ills of modern medicine was accurate. Perhaps I was weighed down by nostalgia, my perspective a product of selective hindsight. Certainly, coldly mercenary physicians were familiar in classical narratives of illness. Tolstoy satirized “celebrity doctors” who were well paid for offering Ivan Ilych ridiculous remedies for his undiagnosed malady while ignoring his suffering. Turgenev in “The Country Doctor” depicted an unctuous provincial physician whose degree of engagement with the sick was tied to the size of their pocketbook. Molière repeatedly lampooned the folly of pompous and greedy physicians.
Such doctors have been members of the profession since its founding. And it would be naive to believe that money is not one part of the exchange between physician and patient. But only recently has medical care been recast in our society as if it took place in a factory, with doctors and nurses as shift workers, laboring on an assembly line of the ill. The new people in charge, many with degrees in management economics, believe that care should be configured as a commodity, its contents reduced to equations, all of its dimensions measured and priced, all patient choices formulated as retail purchases. The experience of illness is being stripped of its symbolism and meaning, emptied of feeling and conflict. The new era rightly embraces science but wrongly relinquishes the soul.
n his book Carrying the Heart, Dr. Frank González-Crussi, a professor of pathology at Northwestern University, has made a sharp departure from medicine as a cold world of clinical facts and figures. Rather, he asks us to return to a view of the body not as a machine but as a wondrous work of creation, where both the corporeal and the spiritual coexist. His aim, he writes, is
to increase the public’s awareness of the body’s insides. By this, I do not mean the objective facts of anatomy, for most educated people today have a general, if limited, understanding of the body’s parts and functions. I mean the history, the symbolism, the reflections, the many ideas, serious or fanciful, and even the romance and lore with which the inner organs have been surrounded historically.
This précis captures the beauty and charm of his book. I learned from González-Crussi that for centuries the stomach was considered the most noble of organs, directing all important physiological functions. The ancients, González-Crussi tells us, called the stomach “the king of viscera,” “the senate or the patrician class; the bodily parts were the rebellious plebeians.” Shakespeare repeats this fable in Coriolanus, where the stomach lectures the rest of the body’s organs about the importance of its function.
Our gastric elements were seen as having a leading part in joy and adversity, and were the seat of the soul—predating the belief that the spirit was housed in the heart or the brain. This regal position was ultimately relinquished through the observations of Dr. William Beaumont in 1822. Beaumont studied a young French-Canadian named Alexis St. Martin, who suffered an accidental musket shot to the belly. He was left with a perforation some two and a half inches in circumference, through which the doctor could look into the living stomach and perform experiments on its workings. Via this “stomach window,” the physiology of the organ was gradually deciphered, and its fabled status faded.
No part of our anatomy, González-Crussi recounts, has failed to fascinate poets, priests, and philosophers—including the working of the colon. In the chapter on feces, we learn that the Chinese had a divinity of the toilet. “This was Zi-gu, ‘the violet lady.’ She was not entirely fictional,” González-Crussi writes,
but took her origin from a flesh-and-blood woman who lived about AD 689. To her misfortune, she was made the concubine of a high government official, Li-Jing. The man’s legitimate wife, overcome by jealousy, killed Zi-gu in cold blood while she was visiting the toilet. Since then, her ghost has haunted the latrines, “a most inconvenient circumstance for anyone in a hurry.”
The colon and its product also were part of the theology of the Aztecs. They believed that excrement
was capable of bringing ills and misfortune, and associated with sin, but also powerful and beneficent, able to ward off disease, to subdue the enemy, and to transform sexual transgressions into something useful and healthy.
Gold was termed “the sun’s excrement” and the sun god Tonatiuh deposited his own feces in the form of this precious element in the earth while he passed through to the underworld.
González-Crussi also reminds us that there was an inordinate fixation on one’s bowels during the Victorian age, which honored values of order, temperance, respect for tradition, and sexual repression. Personal self-control, the mark of British culture, was at odds with that urgent process of expelling air and waste:
Perhaps no greater ambivalence has ever existed toward the bowel than in Victorian England, where this organ was viewed with simultaneous skittish embarrassment and fascination, shame and fixed interest, shy modesty and hypnotic engrossment.
A shocking consequence of this cultural tension is that one of the most proficient surgeons of the era, William Arbuthnot Lane, who devised procedures to successfully set compound fractures, concluded that without a colon, man would free himself from inner toxins and extend his health and longevity. A natural physiological function became a pseudodisease. Initially, Lane devised operations to bypass the large bowel, and he then moved on to perform total colectomies. Patients flocked to him from all over Great Britain and abroad, certain that their lives would be more salubrious and fulfilling without their large intestine.González-Crussi treats with similar scholarship and playful insight the uterus, the penis, the lungs, and the heart. He melds history with literature, religion with science, high humor with serious concerns. The sum of his narrative shows that medicine does not exist as some absolute ideal, but is very much a product of the prevailing culture, affected by the prejudices and passions of the time…But our culture, with its worship of technology and its deference to the technocrat, risks imposing an approach to medical care that ignores the deeply felt symbolism of our body parts and our desperate search for meaning when we suffer from illness…..
Jonathan Edlow is concerned with the doctor not as poet or philosopher or priest but as detective. An emergency room physician at the Beth Israel Deaconess Medical Center, a Harvard teaching hospital in Boston where I also work…Both detective and doctor not only assemble evidence but must judiciously weigh what they have found, seeking the underlying value of each clue. The successful doctor-detective must be alert to biases that can lead him astray. This was the message of the clinical conference those months ago; and in Edlow’s tales of difficult diagnoses, we can observe detours that are due to “anchoring,” “availability,” and “attribution.”…
In his chapter “An Airtight Case,” Edlow implicitly shows why so many of the standard formulas that policymakers promulgate fall short when answers are not obvious. He describes how an office worker (whom he calls Philip Bradford) thought he had developed “the flu—the usual cough, fevers, chest pain, just feeling lousy….” What appeared to be the symptoms of a typical viral illness did not spontaneously disappear. A chest X-ray showed pneumonia, but treatment with antibiotics proved ineffective. The presumptive diagnosis changed from infection to cancer, and Bradford was told by his doctor that he needed his chest opened to resect a piece of lung and identify the tumor.
Fortunately, the patient sought a second opinion, from a senior thoracic surgeon, and the diagnosis was again thrown into doubt—the specialist believed that the problem was neither infection nor an abnormal growth. Over the ensuing months, the mysterious pneumonia spontaneously cleared up, but after a year Bradford again started coughing and running a fever. “His chest X-ray blossomed with ominous nodules,” Edlow writes, “then, as with the previous episode, after a few weeks his symptoms mysteriously vanished.”
It was the good fortune of this ill office worker with the mysterious lung problem to see Dr. Robert H. Rubin, an infectious disease specialist at the Massachusetts General Hospital….what is striking is his “low-tech” thinking: “I was immediately impressed by three aspects of the case,” Rubin recalled.
First was that Bradford appeared healthy and athletic, not the picture of someone with a chronic disease. Second, between episodes, he continued to jog over five miles with no apparent problem. And third, his physical examination was normal.
With such comments, we are a universe away from sophisticated blood tests and CT scans, and deeply rooted in the world of the physician’s five senses. The most seasoned clinicians teach that the patient tells you his diagnosis if only you know how to listen. The clinical history, beyond all other aspects of information gathering, holds the most clues. And it is this part of medicine—the patient’s narrative, the onset and tempo of the illness, the factors that exacerbated the symptoms and those that ameliorated them, the foods the patient ate, the clothing he wore, the people he worked with, the trips he took, the myriad of other events that occurred before, during, and after the malady—that are as vital as any DNA analysis or MRI investigation.
Rubin concentrated that kind of questioning and listening on Bradford. He did not quickly dispatch him for more tests, but instead sharply shifted his focus to investigate clues in Bradford’s environment that could reveal what was causing inflammation in his lungs. Edlow goes on to write in clear and fluid prose about how Rubin systematically pursued what could be the agent provocateur in the case. The lengths to which Rubin went are extraordinary, his skill in eliciting and interpreting the patient’s narrative exemplary, and certainly not part of the rushed practice of today’s clinic. I won’t spoil the end of the story; what is important is that the solution came about only by dogged thinking that required the kind of time and inquiry that is absent in much of modern medical care.
The other detective stories in Edlow’s compilation transmit the same message: we most need a discerning doctor when a diagnosis is not obvious, when the clues are confusing, when initial tests are inconclusive. No simple technology can serve as a surrogate for the probing human mind. Edlow’s book is a welcome complement to González-Crussi’s. Both show us that medicine is truly an art and a science that requires doctors both to decipher the mystery and illuminate the meaning of the body in health and disease.
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O, don’t get me going about “evidence” based medicine…
too late.
In a nutshell, evidence based medicine tells you that your decision should be based on an average – that is, the data from clinical trials. I believe in clinical trials, as limited as the conclusions that you can draw from them are, because some data is better than none.
However, the fact that some limited knowledge can be gleened from clinical trials does not negate how limited the conclusions from such trials are. Each individual may have a different response to a drug – Some will have very good results, many no significant response, and some very adverse reactions.
Furthermore, there is a tremendous bias in not publishing studies that show no effect (EITHER positive or negative – researchers feel that publishing such studies is like kissing your sister).
comparative effectiveness tells us that most cancer treatments are ineffective.
I was going to make a longer comment similar to fresno dan’s but he saved me the trouble. As Yves points out, there is “information loss” in gathering evidence. Every single medical study undertaken results in a huge amount of information loss, mostly because of the assumption that the subjects are all the same. But the subjects are not all the same. Their afflictions may be in different stages. Their genetic codes are without question different. So every single study always fails to prove its underlying assertion. As just one example of the widespread misunderstanding of the results of studies, just because a medication does not “work” (i.e., show a statistically significant difference from the control group) for a wide group of people does not mean that such medication does not “work” for some small subset of the group. Of course, in my opinion, it is the opposite problem that is much worse — the idea that these medications do “work” and the side effects are negligible — but this is a result of the incentives in the system (drug companies make money, doctors can now spend less time with the patient because their sole task is write a prescription, etc.).
Medical diagnosis is fundamentally about pattern recognition and family resemblance. Many small factors co-occur. Other factors cannot occur together. Individuals vary in what symptoms they have, and in the intensity of the ones they share so that two people with identical conditions may have radically different reactions to them. One issue with changing small pieces of data in such patterns is that they are not in and of themselves ‘diagnostic’ and the more one stares at the particular the less one sees the gestalt. Modern medicine hates the imprecision of this all, which makes it no less true.
I’ve known three (at least three) fabulously talented diagnosticians in my life: one a psychotherapist, one an occupational therapist, one an internist. None of them spent any too much time ordering more tests, or comparing case histories. All of them spent a great deal of time with a great number of patients. And that is how one gets good at pattern recognition, confronting a perceiving mind with the pattern to be recognized.
The average practitioner of medicine operates a boutique business, needing to see so many clients each day and spend other available time on business. In the remnants of the industrial society, engineers and scientists will spend years studying and analyzing their system to diagnose and correct problems. When your shooting from the hip 25 times per day and have little time for extending your skill set, it’s amazing there aren’t more accidents !
If I were a betting man, I wager that pharmaceutical and medical device vendors control the “education” of the average practicing physician. Short and sweet technical notes, biased to cover up product imperfections, promote competitive advantage, and ignore unprofitable common sense remdies, that can be scanned for info in seconds between patients.
A very interesting post – I run into similar issues involving environmental chemistry. The EPA has developed standard lists of “target compounds” and contaminants not on the list are often never found.
One site I was involved with was a former dye works. For several years, I tried without success to get samples tested for dye compounds, which are not on the standard lists. After a while, a report was issued which said certain soil samples had no significant contamination. The boring log (the geologist’s description of the physical appearance of the soil samples, which is a rarely-read appendix to these reports) described one of these samples as “orange sludge.” Pointing that out caused sufficient embarrassment that attention was finally paid to the non-target compounds.
It is not only the doctors who are in the wilderness, but our entire public health apparatus. I saw an article in our local newspaper recently in which public health officials said that everyone who has ever had un-protected sexual intercourse should have an AIDS test. Huh?! If applied nationally, this would likely mean hundreds of thousands of false positives, untold mental anguish, and many ruined lives. They just aren’t thinking. Their assumption is that tests are perfect. Tests are not. And how many doctors or public health personel have ever heard of Bayesian statistical analysis? They may not fully understand the odds of a test being accurate in a population with a low incidence of the disease being tested for.
Ted Kaptchuk, author of ‘The Web That Has No Weaver’, and an assistant professor at Harvard Medical School, says that Chinese medicine is quite competitive with Western medicine in its ability to treat illnesses. Each method is better at treating some illnesses than others. In China, local folk medicine practitioners (as opposed to theory heavy doctors of Chinese medicine), treat simple illnesses. I’ll bet that keeps costs down and they spend a lot of time with the patient, increasing the likelihood that the patient is ‘healed by the goodness of their physician’.
I think that in time, with a broader selection of data and a more nuanced way of collecting and processing it and deciding what conclusions to draw from it and with what certainty these should be held, evidence based medicine could be an effective adjunct/tool that might help physicians.
There may be no alternative for experience, but it would help the profession a lot of newer physicians could draw more on the experiences of the older ones, and if poor diagnosticians had the benefit of some of the heuristics used by the better ones.
A lot of these commenters sure do know a lot about practicing medicine…which is interesting considering that none appear to be doctors. I wonder what a practicing physician would say about these simple deductions regarding that which took years and years of education and experience….
Moving on to the post: How would a holistic approach fare within our present tort system? I know most people on this site act as if our current tort system is but a mild inconvenience for the practicing physician…yet that vast majority of practicing physicians will state that our tort system is huge impediment to a more flexible and holistic approach.
So we are left with physicians who are not only incompetent diagnosticians…but also dishonest about the impact of the specter of protracted litigation in the event of a misdiagnosis on an extremely complex system. “Oh Doctor, how you exaggerate! The threat of litigation is not a threat to you. It does not keep you and all of your colleagues up at night. And even if you are troubled, it’s because you are so inept at your work. Everyone knows that malpractice is responsible for hundreds of thousands of deaths each year. Buck up, Doc.”
The idea of Diagnosis as Art in a Complex System is so contrary to our present tort system that the two are wholly incompatible.
Our tort system is a direct response to this very issue…and our Tort Monster demands retribution: “Diagnosis is NOT an Art. Diagnosis is a Science. If a diagnosis was missed, it’s NOT because of this “Complex System” nonsense…it’s because the doctor made a mistake. Thus, if a diagnosis is missed, the doctor must pay. If we don’t make the doctors pay for every mistake possible, just think how bad it will be for future patients. If there is a Victim, then there is a Perpetrator.”
As to Jim at 8:35 who extols the virtues of Chinese folk practitioners…
It might be a myth—or National Geographic might be delusional, but: Many of these “healers” use gorilla fingers to ward off spirits, lions’ teeth for strength and tiger paws for virility. They are a market for poachers and are more medieval quack than effective healer. They really need to be stopped.
Dan Duncan,
Have you ever received Chinese medicine as a form of medical treatment? IF not, I don’t see how you can claim “it’s more of a medieval quack than effective healer.” The scientific literature on acupuncture is also mixed as one can find many papers to both support and refute acupuncture, so the jury is still out on that.
Personally, I’ve been to a Chinese doctor on a number of occasions, usually after I go to see my Western doctor first, and the vast majority of the time the Chinese doctor’s treatments worked. The treatments were mostly herbs, not acupuncture. Do I have scientific proof to back up my claim that the herbs were effective for me? Nope, of course not. All I know is that I feel much better after taking the herbs than before, and that’s all the proof I need.
Having said all this, I’m confident there is a very good scientific basis behind the effectiveness of a lot of herbs prescribed in Chinese medicine that has not been explored, most likely because of bias against Chinese medicine in the West.
Dan, I think most of the people here are not doctors, but do share something else in common: we tend to have very specialized skills in specific fields. At the risk of a lack of humility, I think most of the regular commenters, not to mention Yves, are experts in complex and difficult fields.
And as such, your point on the challenges of diagnosis resonate. Most difficult fields, certainly medicine but also finance, economics, information systems, counseling, etc., focus on complex systems where “scientific” diagnoses are useful, but far from sufficient. They require judgment from experts, based on years of experience. Part of my responsibilities include looking for fraud, and I can assure you that no statistical measure will ever substitute for the judgment of a skilled fraud examiner (or two or three; as in “House”, experts work best in small teams.)
And beyond judgment, certain fields, like medicine, involve a high level of uncertainty. As such, the best approach is sometimes a “wait and see” approach, and the best approach is sometimes trial and error. That obviously may be something that doctors are reluctant to tell patients; but anybody who has worked with a complex system will understand.
Except lawyers. And so I essentially agree with you in your point on litigation. I work with lawyers, and when it comes to complex systems, too many of them simply don’t get it. They live in a world of legal facts, where something is either legally true, or it isn’t, and the truth or falsehood of a fact can either be established, or it can’t. There is little comprehension or appreciation of uncertainty, of complexity, of the role of expertise, of the role of subjective judgements. I have long felt that litigation is out of place in a field where the judgement and expertise of a specialized practitioner is so critical to the outcome; and where constant second-guessing of outcomes can lead to deeply impaired decision-making. I find the notion of lawyers second-guessing seasoned medical practitioners to be deeply problematic; three years of law school are not an acceptable substitute for six plus years of medical education and twenty years of experience.
It is interesting that Dan rebukes everyone else on this site for pontificating about physicians (because the posters are not physicians), and yet he feels justified in pontificating about the tort system’s effect on physicians (even though he is apparently neither a physician nor an attorney, lawmaker or judge).
I find it further odd that he states (without evidence) that the “vast majority” of physicians would “state that our tort system is huge impediment to a more flexible and holistic approach.” It is not only odd that he states this without evidence, but that he states this with the apparent belief that this sentiment among physicians would be dispositive on the issue or somehow make its truth incontestable. I can assure you that even the “vast majority” of experts on any particular issue are sometimes wrong about their area of expertise. I can further assure you that people sometimes even misunderstand *their own motivations* for *their own actions*.
Alas, that’s where most of my disagreement ends. I don’t know why Dan continues to try to exploit every opportunity, no matter how tangential to the topic at hand, to express what I mostly find tired and dull “conservative talking points,” but I do tend to agree that the tort system could tolerate a good amount of reform, as long as we agree that the malpractice insurance companies are part of the tort system. At the same time, I wouldn’t allow physicians alone to design the medical tort system. I can’t imagine that even Dan was suggesting such an obviously idiotic thing.
Writing as a physician, it is true that most physicians can only practice their profession properly using heavy patient interaction. See Wikipedia on the Father of Modern Medicine, William Osler:
Osler insisted that his medical students get to the bedside early in their training . . .
Osler’s contribution to medical education of which he was proudest was his idea of clinical clerkships—having third and fourth year students work with patients on the wards. He pioneered the practice of bedside teaching making rounds with a handful of students, demonstrating what one student referred to as his method of “incomparably thorough physical examination.” . . .
“If you listen carefully to the patient they will tell you the diagnosis” which emphasises the importance of taking a good history.
I believe another must-read is How American Health Care Killed My Father, in the September Atlantic Monthly. http://www.theatlantic.com/doc/200909/health-care
“After the needless death of his father, the author, a business executive, began a personal exploration of a health-care industry that for years has delivered poor service and irregular quality at astonishingly high cost. It is a system, he argues, that is not worth preserving in anything like its current form. And the health-care reform now being contemplated will not fix it. Here’s a radical solution to an agonizing problem.”
Combined with the problems Yves has pointed out today, the problems outlined in this Atlantic Monthly article show that the centralization of health care as envisioned by the health care reform proposals now under consideration in the Congress will not solve our major health care problems. What we will see is another quiet coup, a takeover of health care by an incestuous combination of government and industry. Such change will be primarily for the benefit of government and the health care industry, not for the average American.
In conclusion, we are so screwed. Good night, and good luck.
Anyone who wants to get a sense of what being a doctor was about can read the linked excerpt from John O’Hara’s The Doctor’s Son, from a flu epidemic:
http://books.google.com/books?id=Yli9amzE0kgC&pg=PA141&lpg=PA141&dq=the+doctor's+son+john+o'hara&source=bl&ots=teQ499p80D&sig=JuE6RX_44vu9S_yj0USKJguObto&hl=en&ei=M4_YSpiSJYbQ8QbM5ey2BQ&sa=X&oi=book_result&ct=result&resnum=6&ved=0CCAQ6AEwBQ#v=onepage&q=&f=false
Diagnosis is a true art, not a science. To me, there are three very deeply disturbing things I’ve learned over the years about the medical profession in this country. First, they learn very little about statistics during med school. This means that, while they are obligated to keep current with a continuing education requirement (in most places – remember that this is a state-run enterprise, licensing doctors), they are not really obligated to be equipped to understand the meaning of a well-designed study or to appreciate the failings of a flawed one.
Among other things, this means there are a whole lot of doctors out there who, while they are completely reliant on test results indicating a “normal” range set by a particular lab, have only a passing acquaintance with the nature of the bell curve represented by those results.
Second, doctors do not listen to women at all. I hardly ever meet a man who was told that some problem is just a change of life, in their head, or something to simply be tolerated. Women are told this continually. This is unreal and has to stop. God save you if you suffer from anything involving headaches, stomach pain, or fatigue.
Third, unless you are able to reproduce the right buzz words in describing your symptoms, a doctor will not listen to them in the context of a specific potential problem. You need to be able to trigger a specific piece of the decision tree for them, or they will shockingly often fail to consider a family of possible causes for any given problem. The literature is littered with examples of people describing their problems to a doctor with no result until finally they used a different word, or developed one more symptom, that finally triggered the right thoughts for the doctor. It’s a species of rigid thinking that pervades medicine — and creative thinking, while definitely present in those who are gifted diagnosticians — is not something that is particularly rewarded and fostered by the medical-school environment.
These are flaws in the way that we train doctors and could be remediated. I think that it would help with the vast, underground misdiagnosis epidemic.
Mechanic wrote: If I were a betting man, I wager that pharmaceutical and medical device vendors control the “education” of the average practicing physician.
Mechanic, you can be 100% certain. Just search Dr. Jerome Kassirer’s “On the Take” and John Abrahamson’s “Overdosed America” for all the corroboration you want. Kassirer is former editor of NEJM and Abrahamson is professor of medicine at Harvard.
Nassim Taleb’s notebook entries on the matter of medicine, statistics and iatrogenics may be of interest. See them here under the heading “Medical Notes”:
http://www.fooledbyrandomness.com/notebook.htm
As an oncologist who is a more or less daily reader of the blog, I want to thank you for writing on this topic and more generally for the ongoing thread of economic and finance views that ring true to me and can’t be found in the MSM. I have learned a lot and feel much better informed due to your efforts. I disagree with your comments regarding mammography, however; while I think your larger point may have some merit, mammography is a poor example to use.
To add to the discussion, I would also recommend reading Abraham Verhese’s essay published in the WSJ (The myth of preventive care or something to that effect) regarding the “ipatient”.
Evidence based medicine assumes that medical decisions fall within the bounds of rationality. This is not true. Medical decisions are a combination of science and art. This is from Herbert Simon.
Another problem with evidence based medicine is that someone, somewhere makes the decision as to what is considered evidence based medicine and what is not. This introduces bias. For instance, in the case of a government paying for health care, the tendency will be for cost-benefit type studies to have a prominence above their scientific value. This is from Hayek’s The Use of Knowledge in Society.
It is a truism in medicine that a good history is about 70% of what makes up the diagnosis with physical exam, tests, and imaging making up the rest.
People train to how the system they are in rewards them. In medicine, the development of good clinical skills is rarely taught and is picked up mostly by osmosis. What is emphasized instead is test taking: the introductory MCAT, pimping on rounds, the STEP tests, and boards. So what the system selects for is not good clinicians but good test takers. These are often people with good memories but a kind of tunnel vision. Add in the incentives of high salaries and you have a prescription for mercenary anal-retentive types. There will, of course, be exceptional people in any profession but this describes about 80-90% of the doctors I have known.
The doctors are facing the same problem we are all facing due to Information Technology and technological progress. Each of us faces the problem of discerning valuable information from the deluge of “background” information or “noise” in our lives. In other words, the difference between wisdom and knowledge. Wisdom is knowledge or information that is highly useful and beneficial to the person that possesses it. It also has a long shelf life. Then there’s knowledge that is useful for now, but will be useless in the future. Then there’s information that may just be “noise” – gossip, innuendo, daily news. The more information one has, the harder it may be to discern the answer unless the information is steadily pointing you to the answer. But as pointed out above in the article, it’s asking the right questions that leads to the right answers. If today’s doctors aren’t being taught how to think properly and critically, then what happens to us and them? Also, one wonders if the doctors haven’t brought this upon themselves. They limit their population so that their standard of income and living is high. If there were more doctors and nurses, there might be a more acceptable ratio of caregivers to patients, and less stress and pain all around. They also cloak themselves in science to legitimize their profession such as wearing a white lab coat on rounds. If one thinks that the smartest people go into medicine, think again. It’s harder to be a veterinarian than it is a doctor. The entrance standards are higher for Vet School, and you have to treat multiple species, not just one like doctors do.
Regarding the gorilla fingers, et al…’There are more things in heaven and earth, Horatio,; Than are dreamt of in your philosophy.’ I am opposed to poaching, and tort lawyers, unless they are the poachees. I think you, Dan Duncan, are quite correct in pointing out that the idea of Diagnosis as Art in a Complex System is contrary to the way our Tort system works. However, we see the reality of the Art in the way that some doctors are dramatically better than others in following a diagnostic argument based on a variety of evidence to its logical conclusion. Why is this? The Superior skill must be due to art, intuition, or something that they don’t exactly teach in medical school.
My business school statistics professor loved stats so much that he read medical studies for fun, just to check their statistics. His conclusion? Many of the medical scientists who perform the studies screw up the statistics. And despite being peer reviewed, the mistakes often fall through the cracks.
Jim,
With all due respect to your business school prof, while misuse of statistics is a problem, I doubt well applied statistics would yield as much improvement as he assumes.
Nassim Nicholas Taleb described what he called the fourth quadrant. He sets up a 2 by 2 matrix. On one axis is phenomena that are normally distributed versus ones that have fat tails or unknown tails or unknown characteristics. On the other axis is the simple versus payoff from events. Simple payoffs are yes/no (dead or alive, for instance). “How much” payoffs are complex.
Models fail in the quadrant where you have fat or unknown tails and complex payoffs. A lot of phenomena fall there, such as epidemics, environmental problems, general risk management, insurance, natural catastrophes. And there are phenomena in that quadrant that have very complex payoffs, like payoffs from innovation, errors in analysis of deviation, derivative payoffs.
Medical practice falls in that quadrant.
More here.
There’s several analytical issues here, better considered separately.
Physicians are inaccessible because the financial incentives are set up so that the hourly pay for time doing an invasive procedure is hugely greater than time explaining things to a patient or their family. The pay is set by an obscure, official committee of the great and the good, who publish no rationale for their decisions. Surely by coincidence, the committee is dominated by specialties who have high incomes from doing invasive procedures. The situation is analogous to bonuses in finance which Yves has noted. Bad effects include diversion of the ablest people into the remuneroma specialties, overuse of the procedures, conflicts of interest concerning ownership of diagnostic equipment. In principle, we could change the incentives in both areas.
The general idea of applying science to medicine is essentially a post-Enlightenment project. Flexner said that not until around 1900 did the average patient with the average disease seeing the average physician have a better then even chance of benefit. That fits with the treatment of docs in fiction. The only admirable character in Bovary was the consultant called in from Paris. He’s thoughtful, dignified and authoritative in the only possibly helpful way. He says there’s no hope for Emma, which reassures people that they did all that could have been done. And he wasn’t a quack. The stuff that Groopmen’s pathologist romanticises is quaint gibberish. Yeah, we’ve taken some of the magic and wonder out of our concept of the colon. But if I have colitis I don’t want magic and wonder. I want a doc who knows about electrolyte balances, immune function, effects of drugs on normal flora, etc. I don’t want him to do unnecessary procedures, or do a sloppy history. But problems in delivery don’t mean the product being delivered is bad.
There are many improvements we could make to delivering the results of science to patient care. But throwing out the whole post-Enlightenment enterprise isn’t going to work. And that is what Taleb seems to want. I remember thinking when I read Black Swan that everything he said about medicine sounded like someone who’d never taken a biology course.
Medicine has always been an art. Throwing more cumbersome statistics at it does not make it more scientific — just more arcane and dangerous.
Diagnostic systems are just syndromes, collections of signs and symptoms, that unfortunately share a great deal with one another, and we usually lack true etiologies (causes) of most diseases. This is why a clinician’s clinical judgment is central. Without that, you might as well give a patient 100 different possible diagnoses everytime, and max out their insurance lifetime spending limit just on tests… Sounds like what is going on already, doesn’t it…
As far as these evidence-based approaches are concerned, sure, let these already incompetent American-trained doctors diagnose based on research made by drug companies or universities financed by medical equipment manufacturers, which is exactly what’s going on.
Fortunately, better doctors in India, Argentina, or Eastern Europe are only a plane ticket away. And, as Dan Duncan pointed out above, these doctors do practice holistic medicine, do speak with their patients, and still follow the Hippocratic Oath, which no longer occurs in the US. And yes, Dan Duncam, American doctors are disjonest too, and in fact they are taught how to lie in medical school.
Vinny G.
I think Shakespeare took the lecture about the stomach from Plutarch’s life of Coriolanus, in which the state (republic) is likened to the stomach redistributing resources to the different parts of the body according to their needs.