84 points by dredmorbius 10 months ago
I am a physician in the US. I think the article has valid points (esp. inpatient glucose control) but it also oversimplifies and glosses over some of medicine's more arcane aspects.
To give a tangible example I'll start with the unnecessary ankle x-ray. There is a set of guidelines called the Ottowa Ankle Rules which we use to justify ordering plain films for a suspected fracture, but there are plenty of reasons why a doctor would still get them if the criteria weren't met.
One reason is clinical judgment and experience. Guidelines are just guidelines. Ultimately the doctor is the one making the call, as well as suffering the blame for that call if things go sideways. If everything were as simple as following algorithms and checklists, medical training wouldn't take 7+ years of post-undergraduate work.
But probably the most important reason has to do with the "patient satisfaction" (customer service) aspect. Ideally medicine wouldn't be a business, but it is and there's not much we can do about that.
Patients who present to an urgent care center or ED generally carry an implicit "something is seriously wrong with me or I would have just made an appointment with my PCP" vibe. These patients often don't like it when you explain that based on your history and exam, they most likely have a sprain/strain injury and an xray is not appropriate since we want to avoid unnecessary costs/radiation exposure-- as opposed to being relieved that they only suffered a minor injury. Even when spoken in a compassionate, straightforward manner, this explanation can come across to the patient as "nothing is wrong with you / you are malingering / your concerns aren't valid / I don't care about your symptoms", etc.
Sometimes patients outright demand tests, or worse, they'll say nothing but then complain to your employers that you medically neglected them, or you are incompetent, or what have you. Now if they had the audacity to file a malpractice suit, you'd (ideally) have no problem justifying your actions in a courtroom or deposition. But say they complain to the MBA (or some other person with no medical training) who runs the clinic or care center employing you. Your argument will likely fall on deaf ears, and be countered with some diatribe about how you're causing them to lose money. In that case it's a lot easier to just order the unnecessary xray.
Basically, the squeaky wheel gets the grease. There are plenty of other examples like this, and they all come down to choosing your battles wisely. I think it's kind of hard to blame the over-worked and behind-schedule doctor who orders something like an xray or lab test rather than taking an extra 10-15 minutes discussing the pros and cons with the patient, after which the patient might still not be convinced.
Having said that, there is a problem with superfluous testing in EDs, especially ones that rely on "standing orders" where e.g. virtually any patient presenting with abdominal pain might get a CT scan before the physician even sees them (something I strongly disagree with and can't think of a legitimate excuse for).
In the U.S. I actually have witnessed both, seemingly contradictory, aspects. That is cases as you mentioned in urgent care where there is an extensive work done to you for no reason, that ends up to be even unrelated in the end, just to cover all bases and follow protocol. Yet, cases where a personal doctor is reluctant to prescribe blood work or chase symptoms that are not life-threatening, even with prior family history due to costs.
For instance, there was a with E.U. doctor referral for ultrasound and blood work. The reply was if it bothers me to consider painkillers or wait for it to get worse and come back. (Why should I take painkillers if we are not certain of the cause to begin with?) On the other hand, walking a friend into urgent care for their leg leads to a full checkup.
With the above I want to complement your view, that there is some extreme behavioral gap in how doctors' react that is not related with the patient's ailment.
And there is a lack of a middle ground between urgent care and making a personal doctor appointment. I find it surprising that if I break my leg I need to go to urgent care. There is no contagious disease, and I am not going to die if left untreated, but it is an event that requires time sensitive treatment. Yet, there is no concept of walking into a doctor's office, or at least it is not that easy.
Example case 2. Eye pain etc. After failing to get an appointment with any doctor, K is instructed to go to urgent care. K called ahead and asked if they could handle their case, yet there was no actual ophthalmologist there. K got a full "checkup" and got a "it's probably an infection"; they were prescribed antibiotics. Next day K's eye pain worsens with new symptoms. K gets an appointment with an optometrist so as to be referred to an ophthalmologist. It is the protocol to have an optometrist check you first apparently. Another half a day later, an ophthalmologist actually checks K and comments "thank god you came in this fast." That was after my wife begging several times on the phone with several doctors, that we need an appointment today and not in 2 months. Yes, patient K is I. (I could not make any phone call or walk at this point, I was for all intents and purposes blind and in pain.)
Thus, the system in place from my experience assumes that the patient i) is stupid ii) if not dying does not need a checkup within the next 2 months, or else has to go to urgent care.
Thus is it really the patients' fault when they are used to walk into urgent care to get any sort of timely treatment? Why would a person with a broken leg take the invaluable resources from someone actually in need of urgent care? I argue the system somewhat enforces this over-treatment. You have to go through the urgent care for any timely treatment, it is rightfully instilled in you that perhaps there is something serious going on. You would not pay urgent care prices for a strain right? Thus, it must not be a strain.
My E.U. experience: As a patient,you walk in to a doctor you consider appropriate (You can also make an appointment ahead of time and ask if uncertain). One might wait for a few hours. If it is deemed urgent, the doctor will make sure to see you first, or send you to urgent care/emergency room or hospital. If the doctor is not of the appropriate specialty, they will refer one appropriately. Paying everything out of pocket, costs extremely less compared to my copay for urgent care -- this is a simple doctor appointment, no urgent care.
I wonder how much of it is from the training methods - forgetting things is malpractice and thus things get hard emphasized to practically muscle memory "make sure to x-ray the ankle to confirm if it is a break or sprain" even if it would become very apparent without otherwise via deformation or not getting better and the treatment is immobilize both and ice helps with pain anyway.
I think the military has a similar problem with transition to civilian life in terms of "overdrilling". Medicine being a conservative field given the stakes furthers it.
Yes. Just ask Ignaz Semmelweis.
Thank you. I was not familiar with this term. But to be clear:
Semmelweis was a physician in charge of a couple of clinics who documented differences in mortality rates and used this to suggest hand-washing for physicians before germ theory was a thing. He was thrown in an insane asylum and was badly beaten by the guards and soon died as a consequence of the beating.
I will suggest that people default to habit when they are exhausted and this could be an underlying reason why physicians seem to do a poor job of stopping certain bad habits. Over the years, I have seen articles that suggest that exhaustion on the job is a major contributing factor to medical errors, though stuff that is most readily findable seems to mostly be about nurses and residents, not physicians per se.
I don't have a specific source in mind, so I'm not going to post a link. I have verified that you can find stuff on the topic by searching "medical errors due to staff fatigue". There may be other search terms that work.
Big pet-peeves of doctors:
1. The Academic Elitist: When they act like know-it-alls, poo-poo informed patients or any information that didn't originate from them.
2. The Thickheaded: When they don't LISTEN and go about diagnosing whatever it is they're more interested in.
3. The Evening News Anchor: When they act with over-confident, pseudo-infallibility, which seems to correlate invariably with being wrong.
4. The Snakeoil Salesman: When they hard-sell products and services that aren't even FDA-approved, like this certain brand of CBD that this one doctor was pushing. cough kickbacks cough
Bonus: The Histrionic and Defensive: When they gaslight or accuse their patient of behavior they didn't engage in, especially when they miss lab results and clinical symptoms that would explain said symptoms.
Have to agree with most of this list. My thyroid stopped working when I was a kid and despite many doctor's visits it went undiagnosed for about 2 years. It was ultimately diagnosed by my mother's coworker, a ticket booth attendant, who recognized the symptoms as being similar to her dog's. After enough badgering by my mother a simple blood test confirmed her diagnosis.
I can't say that my experience with doctors since then has improved my opinion of them. I've met with only about 2 physicians in my entire life that actually seemed genuinely interested in solving problems.
I had a similar experience. I had serious gut issues and Kaiser poked my belly, then said "It's a virus. It will clear up". Even after I told them this had been going on for a month. I had to research this myself and it took me almost a month to gain expertise on the gut.
I've had similar experiences in my life as well. Purely anecdotal, but I've found NP's and PA's tend to listen more and just be more personable in general. I sometimes wonder if the extreme hours physicians have to work beat the compassion right out of them.
This so much.
Our NP was great, took time to understand the issue each time we visited and generally was on the mark much more often than other MDs I've seen over the years.
I worked extensively with a number of doctors, primarily pathologists, for about 3 years.
Some of them are among the most humble, caring people I’ve ever met. Some of them had colossal egos and would ignore advice from PhDs on their area of expertise because they had the wrong letters after their name.
On the whole, I felt enriched by the experience. Eventually you learn which to treat like children and which to treat like adults.
Good that there are counterexamples. I have no such luxury as I'm on the fifth PCP doctor this year. I lost two within a week.
> 4. The Snakeoil Salesman: When they hard-sell products and services that aren't even FDA-approved, like this certain brand of CBD that this one doctor was pushing. cough kickbacks cough
You may have been writing more for humour more than to inform but implying that off label use is anything but an utterly normal part of professional medical practice is dangerous.
Off-label use is very common. Generic drugs generally have no sponsor as their indications and use expands, and incentives are limited to initiate new clinical trials to generate additional data for approval agencies to expand indications of proprietary drugs. Up to one-fifth of all drugs are prescribed off-label and amongst psychiatric drugs, off-label use rises to 31%.
> ...Up to one-fifth of all drugs are prescribed off-label and amongst psychiatric drugs, off-label use rises to 31%.
So, in other words, psychiatric medicine is non-scientific voodoo? Cause that certainly doesn't sound scientific. At best, it's 10 minutes per patient anecdotal 'evidence'.
I've always found that doctors' behavior correlate well with that of programmers. Both tend to have a high view of themselves and are therefore less prone to introspection or admitting mistakes. I've definitely seen points 1, 2 and 3 coming from both doctors and developers.
Ironic that 1-3 and the bonus could equally apply to some patients.
True. Not all doctors or patients exhibit these behavior patterns, but many do in my (anecdotal) experience because of the very basic healthcare I have access to. If I had zillion$, there are astronomically-better doctors whom likely treat their patients somewhat better... but it's my fault.
(1) and (2) Absolutely right, and they might tell the patient they need to see a psychiatrist instead
This list applies to all domains.
Even worse is that these items aren't mutually exclusive--you can get a doctor who exhibits them all!
"It's never lupus." :)
This isn’t a very nuanced piece.
The glucose control effect is not unexpected. You are telling ICU drs, who spend their lives trying to adjust physiological parameters to keep the sickest patients alive, to do less. This is anathema to their way of operating. Of course adopting more intensive control and then letting it go will not happen at the same pace.
Apologies, but it is hard for everyone to Unlean Things. It is just human nature/the way we are wired. It take discipline and great effort. What would doctors want to be different? We all got a comfort zone :)
Doctors are credentialed professionals. As professionals, they get a legal barrier to entry protecting them from competition in exchange for maintaining professional standards, which include ethical standards and continuing education. This in turn enables them to charge huge fees.
A lawyer is not allowed to stop learning about new laws; he would eventually be disbarred. An architect is not allowed to construct buildings that would only have been up to code at the time she finished her degree. And doctors should likewise not ignore the state of the art in their field.
Totally true, but it misses the point.
Doctors invest huge effort in keeping up with the state of the art in their field, the problem is that to be a competent doctor you also need considerable amount of intuition and heuristic.
New advances sometimes requires that you unlearn things and this i a completely different process; when you simply keep up with the state of the art you have a set of known facts and techniques and slowly you discover more and more of them. Unlearning things requires you to review entire branches of your knowledge tree to eradicate every trace of the now wrong fact
>Doctors invest huge effort in keeping up with the state of the art in their field
I'm afraid this hasn't been my usual experience.
It's fine for doctors to intuit that "the cost and side effects of HipNewDrug outweight the benefits". It's not fine for a doctor to be unaware that HeretoforeUncurableCondition now has HipNewDrug as a possible treatment -- i.e. to not have unlearned that HUC is a death sentence.
That's not really what the article is about. It's actually about someone finding HipNewDrug is actually not effective at curing Frobulitis and in fact has adverse side effects, and yet doctors continuing to prescribe it for that condition.
It's the same failure mode though.
It's not the same. It's a bigger problem than the one you're talking about, according to the article. It's easier to get doctors to adapt some procedure than to get them to give one up.
Both are the same failure mode: "You used to always do X. You shouldn't do that anymore."
In my example, X was "tell patient they have a death sentence". The fact that yours is closer to a specific situation in the article does not make it "a different failure mode" with different dynamics and causes.
I don't know what to tell you. You are saying the opposite of what the article says and not offering me any reason to take your word over the article.
No, I'm not. I said that "thinking Y is uncurable" is the same kind of failure mode as "prescribing X for Z after the science starts to indicate that X is harmful". I then offered a very good reason to "take my word" on it: I stated the general form of the failure mode, parameterized over X, and showed what X would be in each case.
Did you miss that, or did you not consider it a good reason?
If you can take a moment to review the thread, I only brought it up to distinguish valid vs invalid reasons for not proposing a kind of treatment, and thus why a doctor's intuition would vs wouldn't be defensible given the state of the literature.
Where specifically is the article saying the opposite of any of that? Unless the article talks about the topic of appropriately classifying failure modes, which it isn't, it wouldn't bear on that topic.
The article identifies a discrepancy where it is much easier to get doctors to introduce a new treatment or practice than it is to get them to stop using or recommending it after it is discredited. I don't see how that could be the case if they're "the same failure mode."
People can fail to realize two failure modes are the same and merit the same treatment.
And I don’t see what that would bear on my original point (which was just distinguishing between valid vs invalid reasons not to recommend a treatment).
People can equally well fail to realize that two modes of failure are different.
> Unlearning things requires you to review entire branches of your knowledge tree to eradicate every trace of the now wrong fact
You cannot be serious. So if someone tells you that you’ve got a fact wrong, you have to review entire branches of your knowledge tree to eradicate every trace of the now wrong fact? So if you get the directions to a party wrong it’s a project to get rid of them and learn the correct one?
In a deductive context, yes, that's exactly what you have to do. This is a consequence of the principle of explosion:
Let's say your "knowledge" is a set of propositions which you believe to be true. This set is continually expanding for two different reasons:
1. You're acquiring new facts about the world through direct observation (emperical knowledge)
2. You are thinking: making valid arguments which start from your current knowledge and lead to new propositions (analytic knowledge)
At some point, a false fact creeps in. Your system is now "exploded" - the whole system is inconsistent and with a few lines of perfectly valid argument, you can now arrive at any conclusion. You now believe both "A" and "not A" for all values of A in the set of all well-formed formulas. Obviously this is not ideal. So we need to remove the false fact. But in the mean time, your mind has been at work, adding new propositions to your knowledge set. It is necessary to remove not only the offending bad fact that crept in, but any new proposition resulting from a valid argument which used that bad fact as a premise. Computationally, the easiest way to do this is to maintain a graph where the nodes are propositions and edges connect to their premises. For example, we would record in this graph structure that we now believe X because we deduced it from A, B, and C. If this structure, which the parent comment called "knowledge tree," exists, we can quickly remove all invalid propositions from our knowledge set and return to an consistent system. In practice its a very good idea to also store the arguments themselves. The metamath project does this, and can verify the entirety of its knowledge (which includes set theory, some calculus, complex numbers, trignometry, etc.) all the way back to axiomatic first principles in just a few minutes.
Humans, of course, do not do this in their ordinary lives. They often believe propositions without being able to recall or reproduce the arguments, or cite the facts, which first led them to believe that proposition. This leads to a great deal of intellectual inertia. In mathematics and the sciences the situation is a little better: researchers certainly strive for this as an ideal, and largely succeed - a good research scientist has a deep understanding of the crucial experiments, theorems, and approximations that underpin their own work, and a rigorous practice of citing sources helps keep track of these dependencies. Therefore, if one paper is found fraudulent, other papers which cite it can be reviewed. But it is a difficult, even overwhelming project and no one can do it outside their own narrow area of expertise.
> A lawyer is not allowed to stop learning about new laws; he would eventually be disbarred.
haaah. the things people believe about lawyers. merely being bad at your job isn't nearly enough to actually be disbarred.
If a lawyer were to consistently lose cases as a result of not maintaining their knowledge of the law, they would not be disbarred (they would just lose clients).
If a lawyer were to consistently act illegally as a result of not keeping up with their knowledge of the law, they definitely would eventually be disbarred.
My thought in submitting this was that behaviour (or skills) change is hard. For everyone.
The case of doctors is interesting as they are a well defined, skilled, educated, and reasonably well-measured population engaged in activities for which outcomes can be quantitatively assessed; outcomes, health & wellness measures, or that ultimate outcome metric: deaths.
Which means that in studying doctors there are valuable lessons which might be transferred to other fields. Such as software developers, venture finance, executive management, and end-user practices. Or in addressing social ills, economic inequality, education, opportunity, respecting others, expanding worldviews.
The habit of looking past the immediate to see potential analogues and metaphors is a powerful one, though many seem resistant to acquiring it.
Doctors have too much emotional power of patients. That's when it become very dangerous to get stuck into your own paradigm.
Well it's right there below the headline.
> Procedures live on even after they’ve been proved ineffective. It can lead to harms and wasted resources.
What a surprise - it is easier to get doctors to do things that increase billing than it is to get them to stop doing something if it decreases billing. It is almost as if money is more important than the patient.