What's up with you, Doc?

March 21, 2007 11:06 PM

What's the Trouble? - "How Doctors Think"
posted by Gyan (59 comments total)

Also see Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias
posted by Gyan at 11:06 PM on March 21, 2007

One thing is for certain: It's not Lupus.
posted by sourwookie at 11:27 PM on March 21, 2007 [3 favorites]

sourwookie, though I get the reference, and it's a bit morbid, I had a dream the other night that I had the telltale rash from discoid lupus tattooed on my face. weird, huh?
posted by nonreflectiveobject at 11:31 PM on March 21, 2007

That's a good article.

I wonder how many doctors have a tale about an overlooked buttock abscess damn near killing their patient. I certainly do.
posted by ikkyu2 at 11:35 PM on March 21, 2007 [1 favorite]

Sure, it's scary, but what are you, as a patient, going to do? From what I can gather, doctors hate self-diagnosing patients. Saying, "Are you sure it might not be....?" seems to really tick them off, and if you do it too often, they'll label you a hypochondriac and never take you seriously again.
posted by Poagao at 12:20 AM on March 22, 2007

"You hide your drugs in a lupus textbook?!?"

"It's never lupus!"
posted by Rhomboid at 12:24 AM on March 22, 2007

That was fascinating.
posted by gomichild at 12:36 AM on March 22, 2007

Very interesting article. It reminds me of a research project one of my women's studies students did about women and heart disease. She came across various examples of research showing that because cultural wisdom holds that men, rather than women, are more likely to suffer from heart disease (not true), and because women's symptoms are not the "classic" male symptoms, many doctors misdiagnose symptoms of heart disease in women. I guess that would be an example of the reliability issue the New Yorker author is talking about.
posted by hurdy gurdy girl at 1:44 AM on March 22, 2007

From what I can gather, doctors hate self-diagnosing patients

In my experience it's never a good idea to even cast doubt on something a doctor is saying, lest they fly off the handle and call you a hypochondriac then launch into a long tirade of verbal abuse. Yes, even if the same doctor has tried to prescribe you medication that you're allergic to several times and prescribes antibiotics whenever you sneeze.

Maybe I just need to get a new doctor.
posted by saraswati at 2:52 AM on March 22, 2007

I knew there was a reason I have spent my life pursuing fat bastard status. I just want to provide the best situation for a thorough examination and a quick heuristic diagnosis.
posted by srboisvert at 3:18 AM on March 22, 2007

In my experience it's never a good idea to even cast doubt on something a doctor is saying, lest they fly off the handle and call you a hypochondriac then launch into a long tirade of verbal abuse.

Well, I cast doubt on something a doc said just yesterday. He had run out of ideas on what could be causing my symptoms and suggested some new tests that made no sense to me. I countered with a few ideas that I learned about by reading, and that prompted him to phone a colleague. According to my doc the colleague pointed out a very basic course of treatment that he hadn't thought of.

If your doctor flies off the handle at the suggestion that you want to be involved in your own health, maybe you need to find a new one. Although I have respect for doctors, they aren't perfect, and I suspect that they are even less so if they have commonly large caseloads.
posted by SteveInMaine at 3:49 AM on March 22, 2007

Speaking as someone who does a lot of debugging (of programs, not people--but the thought process is the same) I'm always glad to get suggestions for avenues to explore. Even ones that don't make sense based on the available data because if the solution was something that made sense, I'd have thought of it already
posted by DU at 4:19 AM on March 22, 2007

There is something about the first case described in this account that seems off to me. The way I was trained in medical school was to include, in the differential diagnosis, a number of of possible diagnoses in addition to the one two that seemed on the surface most likely to you and rule these others out. Much emphasis, in my recollection, was placed on how to weight the various diseases one might include in the differential so as to not make the cardinal mistake of missing a common diagnosis completely. Hence certain aphorisms regarding hoofbeats outside the window belonging to horses not zebras and the phrase "common things are common." So in the case of chest pain in 40 year old male it was drilled into us that if "rule out MI" was not included in the differential regardless of the presentation we were practising in a dangerous fashion.

The emergency doc seems to have had, not unexpectedly, similar training, as he included lab and other tests for an MI even though this particular patient's presentation struck him as extremely atypical for this disease. And the results were reportedly normal--until the patient returned the next morning with symptoms that had resolved into a more classical presentation of a myocardial infarct.

So what's the point? This doc did everything right, as far as I can see: he recognized that common things sometimes masquerade themselves as something else and, by virtue of the fact that they are common, need to be ruled out before another diagnosis is settled upon. Even though I now diagnose nothing more critical than computer software problems I am still often reminded of how this way of thinking was drilled into me when I see how my mother approaches diagnoses of friends or family members. Wise woman that she is, she still often makes the classic first year medical student's mistake of diagnosing the problem as something exotic that she's recently heard about in the newspapers or the Internet instead of the more wearyingly common maladies that plague us. I think this doc's training shone through and prevented him from making a similar mistake.
posted by Turtles all the way down at 4:56 AM on March 22, 2007 [4 favorites]

Wise woman that she is, she still often makes the classic first year medical student's mistake of diagnosing the problem as something exotic...

That's just about the 3rd golden rule of pathology:

It's far more likely to be an uncommon presentation of a common entity, than a common presentation of an uncommon one.

posted by i_am_a_Jedi at 5:15 AM on March 22, 2007

> From what I can gather, doctors hate self-diagnosing patients.

Professionals in any field love people who can honestly report symptoms and contexts in as much detail as requested. They have problems with clients who carry their own solutions in their head.

You can witness this weekly on 'Car Talk', where the hosts have to talk somebody past their harebrained self-diagnoses to find out what's actually wrong with their car. Click and Clack will do this by openly mocking their callers in public, something few doctors can get away with.
posted by ardgedee at 5:53 AM on March 22, 2007

This story gives me chills.

My best friend's husband went to the emergency room with chest pains a few years ago. He was 39, not overweight, not a slob. They gave him antacids and sent him home.

Three months later, he was given tests and that's when it was discovered he'd actually had a heart attack three months prior. Of a type that killed a pretty large percent of the guys his age that had one. He wound up having bypass surgery.

He's okay now, I think, but you can imagine how he and his wife felt about that.
posted by konolia at 5:56 AM on March 22, 2007

Oh, and I forgot to mention they didn't even hook him up to a monitor or anything when he first went to the hospital.

Meanwhile MY husband who looks like a heart attack waiting to happen, got the full workup after he'd strained some chest muscles.
posted by konolia at 5:57 AM on March 22, 2007

You can witness this weekly on 'Car Talk',

Any physician will tell you that there's an uncanny similarity between diagnosing car problems and human problems. I think Tom and Ray would have made excellent (and entertaining) physicians.
posted by Turtles all the way down at 6:22 AM on March 22, 2007

Oh, and konolia: if that's what happened that was a bad doc. I say "if that's what happened" because I've heard innumerable third hand accounts of bad medical practice which, when I've had the occasion to see the documented evidence, turned out to be the patient's or the relative's misunderstood version of events. I'm not saying this didn't happen to your friend's husband but I would reserve judgement until I saw the evidence.
posted by Turtles all the way down at 6:27 AM on March 22, 2007

Click and Clack will do this by openly mocking their callers in public, something few doctors can get away with

Other than, of course, the magnificently entertaining Gregory House, M.D.
posted by Turtles all the way down at 6:30 AM on March 22, 2007 [1 favorite]

In 1990, Croskerry became the head of the emergency department at Dartmouth General Hospital, and was struck by the number of errors made by doctors under his supervision.

It's interesting, there was a discussion on MetaTalk a while ago where some people were pushing the idea that people shouldn't ask medical questions on askme because they would get bad advice, and that they should trust their doctor absolutely. It was like these people thought doctors were perfect, flawless, and any other information would only detract from what they were doing. It seemed like a really stupid idea to me, especially given how often doctors really do make mistakes.
posted by delmoi at 6:32 AM on March 22, 2007

I agree wholeheartedly with Turtles all the way down's earlier comment. The only criticism I would have of the original doc is that he might have been a little too quick to reassure the forest ranger that it wasn't his heart, but that could just be me playing Monday-morning quarterback. Certainly he did the right thing by looking for a heart attack; other tests that would have caught the unstable angina, such as a stress test or even cardiac cath could have been done, but probably would have been ordered on an outpatient basis rather than be done right away and so would have been of no value in preventing a heart attack that occured later the same day. Doing those tests or even just keeping him on a monitored bed overnight are not cheap; if doctors ordered them for every fit 40 year old male with suspicious chest pain the cost would be hundreds of thousands of dollars or even millions for every heart attack prevented.

And while medical decision making is certainly a field worth of study, the quote at the end of the article (“Currently, in medical training, we fail to recognize the importance of critical thinking and critical reasoning,”) is not entirely true. For example, in anesthesiology we have to pass an oral exam to become board certified; the American Board of Anesthesiology explitly states that the purpose of the exam is to assess "Soundness of judgment and rationality of thought in making and applying decisions." It may not be a perfect process, but it doesn't ignore the importance of decision making skills, either. Finally I would like to point out that for every cognitive researcher who espouses a detailed, rational decision making proces, there are others who suggest seat of the pants decisions guided by instinct as described in Malcolm Gladwell's Blink are more accurate. Cognitive science is still to young to provide definitve answers to many of these questions.
posted by TedW at 6:46 AM on March 22, 2007 [1 favorite]

fter the internist made the correct diagnosis, Alter recalled his conversation with Begaye. When he had asked whether she had taken any medication, including over-the-counter drugs, she had replied, “A few aspirin.” As Alter told me, “I didn’t define with her what ‘a few’ meant.” It turned out to be several dozen.

On what planet does "a few" = several dozen? In this case the woman lied to him so I don't wonder that he misdiagnosed her. Unfortunately, I get the impression that patients lie pretty routinely when it comes to drugs both OTC and illegal.
posted by Secret Life of Gravy at 7:03 AM on March 22, 2007

On what planet does "a few" = several dozen?

I can't speak for the planet as a whole, but in Georgia that can certainly be the case. I almost never accept vague answers to certain medical questions; for example it is important for me to know when the last time an asthmatic child has used their rescue inhaler and the standard response from most parents is "Oh, he hasn't used his albuterol in a while" On further questioning "a while" can mean anywhere from 2 days to months or even years.
posted by TedW at 7:12 AM on March 22, 2007

Oh, and konolia: if that's what happened that was a bad doc. I say "if that's what happened" because I've heard innumerable third hand accounts of bad medical practice which, when I've had the occasion to see the documented evidence, turned out to be the patient's or the relative's misunderstood version of events. I'm not saying this didn't happen to your friend's husband but I would reserve judgement until I saw the evidence

If you walk into an emergency room with chest pains and don't get any heart monitoring etc and just get handed a bottle of the good antacid, what records are there to check??? My best friend was with him. That's just bad standard of care. The ONLY diff between him and my hubby was appearance. (And final diagnosis!) Hubby got the standard check, friend's hub did not. Period. (I forgot that friend's husband does not outwardly get excited about anything, so I am sure they figured he thought no big deal. Well, almost dying is a big deal.)
posted by konolia at 7:13 AM on March 22, 2007

> From what I can gather, doctors hate self-diagnosing patients.

So? I'm not going to the doctor for the benefit of the doctor. Doctors occasionally make mistakes and occasionally miss things. They're like people that way. If I've done my homework and a doctor patronizes me or says something I think is wrong, I go elsewhere. Good docs love well-informed patients who do their homework.
posted by selfmedicating at 7:17 AM on March 22, 2007

konolia: Everything is documented in an ER visit. These are not handled casually: there will be a form on record that documents the patient's name and other details, the presenting complaint, the ER nurse's triage findings and impressions, the ER doc's (brief) history and physical examination, and any diagonostic tests that were done. Again, I can't know the particular circumstances of your friend's experience but "go to ER complaining of chest pain and be given antacids and told to vamoose" seems unlikely to me. Not that it can't, in the realm of possibility, happen, but I would be confident (as a Canadian) to go to any ER in the US with the same complaint and have the full expectation of receiving competent treatment.
posted by Turtles all the way down at 7:24 AM on March 22, 2007

Well this was a good article to read on the heels of the AskMe question I posted last night. I am currently mustering up the courage to talk to my doctor frankly about what I think is wrong with me and why I am dissatisfied with the current "oh, it's probably just a virus" answers I am getting.
posted by Biblio at 7:26 AM on March 22, 2007

Another good recent New Yorker medical article, sort of related, was on the C-section as an industrialization/standardization of childbirth.

The Car Talk and software debugging conversations have caused me to reflect on diagnosis as a human thought process, including but reaching far beyond what doctors do. Being able to hone in the true cause of a problem is an incredibly valuable skill that can appear almost supernatural.

Doctors certainly have a white-hot spotlight on their diagnostic skills, because we care in a very personal way about the results of their decisions, and they are in a position to have a profound impact on our lives through their choice of actions. But other cases in which analogues of the diagnosis-and-treatment-plan process play a key role come to mind. At sea, for instance, people at the con of a ship rely on a quick survey of conditions, deep professional knowledge, and life experience to decide on course changes and sail plans during extreme weather. Commanders in battle and intelligence workers need to take in information which may be incomplete and choose a course of action intended to produce a useful result. Teachers have to plan instructional strategies and behavior strategies for students who don't respond to standard techniques.

Seems that this thought about diagnostic thinking has useful applications in the world beyond medicine.

We've all got a story about diagnosis. My father was within inches of death due to a situation in which it was zebras, rather than horses. All the treatment for horses (supposed ulcers) in the world wasn't going to help him, until he went into septic shock and passed out on the ER floor and they figured out a strangulating hernia had caused internal hemmorhaging and tissue death. In his case, when he didn't respond to initial treatments, the doctor failed to consider deeply enough that question "What else could this be?"
posted by Miko at 7:33 AM on March 22, 2007

From what I can gather, doctors hate self-diagnosing patients.

Professionals in any field love people who can honestly report symptoms and contexts in as much detail as requested. They have problems with clients who carry their own solutions in their head.

You can witness this weekly on 'Car Talk', where the hosts have to talk somebody past their harebrained self-diagnoses to find out what's actually wrong with their car. Click and Clack will do this by openly mocking their callers in public, something few doctors can get away with.

Ditto desktop computer support. It is interesting to watch doctors indulge in the very behavior they abhor in their patients. What's the old saying? "Doctors make the worst patients."

From the article: "Yet the ideal it implies, of the doctor as a dispassionate and rational actor, is misguided."
Ha! Misguided is right! Ever been around a doctor who might be losing his life's work because he failed to use a network server ("I don't have time for that!") or have any kind of data backup plan? ("I know you told me you didn't backup desktop data, but I thought you did anyway." !?) Dispassionate and rational my ass.
posted by smallerdemon at 7:38 AM on March 22, 2007

I am currently mustering up the courage to talk to my doctor frankly about what I think is wrong with me and why I am dissatisfied with the current "oh, it's probably just a virus" answers I am getting.

And so you should, Biblio! Make sure he or she has set aside some time to talk to you--tell (him) that you have some serious questions whose answers will set you mind at ease. Describe your particular symptoms, and when he says "it's a malalignment of your rondosketiaptic dispeller" say, "well, I was researching this on the internet and it seems that malocclusion of the perspectifier can sometimes cause symptoms very close to what I've experienced."

If he says "I considered that, but X, Y , and Z suggest that's not the case", I would tend to believe him. If, instead, he is defensive or dismissive, rather than intrigued and curious, I would find a new doc.
posted by Turtles all the way down at 7:53 AM on March 22, 2007

From the article:

..the first step toward incorporating an awareness of heuristics and their liabilities into medical practice is to recognize that how doctors think can affect their success as much as how much they know, or how much experience they have. “Currently, in medical training, we fail to recognize the importance of critical thinking and critical reasoning,” Croskerry told me. “The implicit assumption in medicine is that we know how to think. But we don’t.”

This can be summed up simply as a need for humility. Groopman describes intellectual errors that are not failures of intelligence or lack of experience, but simple cognitive biases. Unfortunately, it seems that in medicine there is such a great mystique built up around the skill of doctors as to render them almost infallible. The danger, it would seem, is when doctors believe this themselves.

I'm taking an intensive management seminar right now, and the bulk of the students in the class happen to be various medical professionals from our regional hospital. Beacuse of that we've spent a lot of time on the organizational theory of hospitals as institutions and their standard design, which derive from the history of the hospital as a (female)-volunteer-run charitable structure, meant to minister to the poor at a time when the wealthy were treated by physicians and nurses in the home. (This formation of our present basic construct of 'hospital' all went down between the end of the Civil War and the 1890s).

The doctor, in that construct, was the visiting expert. They spent most of their time in private homes, and only 'attended' hospitals in emergencies and on infrequent rounds - and they did it on a volunteer basis, pro bono.

The underlying assumptions about what doctors did in hospitals were intertwined with the social roles of the time: the doctor was the visiting authority, who made his diagnosis (often without touching the patient), administered any treatment or called in a surgeon, then left the patient to the ministrations of the nurses, who lived with the patients 24-7. Doctors were to be honored for their generosity in granting the hospital their services. They were to be venerated for their superior understanding. The doctors explicitly stated that they were not to be questioned or challenged; we looked at documents from our own regional hospitals' founding that reprimand questioning nurses for being 'disobedient' or 'insubordinate' and list 'loyalty' as one of the most important qualities in a nurse.

That's quite different now, but I think we are all aware of some holdover of some of those assumptions within the practice of medicine. Most doctors I've had the pleasure of knowing have been wonderful and caring, and usually it's care for others or fascination with the human body that seems to encourage people to become medical professionals. But part of what Groopman is suggesting is that medical education include an explicit encouragement of humility, respect for human frailty in the thinking process, not being lulled into thinking that all the skill, knowledge, and training a doctorsn have prevents every mistake.

Humility is the greatest human lesson and a hard one to accept. No one's perfect, though we so desperately want our doctors to be. I think it would be very hard to be a doctor, given the hope and faith and power we laypeople see in their hands, and maintain a simultaneous awareness of both your command of the situation and your own potential for a simple cognitive error.
posted by Miko at 8:04 AM on March 22, 2007 [2 favorites]

Any physician will tell you that there's an uncanny similarity between diagnosing car problems and human problems. I think Tom and Ray would have made excellent (and entertaining) physicians.
posted by Turtles all the way down at 9:22 AM on March 22

The Car Talk and software debugging conversations have caused me to reflect on diagnosis as a human thought process, including but reaching far beyond what doctors do. Being able to hone in the true cause of a problem is an incredibly valuable skill that can appear almost supernatural.
posted by Miko at 10:33 AM on March 22

I've heard this quite a bit, and medical diagnosis appears to be like diagnosing mechanical problems or troubleshooting software, but the analogy is fundamentally wrong.

We know how cars work. We know how software works. We, the human race, know this because we built those things in the first place.

Medicine does not fundamentally understand how the body works. Protein folding, a vital fundamental operation of life, is not fully understood. Drug action is not fully understood. The electrochemical processes within cells are not well understood. The operation of the brain is not completely understood. This is not a failing of medicine as much as it is an acknowledgment of the massive complexity involved in a living organism.

If there is an electrical problem with a car, there are only a handful of parts that could be responsible, and the operation of each of those parts is completely understood. Same with software. Cars don't suddenly vomit machine parts. Software does not randomly print a string unless it is at some point being told to print the string. There are no ghosts in the machine.

But if there are millions of possible proteins, and countless ways for proteins to fold, and we don't exactly know how they fold, how can you predict with any accuracy what caused X when X is a function of structures and processes that rely on proteins.

What causes cancer? Maybe transcription errors, maybe a virus. Maybe a virus causing a transcription error. who knows? Let's just treat it with massive radiation and a flood of chemicals.

If we fully understood these processes, you wouldn't need drug trials, because you could predict in advance all of the possible interactions of a new substance introduced into the body. Medicine is still very much a statistical, regression, correlation based science.
posted by Pastabagel at 8:08 AM on March 22, 2007 [2 favorites]

Good docs love well-informed patients who do their homework.

Bingo. To belabour the Car Talk analogy, go to your mechanic and say "My car, like, freaks out on Thursdays when I go around corners and it's totally weird. And then the gauges go all funny and my friend says it's my brakes and I think that's true because when it's not moving there's no problem but I don't know can you help me?" Then go to another one and say "When I'm going between 50 and 60 miles per hour and I turn left there's a squealing noise coming from the left side; it seems to be worse when it's damp but in either case it clears up when after I've been driving for about a half an hour."

In which case are you going to gain more respect, and in which case is the professional going to be better able to help you?
posted by Turtles all the way down at 8:10 AM on March 22, 2007 [1 favorite]

Biblio: Groopman was also on Fresh Air recently talking about his book. He says in the interview that there are a couple things patients can do to get better help from physicians. One, he said, was to start from the beginning. He expresses surprise at how often doctors look just at the chart history and present presentation of the patient, when something was missed early on that helps explain everything. So for example, rather than walk in and say "I think I have Lyme disease," and the doctor looks at your chart and sees that you tested negative and thinks you're just responding to media hype and you're fine, you would be better off to say "My first awareness that something was wrong was when I was a camp counselor and I came down with chills and fever...." Suddenly, the doctor has a fuller picture of what was going on with you when you became ill and perhaps the potential diagnoses expand.
posted by Miko at 8:15 AM on March 22, 2007

From the article:

Alter’s misdiagnosis resulted from the use of a heuristic called “availability,” which refers to the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind. ... For example, a businessman may estimate the likelihood that a given venture could fail by recalling difficulties that his associates had encountered in the marketplace, rather than by relying on all the data available to him about the venture; the experiences most familiar to him can bias his assessment of the chances for success.

It seems supremely ironic to me that the author mentions this as a logical fallacy, and yet spends about a third of the article detailing an incident that happened to him and another quarter citing examples given to him by the people he interviewed.
posted by Johnny Assay at 8:45 AM on March 22, 2007 [2 favorites]

If we fully understood these processes, you wouldn't need drug trials, because you could predict in advance all of the possible interactions of a new substance introduced into the body. Medicine is still very much a statistical, regression, correlation based science.

Pastabagel: You'll get no argument from me as to the relative difficulty of medicine vs. car mechanics. I'm saying that the decision making process, as far as divining the problem based on 'user reports' and objective diagnostic tests is analogous.
posted by Turtles all the way down at 9:02 AM on March 22, 2007

I have a general problem with the "if your doc won't listen, find another one" advice, because it's damned difficult to find one who will. Personally, I have a number of problems that crop up from time to time in treating various conditions -- for example, if I get poison ivy, the only thing that will make it go away is a cortisone shot. No cortisone shot? It spreads for months and months. And I won't put up with that anymore.

Major pain? Post-surgically or otherwise? Vicodin doesn't work on me, Percocet does. Everything else from Tylenol-3 on down might as well be sugar pills. So -- when finding a new doctor, try telling him that right off the bat. They think you're an addict. And otherwise, you're stuck waiting for the occasion where you need pain medication to happen / praying your doctor won't blow off your concerns when it does.

An abusive surgeon who physically mauled me, intentionally, in front of my physical therapist, has given me a lovely psychological aversion to doctors' offices that makes my blood pressure shoot up when I go there. I can actually feel it rising the closer I get on the drive over. Doc wants to put me on blood pressure meds. I said no, because I can actually feel it going back down on the way home.

In short, I'm lucky to have a fairly decent doctor right now who is willing to listen to me when it comes to my weird issues, but it's not easy to find one who will.
posted by bitter-girl.com at 9:50 AM on March 22, 2007

Feh. 99% of "medical" problems are either not problems or can be solved by a less vaunted and highly paid professional than an MD in full drag. The few cases that take some diagnostic brainwork are often botched by harried, overworked MDs dealing with the 99% they don't need to, because so many people have the idea that if they don't see one of these harried, overworked MDs, they're not getting good medical care.

I also don't like that the author is opposed to evidence-based medicine, believing that it somehow contravenes his ability to use his "clinical judgement," whatever the hell that means (maybe leaping to a conclusion?). Of course, if he doesn't base his diagnosis and treatment on evidence, I'm not sure I'd trust his judgement.
posted by Mental Wimp at 10:04 AM on March 22, 2007

Oh dear. At the risk of being cynical I'd say that the previous two comments, in view of the usernames, represent truth in advertising.
posted by Turtles all the way down at 10:20 AM on March 22, 2007

And I'd say that sounds exactly like what I'd expect a doctor to say, except I don't judge people based on usernames or professions. (Plus, if you bothered to click through, you'd see I got the nickname as a joke).

Might I also add that aforementioned abusive surgeon jerk then got caught self-prescribing Vicodin, which would explain why he was so averse to answering my questions about it?
posted by bitter-girl.com at 10:24 AM on March 22, 2007

Fair enough, bitter-girl: my mistake. Sorry.
posted by Turtles all the way down at 10:27 AM on March 22, 2007

Apology accepted. Thank you.

Though, as someone in the profession, you probably know exactly what I'm talking about. People who don't "fit the mold" when it comes to drug reactions / expected outcomes / etc are probably annoying as hell for their doctors, and frustration comes out on both sides. I took some pretty severe offense to being labeled an addict when I was doing what I thought was the conscientious thing (asking WHY a drug didn't seem to work well for me).

My ex, who was in the room at the time, was a pretty unflappable guy and even his jaw dropped. So I know it's not just my flawed memory painting this guy's response (which he directed first at my ex, another offensive action. You don't say "well, it's not like we cut her arm off!" and you don't let the nurses threaten to keep your boyfriend out "if you don't stop crying" [from the pain]).
posted by bitter-girl.com at 10:33 AM on March 22, 2007

When I see doctors, they are clearly under pressure to get done with a patient in the shortest amount of time. I can imagine an insurer complaining that "Doc X has got to go - he's spending 11.5 min with patients when the average is 7.5!"

Under that pressure, the doctor seems to make a diagnosis in the first few minutes. Over the next few minutes he looks to confirm it, but time is passing and it's easy to ignore a few inconvenient facts that don't quite fit the diagnosis. If a patient starts pointing out problems in the diagnosis, that's even less welcome - we're wasting time here!

After doing several years of tech support, you develop a feeling that all the callers are idiots. Cops come to regard everyone as a potential criminal. I guess it's no surprise that doctors often seem to feel that the patient can't possibly know anything about what is ailing them.

This is especially annoying if you are an unusual case - I have a relatively rare blood disorder that I've been dealing with since I was five. Unless the doctor is a hematologist, it's unlikely that he's researched my condition half as much as I have. I regularly get prescribed meds that aren't safe for me to take. I've just accepted that I'm responsible for my own health, and research everything.
posted by bitmage at 10:37 AM on March 22, 2007

I, as a Computer Guy, want to address Pastabagel's points regarding troubleshooting in Medecine and in Cars/Computers. I see the analogy as extremely apt, and your argument to the contrary is flawed for the following reasons:

WE (the human race) may collectively understand computers more completely than human biochemistry. However I am a lowly, largely self-taught technician and have only a passing understanding of the theory of electronics, transistors, and software modeling theory. My actual understanding of how PCs work in a nuts-and-bolts sense is very limited. I can assemble a working one from available parts and software but would not have the first idea, even if given appropriate tools and raw materials, how to make one from scratch. The same limitaition applies to software.

This means that, like in much of medicine, troubleshooting for me is a long series of if-then statements. IF the computer is stone dead and will not make any noise at all, THEN it is probably a power supply problem.
IF the patient is overweight and has chest and shoulder pain, THEN it is probably a heart attack.

And there IS a ghost in the machine, in some cases - I have seen some incredibly complex and bizzare behaviors in computers where a component was behaving outside of its intended specifications and affecting other components in highly unusual and hard-to-diagnose ways. Fortunately in PCs it is possible to isolate a problem by disassembling the machine one part at a time to isolate the true cause when heuristics have failed.
posted by BigLankyBastard at 10:46 AM on March 22, 2007

Not that it can't, in the realm of possibility, happen, but I would be confident (as a Canadian) to go to any ER in the US with the same complaint and have the full expectation of receiving competent treatment.

HAHAHAHAHAHAHAHAHAHAHAHAHAHH.....whew.

That was funny.

Meanwhile I was the one who sat in the waiting area with my friend while her husband had surgery....you tell HER she was mistaken about what happened. But I'd be backing away when I did it if I were you.
posted by konolia at 10:55 AM on March 22, 2007

Of course, one should be wary of annoying the doctor too much.
posted by bitmage at 12:00 PM on March 22, 2007

Turtles all the way down

You may be right, my mental faculties may not match yours. But I am confident of my statements regarding the medical care system in the US. We waste inordinate resources delivering unproven and perhaps harmful therapies for conditions that could be treated much more efficiently, and sometimes not treated at all. We are near the bottom of industrialized countries in all the common measures of health (e.g., infant mortality), yet our costs are at least 50% higher than our closest competitor for expensive health care, Switzerland. We spend TWICE what Canada does, and yet we are much less healthy as a nation. And 25% of that cost goes to the insurance companies to "manage" the care, making sure that the expensive labor is squeezed as much as possible. Part of what drives this need is that Americans think they have to see an MD about every little thing and that they should get some treatment, even when none is needed. We also think that the more expensive and invasive the procedure, the better the medicine.

Oh, dear, is this being too harsh? I'll shut up now. You are probably unable to relate to such an insane system.
posted by Mental Wimp at 12:49 PM on March 22, 2007 [1 favorite]

I can't believe nobody's mentioned McArthur Award winner Dr. Atul Gawande's fantastic book Complications, which is all about doctor's diagnoses, error, and the human side of medicine. It's a great book.
posted by canine epigram at 1:26 PM on March 22, 2007

I'm going to second BigLankyBastard there.

I find this particularly... malleable: But if there are millions of possible proteins, and countless ways for proteins to fold, and we don't exactly know how they fold, how can you predict with any accuracy what caused X when X is a function of structures and processes that rely on proteins.

Now, substitute:
But if there are millions of possible lines of code, and countless ways for the lines of code to interact, and we don't exactly know how they interact with each other (especially from different companies, independent developers, hardware peripherals and their drivers, etc.), how can you predict with any accuracy what caused X when X is a function of millions of lines of code and processes that rely on millions of transistors functioning together in perfect concert?

Indeed, we don't know all about how human beings function. My wife spent six years of her life studying one tiny little bit of this and wrote her PhD thesis on one single function of cells, and yet, in the long run, it's almost as if nothing more is known now than before she started. But cumulatively, it counts.

But to assume that we can, with ease and accuracy predict how nearly any system will react and suss out the exact causes just because we built it is a radical assumption. If that were true, then, theoretically, we would never need beta testing of hardware or software since, because we made it and manufacture it, then all possible outcomes then can be accurately modeled and predicted. We know that's not the case. System complexity is the issue with predictability in systems overall. Try as we might to design airplanes to be 100% foolproof and safe due to the extreme importance of the cargo of a passenger jet, systems react unpredictably and tragedies happen. This story highlights how we all can get caught in the trap of believing in the predictability of systems, even organic systems.
posted by smallerdemon at 1:50 PM on March 22, 2007

Oh, dear, is this being too harsh? I'll shut up now. You are probably unable to relate to such an insane system.


Let this be a lesson to smartypants MeFi posters everywhere: I made a cheap joke at the expense of Mental Wimp and bitter-girl and now very much regret it. Sorry to you two, and to all.
posted by Turtles all the way down at 1:56 PM on March 22, 2007

So back to the topic:

I also don't like that the author is opposed to evidence-based medicine, believing that it somehow contravenes his ability to use his "clinical judgement," whatever the hell that means

It's not an either/or. Sherlock Holmes was based on a physician for a reason: as others have pointed out, medicine is a phenomenally inexact science, so that even with our current scientific understanding it remains, to a significant degree, an art. We have made quantum leaps in understanding of disease etiology and pathogenesis over the last fifty to a hundred years, but show me a physician practising at a high level who is not confounded by a patient presentation at least once a month.

Things are often very clear in retrospect. When I was training it was a common observation that the senior surgeon would arrive in the ER and proclaim "obviously this patient has acute appendicitis: he needs surgery." The problem was that the patient initially presented to the intern rotating through the ER with vague abdominal pain. At that point it could have been anything, including a tummy-ache that needed only antacids before the patient was sent home. The art and science of medicine is to sift through a thousand 'trivial' complaints and catch the one that is not trivial.

House MD is extremely unrealistic: his proteges not only do all the lab tests by hand but they run the CT, MRI, and probably maintain the boilers in the hospital. What it does very accurately, though, is to give you the flavour of what a challenge it is to guess what might be wrong with a person based on even the best history and diagnostic tests available.
posted by Turtles all the way down at 2:10 PM on March 22, 2007

I had a fantastic doctor for years. He's the type of guy to always err on the side of caution and do batteries of tests for the smallest things. I am convinced that he has saved both of my parents' lives (two separate occasions).

I have learned, though, having lived with a parent that had, and continues to have a host of medical issues, that one must be their own advocate.

I woke up one morning with a terrible pain in my left shoulder. Easily an eight on a one-to-ten scale. I called the doc and made an emergency appointment. Later that day, I saw his partner, who diagnosed me with a muscle strain and prescribed rofecoxib and cyclobenzaprine, saying if it didn't get better in a few days, to call back.

It got worse. Over the next few days, I did some research, and decided it was more serious. I'm thinking something with a disc, maybe?

I went back to the doc, this time seeing my regular guy, who referred me to an Orthopaedic surgeon. We schedule an MRI for my shoulder, which takes two weeks. The pain is ridiculous, and they have me on Tylenol with codeine, which isn't making a dent.

The MRI shows a small tear in my labrum. The orthopedic doc suggests physical therapy, as the tear isn't big enough to warrant surgery. I'm pretty sure that's not what's causing the problem. The research I've done suggests the etiology is something spinal, probably in my neck.

At this point, I can't drive, much less do PT.

In the meantime, I see my mother's rheumatologist, who thinks it might be bursitis. He gives me a shot of cortisone, and seeing how crippled I am (in tears, haven't slept in four weeks), prescribes a low dose of oxycontin. (that was the kindest thing anyone has EVER done for me-- in a sense, it saved me)

I continue to do research, and realize that the kind of pain I am experiencing cannot be due to a labral tear. I think it's spinal.

I go back to my original doctor and ask him for an MRI on my cervical spine. He agrees, and I go for that two days later.

I have to go into nyc for that weekend, because my mother is having surgery there.

The first night, I'm in the elevator at the hotel, and my cell phone rings. It's my doc.

He tells me that I need a spinal surgical consult immediately-- like yesterday, because I have a ruptured disc at C4-5 and osteophytes impinging everywhere, stenosis, all sorts of shit. He's like "please, in the meantime, be very careful. Don't breathe the wrong way."

A few weeks later, I see the surgeon, we talk about options-- I suggest an Anterior Cervical Discectomy and Fusion, which he agrees is the right course of action (of course he would say that-- you go to a surgeon, they want to cut you. It's what they do)

I have the ACDF, and everything is fine (relatively speaking... so much nerve damage was done at that point that I have peripheral neuropathy-- pain in my dominant arm and hand, numbness, blah blah)

The moral of the story is that four doctors couldn't diagnose a fairly simple problem, mostly through no fault of their own. Each one was viewing me through a particular lens, and that colored their diagnoses. Each one assumed a different etiology, and, largely discounting my input, made their own decisions. They all assumed that I wasn't intelligent enough or educated enough to contribute to my own diagnosis, and I suffered because of it.

While I understand that docs these days have to deal with patients that have too little information (and yes, sometimes a little information is worse than none at all), they need to at least keep an open mind to what the patient is telling them; I say "it's a ten out of ten, it's the worst pain I have ever been in (and I've been in enough pain to have an adequate, fairly universal metric) and I don't think it's a muscle ache or torn cartilage", then they ought to consider it.

I'm not bitter, but my fucking arm hurts, and it is a reminder to strengthen my conviction to be a more outspoken patient in the future.
posted by exlotuseater at 2:17 PM on March 22, 2007 [2 favorites]

exlotuseater is nailing one point there - medicine has gotten so complicated and specialized that everyone is "viewing me through a particular lens". And they're not talking to each other.

I've really wanted, nay, needed to have a hematologist present while dealing with other doctors. This saves the steps of being prescribed X, calling the hematologist's nurse that afternoon and leaving a message, starting drug X that night, being called back by the nurse the next day "DONT TAKE THAT!", calling the original doc's nurse and leaving a message...

And that's just me, with one interesting condition. My mom has diabetes, and arthritis, and asthma. She needs a whole group of specialists to follow her around...
posted by bitmage at 2:38 PM on March 22, 2007 [1 favorite]

Turtles all the way down
So back to the topic:

We agree that evidence-based medicine and clinical judgement are not mutually exclusive. It's just that I particularly bristle when some physicians proclaim they are against the former, as though their judgement isn't informed by evidence, but rather by some magical inner light that can divine the nature of reality directly. This is probably a holdover from the days when medicine really was taught by authority and not derived from carefully done studies. One physician I worked with closely described his evolution from clinician to epidemiologist as driven by a mentor who explained that a particular diagnosis was to be made when the value was over such and such. When he asked why, the mentor cited a book written by a famous physician. When my friend looked up the reference he found no supporting evidence for it anywhere. The author just made it up. It turned out to be wrong, so my friend decided that rather than perpetuating such inane behavior he would work to provide the information necessary to make informed clinical decisions. He has since produced many useful findings in the area of cardiovascular disease prevention, HIV/AIDS treatment, and chronic obstructive pulmonary diseases.

The curse of medical diagnosis and treatment is that one can never know the counterfactual, what would have happened had another course been taken. Hence, it is impossible to say whether one has been successful with a given case. One can have a strong gut feeling, but that's all one can have unless there are extensive population data giving the probabilities of outcome for two or more alternative courses of action in a specific situation.

But I blather on too long.
posted by Mental Wimp at 3:14 PM on March 22, 2007

But I blather on too long.

No, actually you don't. ;-)
posted by Turtles all the way down at 3:25 PM on March 22, 2007

exlotuseater

Sorry you had the disk surgery and it didn't eliminate the pain. My sense is that the procedure is done way more often than is helpful. There was a study a few years back (don't have the link immediately) in which asymptomatic adults were given MRIs of their spines and something like 50% had bulging disks. Up until then, such results in presence of back pain were used to indicate the need for disk surgery. Now, not so much.

Similar to your story, but not as bad, I hurt myself playing footie (soccer) (gotta stop playing with those younger, faster, more skilled athletes) and knew it was a pretty serious hip injury. A pop on outside front of the hip, then a shooting pain down my leg as it collapses and I go to ground. After the initial pain subsides, I have slight tingling in the sole of my ipsilateral foot. I describe this to my internist and he says "bursitis" (??!?). Tells me to take NSAIDs and lay off for a week then I can go back to running and build back up to soccer. I do this, and avoid soccer for six months, then go back to playing and reinjure it. Same symptoms and this time the internist says "hamstring" and refers me to PT. The PT guy has me do some balancing and mild strengthening exercises and after 6 weeks declares me cured, but the damn thing still hurts and I continue to tweak it periodically and avoid playing soccer for over a year. I finally get sick of it and self-refer to an orthopod who orders and MRI and finds that not only do I have an acetabular labral tear, but that I also have degenerative tears in my hamstring tendons. I'm currently going through intensive PT, on my 12th week, slowly getting better and the pain is reducing. I also can't tweak it easily like before. I'm considering Prolotherapy, although I'm not convinced by the literature that it is very effective for this condition. I'm also trying to decide whether the labral tear is something that needs to be repaired surgically or if I can just work through that pain.

As an earlier commenter said, it's not an exact science.
posted by Mental Wimp at 3:37 PM on March 22, 2007

Excellent piece.
posted by storybored at 6:09 PM on March 22, 2007

I was thinking about this yesterday and after a while it dawned on me that every single member of my family had been misdiagnosed at one time or another, in some cases with near-fatal results. But happily we are all alive and plugging along so in the end modern medicine did not completely fail us. We were all correctly diagnosed, finally. (Though I am a bit pissed at my primary physician who didn't catch my Grave's Disease for seven years-- I might have a bit more hair now if he had caught it earlier.)
posted by Secret Life of Gravy at 8:10 AM on March 23, 2007