Archive for November, 2008

Kind vs. Kindly

Posted on November 14, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medico-legal issues |

I’m altruistic, which isn’t the same thing as being kindly. I hold doors open for little old ladies. That’s not the same as liking the people I meet. Eliezer Yudkowsky

You know better than to think that a random doctor will have extraordinary clarity of mind and the power to find truth within confusion.  It is not any different in AGI.Eliezer Yudkowsky

There is a dominant part of me that believes one should never be punished for telling the truth. But that’s not realistic, is it? And so the conflict. Rational thought and behavior trumps etiquette, yet much of life (the way it is actually lived) requires going along to get along.

Suppose a doctor happened to possess a combination of the qualities Yudkowsky describes: an altruist with extraordinary clarity of mind and the power to find truth within confusion. That’s what you’d want in a doctor, right? Apparently not, if public record is of any significance. In fact, I would go so far as to predict that such a doctor would have a miserable litany of malpractice tort actions. Note that I did not say “a miserable record of acts of malpractice.” There is a wide berth between actual malpractice and a tort claim of malpractice.

While it may be quite an unpopular concept, I am persuaded that there exists an independent, sometimes antithetical, relationship between true altruism and kindliness. But try to conduct a medical practice based on true altruism and rational principles: you will be among the leaders in malpractice tort actions. The reason: the altruistic action may not seem like a kind action.

The actual practice of medicine is structured around historical outcomes, either clinically or experimentally. The inescapable problem is that no one knows exactly how humans work. There aren’t any treatments that always work. Consequently, the best-intentioned, most conscientious doctor, the one with extraordinary clarity of mind and the power to find truth within confusion, gets bad results. Since it is not truly science, there is always someone who will say the outcome would have been better if so-and-so. And the tort process begins. Unfortunately, not all doctors are like the one described. They are likely to create even worse outcomes. So, naturally, they will experience even more malpractice claims, right? Not necessarily.

Most instances of actual malpractice do not result in litigation; there are so many available references to this that I am not citing one. What converts a patient into a plaintiff? According to the loss-prevention program of my malpractice insurer, plaintiff polls show that the most important factor is the doctor’s attitude. Kindliness and empathy trump clarity of mind and the power to find truth. My medical generation had no courses in kindliness; in terms of skill and rationality, half of all medical students graduate in the lower half of the class. If kindliness and skill are independent variables, what are the chances that a doctor possesses both? I don’t know; I’m just asking.

Altruistic rationalism is Kind; it is not always kindly. Kill ’em with kindliness.

Addendum after comment: My first father-in-law was a pediatrician. He claimed that most of his patients would recover from their illnesses if he did nothing; a very few would not recover no matter what he did; and in the remainder, he hoped to make a difference in the outcome. In my own practice of penile prosthesis surgery, once the surgical wound was closed, there was essentially nothing I could do to improve the outcome. Because of this, in the early portion of my career, I scheduled my prosthesis patients to return two weeks post-op, the time when I intended to inflate the device to prevent healed wrinkles. During that two-week interval, the patients experienced impressive swelling and discoloration, as they had been advised to expect. My receptionist and my office manager, after a while, suggested that I begin seeing the patients three days post-op, to relieve their anxiety. Their people-skills were far superior to mine, and I followed their advice. Patient satisfaction skyrocketed, although outcomes were unchanged.

To combine these two stories (mine and the pediatrician’s), I firmly believe that people want to be told that everything will be OK. The problem is that some will not be OK, in spite of doing everything “correctly”. Occasionally, as the pediatrician told me, a child with a viral upper respiratory infection will go on to develop viral pneumonia. The parent then wants to know, “Why didn’t you give my child antibiotics?” The doctor knows that not only will antibiotics not help, but also they will actually increase the chance of secondary bacterial infection. After years of dealing with angry parents over unavoidable outcomes, the pediatrician treats the parent, rather than the child; antibiotics are started from the get-go. At this point, one ceases to be a doctor, and enters into the field of public relations.

With prostheses, assuming the surgery was done correctly, the big cause of failure is bacterial infection. Infection occurs at the time of surgery, or perhaps a few hours later, the source almost always being the patient’s own skin or fluids (this has been documented by tracer analyses). In my practice, the rate was just under 1%. Nothing can be done to prevent early signs of infection from progressing to conditions that demand removal of the device. Patients cannot be convinced of this. They intuitively feel that one-chance-in-a-hundred means, “it can’t happen to me.” Consequently, the post-op care in such patients turns to techniques of assuagement and demonstration of concern, which only postpone the ultimate outcome, and actually cause the patient an unnecessarily long convalescence. With the “public relations” approach, the failed patient is unhappy; with straight-forward fact-based actions, he is angry. Angry patients are the first step toward malpractice tort actions. Since we can’t completely eradicate infections, we begin to focus on eradicating lawsuits.

And then we’re not doctors.

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    The director of the Sexual Medicine Center leaves penile implants behind, and launches a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry.

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