Everything you wanted to know about doctors

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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What if doctors were tenured?

Posted on October 31, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Personal philosophy, Self-deception |

Reason is the unique path to knowledge. This is the credo of rationalism. Existence as a pure rationalist may be a highly-prized state, but getting there certainly is not “half the fun”. There is a lot of pain involved in recognizing and discarding long-held positions when they do not pass the rationality test. On the lead page of this site, I state that retired urologist has launched a quest for knowledge about Artificial Intelligence, extended life, and the issues inside the health-care industry. The sticky point in the quest is the concept of knowledge, a goal that can be approached only along the path of reason, yet, as Robin Hanson has pointed out, doctors are “lousy at abstract reasoning”. I have agreed with him profusely in this earlier post, yet I still had a knee-jerk defensive response to it’s reiteration recently on his Overcoming Bias blog. I, and you, are wired that way.

It seems like a quid pro quo thing going on. “If I’m going to go through the pain of admitting my long-practiced deficiencies, those who so readily identify them for me should do likewise,” or something like that. But no. Not going to happen. Actually, can’t happen may be a more appropriate description. I have become convinced that the human brain is hard-wired to ignore certain of one’s own biases, while readily identifying those same biases in others. It’s not a new concept, nor original. Long before neuroscience was a word, the Biblical writer of the gospel of Matthew asked, “Why behold you the mote that is in your brother’s eye, but consider not the beam that is in your own eye?” Why indeed? Perhaps because it’s unavoidable. It bears repeating that those gifted with more intelligence are more likely than those with pedestrian IQ’s to exhibit this defect (skill?). Via intellectual attribution bias, smart people are about nine times more likely to attribute their own position on a given subject to rational reasons than they are the position of others, which they will attribute to emotional reasons, even if that position is the same as theirs (Michael Shermer). Via confirmation bias, smart people tend to seek or interpret evidence favorable to their already existing beliefs, and/or to ignore or reinterpret evidence unfavorable to their beliefs. Hanson considers confirmation bias to be a major contributor to ideological fanaticism, the greatest threat to the world, yet he employs it frequently. He can’t help it: he’s very smart.

In fact, he’s so smart that he has tenure. Now, there’s an interesting concept for a libertarian supporter of free markets, idea futures, and outcome-mediated health care plans! Tenure is, at best, an arbitrary system which may or may not reflect effectiveness, yet which virtually guarantees employment and facilitation. Hanson’s espoused ideas revolve around the establishment of “betting markets on controversial issues, in which the real experts (maybe you), would then be rewarded for their contributions, while clueless pundits would learn to stay away.” (quoted here) Yet his own job doesn’t work that way. One would think that when offered tenure, such a person would have turned it down, on philosophical grounds. Ah, but there is the consideration of responsibility to one’s family. Intellectual attribution bias facilitates just such paradoxical behavior, not just in Hanson, but in humans generally.

So comes the question: what if doctors were tenured? Immediately, it comes to mind that all the things Hanson finds wrong with doctors, and the health care system in general, would be magnified. Doctor arrogance, a frequent topic of Hanson’s concern, would soar, perhaps approaching the level of university professors. Health outcomes, as bemoaned in Hanson’s analysis of the Rand Experiment, would surely, and predictably, worsen, as there would be no correlation between quality of work and job security. If there were a doctor agency similar to the insulating university, one could predict soaring rates of malpractice among tenured doctors, since the consequences would be borne by their institution. On the positive side, doctor-related felonies, such as Hanson documents here, would likely decrease, since commission of a felony would be grounds for revocation of tenure. Doctor supply would surely increase, as would the average age of doctors, since, once tenured, there would be no reason to retire and no pressure to perform effectively. In summation, it seems that university professors would view tenure as an excellent idea for university professors, but a very bad idea for doctors. Personally, I agree with the free markets that Hanson talks about, as opposed to the closed market in which he participates.

I am trying to learn how to think differently (more effectively), since my education and profession actually did not include any courses, or even any experience, in clear thinking, sad to say. I know there is a strong bias about the arrogance of doctors, especially given their rather well-documented failure to make a positive impact on *overall* health care in the USA. I abhor the “doctor arrogance” as well. Any arrogance seen in my posts is (usually) unintentional, and comes not from being a “arrogant doctor”, but from the failing of being an “arrogant person”, a quality that seems widespread among intellectuals. The more I learn about how such “ninja-brained” people think, the less I have to be arrogant about. I’m here to learn.

 


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Nude Banzai

Posted on October 20, 2008. Filed under: Everything you wanted to know about doctors, Good ol' days, Personal philosophy |

Today’s post is a chapter from my not-yet-published book, Chasing a Light Beam. If you actually read it, please let me have your criticism.


 

NUDE BANZAI

Many men go fishing all of their lives without knowing that it is not fish they are after. 

                                                                                                        -Henry David Thoreau                                              

 

The man shifted a little in his chair. He thumped the edge of the crystal martini glass; it made a musical tone. With his foot propped, he could stay comfortable like this for quite a while.

I was single again, and I called my cousin Punky in Jacksonville to see if he wanted to go on a guy-trip. He was nine years younger and had no wife to convince. I knew his dad way before he did. Big Punky wasn’t a blood relative, but after Mom moved us to Jacksonville, he was the closest thing I had to a father. Just like Daddy, he liked to fish, and he liked to take me along.

Big Punky was the one who taught me to catch sheepshead with fiddlers. The first thing you had to do was find a bank on a tidal river when the tide was out. The fiddler crabs would be cruisin’ around on the mud and oyster shells in droves, each waving his larger claw. If they saw you coming, they’d crab-walk faster than a light beam – that’s not really possible, like I said in the beginning, but whatever – back to their burrows and disappear. You had to sneak up on them, and you had to get between them and their holes. Then you ran out with a bucket and used your free hand to scoop up as many as you could. You grabbed them, and they grabbed you, but it wasn’t true pain. Most of them would get away, but if you were good at it, several dozen would go in the bucket. As to the actual fishing, I never understood how sheepshead could use those human-looking teeth to get the meat out of a fiddler shell without sending any vibrations at all up the line. At least, that’s the way it seemed to me; Big Punky could feel the slightest twitch, and we usually came home with plenty to eat.

Punky was only six when his father died. When he was older, he’d get me to tell him about the times I spent with his dad. His favorite was the day Daddy took Big Punky and me to a little lake in the Ocala National Forest. We were after largemouth bass, and the bait was wild shiners, hooked through the lips. Daddy had a flat-bottomed plywood boat with a three-horse Champion outboard. We trolled the shiners behind the boat, slow enough to let them swim. One line was out each side, and Daddy’s line was out the back. When the bass would hit, the click on the reel would scream. You’d count to ten, and then jerk, to set the hook. The limit was eight bass in those days, and there was no such thing as catch-and-release; it was catch-and-eat. We caught twenty-four bass that afternoon. Big Punky had one that went nine pounds, two ounces, and another that weighed eight pounds, fifteen ounces. I know that, because Daddy always stopped at a little roadside store on the way home to weigh any “lunkers” on their certified meat scales. ‘Til the day he died, Big Punky said that was the greatest fishing trip of his life.

I figured Punky might like to try to find that pond with me; he’d never been there. When Daddy was alive, he tried to keep that fishin’ hole a secret; you could drive right by it on the two-rut forest road, and never know it was there. His effort succeeded until the day he took the preacher of the First Baptist Church out for a chance at a big bass. He made him swear to secrecy, and the preacher caught an eight-pounder. The next time Daddy went there, the preacher and two other boatloads were on the lake. It wasn’t a secret after that.

(more…)

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No good deed goes unpunished

Posted on October 10, 2008. Filed under: Everything you wanted to know about doctors, Medico-legal issues, Sexual issues |

“Doc, I just cain’t get a hard-on by no-ways, and it’s torturin’ my wife and a-killin’ me.” The man was from the “redneck” area of Louisiana, a society very different from the Cajun-influenced culture of “Acadiana”, the site of my practice. He was an evangelical born-again-Christian 54-year-old hypertensive diabetic who had not been able to have sex with his wife for over two years. He had been referred by his family-practice doctor, who managed his diabetes and hypertension, after failing to respond to the pills. Short of traumatic nerve damage, such as is seen in spinal cord injuries, impotent men usually retain the ability to have orgasms. Many are incredulous when they first find that they can ejaculate without ever achieving an erection, but in reality, the two functions are completely separate. Consequently, if erections can be restored, they’re back in business.

There are very few physical causes of erectile dysfunction for which treating the underlying cause improves the erections. For example, normalizing the blood pressure or gaining better control of the blood glucose will not help the problem at all (in fact, getting the BP back to a normal level actually makes atherosclerotic ED worse, since there is less pressure to drive the blood through the narrowed penile arteries). To see where we stood, I tested the man by injecting alprostadil into the muscle of his penis (described here). He developed about 50% rigidity, a level which buckles easily when pressed (such as in the attempt at intromission). As often happened, he was thrilled at what seemed to me to be a terrible result, since he had not been seeing any response at all. He felt certain that self-administered injections were the answer. As another similarly encouraged patient told me, when I opined that the injection-produced rigidity was inadequate: “Doc, I’ve been screwin’ with a limp dick for so long that I’m sure I could shoot pool with a wet rope.” (more…)

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Doctor education #2… more real-life drama

Posted on October 7, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medical marketing, Self-deception |

I got a call from a pharm rep for a company that markets one of the three well-known pills for treating erectile dysfunction one day about five years ago. She lived and worked in the alluvial plain area of the Mississippi delta. If you have never listened to a woman from “the delta”, as they say, you owe it to yourself to call someone in that area. The female version of the accent is melodiously syrupy; a conversation about anything is musical entertainment. “Yankees” seem to think the drawl is an indicator of ignorance or low intelligence. I assure you, that is not the case. There is a reason that William Faulkner spent most of his time in Oxford (Mississippi, not England), and it wasn’t because it was full of “hicks”. 

She sought me out because I was a “consultant” for her company. At the time, I justified that position by using what I now know is “confirmation bias”. I distinguished myself from the “medical whores” I have previously discussed by reasoning that I never consulted for competing products; that I promoted the one I actually used with my patients; and that I truly believed the product was the best in its field. I saw no conflict of interest, because I was only saying what I would have said anyway, pay or no pay. I should have considered things this way (as told by Kenny Tilton):

Once upon a time my sleazebag ward politician buddy and I were cruising the singles bars back when they had such things and he got nicely eviscerated by a woman we were chatting up. My buddy had said something cynical and she had challenged him on it.

“Oh, I have compromised my principles a few times,” he conceded with a sly grin.

“You can only compromise your principles once,” she replied. “After that you don’t have any.” (more…)

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Bias on the hoof: Hanson and RU continued

Posted on October 5, 2008. Filed under: Everything you wanted to know about doctors, Personal philosophy, Self-deception |

Today’s post is a study of bias in the intellectually gifted (at least as pertains to one of the parties; I’ll let you guess which one). 🙂

In my October 4 post on Disagreements, I used a disagreement between Robin Hanson and me as subject matter for a set of disagreement analysis questions Hanson had requested readers of his blog to use. To refresh the particulars, we disagreed on the suitability and veracity of this anecdote in an article he posted called “Doctors Kill”:

A colleague of my wife was a nurse at a local hospital, and was assigned to see if doctors were washing their hands enough.  She identified and reported the worst offender, whose patients were suffering as a result.  That doctor had her fired; he still works there not washing his hands. Presumably other nurses assigned afterward learned their lesson. 

A reader (not me) saw coverage of the post on the blog of Seth Roberts, and asked Hanson “whether you actually ever met and talked to the fired nurse, how strong her evidence was that she was fired for the reason in the story, etc.? Did your wife actually know her, or know someone who knows her (who might turn out to be someone who knows someone who knows someone), that sort of thing? ” Hanson replied: ” the nurse was a close co-worker of my wife, who I’ve met.” (Nothing more.)  

I contacted Hanson privately to express all the factors mentioned in yesterday’s post, as well as the fact that the article quoted was not evidence against doctors so much as against other hospital employees. In addition, I told him:

I cannot imagine a hospital administrator telling a nurse, “We are firing you because a doctor you reported has requested your dismissal”. If that statement were not made, the nurse could not know that it was the reason for her dismissal.

Hanson replied, making no mention of any of my evidence of inaccuracy, lack of veracity, and bias, save this:

If you think no one in a work place can know anything other than what people say through official channels, you don’t know much about ordinary workplaces.  

According to his curriculum vitae, Hanson has never spent time in an “ordinary workplace”. I, on the other hand, have been a printer, electrician’s helper, warehouseman, assistant to television repairman, gasoline station employee, yardman, laborer in an asphalt plant, infantryman in Army (PFC), university information employee, delivery-man, ER doctor, breath-spray franchisee, computer technician for a beer/whiskey distributor, employee in a medical practice, owner/director of a medical practice, owner-partner of a hospital, chief of surgery at two hospitals, and laboratory research assistant in a psychiatric hospital (that I can recall; never fired, by the way, even though none involved tenure). I am particularly experienced at job relations and administration in hospitals, and especially at doctor-nurse relations. This would, if nothing else, seem to give some credence to my claim that Hanson should take another look at the value (truth?) of the story. (more…)

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Disagreements

Posted on October 4, 2008. Filed under: Everything you wanted to know about doctors, Personal philosophy, Self-deception |

Prologue:

Robin Hanson and I had a disagreement about the accuracy of an anecdote he used to illustrate doctor arrogance. I was dissatisfied with the lack of resolution to the disagreement, unless one considers “no change at all in either party’s postion” to be a “resolution”. He titled his piece “Doctors Kill“; it’s subject is nosocomial (hospital-acquired) infections. The anecdote:

A colleague of my wife was a nurse at a local hospital, and was assigned to see if doctors were washing their hands enough.  She identified and reported the worst offender, whose patients were suffering as a result.  That doctor had her fired; he still works there not washing his hands. Presumably other nurses assigned afterward learned their lesson.  

I objected that this anecdote was based on a third-party uncorroborated snippet amounting to gossip, and certainly in the category of ad hominem criticism. The statement “he still works there not washing his hands” is indicative of the inflammatory intent of the anecdote, since Hanson had no way to know what the doctor may have been doing subsequently. I pointed out that the anecdote added nothing to the statistical presentation of evidence, and as such was egregious expression (and strong evidence) of personal bias. I expected that Hanson, an extreme advocate for eliminating personal bias, would have seen that his personal bias against doctors had crept into his writing. Instead, Hanson replied that the nurse was also a a personal acquaintance of his, so the story must be true, and that his readers had found it to be valuable.

Analysis of Disagreement:

Recently I have come across Dr. Hanson’s post on “disagreement case studies“. Today, I will use his questions for analyzing our disagreement. (more…)

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Vanity, thy name is “expert”

Posted on September 29, 2008. Filed under: Everything you wanted to know about doctors, Layman's AI, Personal philosophy, Self-deception |

As my medical school years drew to a close, each of us faced the choice of residency that would determine how we spent our professional lives. A close friend and member of AOA, the medical honor society comparable to Phi Beta Kappa or Law Review, declared that he had chosen OB/GYN. He and I had shared what I felt was a miserable experience as “acting interns” on the obstetrics service our senior year, so his choice astounded me.

“Why?”

His answer was seminal: “Have you noticed the size of the textbook?” Indeed, the OB/GYN text was far smaller than that of any other subject we studied. “I think it’s possible to learn everything there is to know about OB/GYN. I can be an expert.” Perhaps he was citing the mental comfort associated with mastery of a skill, and the unlikelihood that he would find himself in a situation beyond his capabilities, akin to a world-class martial arts expert walking alone at night. I suspect the knowledge that one’s work was done as well as could be done would provide substantial comfort, especially if one were well-paid, and the importance of that work were protected and promoted by a guild system. [NOTE: in those days, there was little concept of medical malpractice, a scourge which subsequently would hit the OB/GYN specialty harder than any other.]

Yet, I think his answer (and his career choice) may have been more instinctive, and perhaps outside his conscious awareness: the possibility of being an expert may have been subsumed by the possibility of being recognized as an expert. Dr. Robin Hanson, on the Overcoming Bias blog, initiated a discussion of a similar concept, referring to “expert at” versus “expert on, in which the former could perform successfully and the latter could talk about it successfully. I’m referring to a third entity: an expert on a topic who also is an expert at that topic. He is an expert by all practical considerations, and he is well-remunerated. Is that enough? Perhaps not.

I have observed a distinct change in attitude when the expert-aspirant is exposed to his peers. In my own field, I wanted to be, planned to be, and worked to be the best in the world. In my own mind, I achieved that (male surgical sexual medicine is a very small pond for any size frog), and I was compensated financially in adequate fashion. I want to be satisfied with the knowledge that my work was of superior technical and ethical quality. But it’s a self-edited summary; often (not always) at the highest levels of anything, self-satisfaction seems overrated, and inadequate. At a conference of IPP (inflatable penile prosthesis) technical experts, early in my career, I was seated at dinner next to a surgeon who was prolific in numbers of successful operations. In fact, studying his methods had caused me to take a number of steps that benefitted both my technical skills and my practice success. Because of his influence, and my subsequent personal experience, he and I both used the same brand of IPP in our patients. Neither of us was in academics, so our “fame” came only from our patients and from the recognition of the manufacturer. He mentioned that he had performed “3- or 4-hundred” procedures that year. Unlike some areas of surgery, the number of IPP surgeons who ever perform more than 100 procedures in a year can be counted on two hands. My pride was piqued, and I replied, “I did 201, and Mr. X (the manufacturer CEO) told me that was tops in the world.” When I was just starting, this same surgeon had asked me to join his practice; after the dinner encounter, he was never friendly to me again. It was vanity versus vanity. Of note, I am very unpopular with the “experts on” in my field, those I call the “thought leaders”, none of whom are “experts at”. It’s the recognition, stupid.

Lest you think that the self-satisfied expert at/expert on doctor is immune to this vanity, give him a chance for recognition. Pharmaceutical and device manufacturers have caught on to this weakness in spades. The opportunity to be the star at doctor-to-peer lectures and presentations has changed the attitude of many a current physician, and strongly influenced his practice habits. Even when one has reached the pinnacle of both actual and recognized expertise, the vanity drive remains strong. Dr. Michael DeBakey gave the AOA visiting professor lecture during my junior year. I don’t remember much of what he said, but one quote has stayed with me: “I could make a career simply correcting the mistakes of other vascular surgeons.” Probably a true statement, especially at the time, but of what value was this knowledge to junior medical students? Could there be any doubt that recognition was the driving force?

Recently on Overcoming Bias, the smartest of the smart have shown not only are they are not immune to the vanity of the experts, they actually are as pedestrian as the rest of us when it comes to this human frailty. In the posts and discussions here, here, and here, it’s all about who is the smartest, who is the best qualified, and who is the leading expert. One would think pride in one’s intelligence is severely misplaced. As one of the main posters, Eliezer Yudkowsky, has said, “We are the cards we are dealt, and intelligence is the unfairest of all those cards.” Yet note the ego-involvement. One would think that accomplishment was a far better source of pride. And if that accomplishment has not yet occurred? Such encounters as this are the result. I choose Mr. Yudknowsky as an example only because he is a dedicated student of the human thought process, and one of two main writers on a blog dedicated to eradicating bias. If it can happen to such as him, perhaps it’s innate.

*Pro tip*:The ultimate goal is not only that I succeed, but also that you fail.

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The truth will set you free… but first, it will piss you off.

Posted on September 25, 2008. Filed under: Everything you wanted to know about doctors, Medical marketing, Personal philosophy, Self-deception |

David J. Balan, on Overcoming Bias, writes about the difficulty of responding honestly when people say, “Give it to me straight.” Generally, it’s such a bad idea that the Cajuns in my neighborhood have a story to illustrate:

Boudreaux was a widower whose most valued possession was his cat, Felix. Boudreaux won a trip to Europe, and he asked his friend Thibodeaux to look after the cat in his absence. “Thib,” he said, “I’ll call you from England to check on Felix.” Three days into the trip, Boudreaux indeed called Thibodeaux and asked, “How’s my cat doin’?” Thibodeaux replied, “Mai, Boudreaux, your cat died.” Boudreaux was beside himself, first with grief, then with anger. “Thib,” he wailed, “You don’t just tell somebody flat out that their cat died. You got no sensitivity. You should ease into it. Like, you should say, ‘Boudreaux, your cat’s on the roof, but I’m pretty sure we can get him down.’ Then when I call the next day, you say, ‘We got your cat down, but he caught pneumonia. The vet’s pretty sure he’ll be OK.’ Then on the next call, you say, ‘The cat took a turn for the worse, but the vet’s giving him some powerful medicine.’ Then the next day, you finally say,’Boudreaux, we did all we could, but your cat passed on.’ That’s the way you handle bad news like this.”

Thibodeaux expressed his remorse for his insensitivity and vowed to be more thoughtful. Two days later, Boudreaux called again. “Thib, how’s my mother?” Thibodeaux replied in his kindest voice, “Boudreaux, your mother’s on the roof.” (more…)

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Medicine as a guild

Posted on September 18, 2008. Filed under: Everything you wanted to know about doctors |

Only recently, with the reflection time provided by the onset of disability retirement, and with the prodding of Robin Hanson’s posts on Overcoming Bias, I realized that the practice of medicine is not a science. It’s closer to a “guild”.

The art of medicine is a well-known cliche, apparently referring to the use of one’s “clinical judgment”. Such judgment, to a great degree, is anecdotal, based both on individual experiences and that of our mentors. These mentors, or their peers, hold the power to determine the student’s eligibility for guild membership, and as one would expect, their customs and belief systems are parroted back to them. Yet our medical dean told us as freshmen: “In order of increasing unreliability, there are lies, damn lies, statistics, and anecdotes.” The practice of medicine involves a lot of science, but at best, it’s a hybrid. Its guild characteristics are undeniable (it’s my blog: with possession comes privilege), with exclusive selection requirements, rights of membership, and extensive turf-protection mechanisms. I touched on this in the maiden post for this blog. (more…)

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Penile undermarketing

Posted on September 6, 2008. Filed under: Everything you wanted to know about doctors, Medical marketing, Sexual issues |

Alert blog-reader Moshe has asked the question: “If these penile implants you’ve talked about are so wonderful, how come I haven’t heard much about them?” You know, Moshe, I’ve been asking that same question since 1975, when I scrubbed in for my first inflatable penile prosthesis (IPP) operation. The result was so impressive that the female scrub nurse (unmarried) remarked, “Can you get me a list of men who have these things?” She wasn’t referring to size; the finished product was no bigger than the original. What she saw was control: comes up when you want it to (no matter how drunk the guy, nor how ugly the girl), stays up ’til everybody’s happy (or at least finished). The most urgently anxious patient I ever had was a widower in his 70’s who had just married a similar-aged widow. “Doc,” he begged, “I just got to get me one of those transplants (sic) right away: I just found out her late husband had one!” Ah yes, tough competition there. (more…)

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Here’s your summons, doctor. Wanna play tennis?

Posted on August 22, 2008. Filed under: Everything you wanted to know about doctors, Medico-legal issues |

In this recent post, I mentioned in concluding that I would give an opinion about a cause for the lack of aggregate marginal value of American medicine, as documented by economist Robin Hanson. I began reading Overcoming Bias a little while back, and, being a doctor, my curiosity was tweaked by a series of articles like this one about the lack of efficacy of American medicine. As I mentioned in a previous post, I found the arguments of math-ninja/economist Robin Hanson persuasive. He goes overboard, as you can judge for yourself, by suggesting that modern medicine is a conspiracy to defraud. (more…)

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We don’t wanna hear it

Posted on August 21, 2008. Filed under: Everything you wanted to know about doctors, Self-deception |

I have an investment partner whose gainful employment, unlike mine, cannot be succinctly described. Truly he is an entrepreneur. He uses his superior intelligence and education to take an entity’s high-potential, low-performance business, reorganize it, and sell it for enormous profit. He manages the affairs of people who have marketable talent, but no financial skills (popular bands). He buys onto the boards of tech companies that have wonderful products and no knowledge of how to sell them. He buys small oil and gas companies whose owners have no idea of the actual worth of their companies (plus or minus), and resells them. He wears a lot of hats. He is a gazillionaire.

I met him because he realizes that doctors have very marketable skills, which are always in demand, but virtually no business expertise (because of the channeled educational curriculum they followed), and who are so arrogant about their abilities to handle anything, in any field, that they will run into bankruptcy most of their personally-managed investments outside their own practice  post haste. Our acquaintance occurred when a number of my colleagues (doctors) decided to start a private, for-profit cardiovascular hospital. This businessman could never be productive, in the sense of directly generating income (he has no license to practice medicine), but his non-productive (again, business definition) efforts are the only reason we are viable. The resistance of the other doctors (never me) to his involvement in our our project is part of a future post. Suffice it say, it never occurred to me in college simply to obtain my diploma, and then use my intellectual ability to make a living by thinking better than the competition. In fact, my first senior surgical partner told me, “Just do the work. The money will take care of itself.”

Recently, the businessman and I were having a conversation about my current status: professionally disabled. I sustained an injury about three years ago that prevents me from continuing as a surgeon. I was relating this sad story, along with details of a nearly concomitant divorce for which I was not liable in any moral way, yet lost my shirt, and the necessity to sell my house in a down real-estate market for the division of the equity. I wasn’t looking for sympathy (I probably was), but the effect on him was immediate and total. He said, “I admire you for what you went through to get your credentials, and for your skills. It’s too bad the way things have turned out. But don’t ever tell that story to anyone again. The average man does not want to hear about the rough life of a surgeon. You’re living far better than 99% of the people, and the business world will reject you if you make that story your mantra.” This is the first time I’ve mentioned it since.

In recent times, chasing a better understanding of the quest for the technological Singularity, I began reading (and unwisely commenting) on the posts at Overcoming Bias. This has brought about several realizations, unfortunately all later in life:

  • Most branches of true science rely heavily on math as the language. Some mathematical concepts literally cannot be put into words, yet another mathematician knows exactly what they say.
  • Medicine is not a true science; doctors are not mathematicians.
  • Scientists base all their conclusions on falsifiable evidence; doctors, for the most part, are not even familiar with the methods for evaluating evidence in their own fieldsSee this, for example. I didn’t come close to the correct reasoning.
  • Anecdotal experience, to a scientist, is no different from lies; anecdotal “experience” plays a major role in the decisions doctors make about patient management.
  • Doctors have an incredibly positive influence on the health of some individuals, at some particular times, but for the most part they are unaware of, or unwilling to accept the statistical evidence for, their ineffectiveness regarding the health of the American populace as a whole. See the evidence here and here, for instance. I have been in medicine for 38 years, and I was unfamiliar with these statistics. As Eliezer Yudkowsky chided one doubtful responder about this information: “I don’t think you understand what statistics mean. They are not a sort of weak extra argument that you weigh in addition to your much more reliable personal experience; statistics are a stronger, more reliable way of looking at the world that summarizes far more evidence than your personal experience, even though it just looks like a little number on paper while all that other experience weighs so heavy in your mind.” Elegant, and a statement that I guarantee most of my colleagues would reject.

Of course, I’m not yet aware of what, if at all, studies have to say about the marginal value of professions other than medicine. I suspect another post will follow addressing that. But for now, I’m reminded of the original United Negro College Fund ads that asserted, “A mind is a terrible thing to waste.” American physicians are smart; the selection system almost guarantees it. But, we’re not the smartest of the professions, and much of our smartness is wasted by our undisciplined thinking.

I think I know one very good reason for this, and I’ll discuss it soon.

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How do you like this education, doctor?

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics, Medical marketing, Self-deception |

Chances are, if your doctor seems quite successful, he is a drug rep. He may not even know it. He surely won’t admit it, especially not to himself. It probably started out as a part of his continuing education.

I wrote: In my next post, I’ll talk about the real leaders in doctor “education”; they weren’t included in this one because it’s not official CME. I’ll also throw in some first-hand, saw-it-with-my-own-eyes anecdotes. Here it is; I know you’ve been waiting with bait on your breath.

You’re sitting in your doctor’s waiting room. You have the first appointment of the afternoon, yet there are five others waiting as well. They are all relatively young women in very nice outfits. They’ve got some cleavage working, and they’re shod in FMP’s, the good kind, maybe Jimmy Choo’s. They don’t seem to be ill. They’re pharmaceutical reps. (NOTE: if your doctor is a woman, these people will instead be athletic-looking youngish men, or perhaps an occasional older, plainer chick, no cleavage. Nothing suggesting competition). They are waiting to help your doctor with his continuing medical education. In fact, statistically, they are the major source of your doctor’s new knowledge about medicines. You will be ushered to an examining room and told, “The doctor will be with you shortly.” One or two of them will see him in his private office before he comes to see you. And so the day will go. (more…)

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Why your doctor thinks what he/she thinks

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics |

 

When it comes to the source of your doctor’s upgraded medical knowledge, follow the money. I thought that phrase was from Jerry Maguire but apparently it’s not. Whether from the mouth of a sports agent, an investigative journalist, a movie script writer, or just someone who knows what he’s talking about, when it comes to your doctor, chances are it’s right on. Once your doctor finishes his training, he is on his own for further education (the editorial “he”; I’m not going to say “he/she” every time, regardless of PC, and regardless that we will soon have more female doctors than male; that’s another post). All US state medical boards now require doctors to show evidence of Continuing Medical Education (CME) in order to retain their licenses to practice. Talking over a problem in the doctor’s lounge, or calling the old professor to see what’s new, does not qualify as CME. Neither does reading the new edition of a comprehensive textbook (which, by the way, is already years out of date by the time it’s published). So how is CME accomplished? Commonly, there are four ways: (more…)

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Doctor, are you FDA-approved?

Posted on August 16, 2008. Filed under: Everything you wanted to know about doctors, medical ethics |

For the most part, the “practice” of medicine does not work like a science. I wrote that comment recently on the Overcoming Bias blog. Prior to 1910, when the Flexner Report was released, there were no general guidelines for teaching American doctors. As a result of Flexner’s recommendations, over half of the American medical schools had been closed by 1935, leaving a total of 66. Since then, with the growth in population, the number has climbed to 129, with each of these following the same rigorous standards. There are no “bad” American medical schools (unless they all are bad). All American doctors are trained in a evidence-based curriculum. All “board-certified” doctors must give at least the minimum number of  correct answers on the Board examination, and demonstrate the ability to avoid being fired for the duration of their specialty training, such that the Professor is somewhat obligated to give a recommendation, since the candidate was allowed to complete the program. 

So why isn’t the practice of medicine a “science”? (more…)

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    About

    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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