The Good Doctor

by Kenneth Brigham

  But how can you know whether the tests your doctor orders are reasonable, appropriate, and necessary for your optimal health care or whether they’re being ordered primarily to satisfy the doctor’s desire to know the answer? There are some clues and also some things you can do to flush out this doctor’s real motives.

  Does your doctor explain the reason for tests, the risks involved, and how the results will or will not affect your care? If not, you should ask those questions, but if it comes to that, you might start to wonder whether you and the doctor are on the same page. You are supposed to be the focus of this relationship and it is hard to believe that to be true if you’re not told what’s going on. The doctor who is laser focused on getting a definitive answer to every question is often not long on explaining her actions; she really doesn’t see the point. She’s determined to get the answers and you just happen to be her current source material.

  You should never hesitate to get another opinion of the plan for diagnosing your condition and recommendations for what to do about it. This is especially true if things get complicated and expensive and invasive tests are in the offing, therapies with serious possible side effects are suggested, or there is a series of interventions that are progressively more risky (beware the slippery slope). Insisting on another professional opinion may well not please this doctor. In fact if she is too displeased with or threatened by such a request, that’s a pretty reliable clue that you may not have chosen the best health care collaborator. You should never be intimidated by the displeasure of your doctor. You’re not there to make her happy. You’re there because you need the doctor’s help and if the two of you can’t work together on your problem amiably, the result is not likely to be as good as it ought to be.

  If there is anything that you don’t understand or are unsure about, you should ask as many questions as needed to be sure that you’ve got it right. That isn’t likely to make this doc happy, but that’s her problem. You should just keep asking the questions until you’re satisfied. Sincere questions politely asked will not annoy the good doctor; she will answer them in kind.

  The questions you need to ask will depend on your personal needs, how much information your doctor volunteers, and the specific health related situation. But you need to be totally honest about what you need to know. The U.S. government’s Agency for Health Care Research and Quality suggests the following ten questions to consider as a starting point.52 It is clear from this list that you need not be shy about being specific:

  1.What is the test for?

  2.How many times have you done this procedure?

  3.When will I get the results?

  4.Why do I need this treatment?

  5.Are there any alternatives?

  6.What are the possible complications?

  7.Which hospital is best for my needs?

  8.How do you spell the name of that drug?

  9.Are there any side effects?

  10.Will this medicine interact with medicines that I’m already taking?

  Questions like these will go a long way toward revealing this doctor’s true colors. Best to get that done early. If this relationship isn’t going to work for you, the sooner you realize that and move on, the healthier you will be.

  With the obsessive yes-or-no brand of medicine you will pay too much for care that is not as good as it should be and sometimes carries unnecessary risks. The same is true of a doctor who believes that she knows all the answers—we’re about to meet one of those in the next chapter.

  Recalled patient encounter, KB.

  Michael B. Rothberg,“A Piece of My Mind. The $50,000 Physical,” Journal of the American Medical Association 311 (2014):2175-2176, doi:10.1001/jama.2014.3415.

  “Choosing Wisely: An Initiative of the ABIM Foundation,” ABIM Foundation, http://www.choosingwisely.org/.

  Michelle Andrews. “Doctors Estimate $6.8 Billion in Unnecessary Medical Tests.” The Washington Post, October 31, 2011.

  Michelle Andrews. “$6.8 Billion Spent Yearly On Twelve Unnecessary Tests And Treatments,” Kaiser Health News, October 31, 2011, http://khn.org/news/michelle-andrews-on-unneccesary-tests-and-treatments/.

  Jamie Holmes. “Doctors Hate Ambiguity: How an Obsession with Certainty Can Hurt Patients’ Health.” From Nonsense: The Power of Not Knowing by Jamie Holmes. Crown, 2015.

  “The 10 Questions You Should Know: Questions Are the Answer,” Agency for Health care Research and Quality, http://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/10questions.html.

  CHAPTER 6

  The Infallibility Illusion

  What the good doctor doesn’t know could save your life and what this doctor “knows” could do you some serious harm. That almost happened to Susan Black (not her real name). It would have, too, if she hadn’t taken matters into her own hands. We can learn something important from Susan Black.

  When Ms. Black discovered a golf ball size lump on her chest, she immediately consulted her family doctor.53 She had no pain, she hadn’t lost any weight, and she felt perfectly fine. The lump just appeared out of the blue. She was referred to a surgeon who removed the lump and finally, after waiting two agonizing weeks, she was told that two pathologists had reviewed the biopsy and concluded that it was a “panniculitis-

  like T-cell lymphoma,” a rare cancer that could very well kill her and that required immediate treatment. She was referred to an oncologist who ordered extensive blood tests and a CT scan. When she protested to the oncologist that she felt fine he responded that the periodic hot flashes she was having were symptoms from her tumor. “But,” she said, “I’m fifty-two! At fifty-two all women have night sweats and hot flashes.” She asked whether there wasn’t a chance that the lab results were wrong, and he replied absolutely not and encouraged her not to delay starting treatment. When she told him that she wanted a second opinion before consenting to start his recommended chemotherapy, the doctor responded, “What you have is so rare, no one will know any more about it than I do.” Fortunately, Ms. Black, no fan of the myth of the infallible doctor, didn’t buy that. She did consult another expert, who reviewed all of her test data including the biopsy and concluded that she didn’t have cancer at all, but rather a completely benign lesion that would resolve without treatment. She had no therapy and continued in good health, narrowly escaping certain misery from the oncologist’s supremely confident recommendations.

  What Ms. Black’s doctor knew for certain, like many medical certainties, turned out to be wrong. All of the doctors involved here, the internist, the pathologist, and the oncologist, were too sure of themselves and the attitude of each reinforced certainty in the others. Ms. Black was in danger of being caught up in a positive feedback loop resonating among her multiple doctors that was leading her full tilt in the wrong direction. Although the root cause of that situation may have included arrogance, we suspect knowledge without understanding was the real problem. The pathologist said it was cancer so the internist referred her to a cancer doctor and the cancer doctor did what he was trained to do, choose a chemo regimen based on the pathologist’s diagnosis and move on. But they were all wrong because nobody paused to consider the possibility that there was something worrisome about this case. Fortunately Ms. Black found a doctor who was more open to alternative explanations for her problem, but she had to summon the courage to challenge the confident recommendations of several experts to get there. And it took her four tries!

  You should not confuse your doctor’s confidence in her expertise with how right she is about your condition. In fact, how certainly the overconfident doctor answers your questions may have nothing to do with whether or not she’s right. British pediatric neurosurgeon Richard Hayward observes of doctors’ attitudes, “Infallibility refutes the possibility of error to which all human beings are susceptible. Authority is t
he uniform it wears.”54 You can be absolutely certain that your doctor is not infallible. If she mistakes her white coat for a uniform of authority, you should take your business elsewhere.

  Knowledge, whether a little or a lot, is dangerous. History is full of examples. Knowledge implies certainty and certainty has done a lot of mischief—driven religious intolerance, perpetuated scientific error, distorted our understanding of cosmology, and caused doctors to harm the very people they were sworn to help. The idea that doctors have irrefutable knowledge may have its roots in an era when shaman healers laid claim to a spiritual inside track. Shedding the claim of a special connection to God may be progress, but there are still too many doctors around who relish their roles as unquestionable authorities. It doesn’t serve their charges well. The doctor who knows all the answers doesn’t understand the information; uncertainty is hard wired to understanding. The all-knowing doctor is lying to herself and the doctor who lies to herself will, inevitably, deceive her patients.

  As happened with Ms. Black, the doctor who’s too certain can hurt you by missing the diagnosis and so prescribing the wrong therapy. She can also be so certain that she knows all of the possible effective therapies that she keeps you from getting something innovative that might save your life. Although hopefully this happens rarely, it does happen and the results can be tragic.

  Here is a deeply painful tragedy, the blame for which lies squarely at the feet of an overconfident doctor. A man getting chemotherapy in his small local hospital was responding well without complications.55 His cancer was improving and it looked like he would recover. After a regular treatment late on a Friday, he developed diarrhea. By the next day the diarrhea was so severe that his wife took him to the local emergency room. He was admitted to the hospital and found to have an infection of his bowels with the dangerous bacterium, Clostridium difficile (C. diff). That is not a rare complication of chemotherapy, but it is a serious one that is devilishly difficult to treat and can be fatal. The patient got rapidly worse until he was nearing death in spite of antibiotics. His wife had a friend who had had chronic C. diff diarrhea that did not respond to antibiotics but was essentially cured by a fecal transplant. From the internet, they learned that this still experimental treatment could cure resistant C. diff diarrhea in up to ninety percent of cases. The patient’s wife pleaded with the doctor to try it. Her husband was nearing death and nothing seemed to be working. What was there to lose? The doctor said that he had never heard of fecal transplant therapy. When she continued to plead with him to reconsider, the doctor refused to discuss it further, telling her that he didn’t want to hear any more of her “bullshit quackery.” The next day, the patient died. He died for want of a doctor with the knowledge, understanding, courage, and human decency to entertain the possibility that maybe there was something he did not know.

  And this attitude of infallibility can develop early. A nurse in a Washington hospital was alarmed when she saw that her patient who had a shunt in place to drain fluid from his brain was vomiting and complaining of headache.56 She knew those were symptoms of increasing pressure in his brain, probably because the shunt had clotted off and stopped draining the fluid. When she called the resident on duty who was sleeping in the hospital, he told her not to worry about it. But she did worry about it, a lot. After a while when the patient’s symptoms didn’t improve, she called the resident a second time to which he responded, “You don’t know what to look for—you’re not a doctor!” and slammed down the phone. Fortunately for the patient, the nurse called the attending doctor and the patient was treated appropriately, narrowly escaping serious brain injury or death. We don’t know whatever happened to the resident; surely he was severely chastised for this kind of behavior. We hope he learned from that experience, but we fear that he may be practicing medicine somewhere, supremely confident of his exceptional knowledge and thoroughly certain that he rarely if ever makes mistakes.

  But that resident still makes mistakes, no matter how much he knows. It’s said that preventable medical mistakes account for a sixth of all annual deaths in the U.S., and we’d bet a lot that overconfident doctors account for more than their fair share of those errors.

  So you don’t want the services of an overconfident doctor because she makes too many mistakes. She does that in many ways—by doing the wrong thing, by assuming she knows something that she doesn’t, and by failing to look beyond her headlights. Here is an example of a doctor who was so confident of the diagnosis that he didn’t look for anything beyond his immediate field of vision. After all, he knew what was wrong with the patient. Why look any further?

  A Washington pediatrician had practiced medicine for forty years when his throat started hurting.57 He arranged to see a doctor about it and after recounting his symptoms he was told that his throat pain was due to reflux of acid from his stomach backing up into his esophagus. He went home and did as he was told but the pain didn’t go away. He revisited the doctor and was told again that his problem was acid reflux. Finally, after seven months of this, the patient happened to see an astute resident who decided to look down his throat using a simple technique commonly done by ENT doctors. Lo and behold, there sat a cancer, “the size of a peach pit.” The cancer was cured by completely removing the patient’s voice box, but what if the doctor he saw at first hadn’t been so sure of himself and had taken a look seven months earlier? An arrogant doctor doesn’t know what he doesn’t know.

  What happens behind the scenes can also impact your care, even though you rarely get a good look at the back office operations. An arrogant doctor doesn’t always behave well back there. When cornered, this doc can turn mean and the consequences aren’t good. In one survey, 67 percent of health care workers at 102 nonprofit hospitals believed that doctors’ disruptive behavior caused medical mistakes, and eighteen percent reported firsthand knowledge of a medical mistake caused by an obnoxious doctor.58

  Highly opinionated and defensive doctors also cause collateral damage by creating an unpleasant and threatening environment that makes it difficult for other health professionals to do a good job. The stress of the operating room can bring out a surgeon’s worst—thrown scalpels, demeaning epithets hurled at assistants, irrational outbursts of temper. It happens on medical wards too. An attending doctor flings a patient’s chart clear across a nurses’ station at a cowering intern who failed to get a requested test done on time (that actually happened more than once in an elite medical institution).59 A survey by the Institute for Safe Medication Practices says that forty percent of hospital staff report being so intimidated by a doctor that they dared not raise questions about apparently incorrect medicine orders.60 The arrogant doctor leaves casualties—colleagues and patients—in her wake. You don’t want to be one of them.

  And heaven help us if the “infallible” doctor winds up in charge of writing guidelines that are imposed on the other doctors practicing in his system. Guidelines can be misunderstood as implying unyielding certainty, and wind up being used to coerce doctors into uniform application of a practice. This kind of thing plays right into the overconfident doctor’s hands. The problem is that there are always maybes, exceptions to virtually any guideline that anyone can write. So you may stand to benefit from a rigid application of a guideline that benefits most people. Or you may not.

  For example, there are guidelines that recommend giving a heart drug called a beta blocker (how it works is not important to the point) to patients getting anesthesia for a heart operation.61 At least in some cases, insurance companies require that this be done in a very high percent (preferably 100) of patients in this category or they won’t pay. So, institutions go to great lengths to get anesthesiologists to give the drug—computer popup reminders, admonishments from administrators, constant review of the success rate, etc. With the imprimatur of the power structure behind the practice, the doctor can be absolutely certain of what do to; don’t think about it, just give the drug. The overconfident doct
or loves this stuff. However, there are some patients who are likely to be harmed rather than helped by a beta blocker. If a doctor is caring for a patient whom he is pretty sure is in that category, what does he do? Powerful organizational and financial forces say give the drug anyway, while that pesky dictum of Hippocrates to which a doctor is sworn—primum non nocere—says safety of the patient is paramount. There was a memo from the chief of anesthesia congratulating the group on 100 percent compliance with the practice over the past several months and warning that missing giving the drug to even one patient would drop the group out of the top 10 percent of peer institutions and risk decreased payments from the insurance company—damned if you do, damned if you don’t.

  No problem, says the supremely confident doctor. If she fears that the patient is likely to be harmed by the drug, she should give a very small dose (sub-therapeutic is the medical term) of a very short acting form of beta blocker. Then everyone is happy. The box in the patient’s record that says a beta blocker was given can be truthfully checked, but the patient is spared any effect of the drug. The result? Consistently 99 percent compliance; everybody’s happy. This is the kind of ludicrous practice that certainty of universal benefit can cause. What’s best for you is not front and center in this situation. Front and center is getting a check mark in the box that will assure compliance with a universal guideline. But no universal guideline is really universal. If your doctor tells you anything is 100 percent effective, don’t believe it!

  But perhaps we’re being too hard on the self-confident doctor. There is a place for informed certainty in medicine. In fact there are situations in which a doctor needs to have the courage and confidence to act on the best available information. In some circumstances, the right thing for you is for the doctor to do something . . . now. Your life could depend on it. You don’t want a timid surgeon!