The Good Doctor

by Kenneth Brigham

  In one study of seven hundred surgeons who believed they had made a medical error in the past three months, over two-thirds thought their errors were caused by burnout.79 The numbers of medical errors have prompted some alarmists to opine that conventional medicine “kills more people than it saves.”80 That isn’t true. There are too many medical mistakes, any is too many, but that opinion ignores the noble and effective efforts of the many dedicated, knowledgeable, and empathetic doctors of the world. While the fact that there are too many medical mistakes is not a fair indictment of the entire system, it does mean that you need to pay careful attention when selecting the people and places involved in your health care. It almost certainly means that you should avoid doctors suffering from the “poor me” syndrome.

  Are doctors hapless victims of a diabolical health care system or can they do something to improve their lot? There probably is not a simple answer to that question, but there is a basic principle that the “poor me” syndrome may obscure. The critical people in any health care system are the health professionals—doctors, nurses, and others—and the patients, but the culture is largely driven by managers and other business types. The managers of the health care business need doctors and patients to manage or they have no business. If enough doctors refused to enable a viciously profit-driven practice that they claim to hate and enough patients refused to patronize such practices (patients are also dissatisfied with them), then the culture might be forced to change. More doctors would necessarily grow into open-minded and caring professionals who were comfortable with uncertainty or they’d be out of business.

  So as you go about trying to locate for yourself that kind of doctor, you should keep a keen eye out for symptoms of the “poor me” syndrome. Although doctor “burn-out” is a serious and increasing problem that needs to be addressed by the profession, your relationship with your doctor should be focused on your health. It will only depress you to be subjected to a litany of travails of the profession, and that will not make you healthier.

  Sandeep Jauhar, “Why Doctors Are Sick of Their Profession: American Physicians Are Increasingly Unhappy with Their Once-Vaunted Profession, and That Malaise Is Bad for Their Patients,” The Wall Street Journal, August. 29, 2014, http://www.wsj.com/articles/the-u-s-s-ailing-medical-system-a-doctors-perspective-1409325361.

  Sanjeep Juahar, Doctored: The Disillusionment of an American Physician (New York: Farrar, Straus and Giroux, 2014).

  Sandeep Jauhar, “Why Doctors Are Sick of Their Profession: American Physicians Are Increasingly Unhappy with Their Once-Vaunted Profession, and That Malaise Is Bad for Their Patients,” The Wall Street Journal, August. 29, 2014, http://www.wsj.com/articles/the-u-s-s-ailing-medical-system-a-doctors-perspective-1409325361.

  M. Quinn, A. Wilcox, E. J. Orav, D. W. Bates, and S. R. Simon, “The Relationship between Perceived Practice Quality and Quality Improvement Activities and Physician Practice Dissatisfaction, Professional Isolation, and Work-Life Stress,” Medical Care 47 (2009): 924-928.

  Roni Caryn Rabin, “A Growing Number of Primary-Care Doctors Are Burning Out. How Does This Affect Patients? The Washington Post, March 31, 2014.

  Carol Peckham, “Medscape Physician Compensation Report 2015,” Medscape, April 21, 2015

  Abraham Verghese, “A Doctor’s Touch,” TED, http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch.

  Robert Kocher, “The Downside of Health Care Job Growth,” Harvard Business Review, September 23, 2013.

  Carol Peckham, “Medscape Physician Compensation Report 2015,” Medscape, April 21, 2015.

  Carmen DeNavas-Walt and Bernadette D. Proctor, “Income and Poverty in the United States: 2013: Current Population Reports,” U.S Census Bureau, Department of Commerce, Economics and Statistics Administration, September, 2014.

  Dan Mangan. “Medical Bills Are the Biggest Cause of U. S. Bankruptcies: Study,” CNBC, June 25, 2013, http://www.cnbc.com/id/100840148.

  Roni Caryn Rabin, “A Growing Number of Primary-Care Doctors Are Burning Out. How Does This Affect Patients?,” The Washington Post, March 31, 2014.

  Victoria Sweet, “Should a Doctor Be Like a Gardener?,” The Wall Street Journal, April 25, 2012.

  Meghan O’Rourke, “Doctors Tell All—and It’s Bad,” The Atlantic, November 2014.

  To Err Is Human: Building a Safer Health System, Institute of Medicine (Washington, D. C.: The National Academies Press), https://doi.org/10.17226/9728.

  T. Shanafelt, C. Balch, G. Bechamps, T. Russell, L. Dyrbye, D. Satele, P. Collicott, P. Novotny, J. Sloan, and J. Freischlag, “Burnout and Medical Errors Among American surgeons,” Annals of Surgery 251 (2010): 995-1000.

  “New Report: Preventable Medical Mistakes Account for One Sixth of All Annual Deaths in the United States,” Mercola, October 9, 2013, http://articles.mercola.com/sites/articles/archive/2013/10/09/preventable-medical-errors.aspx.

  PART III

  Some Things That Your

  Doctor Should Know

  . . . And Why They Matter

  CHAPTER 8

  The Difference between “Facts” and Facts

  There is nothing more deceptive than an obvious fact.

  —ARTHUR CONAN DOYLE, “The Boscombe Valley Mystery”

  The good doctor is very suspicious of things that everybody knows. There are too many examples of accepted “facts” based on popular beliefs that turn out not to be true. For example, everybody knows that Sherlock Holmes was fond of responding to a compliment of his deductive powers from his colleague with the words, “Elementary, my dear Watson.” But what everybody knows in that case is not true. The great detective spoke all of those words on multiple occasions, but did not once speak them linked together.81 One could call that the “everybody knows fallacy.” There is a long list of obvious facts, things everybody knows, that are untrue; conventional wisdom may be conventional, but it is not reliably wise.

  The good doctor also knows that a lot of harm can come from believing “facts” loudly proclaimed by public figures whose opinions are at odds with the best science and even by so-called experts whose judgment is clouded by a personal agenda—the “celebrity expert fallacy.”

  Here is an example. British gastroenterologist Andrew Wakefield and colleagues published a paper in 1998 claiming that vaccinating children against infectious diseases caused autism.82 The paper was subsequently retracted by the journal and there is no credible evidence that supports the claim. However, that paper has become “the holy text” of the anti-vaccine movement.83 That movement, energized by various celebrities with wide exposure as well as by Dr. Wakefield’s efforts in the popular media, almost certainly shares responsibility for the failure of a number of children to get the MMR [measles, mumps, rubella (German measles)] triple vaccine. That vaccine is one of the most dramatic success stories in the history of childhood medicine. More unvaccinated children in the population risks an epidemic and fatalities.

  This is not just a theoretical risk. Although measles was eliminated from the U.S. a couple of decades ago, that doesn’t mean that in this decade your unvaccinated child is safe from a disease with potential complications of encephalitis, pneumonia, and even death. Measles and other childhood infections are still common in large parts of the world. So the parents of a kid from one of those places take their child on her dream trip to Disneyland, unaware that she is incubating the measles virus. In Anaheim the kid, infectious but not yet sick, bumps into unvaccinated children from all over America as the happy family ambles about the theme park. Then the kid comes down with a full blown case of measles and is the index case for a large multi-state measles outbreak. We didn’t make this up. Something like this actually happened in 2015.84 And in 2019, a similar situation occurred in N
ew York.

  This good doctor knows that withholding vaccination puts children at risk for a variety of preventable diseases and invites recurrence of epidemics of infectious diseases that have all but disappeared. She also knows that most medical opinions of celebrities are worse than useless as evidence. She’ll help you make sure that you’re not dazzled into making bad health decisions by either glib hucksters or the seductive glamour of celebrities. As just one example, she will do everything in her power to see that you vaccinate your kids. This doctor has serious doubts about anything that everybody knows and has a healthy suspicion of facts, obvious or not, because she knows a thing or two about the nature of medical evidence.

  Evidence-based medicine aims to rescue medical practice from the maw of myth, folklore, misguided opinion, and conventional wisdom and bring some rigor and consistency to the field. Hard to argue with the motive, but how do you and your doctor know what evidence to trust? How do we parse “facts” from facts?

  In medicine as in the rest of life, questions have three possible answers—yes, no, or maybe; the drug (or operation or whatever) works, doesn’t work, or there’s not enough evidence to tell either way. Or there may be no rigorously analyzed data, no evidence at all. The old saw “absence of evidence is not evidence of absence” is true enough in medicine to give the good doctor pause before she becomes too dogmatic about anything.85 Nassim Nicholas Taleb’s fascinating book, The Black Swan, referred to earlier, deals with this idea.86 A single black swan belied the prevailing concept that all swans were white. And you can never know whether there is an undiscovered exception lurking out there somewhere (one of Donald Rumsfeld’s unknown unknowns) that will stand your solid reliable fact on its ear.

  Well aware that not all “evidence” is created equal, the good doctor is a tenacious critic of medical dogma. She pays a lot of attention to where information comes from. One of her most valued sources is the Cochrane Collaboration.

  When the Scottish doctor, Archibald Cochrane, was a captive of the Germans and caring for the unfortunate prisoners in World War II concentration camps, he became acutely aware of how precious little evidence there was to support most of what doctors did.87 Less speculation and folklore and more sound science is what he thought was needed to make the best conclusions about what did and didn’t work. Cochrane’s preoccupation with the need for carefully designed and controlled studies in people became his lifelong raison d’être. His 1971 book, Effectiveness and Efficiency: Random Reflections on Health Services, made an eloquent case for randomized controlled clinical trials, and Cochrane’s effective advocacy for such trials eventually led to the international collaboration that bears his name.88 The Cochrane Collaboration is widely accepted as the premier source for critical evaluations of medical practices.

  Given its origins, it is no surprise that the Cochrane Collaboration considers randomized controlled trials the best possible evidence, the gold standard, and most people agree that such studies (commonly abbreviated RCT) are the ideal.89 In such trials, groups of people with a given condition are treated with test intervention or a placebo. Who gets which is entirely random and the doctor doing the study doesn’t know which patients get which treatment (the design is called “double blind,” i.e., neither the patient nor the doctor knows what the treatment is). How many people are going to be studied is decided in advance and (barring something unforeseen) studies must be completed on that number of patients before the master code showing who got what is broken and the statisticians analyze the results. That’s about as good as one can design a study to keep everybody honest and eliminate even unconscious bias on the part of the doctors involved.

  The highest level of evidence, then, is the systematic evaluation of all of the relevant randomized controlled trials (assuming there are several and the more the better) in an area with a stated degree of certainty (statistical precision) of the conclusion. Cochrane’s panels of experts scrutinize study designs for the potential for bias. They look at the size of any effect, whether what looks good to the statisticians is big enough to make any difference in the real world; statistical significance doesn’t necessarily mean biologic significance. And then there’s the source of funding for a study. There are, unfortunately, examples where a funding source with a dog in the fight could have unduly influenced what got into the published literature. There is no place for blind trust even in randomized controlled trials.

  Cochrane reviews are daily fare for the good doctor. But she also read a 2010 Atlantic article titled “Lies, Damned Lies and Medical Science” that made her look a little more carefully at the work of statistician John Ioannidis, director of the Stanford Prevention Research Center.90 The article says that Ioannidis “and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies . . . is misleading, exaggerated, and often flat-out wrong.” Ioannidis opines that 90 percent of the published medical information that doctors use to decide how to treat their patients may be flawed. Dr. Ioannidis doesn’t buy the RCT thing, at least not the way such studies are generally done.

  Dr. Ioannidis says that conclusions of random controlled trials may be wrong because they are too small, too sensitive to small effects, too unselective (i.e., too many things are measured), too imprecise in design, or too dependent on support from sources which stand to benefit from a specific result. And those factors do not act independently; their interactions can also affect the validity of a conclusion. Sometimes, a thoughtful and critical doctor wonders whether available evidence can support even a maybe, much less a yes or no. So she learns the best evidence available and uses it, but never forgets that she could still be wrong.

  Ioannidis also introduces a paradox: “The hotter a scientific field (with more scientific fields involved), the less likely the research findings are to be true.” He argues that in a rapidly moving field, researchers are anxious to get their positive findings into print, to establish priority, while downplaying (i.e., under-reporting) negative results. This can result in an initial conclusion that either can’t be duplicated, has to be modified, or is proven wrong subsequently.

  So before swallowing new data completely, the good doctor recalls a familiar description of medical discovery as happening in three phases: gee whiz, followed by aw shucks, and finally yes, but (illustrated in the adjacent graph; this has been called the Hype Cycle)91. Since gee whiz is the most attractive of the three phases to scientists (as well as journalists and granting agencies), exciting results dominate the early phases of discovery. But, as surely as night follows day, there are disappointments waiting in the wings that must be dealt with (aw shucks) before arriving at the modified expectations of clinical value (yes, but). The ultimate clinical value of new information, even when it turns out to be true, is almost never as great as originally claimed.

  So you start to understand why the good doctor has the best chance of getting it right. Consistently attentive to new information but undazzled by extravagant claims, this doctor casts a critical eye on every source of information before using it to help you decide what to do about your health.

  Randomized controlled trials are the best possible evidence, but there are many conditions for which such studies have not been done. If you have one of those conditions, how do you and your doctor decide what to do? The only choice is to resort to less reliable evidence—results of uncontrolled, non-randomized studies compared to what has been reported to happen historically, or single case reports. Even closer to the bottom of the barrel are “expert” opinions, clinical impressions, and conventional wisdom. (An old joke says that doctors tend to overvalue their clinical experience so that “in my experience . . .” is one case, “in case after case . . .” is two cases, and “in my series . . .” is three cases.) As we said earlier, opinions of TV stars, sports personalities, and other notable persons with absolutely no relevant expertise (and who are often handsomely compensated for
stating their opinions on TV and in other conspicuous places) should be roundly ignored; such opinions are not evidence at all.

  When the folks at the Cochrane Collaboration review a topic, they look at every level of evidence in an effort to reach some kind of expert consensus; they often fail. In forty-nine percent of 1,016 reviews in 2007, the best they could do was not yes or no but maybe; they often recommended more research. And these are the experts! For many medical conditions, there is just no clear and unequivocal answer that works for everybody. That is likely to always be true because the effects of interventions are studied in people, and people are notoriously varied and unpredictable.

  What about reproducibility as a criterion for evidence? Hard scientists say to forget about any claim that cannot be duplicated by at least one more laboratory or scientist. But, assuming that most scientists don’t make up results (some do and they get caught at it sooner or later), how can a scientist set up the same experiment exactly as reported by someone else and get a different answer? The good doctor knows that, unlikely as it sounds, this happens all the time. The reason is that biology, especially human biology, is so complex that it is impossible to design an experiment that doesn’t have “unknown unknowns.” One does the best one can to make sure that everything in the test and control groups is the same except for whatever is being tested, but one can never be absolutely sure. Human biology is not theoretical mathematics or quantum physics. These are human beings with all of the ambiguity that they bring to the table. What was the barometric pressure? What was the phase of the moon? What time of year was the study done? Where on our planet was the investigating laboratory? What was the source of reagents? For female subjects, where were they in their menstrual cycle? What was the emotional state of the test subjects? Were there critical events happening in the world at the time of the studies? Were any of the subjects survivors of intensely traumatic events either recently or in the past? Where did the test subjects live and under what circumstances? What was happening in the test subjects’ families at the time of the study? Were the test subjects on some kind of fad diet? What about drugs, legal or otherwise? I’d give very long odds that the published studies your doctor reviews in an effort to decide what is right for you don’t answer many of those questions. That in spite of the fact that every one of those questions could possibly affect the results of any study involving humans and so could be relevant to deciding what is right for you!