September 6, 2007

How Doctors Don't Think

how dotors think 


Jerome Groopman's book, How Doctors Think, is porn for doctors.  While ostensibly about the ways in which doctors make errors, the real message is sure to elicit hands-free climax in clinicians: "good" doctors make fewer mistakes because they go beyond statistical probabilities and treatment algorithms to consider the whole patient.  They use their clinical judgment.  Many of the enemies are the usual suspects, insurance companies, Pharma. 

While the book is worth reading, it isn't worth reviewing, I'm afraid-- I'll egocentrically say I think I already covered much of his ground.

But what is worth reviewing is a review of his book, by Charles Lambdin, a grad student in psychology.  The review is called How Doctors Think They Think.  And it is outstanding. 


You should read the article in its entirety, this guy gets it, I'll add only two short points specific to psychiatry.

Groopman acknowledges that medicine has considerable data and science available to it, but doesn't like blindly following "evidence based medicine" because it fails to take into account the nuances of the individual sitting in front of you.  Through a good interview, a doctor has access to extra information, often subtle, that an algorithm or "evidence based medicine" doesn't have, that can increase his accuracy rate.  Fair enough. 

Lambdin, however, points out that doctors are susceptible to all sorts of errors and biases in the application and detection of this "extra" information, that can make these augmented decisions  even worse than simply applying the algorithm blindly.  Touche.

The problem in psychiatry is a little different, however: here, psychiatrists make biased and error-prone judgments-- often simply prejudices-- that they use to augment studies and evidence  which themselves are faulty and biased.  It never ceases to amaze me how people are suspicious of drug company studies, but not at all suspicious of studies from the universities or the NIH-- they don't have any biases there?  Is it magic that allows me to predict that an NIH study will find the generic the best choice?   Researchers not only can influence the data-- mostly unconsciously, but also by not publishing a study that didn't show the expected results-- but also which questions to investigate, and how questions are framed.  Is there any possible reason Harvard, Yale, and Cleveland will always find a reason to study Depakote or Lamictal?  And now Seroquel?   But not Zoloft (now generic?)

An example of this is the the doctor who has a patient who has no history of bipolar, and any rating scale or screen would not suggest bipolar, but uses his clinical skills (read: bias) and says "there's  something about him" and "discovers" that the patient is an undetected bipolar-- but then puts him on Depakote, because that's what the "evidence" shows is the first line for bipolars.  Really?   Which studies did you read, again?  The orange ones?  In the Trapper Keeper?

As anyone who has ever dated a girl who was too much into the occult will tell you, astrology is difficult. It has a highly structured set of rules-- math, really-- so precise and complex that, theoretically, any two astrologers should independently arrive at the same result, which is correct enough times to keep people from breaking out into hysterical laughter all the time.  However, astrology is crap, right?  Some other factors explain the few successes.  Is the fact that so many schizophrenics are born in the spring related to Mars rising in Orion, or to a virus women contract in the winter?  Etc.  In other words, just because a system is reliable, doesn't mean it's valid.

The other point is on the subject of "zebras"-- rare, outlier diagnoses that should be investigated last after more common and likely ones. Lambdin writes:

Oddly, Groopman rebukes doctors guilty of “zebra retreat,” but bungles the example this term is derived from. He quotes: “When you hear hoofbeats, think about horses, not zebras.” The actual lesson is, “When in Wyoming, if you hear hoofbeats and think you see stripes, it’s still probably a horse.”

In psychiatry, however, the problem isn't suspecting a rare disorder before a common one; it is inventing a disorder rather than dealing with the complexities of a person's life.  "It's not bipolar--he hasn't responded to Depakote or lithium-- I think it may be Intermittent Explosive Disorder."  If you apply the same rigor, analysis and logic, alien abduction is also on the differential.  As I've written before,

the real problem of a critique of our cultural models is to ask, when we see a unicorn, if by any chance it is not a rhinoceros.

-- Umberto Eco

(Thanks to reader Walter F for sending me Lambdin's review.) 


Right on - I couldn't have ... (Below threshold)

September 6, 2007 7:06 PM | Posted by Steve: | Reply

Right on - I couldn't have said it better myself. Okay, maybe I could, but you did a commendable job as well.

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Because of an erroneous ent... (Below threshold)

September 7, 2007 9:35 AM | Posted by Sally: | Reply

Because of an erroneous entry in my chart that I am bipolar though I've never met any of the dsm criteria for bipolar disorder, I can't take the bar exam even though I finished lawschool. I'm working through the legal system to get this changed but its already been three years since my graduation. Of course I have the one symptom of bipolar that seems enough for a conclusive diagnosis these days, I don't think i have it.

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An example of your example,... (Below threshold)

September 8, 2007 12:32 PM | Posted by PsyFie: | Reply

An example of your example, straight from my medical records:

In his Initial Psychiatric Examination, an Attending Psychiatrist wrote the following:
"High affect but “under wraps” – but obvious patient working on containing emotions, underlying irritability / demandingnes, articulate, referring to illegality of involuntary admission, mental health law. Appears to have poor insight and low judgment, not quite pressured, but thoughts seem accelerated. Bipolar, manic – moderate vs. severe (+ (?)psychotic features. Will hold on routine scheduled meds to allow time to further clarify history, build patient trust/therapeutic alliance."

Based on this drivel, I was kept in a Texas psych hospital involuntarily for 3 weeks. A judge concurred with the doc that, since I didn't agree I had Bipolar Disorder when the doc said I did, I was incapable of making decisions about my "treatment" and could be forced to ingest any of the following meds the doc wanted to give me -- "antidepressants, antipsychotics, anxiolytics/sedatives/hypnotics, and mood stabilizers."

When I rfused to take pills, I was forcibly injected with Prolixin until a an acute dystonic reaction convinced me to take the Depakote and Risperdal the doc ordered.

Prior to this experience, I had NO history of mental illness, and I was 50 years old at the time.

Why don't more people recognize what is going on in the psych community? Bless you for getting the word out!

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Medicine is an art more tha... (Below threshold)

September 9, 2007 1:24 AM | Posted by Gloria: | Reply

Medicine is an art more than a science and few doctors have the gift.

When I developed shoulder, arm and head pain, I was immediately diagnosed as stressed out--ya know, anxiety with underlying depression. Why? I'd been so tired, I was worried about losing my job-- important, since I was single mom with two young kids.

Almost two years, 7mg of ativan, and 5 trials of various antidepressants later (and my first-ever experience being laid off as an editor), I was diagnosed with primary bone cancer and had three tumors removed--upper arm, shoulder, brain--my presenting symptoms.

I knew it wasn't stress, anxiety or depression but the more I disagreed, apparently the more I exhibited "stress", further validating the initial shoot-from-the-hip diagnosis.

The arrogance of doctors is appalling--that they assumed as a woman I had no sense of whether what I was feeling was in my mind or body. I almost checked myself into a psych ward in an attempt to demonstrate my sanity--see, I was literally at my wit's end.

The cancer is now in remission, I have no residual ill effects from any surgery, but the friggin' GP who diagnosed me as anxious and depressed refused to admit he made a mistake and so I now have a "mental health history." Go figure. Doctors ruin as many lives as they save because they think like George Bush and insist on staying the course in terms of diagnosis. the deal is they simply can't be wrong. Ever.

Ironically, I'm depressed now. And anxious, too. I had to sell our home and cash in my stocks and liquidate my 401K to pay for time off work and medical expenses--which involved seeking second and third opinions in order to receive the proper medical diagnosis.

So here's my final diagnosis: doctors don't think. They guess.

Oh, and a big PS to all psychiatrists--never prescribe benzos. They're nearly impossible to get off and come with protracted withdrawal symptoms. Getting off the ativan was worse than the brain tumor. Really. I hope some doctors will think about that when they dole out the stuff.

Alone's response: Wow, I don't know what to say to this story. I'm glad for you that you are all right physically. As for doctors guessing, I'm not sure that's right. An educated guess is pretty good in many circumstances. What worries me is bias, prejudice-- which we consistently apply to every situation, but are unaware of it. Example: is it me, or has anyone noticed you can tell what doctor a patient sees simply by the med list, and not the diagnosis or anything else?

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.."is it me, or has anyo... (Below threshold)

September 11, 2007 6:35 PM | Posted by Stephany: | Reply

.."is it me, or has anyone noticed you can tell what doctor a patient sees simply by the med list.." Would that be inpatient or outpatient?

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"Medicine is an art more th... (Below threshold)

September 13, 2007 6:22 PM | Posted by Schizo: | Reply

"Medicine is an art more than a science" -- Gloria, did you even read the review that this article was written about?! The _whole point_ is that this is not true, or at least should not be. Your statement word-for-word contradicts the end of that review: "Medicine needs to become more science and less art." I hope for your sake that you were kidding.

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"Medicine is an art more th... (Below threshold)

December 31, 2007 3:13 PM | Posted by b.f.edwards: | Reply

"Medicine is an art more than a science"

The art of practicing medicine is having the correct diagnosis. The art of medicine is knowing how to apply the science to the correct diagnosis.

At some point the physician should realize that the applied science is a dogma that reflects current practices, beliefs, experimentation, and therapeutic possibilities.

The therapeutic tools used by the physician are based upon that physician's beliefs and practice habits. So yes, one may tell who is prescribing by what is prescribed.

Algorithms and "best practices" are an attempt to standardize the beliefs for uniform outcomes. If you are average or below average in your skills, then algorithms are fine as you can do no better on your own. If you are at the top of the game, you can look at the algorithm, know the thought process derivation and where and when to ignore it. It helps to have the correct diagnosis in the original differential so that one can apply the correct algorithm.

I find it deplorable that many of the clinical studies that determine the "best practices" are sponsored by the pharmaceutical corporations.

Garbage in; garbage out.

The patient suffers.

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With a very few exceptions,... (Below threshold)

June 28, 2009 4:26 PM | Posted by Altostrata: | Reply

With a very few exceptions, psychiatrists are all idiots.

One could hardly imagine a discipline less suited to dealing with human emotions.

I am sure many assume that, if a patient contacts them, there must be something seriously wrong mentally with that patient. And they would be right. The patient has been misled by marketing into thinking psychiatry is a medical discipline rather than a research and distribution arm of the pharmaceutical industry.

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