Sunday, 27 January 2013

Don’t just do something, stand there


This reversal of a commonly used phrase is a plea. A plea against the bias that leans doctors towards diagnosing and treating, even when the scientific evidence may not support it. Sure, it is expected that a doctor will diagnose and treat you, but sometimes there is no diagnosis or effective treatment, and pursuing either may be harmful. When in doubt, your doctor will continue to run tests until something comes up, and will continue to treat you for as long as you return with symptoms. Sometimes, not pursuing a diagnosis and not treating a patient are reasonable options. Sometimes they are the best option.

The biases towards ‘doing something’ instead of reassuring patients and having them rely (heaven forbid) on their own coping skills are grouped below. The harms from overdiagnosis and overtreatment are covered extensively in previous blog posts such as: Overdiagnosed (book review), Overtreated (book review), Reasons to Operate, Overdiagnosis (overview), and Cancer Screening Part 1 and Part 2.

1. Defensive medicine
Defensive medicine is commonly practiced and can take many forms, such as ordering extra tests, sending patients for more referrals, avoiding patients with certain conditions, and avoiding performing high risk procedures. The area of concern here is not the avoidance of procedures, but the deliberate intervention, in the face of doubt, in order to be seen to be acting (presumably in the patients best interests).

When there is doubt about the advisability of an intervention, you are less likely to be blamed for taking the more aggressive approach and subjecting the patient to the intervention, than choosing the conservative, wait-and-see option. “At least the doctor tried” the relatives and the jury will say. Had you taken the conservative option, they would be thinking: “He didn’t even give it a chance” or “He didn’t do anything”. Judges, juries, patients and relatives do not always consider a scientific analysis of the relative risks and benefits of two alternative treatments, and nor are they often offered such an analysis to consider. What they do consider is the perception of the intent of the doctor.

The downside of defensive medicine is comprehensively recorded at defensivemedicine.org. Defensive medicine is not the only reason that doctors intervene more than they should, but it is just one of the areas we should be working on to reduce overdiagnosis and overtreatment.

2. The language of action versus inaction
The legal system is responsible for at least some of the over-intervention in medicine. Language (or at least the hijacking of meaning) is also partly responsible. The term ‘conservative treatment’ used to mean mainstream, now it means old-fashioned or over-cautious, and it can be used to imply reluctance, fear or lack of competence in the face of new interventions.

There are examples of how we can use language to influence decision making. Facing patients with common fractures, often a decision needs to be made between surgical and non-surgical treatment. The surgeon would be correct, but misleading, if he explained the alternatives as either “fixing the fracture” or “leaving it alone”. This tells us nothing of the relative risks and benefits of the alternatives, but who wouldn’t choose the former?

3. The influence of recent experience
Doctors are human, and are therefore influenced by their own recent experiences. For example, obstetricians who attend a birth with complications are significantly more likely to recommend and perform a Caesarean section in their next 50 cases (here), showing how we are influenced by recent experience and how we tend to practice defensively.

4. The lottery mindset
“I know the chance is slim Doc, but let’s go for it”, is how Nortin Hadler puts it (see my next book review). People will go for the aggressive treatment with the one in a thousand chance of pulling off something great (that is probably closer to one in a million, or zero in a thousand), and accept all the associated risks, rather than leaving the condition to the vagaries of nature. Doctors play on that mindset.

5. Misplaced belief
One of the main reasons that doctors continue to diagnose and treat at any cost is that they overestimate the benefits and underestimate the harms. They see what they want to see when they recall the successful cases from the past and downplay or block out the poor outcomes. Patients share this bias, and as Ivan Illich said: “Magic works if and when the intent of the patient and magician coincides”.

6. The prevailing wisdom
Currently, doctors appear more likely to be acting in the best interest of the patient if they act; even more so if they act aggressively. It also appears to be an admission of failure if the doctor does not (or cannot) diagnose or treat a patient, regardless of whether of not it is in the patient’s best interest. There is a lack of skepticism towards medical practice.

The bottom line
The underestimated harms of pursuing treatment and diagnosis need to be recognised, and there needs to be acceptance of a doctor saying: “I don’t know what is causing your symptoms, but further tests are unlikely to be helpful and may show up other things that will concern you or lead to further tests and treatments that may harm you and provide no benefit. Similarly, there are no effective treatments for this condition, so it would be better if you adapted your activities, accepted that some symptoms may persist, be comforted that they are unlikely to get worse, and spend your time (and money) on more rewarding activities than seeing me”.

11 comments:

  1. Can I have a second opinion please.

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    1. Thanks. Of course, you are entitled to as many opinions as you like, but be warned that increasing the number of opinions increases the likelihood of receiving more diagnoses and more treatments.

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    2. Ah Dr Skeptic you took the bait.....we are singing off the same hymn sheet. See you in the Bay of Fires!

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    3. Ah, good sir, you have revealed yourself! Ironically, I have just sent a patient to you for a second opinion.

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  2. Replies
    1. Thanks Fiddy, feel free to browse through the others.

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  3. How on earth do you survive as a doctor, many of your colleagues must squirm reading this. Great stuff, very refreshing to find this kind of professionally critical thinking not only going on but being placed in the public forum.

    Lead on ...

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  4. Spot on! The dea that more tests and more treatment equals better health is flawed. People have not been told the full story as vested interests have "hijacked" the agenda to promote screening and testing.

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  5. Hi. I am an anaesthetist, also in Australia. I also run www.allaboutepidural.com, evidence-based site.

    I agree with your post one hundred percent: "do nothing" is often (much) better than dragging the patient through the maze of tests.

    As far as evidence-based medicine is concerned, do you reckon it has limitations? The problem is there is a lot of bad evidence around. I am sure you're aware of John Ioannidis' paper "Why most research findings are false" (here: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0020124)

    As I see it, there are two types of medical knowledge. One, academic, systematic. It is easily transferred to students. Example - anatomy, physiology etc. Another - based on experience, a judgement call. It is intuitive and is difficult to teach. I am sure you experienced it in acute surgery: with some patients you just know you have to take them to theatre. There are lots of judgement calls in anaesthesiology. This type of knowledge is what differentiates a good cook from an average one. This it the knowledge that results in the following statement: "according to the books we should do this and that, but I would rather do that instead".

    Procedural stuff has a lot of type two knowledge: tracheal intubation, epidurals/spinals etc.
    My problem is that the second type of knowledge is not studied and not encouraged in medical training. What do you think about this?

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    1. Thanks for your comments Eugene,

      I am not sure about having "two types" of knowledge, and I would be wary about using that "art vs science" argument to justify unsupported practice. Remember that there is a lot of science in art.

      For thousands of years, doctors "knew" that patients needed venesection for just about every complaint. What scientific evidence has shown us repeatedly is that our judgement is wrong, and specifically that it is skewed (biased) towards performing interventions and to perceiving those interventions as being more effective and less harmful than they really are (the "truth"). Scientific enquiry allows us to get a clearer picture of the truth.

      Regarding the reliability of the scientific evidence (as shown by Ioannidis' papers), this reflects the spectrum of validity in science. The Cochrane group measures this using a "risk of bias" tool that gives us some idea of how much we can rely on the findings from any particular study. The fact that the scientific literature is of variable quality should not allow us to dismiss some or all of it. It should push us to improving the quality of future studies, and to take into account the possible bias within studies.

      Regarding procedural skills, the transfer of knowledge in that situation requires more than just reading, but can still be done in a reliable and effective manner, and can be studied.

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    2. Thanks for the great reply. I so often see the Ioannidis papers - especially that one - being cited as "proof" that evidence based practice not completely valid, when it's really pointing out the need for better quality research. Great article overall by the way Dr. Skeptic!

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