Jul 31 2008

Doctor Bashing

The essence of bigotry is making assumptions about an individual or treating them based upon a group to which they belong. This is not limited to race and ethnicity, and can also include profession. There is a difference in that people are not born into their profession; there is a sorting process (both self-selection and societal), and so statistical observations about those who enter a profession are legitimate. Never-the-less, simple-minded statements to the effect that all lawyers are crooks, all doctors are arrogant, and all priests are pedophiles, is bigotry plain and simple.

It seems that people are most sensitive to bigotry aimed at groups of which they are members, and so when people try to tell me how doctors are (sometimes not knowing at the time that I am a doctor) I admit that gets my attention more than if they chose to insult oceanographers as a group.

Doctors are a popular target of bigotry these days for various reasons, some earned but mostly unfair. Historically physicians enjoyed a place of privilege in society. A generation or two ago nurses would stand when a doctor entered the nursing station, and no one questioned the paternalistic style that was typical of the doctor-patient relationship. Believe me – those days are long gone, but culture has inertia and that quaint image of the physician persists to some degree, although only in the negative sense it seems. Because doctors are seen as privileged many people think that they are a fair target for unfair criticism – that bigotry against doctors is OK.

Don’t get me wrong – there is much to criticize about the medical profession and many individual doctors. Criticism is good and healthy. In fact one of the aspects of my own profession that I think is the core of its strength is its self-criticism. But when criticism goes far beyond being constructive and factually based, and becomes an end to itself for the purpose of tearing a group down, that is bashing.

And that, in my opinion, is exactly what PhysioProf was engaged in when writing this post. He was reacting to a news story about an orthopedic surgeon who was placing, without consent, temporary tattoos on his patients while they were under anesthesia, including a tattoo of a rose placed beneath the panty line of one female patient. PhysioProf used the incident as an opportunity to gratuitously bash the medical profession. I also think he missed the point about this case.

I don’t think the actions of this surgeon result from the arrogance of the medical profession. He justified the action by saying that he wanted to give his patients something to smile about – a little post-operative surprise that would elevate their mood. This was not about arrogance, but rather about a misguided and utterly failed attempt at good bed-side manner. The surgeon wanted to be soft and cuddly, to concern himself with his patient’s feelings. This, of course, is a good thing, but should never be placed before professional ethics. We cannot lie to patients to make them feel good, we should not cross personal barriers that threaten our professional judgment, and we should not place temporary tattoos on unconscious patients. This was a well-intentioned but incredible lapse of professional judgment.

I will also point out that physician bloggers, especially surgeons, were the first to criticize this bone-headed move.

Here is PhysioProf’s take on the incident:

As someone who spends a substantial portion of his professional time teaching medical students, I can tell you that this kind of attitude–that physicians are gods, not mere mortals, and wield power over other human beings that no one dare question–is inculcated in them from the very beginning of medical training. It is an ugly secret of our medical training system. And the more prestigious the institutions where physicians receive their training, the more overweening is this attitude.

Apparently PhysioProf is living in the 1950’s (which perhaps is even unfair to doctors from the 1950’s). It is difficult for me to comment on PhysioProf’s experience, because he blogs anonymously. I do not know what institution he works at, in what capacity, and for how long. My guess is that he teaches physiology in the first-year pre-clinical classroom course. I don’t know, but I guess that he is not a doctor but a PhD physiologist, or perhaps he is an MD/PhD but does research and does not practice clinically. I had such instructors in medical school.

What I do know is that PhysioProf’s statement bears no resemblance to my personal experience with medical training or medical practice. For me, medical school was a deeply humbling process. It takes years to get over the constant sense that you are overwhelmed by your own ignorance. Respect for patients as individuals was the rule, not the exception. In fact I remember an incident on my surgical rotation when a fellow student referred to a patient as a case – by the type of surgery that was performed. The senior resident spent a good time pointedly telling him that we refer to patients by their names and that we are expected to know as much as possible about our patients – not just their surgery.

Of course, physicians, like any other group, are greatly variable. There are doctors who are jerks, those who are full of themselves, those who are simply incompetent yet are confident in their own infallibility, those who are intellectually lazy, and those who are fatally gullible. There are also doctors who are brilliant, insightful, sensitive, caring, and diligent. I have personally witnessed the full spectrum.

In my experience academics, those who teach medical students, tend to be more thoughtful than the average physician, take their duties seriously, and if anything go out of their way to teach proper respect for patients and an appropriate professional attitude. There are exceptions – there always are – but PhysioProf was not talking about individuals – he was talking about a systemic character of medical training. He was using his pseudo-anonymous authority to bolster his opinions, but I think if you solicited a broader base of opinion and experience you will find his views to be extreme and not representative.

Confirmation Bias

I cannot talk about bashing and bigotry without talking about confirmation bias, which, in my opinion, is the greatest intellectual pitfall that contributes to bigotry. People will tend to remember those bits of information that support their bigotry, while ignoring, forgetting, or explaining away those that contradict it. If you read the comments section of PhysioProf’s entry you will see a lot of confirmation bias. For example, Anna wrote:

My fav was listening to doctors standing around smoking (right near the entrance of the no-smoking hospital, which meant everyone had to go through their damned smoke) complaining loudly about how SOME patients just coudn’t be convinced to give up their bad habits for their health.

Strangely, I hear this a lot. It’s practically an urban legend that many doctors smoke. A more complete view is that in the US only about 3% of doctors smoke, compared to the general population which is about 20%. I don’t know any doctors personally who smoke – if they do, they hide it. Within medical culture today smoking is practically taboo.

Jessi wrote:

after reading these stories i feel so lucky. ive had 15 kidney surgeries all with the same doctor and hes been amazing in every way. he has cried with my mother while discussing my health.

my shrink is amazing too as is my GP. my dentist is so great i dont even mind getting dental work done.

A key component of confirmation bias (and superstitious thinking) is the dismissal of counter examples as exceptions. Jessi feels that her personal experience with good doctors makes her lucky, rather than calling into question the negative stereotypes being promoted. Many friends and family have told me about how bad other people’s doctors are, but their doctor is great. Everyone thinks they are the exception.

People do not instinctively think this way, but all examples, good and bad, are data. Counter examples are just as much real data as confirming examples, but we do not treat them that way. We tend to formulate our assessment of the data as – all doctors are arrogant jerks with a god-complex, except for those exceptions who aren’t. Whereas a more rational view of the data would be – some doctors and jerks and some aren’t.

I see this personally on a regular basis. After telling me how doctors behave, I often inform people how I behave, which is usually in stark contrast to their caricature. The near universal reaction is – well, you’re the exception. I may follow with the observation that most of my colleagues behave this way as well. To which the common response is – that may be the way things are up at Yale, but not everywhere else. What about my colleagues at other academic institutions? Well, then maybe at academic centers, but not in private practice. But I have friend and colleagues in private practice who behave the way I do. There doesn’t seem to be any number of counter examples I can give that will shake them from their pre-existing conclusions.

Confirmation bias is a powerful straitjacket.

Those Darn Physicists

While I’m talking about doctor bashing, it is always disturbing for me to encounter it within the skeptical community itself. I have now been to several skeptical meetings where a non-physician skeptic gratuitously bashed the medical profession and received enthusiastic applause from the audience. This may be a coincidence, but in every case it was a physicist doing the bashing.

Most recently at TAM6, Neil deGrasse Tyson gave an excellent skeptical lecture. Neil is an astrophysicist, the director of the Hayden Planetarium, and a wonderful science popularizer. He also seems to be an all-around great guy. But for some reason he doesn’t seem to like the medical profession very much.

Years ago I was at another skeptical meeting on science and medicine, and Neil, who was just in the audience at that meeting, asked a question that amounted to – what’s all this fuss about alternative medicine? Isn’t this just doctors defending their turf? He was rebuffed by a speaker who asked how he would respond as the director of the Hayden Planetarium if the board forced him to carve out a substantial portion of the planetarium to promote astrology. He acquiesced the point.

During his keynote at TAM6 he told the following hypothetical tale. A patient sees three doctors, the first tells them they have a terminal illness with 6 months to live, the second that they have 7 months to live, and the third that they have 5 months to live. Taking the average, the patient concludes they have 6 months to live, and yet they survive for years. Neil wondered why they would think this was a miracle rather than just conclude that they saw “three idiot doctors.” He further argued that the agreement in their prognostications was due to similarities in their indoctrination. These statements were met with enthusiastic applause from a room of skeptics, and a few skeptical doctors quietly shaking their heads (myself included).

First, I have never told a patient they have X amount of time to live – and I diagnose patients with incurable terminal illnesses on a regular basis. We just don’t express the situation in that way. Rather we give statistical information – 50% of patients survive for about two years, but some survive longer, even up to 10 years, and there are rare cases of remission. I understand that patients will often walk away thinking – I have two years to live – but that is not what doctors actually say.

Second, it is incredible that a scientist would dismiss medical science as indoctrination, as if it is not evidence-based. Perhaps different doctors may give a similar prognosis to the same patient because they are reading the same published scientific data.

What such a tale, hypothetical as it is, really teaches us is the challenge of communicating statistics, such as survival curves, to patients – especially during an overwhelming emotional situation. A patient who survives to the tail end of a survival curve is not miraculous, not because their doctor is an idiot but because some people survive to the tale of the curve – otherwise the tail would not be there.

The tragedy is that such attitudes do great harm to the skeptical cause. Believing that physics is more of a “hard” science (a misleading term in itself) than medicine, sociology, or evolutionary biology obscures the real line between science and pseudoscience. That is what we are trying to teach the public – how to tell the difference between fake science and the real thing. The fact that physicists can have precision to many digits to the right of the decimal place does not make their data more scientific. What matters is the process.

Such attitudes also blur the line between legitimate medicine and fraudulent medicine. Medicine is – or at least should be – science-based. That is what matters. Dismissing all medicine as soft and based upon culture, rather than evidence, serves to level the field between magical-thinking charlatans and science-based professionals.

Conclusion

Well, that’s the end of my rant. I admit I may be a little defensive on this topic. Take my opinions for what they are worth. I only ask that you do not dismiss them as an exception. I am a doctor too, I am part of the data.

Like this post? Share it!

51 responses so far