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Who Do You Think You Are, A Doctor?

March 28, 2014

Remember the scene in the movie Knocked Up, where the obstetrician is telling Allison she can’t have an epidural?  Greatest scene ever.  I know for a fact that at least three of my most loyal and beloved readers won’t get this cultural reference, so I’ll quote it for you:

Setting:  Labor room, Allison (Katherine Heigle) about to have a baby, Seth Rogen’s character, the father, is there, along with the nurse, Deb, and the obstetrician, played by Ken Jeong, who is actually a real doctor.

Allison:”Oh this really hurts.”

Jeong: “I see we’re well on our way.”

Allison: “I want the… I want the epidural.  Okay?”

Rogen: “Give it to her now.”

Jeong: “Ok Allison.  We’re past the point of an epidural.  Okay?  The cervix is fully dilated.”

Allison: “No seriously, I want an epidural…”

Jeong: “We can’t give you the epidural.”

Allsion: “I’ll make sure it doesn’t come out!  I’ll stop pushing!’

Jeong: “We’re gonna just have to do this the all-natural way, okay?  The way you wanted to do it.”

Allison: “This is messed up.  Something’s wrong in there.”

Jeong.  “Oh, no, no.  I mean, granted, gynecology’s only a hobby of mine, but it sounds to me like she’s crowning.  Is that right, Deb?”

Actually, there a few scenes in the movie in which Ken Jeong’s character hilariously says things that doctors would love to say on occasion but never do. They are variations on the theme of “Who’s the doctor here?”  This post is not a yearning for the old, paternalistic way medicine used to be practiced, but every time I see these scenes I remember similar discussions with patients who are trying to play doctor.

This rant started because a colleague pointed out  a piece by Tom Nichols at The Federalist entitled “The Death of Expertise”. (Thanks Jess Geerling!)  http://thefederalist.com/2014/01/17/the-death-of-expertise/.  Here’s how he introduces the topic:

“I fear we are witnessing the “death of expertise”: a Google-fueled, Wikipedia-based, blog-sodden collapse of any division between professionals and laymen, students and teachers, knowers and wonderers – in other words, between those of any achievement in an area and those with none at all. By this, I do not mean the death of actual expertise, the knowledge of specific things that sets some people apart from others in various areas. There will always be doctors, lawyers, engineers, and other specialists in various fields. Rather, what I fear has died is any acknowledgement of expertise as anything that should alter our thoughts or change the way we live.”

I’ll ignore the blog-sodden comment.  Here’s the thing.  Information is readily available.  Access to the greatest minds in every field is more accessible than it’s ever been.  Information, however, even from thought leaders, is useless unless it is processed appropriately in the right context.  For example, imagine that I, arguably an “expert” in the field of anesthesia, decide to go consult a lawyer on a possible real estate purchase.  This lawyer would presumably be an “expert” in the field of real estate law.  I could play my visit two ways:  I could go to her (it’s a her.  It’s my blog.) and say “Here’s this building I was thinking of investing in, but it has several zoning regulations, what do you think…” and then do what she says.  Which is what I would do, since I know zilch about real estate.  Or, I could go to her and say “I’ve spent all day on the internet and I’ve discovered that in zone 3 in this state the statute of limitations on blah blah…”  If she then patiently explains zoning laws to me, I could come back with “Are you sure, because realestaterus.com says that according to article 33 of amendment 501 of the zoning regulation…”.  But I’m not going to do that, right?  Because she is the expert, and I am not.  It doesn’t mean I’m inferior to her, or somehow in her debt, or that I should feel bad about myself because I don’t know anything about zoning.  Nor should I feel attacked or threatened by her superior education and skill in law.  I subjugate myself to her in this particular area.

Patients are in a difficult spot.  They feel vulnerable, threatened, fearful of pain and unfamiliar circumstances.  Especially in anesthesia, which is a black box to most folks.  In medicine, patients must subjugate themselves, within reason, to an expert.  So many people feel threatened by this. The source of this feeling is distrust.  I’ll admit to feeling the same way about my mechanic. But I know less about cars than I know about real estate law.  I can, and should, look at the information that’s available that I can understand, but ultimately I must trust.  May we doctors be forever worthy of yours.

 

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From → Healthcare

9 Comments
  1. Shirie,

    The biggest problem that I see with that is the fact that way too many physicians have made mistakes because they were blatantly wrong and fell back on this argument. Too many who have paid the ultimate price or other prices because the doctor didn’t know what they were doing, didn’t read the signs or ask, thought they were right and refused to budge even when the patient got worse or developed new symptoms that should have signaled red flags, relied on the wrong things, or most specifically, weren’t up to date. I’ve seen one who told me “I’ve been a doctor for 20 years” but couldn’t diagnose something that was in the medical literature for years saying that specialist should be able to get it. I’ve seen docs in another who didn’t do all the appropriate testing.

    On top of that, when doctors won’t report when others are doing wrong, when risk managers “hide it all away”, when there are gag clauses in lawsuits, when medical boards just “let things slide”, it only makes the credibility worse.

    Trust is earned, arrogance and ego have no place in medicine, but a lot of the time its ‘don’t question me, I went to school and I know what I’m doing’ rather than here is the science behind this and the willingness to consider and show the patient in a respectful way, what the facts/basis of the decision is. So much of medicine is based on what people are taught, their experiences, when the rates of missed and delayed diagnosis are a big issue and the #1 reason why doctors are sued, in addition to the communication issues.

    Frankly, the “experts” aren’t always “expert” and sometimes a fresh perspective is what is needed. Experts would be someone who is expert in my disease and none of them are, but asking them to read the medical literature is something they won’t do: they want to ask their colleagues (if that) and when none of them know what is going on, they blame the victim/patient.

    There is a reason why blacklisting and cherry picking occurs in medicine and its not on the part of the patient that they choose that.

    I’m one of many who has said its past time for the medical community to get their heads out of the sand and start addressing the way things are done.

  2. Here is another good one:

    I have signs/symptoms of X. I’ve had years of medical research behind me, from multiple fields, agreeing with the diagnosis of X. Instead of doing the necessary testing (which is small), and presenting this information to doctors, most all dismiss it. However, when asked what they are basing their decisions on, the medical evidence, none can give me anything. Just their experience – and I’m a zebra.

    This is EXACTLY what the medical community does to “woo”. They say you have no scientific basis for your “woo”, but it is ok when the medical community does the same thing when it comes to not using evidence based medicine. Actually, if you are talking about drugs and the like, I see the point, but when years of evidence is put before you, and you can’t make a decision, what do you think it says about doctors? They can’t read medical literature? They don’t know how to interpret signs/symptoms? They can’t do anything that they weren’t trained to do (in the case of a PCP, or in where I present medical literature in their field, what were you trained in), so what happens when a new strain of the flu comes out, etc.?

    The dichotomy between what doctors are taught and their singular experiences (its ok for a doctor to base everything on their own experience or someone elses’ experience, but if you don’t throw a double or triple blind placebo study of thousands of people from all walks of life, then it isn’t a “real study”) is not lost on many of us.

    The AMA was reputed to be upset with the coming of the internet. I can certainly understand why.

    • Oh Bettercareelsewhere, I knew you’d be all over this post!

      • Bettercareelsewhere permalink

        Well yeah. You can’t expect that when someone isn’t diagnosed or its missed when the evidence is there and no one can or will read it. That’s an issue of personality and/or education, both of which shouldn’t happen from physicians now. The education I can sort of understand because no one can know everything, but its the attitude that has no place when a patient suffers damage because of it.

        I exposed “woo” but it seems when the tables are turned and the doctors are now exposed, its another story. Comes back to attitude and that right there is why respect is going out the door for medicine.

        It has long been past time for changes in the medical profession. The longer it goes on, the worse the reputation it will get. When people can get diagnoses from the internet and figure it out, that’s another side of the coffin that is getting nailed shut.

        I want to see changes that would work out for both medicine and patients. Same for admin but that’s more of getting rid of them and chucking a lot of their pay. Doctors getting paid for email and telephone “visits”. More nurses, getting treated better. Medical boards who aren’t “rubber stampers” & let doctors off. Publishing the NPDB.

        Something for everyone.

  3. Phillip Gale permalink

    Perhaps this problem began back in the sixties when it was not cool to “flaunt” your position even if earned by years of study and experience. Nurses stopped wearing caps and uniforms, housekeeping no longer wore uniforms, and doctors came in dressed in casual cloths, rather than looking professional. When I am in the hospital today and someone comes into the room I do not know whether they are the doctor, nurse, technician, janitor , or someone just wandering around. If you do not act professional (as an expert in a chosen field), or dress professional, people will not respond to you as a professional. This attitude of not setting yourself apart as a professional leads to disrespect, which is the core problem here. Why does the military wear uniforms? Everyone knows everyones rank and level of expertise and the private does not tell the sergeant go the general what he should do. It is true that true respect is earned. But if the lines of differentiation are blurred so will be the lines of authority.
    I know that this is just a small part of the issue. There is the whole cultural issue of lack of respect for authority as well as the issues of the individual taking control of their own health, and being their own advocate. It is a complex topic. But ultimately, in this case, it is the the medical profession that will have to change to earn the respect it deserves.

  4. Bring back paternalism! Medicine was so much easier to practice then. Yes, we should go one step further and explain what we are/want to do and why but now we are constantly up against the “20 minute experts”. You know, the ones who spend 20 minutes on Google and then are certain they know better; they are the expert! They feel they are in a strong position to tell someone with 20 years expertise, YES, “EXPERTISE”, where they are wrong and what they should really be doing. When of course it goes “pear-shaped” and a disaster occurs it is of course all the doctors fault.

    • Thanks for reading Alex! Expertise has become synonymous with “Superior” or “know-it-all” or “I’m better than you”. People feel threatened by that, for some reason more in health care than elsewhere. Also, nobody likes being told what to do, me included. A little bit of human nature combined with too much available information = where we are now.

      • Bettercareelsewhere permalink

        Im not threatened by the knowledge. I’m threatened by the ones with an MD and they don’t know stuff. I had a 2012 graduate, in 2013, tell me albumin was a measure of nutrition and when it goes low, you have malnutrition. I said prealbumin is better but hasn’t been the real standard for several years (its a liver measure) by the nutrition experts and I have the journals from 2011 and back.

        That MD was threatened by me. Not the other way around.

        That’s not the only time its happened. I can get doctors on stuff that have happened within the past 5 years, some of these are not up on everything. I’m there to help it out. They consider me the threat.

        Actually, I’m helping them and not just me. Its Team Patient, not Team Doctor Ego.

    • Bettercareelsewhere permalink

      Alex,

      Unfortunately, there is a good group of educated people who are doing a better job than a lot of doctors. Enough to make a dent in what you’re talking about. I’ve had doctors who trust my judgement. I don’t watch TV or anything else, and I do come in with medical research. In other words I won’t say/do something unless its from a “superior” or “expertise” source that you all get your info from.

      You have to realize that I have had paternalistic doctors who were wrong. All the ones I had are ones who didn’t base anything on medical science that I could find, they didn’t have anything but a few options, and weren’t open to trying different options when the patient didn’t get better on their diagnosis and treatment. So yes, people do ask my opinion and I do give them “educated” answers. It won’t be swayed by “Mr. Google”, it will be formed by “Dr. UpToDate, ClinicalKey, StatRef!”.

      I think we need to make a difference between truely educated patients who can handle medical decisions vs. those who can’t. We also need to make room for those people who don’t want to make those decisions.

      I think what is also not recognized is that doctors don’t walk in the shoes of every one of their patients. They don’t know the patients values, their mores, their finances, what drives their choices. That’s why you really need to let the patient drive a lot of that.

      VN

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