
It’s Hard for Doctors to Unlearn Things - dredmorbius
https://www.nytimes.com/2018/09/10/upshot/its-hard-for-doctors-to-unlearn-things-thats-costly-for-all-of-us.html
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dbbolton
I am a physician in the US. I think the article has valid points (esp.
inpatient glucose control) but it also oversimplifies and glosses over some of
medicine's more arcane aspects.

To give a tangible example I'll start with the unnecessary ankle x-ray. There
is a set of guidelines called the Ottowa Ankle Rules[1] which we use to
justify ordering plain films for a suspected fracture, but there are plenty of
reasons why a doctor would still get them if the criteria weren't met.

One reason is clinical judgment and experience. Guidelines are just
guidelines. Ultimately the doctor is the one making the call, as well as
suffering the blame for that call if things go sideways. If everything were as
simple as following algorithms and checklists, medical training wouldn't take
7+ years of post-undergraduate work.

But probably the most important reason has to do with the "patient
satisfaction" (customer service) aspect. Ideally medicine wouldn't be a
business, but it is and there's not much we can do about that.

Patients who present to an urgent care center or ED generally carry an
implicit "something is seriously wrong with me or I would have just made an
appointment with my PCP" vibe. These patients often don't like it when you
explain that based on your history and exam, they most likely have a
sprain/strain injury and an xray is not appropriate since we want to avoid
unnecessary costs/radiation exposure-- as opposed to being relieved that they
only suffered a minor injury. Even when spoken in a compassionate,
straightforward manner, this explanation can come across to the patient as
"nothing is wrong with you / you are malingering / your concerns aren't valid
/ I don't care about your symptoms", etc.

Sometimes patients outright demand tests, or worse, they'll say nothing but
then complain to your employers that you medically neglected them, or you are
incompetent, or what have you. Now if they had the audacity to file a
malpractice suit, you'd (ideally) have no problem justifying your actions in a
courtroom or deposition. But say they complain to the MBA (or some other
person with no medical training) who runs the clinic or care center employing
you. Your argument will likely fall on deaf ears, and be countered with some
diatribe about how you're causing them to lose money. In that case it's a lot
easier to just order the unnecessary xray.

Basically, the squeaky wheel gets the grease. There are plenty of other
examples like this, and they all come down to choosing your battles wisely. I
think it's kind of hard to blame the over-worked and behind-schedule doctor
who orders something like an xray or lab test rather than taking an extra
10-15 minutes discussing the pros and cons with the patient, after which the
patient might still not be convinced.

Having said that, there is a problem with superfluous testing in EDs,
especially ones that rely on "standing orders" where e.g. virtually any
patient presenting with abdominal pain might get a CT scan before the
physician even sees them (something I strongly disagree with and can't think
of a legitimate excuse for).

[1]
[http://www.theottawarules.ca/ankle_rules](http://www.theottawarules.ca/ankle_rules)

~~~
eftychis
In the U.S. I actually have witnessed both, seemingly contradictory, aspects.
That is cases as you mentioned in urgent care where there is an extensive work
done to you for no reason, that ends up to be even unrelated in the end, just
to cover all bases and follow protocol. Yet, cases where a personal doctor is
reluctant to prescribe blood work or chase symptoms that are not life-
threatening, even with prior family history due to costs.

For instance, there was a with E.U. doctor referral for ultrasound and blood
work. The reply was if it bothers me to consider painkillers or wait for it to
get worse and come back. (Why should I take painkillers if we are not certain
of the cause to begin with?) On the other hand, walking a friend into urgent
care for their leg leads to a full checkup.

With the above I want to complement your view, that there is some extreme
behavioral gap in how doctors' react that is not related with the patient's
ailment.

And there is a lack of a middle ground between urgent care and making a
personal doctor appointment. I find it surprising that if I break my leg I
need to go to urgent care. There is no contagious disease, and I am not going
to die if left untreated, but it is an event that requires time sensitive
treatment. Yet, there is no concept of walking into a doctor's office, or at
least it is not that easy.

Example case 2. Eye pain etc. After failing to get an appointment with any
doctor, K is instructed to go to urgent care. K called ahead and asked if they
could handle their case, yet there was no actual ophthalmologist there. K got
a full "checkup" and got a "it's probably an infection"; they were prescribed
antibiotics. Next day K's eye pain worsens with new symptoms. K gets an
appointment with an optometrist so as to be referred to an ophthalmologist. It
is the protocol to have an optometrist check you first apparently. Another
half a day later, an ophthalmologist actually checks K and comments "thank god
you came in this fast." That was after my wife begging several times on the
phone with several doctors, that we need an appointment today and not in 2
months. Yes, patient K is I. (I could not make any phone call or walk at this
point, I was for all intents and purposes blind and in pain.)

Thus, the system in place from my experience assumes that the patient i) is
stupid ii) if not dying does not need a checkup within the next 2 months, or
else has to go to urgent care.

Thus is it really the patients' fault when they are used to walk into urgent
care to get any sort of timely treatment? Why would a person with a broken leg
take the invaluable resources from someone actually in need of urgent care? I
argue the system somewhat enforces this over-treatment. You have to go through
the urgent care for any timely treatment, it is rightfully instilled in you
that perhaps there is something serious going on. You would not pay urgent
care prices for a strain right? Thus, it must not be a strain.

My E.U. experience: As a patient,you walk in to a doctor you consider
appropriate (You can also make an appointment ahead of time and ask if
uncertain). One might wait for a few hours. If it is deemed urgent, the doctor
will make sure to see you first, or send you to urgent care/emergency room or
hospital. If the doctor is not of the appropriate specialty, they will refer
one appropriately. Paying everything out of pocket, costs extremely less
compared to my copay for urgent care -- this is a simple doctor appointment,
no urgent care.

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Nasrudith
I wonder how much of it is from the training methods - forgetting things is
malpractice and thus things get hard emphasized to practically muscle memory
"make sure to x-ray the ankle to confirm if it is a break or sprain" even if
it would become very apparent without otherwise via deformation or not getting
better and the treatment is immobilize both and ice helps with pain anyway.

I think the military has a similar problem with transition to civilian life in
terms of "overdrilling". Medicine being a conservative field given the stakes
furthers it.

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teddyh
Yes. Just ask Ignaz Semmelweis.

~~~
pella
[https://en.wikipedia.org/wiki/Semmelweis_reflex](https://en.wikipedia.org/wiki/Semmelweis_reflex)

~~~
DoreenMichele
Thank you. I was not familiar with this term. But to be clear:

Semmelweis was a physician in charge of a couple of clinics who documented
differences in mortality rates and used this to suggest hand-washing for
physicians before germ theory was a thing. He was thrown in an insane asylum
and was badly beaten by the guards and soon died as a consequence of the
beating.

[https://en.wikipedia.org/wiki/Ignaz_Semmelweis](https://en.wikipedia.org/wiki/Ignaz_Semmelweis)

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DoreenMichele
I will suggest that people default to habit when they are exhausted and this
could be an underlying reason why physicians seem to do a poor job of stopping
certain bad habits. Over the years, I have seen articles that suggest that
exhaustion on the job is a major contributing factor to medical errors, though
stuff that is most readily findable seems to mostly be about nurses and
residents, not physicians per se.

I don't have a specific source in mind, so I'm not going to post a link. I
have verified that you can find stuff on the topic by searching "medical
errors due to staff fatigue". There may be other search terms that work.

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swingline-747
Big pet-peeves of doctors:

1\. The Academic Elitist: When they act like know-it-alls, poo-poo informed
patients or any information that didn't originate from them.

2\. The Thickheaded: When they don't LISTEN and go about diagnosing whatever
it is they're more interested in.

3\. The Evening News Anchor: When they act with over-confident, pseudo-
infallibility, which seems to correlate invariably with being wrong.

4\. The Snakeoil Salesman: When they hard-sell products and services that
aren't even FDA-approved, like this certain brand of CBD that this one doctor
was pushing. _cough_ kickbacks _cough_

Bonus: The Histrionic and Defensive: When they gaslight or accuse their
patient of behavior they didn't engage in, especially when they miss lab
results and clinical symptoms that would explain said symptoms.

~~~
AnIdiotOnTheNet
Have to agree with most of this list. My thyroid stopped working when I was a
kid and despite many doctor's visits it went undiagnosed for about 2 years. It
was ultimately diagnosed by my mother's coworker, a ticket booth attendant,
who recognized the symptoms as being similar to her dog's. After enough
badgering by my mother a simple blood test confirmed her diagnosis.

I can't say that my experience with doctors since then has improved my opinion
of them. I've met with only about 2 physicians in my entire life that actually
seemed genuinely interested in solving problems.

~~~
zeroego
I've had similar experiences in my life as well. Purely anecdotal, but I've
found NP's and PA's tend to listen more and just be more personable in
general. I sometimes wonder if the extreme hours physicians have to work beat
the compassion right out of them.

~~~
vvanders
This so much.

Our NP was great, took time to understand the issue each time we visited and
generally was on the mark much more often than other MDs I've seen over the
years.

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Gatsky
This isn’t a very nuanced piece.

The glucose control effect is not unexpected. You are telling ICU drs, who
spend their lives trying to adjust physiological parameters to keep the
sickest patients alive, to do less. This is anathema to their way of
operating. Of course adopting more intensive control and then letting it go
will not happen at the same pace.

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HenryBemis
Apologies, but it is hard for everyone to Unlean Things. It is just human
nature/the way we are wired. It take discipline and great effort. What would
doctors want to be different? We all got a comfort zone :)

~~~
olooney
Doctors are credentialed professionals. As professionals, they get a legal
barrier to entry protecting them from competition in exchange for maintaining
professional standards, which include ethical standards and continuing
education. This in turn enables them to charge huge fees.

A lawyer is not allowed to stop learning about new laws; he would eventually
be disbarred. An architect is not allowed to construct buildings that would
only have been up to code at the time she finished her degree. And doctors
should likewise not ignore the state of the art in their field.

~~~
kiriakasis
Totally true, but it misses the point.

Doctors invest huge effort in keeping up with the state of the art in their
field, the problem is that to be a competent doctor you also need considerable
amount of intuition and heuristic.

New advances sometimes requires that you unlearn things and this i a
completely different process; when you simply keep up with the state of the
art you have a set of known facts and techniques and slowly you discover more
and more of them. Unlearning things requires you to review entire branches of
your knowledge tree to eradicate every trace of the now wrong fact

~~~
SilasX
It's fine for doctors to intuit that "the cost and side effects of HipNewDrug
outweight the benefits". It's not fine for a doctor to be unaware that
HeretoforeUncurableCondition now has HipNewDrug as a possible treatment --
i.e. to not have unlearned that HUC is a death sentence.

~~~
emodendroket
That's not really what the article is about. It's actually about someone
finding HipNewDrug is actually not effective at curing Frobulitis and in fact
has adverse side effects, and yet doctors continuing to prescribe it for that
condition.

~~~
SilasX
It's the same failure mode though.

~~~
emodendroket
It's not the same. It's a bigger problem than the one you're talking about,
according to the article. It's easier to get doctors to adapt some procedure
than to get them to give one up.

~~~
SilasX
Both are the same failure mode: "You used to always do X. You shouldn't do
that anymore."

In my example, X was "tell patient they have a death sentence". The fact that
yours is closer to a specific situation in the article does not make it "a
different failure mode" with different dynamics and causes.

~~~
emodendroket
I don't know what to tell you. You are saying the opposite of what the article
says and not offering me any reason to take your word over the article.

~~~
SilasX
No, I'm not. I said that "thinking Y is uncurable" is the same kind of failure
mode as "prescribing X for Z after the science starts to indicate that X is
harmful". I then offered a very good reason to "take my word" on it: I stated
the general form of the failure mode, parameterized over X, and showed what X
would be in each case.

Did you miss that, or did you not consider it a good reason?

If you can take a moment to review the thread, I only brought it up to
distinguish valid vs invalid reasons for not proposing a kind of treatment,
and thus why a doctor's intuition would vs wouldn't be defensible given the
state of the literature.

Where specifically is the article saying the opposite of any of that? Unless
the article talks about the topic of appropriately classifying failure modes,
which it isn't, it wouldn't bear on that topic.

~~~
emodendroket
The article identifies a discrepancy where it is much easier to get doctors to
introduce a new treatment or practice than it is to get them to stop using or
recommending it after it is discredited. I don't see how that could be the
case if they're "the same failure mode."

~~~
SilasX
People can fail to realize two failure modes are the same and merit the same
treatment.

And I don’t see what that would bear on my original point (which was just
distinguishing between valid vs invalid reasons not to recommend a treatment).

~~~
emodendroket
People can equally well fail to realize that two modes of failure are
different.

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danieltillett
What a surprise - it is easier to get doctors to do things that increase
billing than it is to get them to stop doing something if it decreases
billing. It is almost as if money is more important than the patient.

