"Whenever I go into a restaurant, I order both a chicken and an egg to see which comes first"

Sunday, October 20, 2013

Second Opinions Are Worth Nothing Especially When They Are Your Own

It is a well-known fact that we hear what we want to hear and believe what we want to believe. There is no point in arguing with people who are convinced down to their shinbones that Obama was born in Africa, or that fluoride was put in the water by Communist agents to make us more receptive to Marxist-Leninism.

Things get far worse when it comes to medical advice. Patients are concerned when their doctor tells them, “You need an operation; but the good news is that the risk of complications is only 20 percent”; so they go online and search until they find a source which says that the risk is actually only 10 percent.  They are relieved.  They ignore the fact that the site is sponsored by a Yemeni doctor working in Chad, and go ahead with the operation.  It turns out that the doctor himself has relied on insufficient and erroneous data produced by old classmates.  Although they have advised him that the risks are only 20 percent, they are actually more like 50.  As fate has it, you fall into the unlucky half and come out of the anesthesia with a sliced peritoneum.  You and the doctor both heard what you wanted to hear.

In an article in the New York Times (10.20.13) Noreena Hertz suggests that no one should take a doctor’s word for it and should undertake independent research on one’s own.  Most importantly, patients should force themselves to be objective, critical, and relentlessly thorough and make up their own minds.

Easier said than done, of course, for even the smartest and most disciplined lay reader will soon run into impenetrable thickets of medical-ese, daunting equations, and indecipherable statistical methodologies.  A regression analysis has to be bad, right? Aren’t progressive analyses what we should be doing?

If that weren’t bad enough, the reader will soon drift into the bulrushes of alternative opinion. Hip surgery is never necessary, he reads, for combinations of horse serum and Echinacea blossoms have proven overwhelmingly successful in field trials. Mary Baker Eddy was convinced that prayer cured all disease, and cleansing enemas eliminate all arthritis-producing toxins from the body.

Many years ago while living in India, two English hippies came to stay with us.  Zebbede and Zoe were wraith-thin, flushed, and consumptive-looking.  Zebbede had suffered from fever and crippling joint pain, and Zoe had periods of delirium and mental vacancy.  They had been on a mango fast for weeks.  A swami in Rishikesh had advised them of the curative powers of the ripe mango, and despite deteriorating health, they persisted.in eating only this fruit.

My wife insisted that they see a doctor and after weeks they relented, but went to an Ayurvedic quack who sent them home with a packet of star anise, pounded sorghum, and verbena powder.  “Take as infusion”, he had told them, “and fever will disappear”.  It did not, and soon Zebbede and Zoe could barely make it out of bed.

I drove them to Breach Candy clinic where they were seen by a real doctor. Zebbede had brucellosis which he had picked up drinking raw camel milk in Rajasthan, amoebic hepatitis, and hookworm.  Zoe had hepatic tuberculosis, typhoid fever, and dengue. The next morning they were gone, and the only traces of their stay were a few mango husks and a half-burned stick of incense.

Most of us are scared of dying and blanch at just the mention of ‘cancer’; but each of us has ways of dealing with disease.  I have a friend who has not looked in the mirror for years because he is afraid that he will see a malignant growth on his face.  He learned how to shave blind and rarely nicks himself.  Another friend uses a magnifying glass to inspect every blemish on his body.  He photographs them, compares them with images found in online medical books, and when he can’t make heads nor tails of the squiggles, color shadings, and aureoles in the pictures, he runs to the dermatologist.  Because of his hypochondria, he got on a skin doctor no-fly list, and no doctor in Washington would see him.

I fall between these extremes. I am patient with minor aches and pains, and if they don’t go away, I consult my doctor and listen to his advice.  I have selected my primary physician very carefully – he is a graduate of Harvard Medical School, with residency at Beth Israel, and post-doctoral work at Mass General – and I know I can trust him. It is better and easier to select a good doctor before getting sick than than to wade through the swamps of the Internet afterwards.

Everything in today’s complex world is about probability.  The more data we generate, the more we understand that nothing is certain.  Under the threat of liability, even the best doctors will give you the probabilities of alternate treatments and require you to choose among them.  He might be sharing the best medical information available, but unfortunately nothing is 100 percent. The patient is then faced with crippling choices.  If an invasive, debilitating procedure has a failure rate of only fifteen percent, is that worth taking?  And if a less savage operation increases the failure rate to 20 percent is the five percent differential worth worrying about?

I am friends with a very smart woman who has spent her life in public health.  She is used to data sifting, organization, and analysis, but when dealing with her own cancer diagnosis, she was crippled.  She spent hours poring through online medical journals, more at the libraries of NIH and CDC.  She drew algorithmic charts that resembled the crazed drawings of a schizophrenic.  The walls of her office were papered with graphs, ascending and descending arrows, and colorized enlargements of microscopic lesions. Visiting her was like walking into a nightmare, and I could only imagine what was going on in her head.

My father was a doctor who practiced in the days when medicine was still very simple.  In fact he began his practice before WWII and the discovery of antibiotics.  His job was to make people feel better, rarely to cure them.  Medical science advanced rapidly, and by the time he retired he had plenty of pharmaceutical weapons in his armory. Nevertheless, he always practiced medicine the old-fashioned way – he listened to his patients, knew their families, and could rule out 95 percent of complaints. For the rest, he referred them to specialists. “Take my word for it”, he would tell patients. “You don’t have that.  Go home and relax”.  He rarely made mistakes, and even if he had, there was no such thing as malpractice, and a misdiagnosed patient would accept the roll of the dice, understand that nobody was perfect, and would never blame the doctor. If a patient ever tried to tell my father what to do, he got pissed.

The pendulum has come right around, and many patients go into their medical consultation armed with printouts generated from every website from Sloane Kettering to the Yemini doctor in Chad.  They meet the doctor not so much to hear what he has to say, but to tell him what to do and what to prescribe. Half the visit is spent dismissing false claims and arguing for sensible treatment.  It is no wonder why in this patient-dominated culture many potential doctors turn to investment banking. Who needs the headaches?

Many others, however, simply do what the doctor ordered:

In a 2009 experiment carried out at Emory University, a group of adults was asked to make a decision while contemplating an expert’s claims, in this case, a financial expert. A functional M.R.I. scanner gauged their brain activity as they did so. The results were extraordinary: when confronted with the expert, it was as if the independent decision-making parts of many subjects’ brains pretty much switched off. They simply ceded their power to decide to the expert.

This is not surprising. The deference to expert opinion is logical and natural. Most of us defer to people with legitimate authority; and studying for 12 years has to be worth something.  More importantly, however, is the equally understandable tendency to avoid the disorienting chaos of differing opinions – the hundreds of websites, range of probabilities, laws of unintended consequences, rating systems, outcome analyses, and value-for-intervention studies. 

I grew up on the cusp of modern medicine. I could never go out in the cold with a wet head, had to shut my windows against the night air, was wrapped with mustard plasters when I had the croup, and was told that the bowels were the key to well-being.  When penicillin first hit the commercial market after the war, my father jabbed me at the first sign of a sniffle. The contraption he used was much like a 12-gauge shotgun.  He cleared the breech, rammed in the cartridge, and fired away. It was a far simpler era than today.

My approach these days is a blend of my father’s simplicity and sanity and the need to be modestly informed.  As I have mentioned, I do my vetting and investigations before I get sick; and when I do, I trust my choice of doctor.  It is the same approach I have with car mechanics.  I bring my beater only to the best,  most experienced, best-trained, and critical car guys.  I believe what they say, and pay them. 

Is this head-in-the sand optimism?  An abrogation of the consumer responsibility?  Nothing of the sort.  Find, select, and pay for excellence, and most of your worries will be over. 

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