Why Doctors Hate Science

[Ivor the Engineer]

How do you determine what is in the best interests of a patient?

Evidence-based medicine plus consideration of the individual.

How do you go about taking consideration of the individual?

IIRC, I didn’t suggest starting with the Golden Rule, but falling back on it when other sources of information are unavailable. But you saw a chance to assert your superiority and just couldn’t resist.

Why would you assume my opinion is superior to yours? I doubt that you actually believe that.

Because 90% of the posters in any particular thread in which we have a difference of opinion will agree with you and ridicule me. I therefore believe your opinions are considered by most people to be superior to mine.

<snip>

1. Has there been any studies performed on what type of doctor-patient relationship produce the best outcomes? If so, did any of them have the doctor being open about her reasoning with the patient?

Yes.

Yes.

Could you elaborate please?

2. Do medical students fail if they don’t follow a particular model of interacting with patients?

No, although that depends upon how vaguely you define "particular model".

Do you think the roles of physician and patient are learned? If so, when do you think this learning takes place?

3. In general are physicians open about their reasoning processes with their patients? If not, is this because they believe (rightly or wrongly) that their patients expect them to behave in a certain way?

I think generally they are and then circumstances influence whether it is possible or appropriate.

I don't think that physicians generally ignore patient expectations.

I personally have never experienced medical professionals being open about their reasoning, but this may be because they considered me to be not very intelligent and so not possible or appropriate.

I think physicians have expectations which most patients acquiesce to.

4. If patients are used to physicians behaving in a particular way, would they be distressed if physicians changed how they behaved? Would this distress be permanent, or would patients get used to the different way of behaving and begin to prefer and expect it after a while?

I don't think so. Satisfaction is somewhat tied to expectation, but it mostly seems to be tied to patient-centered factors - discussing psychosocial concerns instead of biomedical concerns, patients doing the talking, etc.

Or perhaps patients just stick to questions on topics they think will not offend or threaten the doctor’s status.

5. Do physicians resist being moved from their zone of comfort as much as everyone else does?

I suppose. Although, we have more experience with being forced out of our zone of comfort than average, which may lead to less resistance than average due to familiarity.

Linda

What do you consider to be physicians’ comfort zone?

 

[fls]

How do you go about taking consideration of the individual?

You ask them questions and listen to the answers.

Because 90% of the posters in any particular thread in which we have a difference of opinion will agree with you and ridicule me. I therefore believe your opinions are considered by most people to be superior to mine.

Ah, so in order to avoid your scorn, I should make my posts dull and stupid.

Could you elaborate please?

There are hundreds of studies of the effect of the physician-patient relationship on various outcomes (such as health and patient satisfaction), including studies on the amount and type of communication. Clear communication improves both health outcomes and patient satisfaction. The perception of some participation in the decision-making process improves patient satisfaction. Those benefits are lost with the inclusion of excess information not related to the patient's management and treatment, and with the introduction of increasing uncertainty.

Do you think the roles of physician and patient are learned? If so, when do you think this learning takes place?

Yes.

During physician-patient interactions.

What do you consider to be physicians’ comfort zone?

Confidence in the effectiveness of recommended management plans. Experience with various procedures. Familiarity with a practice setting. Patient visits that follow a routine.

Linda

 

[Ivor the Engineer]

You ask them questions and listen to the answers.

How do you know which questions to ask? Wouldn't it be easier to give patients permission to chip in with their thoughts while the physician explains her reasoning?

Ah, so in order to avoid your scorn, I should make my posts dull and stupid.

I don't know how you got to that conclusion from my observation. In many cases I don't think the actual opinion expressed really matters, more the status of the person who is expressing it. Since your status on the forum is much higher than mine, any time our opinions differ you will tend to get far more support than I will.

There are hundreds of studies of the effect of the physician-patient relationship on various outcomes (such as health and patient satisfaction), including studies on the amount and type of communication. Clear communication improves both health outcomes and patient satisfaction. The perception of some participation in the decision-making process improves patient satisfaction. Those benefits are lost with the inclusion of excess information not related to the patient's management and treatment, and with the introduction of increasing uncertainty.

Given homoeopaths get good marks on patient satisfaction surveys I don't think it's a particularly important measure. Health outcome on the other hand is. I would be interested to see studies which showed health outcome was significantly impaired by physicians expressing uncertainty in their diagnoses.

Yes.

During physician-patient interactions.

<snip>

I think it happens much earlier than that, probably in childhood when we're taught how to behave towards and around authority figures.

 

[fls]

How do you know which questions to ask? Wouldn't it be easier to give patients permission to chip in with their thoughts while the physician explains her reasoning?

By listening.
No.

Given homoeopaths get good marks on patient satisfaction surveys I don't think it's a particularly important measure. Health outcome on the other hand is. I would be interested to see studies which showed health outcome was significantly impaired by physicians expressing uncertainty in their diagnoses.

http://www.ncbi.nlm.nih.gov/pubmed/3109581

Linda

 

[Ivor the Engineer]

Before I pass comment on the study Linda provided, perhaps others (especially the medical practitioners on the forum) would like to review it themselves and tell us what they think. Here's the full article:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1246362

A group of 200 patients who presented in general practice with symptoms but no abnormal physical signs and in whom no definite diagnosis was made were randomly selected for one of four consultations: a consultation conducted in a "positive manner," with and without treatment, and a consultation conducted in a "non-positive manner," called a negative consultation, with and without treatment. Two weeks after consultation there was a significant difference in patient satisfaction between the positive and negative groups but not between the treated and untreated groups. Similarly, 64% of those receiving a positive consultation got better, compared with 39% of those who received a negative consultation (p = 0.001) and 53% of those treated got better compared with 50% of those not treated (p = 0.5).

Here's the definition of positive and negative consultations and the treatment:

In the positive consultations the patient was given a firm diagnosis and told confidently that he would be better in a few days. If no prescription was to be given he was told that in the doctor's opinion he required none, and if a prescription was to be given that the treatment would certainly make him better. The negative consultation was an artificial consultation, devised so that no firm assurance was given. This was done by the doctor making one statement: 'I cannot be certain what is the matter with you." If no prescription was to be given the following words were added: "And therefore I will give you no treatment." If a prescription was to be given the patient was told: "I am not sure that the treatment I am going to give you will have an effect." The negative consultations were brought to a close by telling the patient that if he or she was no better in a few days to return to the doctor.

"Treatment" was a prescription for tabs thiamine hydrochloride 3 mg, used as a placebo, and "no treatment" was no prescription.

 

[Ivor the Engineer]

How do you know which questions to ask? Wouldn't it be easier to give patients permission to chip in with their thoughts while the physician explains her reasoning?

By listening.
No.

<snip>

How are patients supposed to be able to catch errors in the doctor's reasoning if the flow of information during the diagnostic stage is one way?

Have you changed your mind when you thought the recommendations for patients I posted earlier were reasonable?

Here they are again (for reference):

Be Watchdogs for Cognitive Errors

Traditionally, physicians share their initial impressions with a new patient, but only to a limited extent. Sometimes the suspected diagnosis isn't explicitly mentioned, and the patient is simply told what tests to have done or what treatment will be used. Patients could serve an effective role in checking for cognitive errors if they were given more information, including explicit disclosure of their diagnosis, its probability, and instructions on what to expect if this is correct. They should be told what to watch for in the upcoming days, weeks, and months, and when and how to convey any discrepancies to the provider.

If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run. In this framework, patients would be more comfortable asking questions such as “What else could this be?” Exploring other options is a powerful way to counteract our innate tendencies to narrowly restrict the context of a case or jump too quickly on the first diagnosis that seems to fit.

 

[fls]

How are patients supposed to be able to catch errors in the doctor's reasoning if the flow of information during the diagnostic stage is one way?

It's not.

Have you changed your mind when you thought the recommendations for patients I posted earlier were reasonable?

No.

Linda

 

[Ivor the Engineer]

Linda,

I'm now totally baffled as to what you are suggesting. As you're now responding with single word answers I presume you no longer wish to discuss the subject with me. Am I correct?

If so, thank you for the interesting (if confusing) discussion.

 

[BillyJoe]

Ivor,

Linda has tried the long explanation and it didn't work for you.
Now she's trying (or resorting to) the short explanation and it still doesn't work for you.
What would you like her to try next?

And that study is about the placebo effect.
What it tells you is that.....(I will let you finish)

....hey, that's an idea...maybe Linda can lead you to the answers by asking you questions that you must answer by thinking them out for yourself...hmmm...

In many cases I don't think the actual opinion expressed really matters, more the status of the person who is expressing it. Since your status on the forum is much higher than mine, any time our opinions differ you will tend to get far more support than I will.

Hmmm...maybe

regards,
BillyJoe

 

[Ivor the Engineer]

Is no one else going to comment on the study Linda linked to?

Here's an idea: Imagine (if you can) Ivor linked to it instead.

Also imagine I'd just said I agreed with the following statement: "If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run."

What would you be calling Ivor? How stupid would Ivor be for linking to a paper which adds support to the exact opposite of what I'd just said I thought was a reasonable idea. Wouldn't many of you be pointing it out with glee?

The interesting thing about this thread is what is demonstrates about most of the people posting in it, which is that you seem incapable of thought which deviates from what those with authority think, and insult anyone who displays this undesirable trait.

So perhaps Linda and the other physicians are right; there really is no point trying to include patients in the consultation (other than giving them the perception they have a choice) because, like you, they really are weak-minded fools who need to be protected from themselves.

 

[fls]

Is no one else going to comment on the study Linda linked to?

Here's an idea: Imagine (if you can) Ivor linked to it instead.

Also imagine I'd just said I agreed with the following statement: "If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run."

What would you be calling Ivor? How stupid would Ivor be for linking to a paper which adds support to the exact opposite of what I'd just said I thought was a reasonable idea. Wouldn't many of you be pointing it out with glee?

The interesting thing about this thread is what is demonstrates about most of the people posting in it, which is that you seem incapable of thought which deviates from what those with authority think, and insult anyone who displays this undesirable trait.

So perhaps Linda and the other physicians are right; there really is no point trying to include patients in the consultation (other than giving them the perception they have a choice) because, like you, they really are weak-minded fools who need to be protected from themselves.

I dunno Ivor. What do you advise?

After 16 pages of long involved explanations, short direct answers, humour, ridicule, friendship, dismissal, you summarize the conversation by claiming that what has been said is pretty much the direct opposite of what has actually been said. What can we do about that? What would you do?

Linda

 

[BillyJoe]

Ivor,

I have read the whole article now and was not surprised to see the word placebo at least half a dozen times. As I said before, it is a study of the placebo effect. When faced with a patient who has symptoms but no abnormal signs and in whom a diagnosis cannot be made (there is an underlying assumption that the patient does not have a serious illness), a positive attitude by the doctor leads to a more postive outcome for the patient. I don't think I would expect anything less of a placebo effect. This positive attitude of the doctor in these situations is at odds with the modern trend towards the "shared consult".

However....

"If there is no clear diagnosis, this too should be conveyed. Patients prefer a diagnosis that is delivered with confidence and certainty, but an honest disclosure of uncertainty and the probabilistic nature of diagnosis is probably a better approach in the long run."

...in the long run, it is probably better to be honest with patients becasue that assumption about the patient not having a serious disease could actually tuen out to be wrong!

So, it makes good sense for the doctor to convey some doubt about the diagnosis or that a diagnosis can be arrived at, even though this might cause some discomfort for the patient. (Of course they don't necessarily have to be told that one of the possibilities is terminal cancer! - is there any other kind as far as patients are concerned? - especially if that is unlikely).

BJ

 

[BillyJoe]

After 16 pages of long involved explanations, short direct answers, humour, ridicule, friendship, dismissal, you summarize the conversation by claiming that what has been said is pretty much the direct opposite of what has actually been said. What can we do about that? What would you do?

I think you stole that line from an...um...authority!

 

[Ivor the Engineer]

I dunno Ivor. What do you advise?

After 16 pages of long involved explanations, short direct answers, humour, ridicule, friendship, dismissal, you summarize the conversation by claiming that what has been said is pretty much the direct opposite of what has actually been said. What can we do about that? What would you do?

Linda

Rather than just making an assertion, would you care to provide a consistent set of facts and reasoning to support it?

No, I didn't think so.

 

[Dr. Imago]

Rather than just making an assertion, would you care to provide a consistent set of facts and reasoning to support it?

No, I didn't think so.

With all due respect, Ivor, trying to send Linda on a "fools errand" is the lamest of all debate tactics.

~Dr. Imago

 

[paximperium]

I treat Ivor as seriously as any rant from EJ Armstrong or DOC.
You have no idea how uninterested I am with having any conversation with Ivor.

 

[fls]

Rather than just making an assertion, would you care to provide a consistent set of facts and reasoning to support it?

No, I didn't think so.

I would like to. It is, after all, what I spend the bulk of my time here doing. And I think that is what accounts for others giving consideration to what I have to say.

But how can I possibly believe that such an activity would be useful, when you've already rejected the possibility that I would do so, as if I hardly ever undertake this endeavour? My normal activities of providing information and explaining my reasoning has made no impact whatsoever on your comprehension. And those same activities from others in this thread has had the same (non)effect. So clearly what is needed is something different. And I'm willing to try something different, but it's also clear that I cannot guess what that would be. What would you suggest?

I honestly don't see how going through the thread cutting and pasting statements from T.A.M., Pax, Skeptigirl and Dr. Imago (and any other health professionals I've forgotten) is going to make a difference. Those statements are already available to you. They obviously did not make an impact the first time you read them. And you simply do not trust me as a source of information, so you would have to repeat the task for yourself anyway, if you were sincerely interested in understanding what has been said here.

Linda

 

[fls]

I think you stole that line from an...um...authority!

Does "fair use" or "derivative work" allow me to get away with stealing and/or failing to attribute the work?

Linda

 

[Ivor the Engineer]

I would like to. It is, after all, what I spend the bulk of my time here doing. And I think that is what accounts for others giving consideration to what I have to say.

Perhaps the reason other people give consideration to what you have to say is because you are a medical doctor with a PhD and rarely say anything most people who identify with the label ‘sceptic’ disagree with. I.e. you are a person of high status telling people what they want to hear.

But how can I possibly believe that such an activity would be useful, when you've already rejected the possibility that I would do so, as if I hardly ever undertake this endeavour?

Because I know you well enough to know that if I fail to bow to whatever you believe after a page or two you clam up.

My normal activities of providing information and explaining my reasoning has made no impact whatsoever on your comprehension. And those same activities from others in this thread has had the same (non)effect. So clearly what is needed is something different. And I'm willing to try something different, but it's also clear that I cannot guess what that would be. What would you suggest?

The problem is that your reasoning is frequently inconsistent. When I suggest something in one thread it is wrong (and your followers in the thread come along and give me a kick just to let me know that I'm wrong). You suggest exactly the same thing in another thread and it is right (and your followers in the thread come along and give me a kick because giving Ivor a kick is the thing to do whenever he disagrees with you).

Probably the best thing for me to do is not even bother to challenge people's preconceived ideas, particularly when you happen to share them.

Let me start for this thread: The vast majority of medical professionals respond to ‘good’ incentives and are resistant to ‘bad’ incentives, always put patients’ needs before their own wants and are right 99.99% of the time when they post on the JREF.

I honestly don't see how going through the thread cutting and pasting statements from T.A.M., Pax, Skeptigirl and Dr. Imago (and any other health professionals I've forgotten) is going to make a difference. Those statements are already available to you. They obviously did not make an impact the first time you read them. And you simply do not trust me as a source of information, so you would have to repeat the task for yourself anyway, if you were sincerely interested in understanding what has been said here.

Linda

The only one of those posters I’ve been consistently impressed by in this thread is TAM. DeeTee is also another poster whom I admire. Perhaps you can figure out why?

 

[fls]

Perhaps the reason other people give consideration to what you have to say is because you are a medical doctor with a PhD and rarely say anything most people who identify with the label ‘sceptic’ disagree with. I.e. you are a person of high status telling people what they want to hear.

I do not have a PhD.

However, I do not see people with professional degrees being given a free pass here. People argue vociferously with me, with Pax, with Skeptigirl, with Jeff Corey, with DrKitten, with JJM, with you...it seems to be the content that matters more than the status. And your statements show a quite disturbing lack of respect for others here.

Because I know you well enough to know that if I fail to bow to whatever you believe after a page or two you clam up.

What would you have me do? I say something, you read it as saying something quite different from what I meant, I spend page after page trying to explain what I meant....how long should I carry on? I have yet to figure out how to say things in a way that allows you to comprehend what I have to say. Doesn't it make more sense to just give this up?

The problem is that your reasoning is frequently inconsistent. When I suggest something in one thread it is wrong (and your followers in the thread come along and give me a kick just to let me know that I'm wrong). You suggest exactly the same thing in another thread and it is right (and your followers in the thread come along and give me a kick because giving Ivor a kick is the thing to do whenever he disagrees with you).

But you rarely manage to comprehend my reasoning. That others do manage to comprehend it is not a sign that they are "my followers". I can't even think of more than one or two people here who would tend to accept what I say without question. The rest of us agree and disagree with each other at will. And this is quite a nasty thing for you to say about anyone who happens to disagree with you or happens to share my opinion in any particular thread.

Probably the best thing for me to do is not even bother to challenge people's preconceived ideas, particularly when you happen to share them.

Let me start for this thread: The vast majority of medical professionals respond to ‘good’ incentives and are resistant to ‘bad’ incentives, always put patients’ needs before their own wants and are right 99.99% of the time when they post on the JREF.

Again, how can you expect anyone to have a conversation with you when you so woefully misrepresent what anyone else has to say?

The only one of those posters I’ve been consistently impressed by in this thread is TAM. DeeTee is also another poster whom I admire. Perhaps you can figure out why?

I don't know why.

Linda