Monday, May 2, 2016

The Medical Bait and Switch

Image result for thinking fast and slow

I just discovered a thinking fallacy featured in the book "Superforecasting." It happens all the time in medicine.

It's called the bait and switch. It's similar to anchoring, but different.

It happens when, confronted with a difficult and foreign problem, a person substitutes an easier-to-solve and more intuitive problem, and then answers that problem. 

When someone comes to the emergency room with shortness of breath, this is a complex problem with many, many possible causes, often mixed together. Rather then get to the bottom of this, we substitute shortness of breath with a simpler problem- pulmonary edema from heart failure. Mild pulmonary edema is a much easier problem than shortness of breath. We give a relatively harmless medicine, furosemide, quantify that we're making progress by measuring its effect on weight loss or negative fluid balance, and then dust our hands of the problem and congratulate ourselves on another job well done. 

Meanwhile, while hospitalized for a few days, the patient is removed from whatever insult caused the shortness of breath (maybe the mold in their apartment triggers asthma, or the challenges of insecure housing, nutrition or basic safety, or substance use). During that remove, they feel better and their shortness of breath improves. 

They feel especially better when suggested by their doctors' leading query: "Are you feeling better?" 

This is even more effective when phrased like "You've lost a liter of fluid and your chest X-ay is clear, are you breathing better?" Who could say no?

Tuesday, April 26, 2016

Five magnitudes of medical harm

Despite the dictum to do no harm, everyone agrees that medicine is harmful. But just how harmful is it?

Level 1- The unavoidable, almost necessary harm of practicing medicine.
Example: the pain and discomfort of surgical excision of a ruptured appendix. When slicing into someone's body, causing pain and discomfort simply cannot be avoided. The benefits of surgery dramatically outweigh these travails, and so we simply soldier on. In some ways, the doctor's role is to be the authority, the stoic bearer of bad news who unflinchingly faces the facts, and disregards these unavoidable harms so that they don't impede the grisly work that simply must be done. This role was probably prominent in the early days of medicine, before anesthesia, when on the battlefield, the qualities one wanted in a surgeon were grit and speed. This level can found among retired docs and scattered about a few naive young residents.

Level 2- The enterprise of medicine is more harmful than it seems.
This level is more humble than level one. It is sensitive to the fact that mistakes and pitfalls are everywhere, and they aren't always outweighed by medicine's benefits. It knows that bad things happen just by in the hospital. Reducing this harm depends chiefly on competence, on being a good doctor. Good doctors are careful, they know their craft and try very hard to make the correct diagnoses and perform their procedures with skill. As long as the doctor is diligent, there is a certain fatalism around bad outcomes. This level is embodied by the league of residency program directors and department chairs.

Level 3- Preventable harm exists on a large scale and requires changes in the systems of care.
These were described well in the Institute of Medicine's report "To Err is Human." It detailed the massive scale of health care induced harm (hospital acquired infection, medication error, etc), far exceeding the public and most physicians' worst estimates- over 100,000 preventable deaths a year. It was recognized that medical knowledge and clinical skill had little to do with it, and that the chief drivers or mortality were in the basics-hand hygiene, timeouts before procedures, checklists for surgery. Wide scale harm is a built into the system. Change the system, reduce the harm. And the quality improvement movement was born.

Level 4- The health care system is so broken and dysfunctional that dramatic action is warranted.
This level compares the ideal of health care as a human right that society makes available to all, like education and public safety, to the reality of health care as a deeply unfair, inaccessible and expensive wealth extraction system that serves the revenue streams of multinational pharmaceutical and device companies, large insurers, and sprawling hospital systems and physician organizations. This level seeks major structural changes, such as realigning payment incentives and legislation, to better serve the underserved- the poor, the elderly, the chronically ill. The single payer movement is a prime example of level 4.

Level 5- The health care system is more harmful than helpful.
This radical fringe believes that if all hospitals and doctors' offices were eliminated, society would live better and longer lives. They see harmful corruption and misinformation in almost every facet of health care, from the faulty evidence underlying common treatments and guidelines to the delivery of health care in profit-motivated institutions. When you add up the harm from medicalization of birth and death, overtreatment of most common conditions, and society's lost investment opportunities in education, housing, and public health, coupled with the unmeasurable but devastating crisis of human dignity visited upon more than one million nursing home residents crowded into close quarters, totally dependent on underpaid staff, living out their remaining days immobile in front of a TV, it's at least plausible that these harms outweigh health care's benefit. Proponents of level 5 are mainly found on the books with titles like "We're Doomed."