Discussion:
NY Times: Judges, Not Juries, for Medical Malpractice Cases?
(too old to reply)
Caliban
2003-07-27 14:54:46 UTC
Permalink
Excerpt from a July 21st NY Times Op-Ed:

Studies about jury awards in health care confirm what every doctor fears -
and every victim should fear: justice is random. Most doctors who make
mistakes don't get sued. But most lawsuits are against doctors who did
nothing wrong; the cases involve human tragedy but not medical negligence.

The common ground here is the need for reliable justice. For doctors,
reliability would offer protection against baseless claims. For patients, it
would provide victims with quicker compensation without the legal costs that
consume almost half the awards. A system of reliable justice could also
remove from practice incompetent doctors who often escape accountability now
by threatening to sue their hospital or state licensing board.

Creating a reliable system of medical justice, however, requires changing
one aspect of the system that is so ingrained it is hardly even part of the
debate: the jury. Expert judges, not juries, must decide what is a valid
claim.

[Author Philip K. Howard is a lawyer and author, most recently, of "The
Collapse of the Common Good: How America's Lawsuit Culture Undermines Our
Freedom."]

http://www.nytimes.com/2003/07/21/opinion/21HOWA.html?8bl

Caliban comment:
Howard's opinion that most lawsuits are against doctors who did nothing
wrong may be at least partly hyperbole. Is he second-guessing juries who
found for plaintiffs?

Unfortunately, his being a lawyer, whose reputation these days is to argue
not for truth but to win a point or personal acclaim, subtracts from his
credibility in my eyes. It is so sad that one cannot assume lawyers have at
least as unbiased an opinion as researchers do. (Though I grant researchers
certainly may be biased.)
David Johnston
2003-07-27 18:32:01 UTC
Permalink
Post by Caliban
Studies about jury awards in health care confirm what every doctor fears -
and every victim should fear: justice is random. Most doctors who make
mistakes don't get sued. But most lawsuits are against doctors who did
nothing wrong; the cases involve human tragedy but not medical negligence.
The common ground here is the need for reliable justice. For doctors,
reliability would offer protection against baseless claims. For patients, it
would provide victims with quicker compensation without the legal costs that
consume almost half the awards. A system of reliable justice could also
remove from practice incompetent doctors who often escape accountability now
by threatening to sue their hospital or state licensing board.
Creating a reliable system of medical justice, however, requires changing
one aspect of the system that is so ingrained it is hardly even part of the
debate: the jury. Expert judges, not juries, must decide what is a valid
claim.
[Author Philip K. Howard is a lawyer and author, most recently, of "The
Collapse of the Common Good: How America's Lawsuit Culture Undermines Our
Freedom."]
http://www.nytimes.com/2003/07/21/opinion/21HOWA.html?8bl
Howard's opinion that most lawsuits are against doctors who did nothing
wrong may be at least partly hyperbole. Is he second-guessing juries who
found for plaintiffs?
Of course he is. But that doesn't make the claim hyperbole.
Let's face it, there's a very limited causal connection between a
doctor actually having done anything wrong, and said doctor getting
sued. The relevant variable would be the injured party or next of
kin's tendency to sue when things go wrong, since more than 90%
of the time, the person laying the lawsuit is entirely incompetent
to evaluate whether or not the doctor did a good job and things
just turned out badly.
Post by Caliban
Unfortunately, his being a lawyer, whose reputation these days is to argue
not for truth but to win a point or personal acclaim, subtracts from his
credibility in my eyes. It is so sad that one cannot assume lawyers have at
least as unbiased an opinion as researchers do. (Though I grant researchers
certainly may be biased.)
There are no lawyers who stand to personally profit from putting some
kind of restraint on "lawsuit culture". Therefore it is reasonable
to surmise that his intentions at least are sincere.
Caliban
2003-07-27 19:16:08 UTC
Permalink
Post by David Johnston
Post by Caliban
Studies about jury awards in health care confirm what every doctor fears -
and every victim should fear: justice is random. Most doctors who make
mistakes don't get sued. But most lawsuits are against doctors who did
nothing wrong; the cases involve human tragedy but not medical negligence.
The common ground here is the need for reliable justice. For doctors,
reliability would offer protection against baseless claims. For patients, it
would provide victims with quicker compensation without the legal costs that
consume almost half the awards. A system of reliable justice could also
remove from practice incompetent doctors who often escape accountability now
by threatening to sue their hospital or state licensing board.
Creating a reliable system of medical justice, however, requires changing
one aspect of the system that is so ingrained it is hardly even part of the
debate: the jury. Expert judges, not juries, must decide what is a valid
claim.
[Author Philip K. Howard is a lawyer and author, most recently, of "The
Collapse of the Common Good: How America's Lawsuit Culture Undermines Our
Freedom."]
http://www.nytimes.com/2003/07/21/opinion/21HOWA.html?8bl
Howard's opinion that most lawsuits are against doctors who did nothing
wrong may be at least partly hyperbole. Is he second-guessing juries who
found for plaintiffs?
Of course he is.
No, not of course. He may have statistics on malpractice lawsuits filed
where the defendant won. Or he could be extrapolating from data on
settlements where the MD claimed no wrong, but the insurance company lawyers
said it's cheaper to settle.
Post by David Johnston
But that doesn't make the claim hyperbole.
Let's face it, there's a very limited causal connection between a
doctor actually having done anything wrong, and said doctor getting
sued.
We're not facing anything with more secong guessing.
Post by David Johnston
The relevant variable would be the injured party or next of
kin's tendency to sue when things go wrong, since more than 90%
of the time, the person laying the lawsuit is entirely incompetent
to evaluate whether or not the doctor did a good job and things
just turned out badly.
I'm sure the 90% is hyperbole, but for the sake of discussion, I am meeting
doctors everyday who have less knowledge than patients. Why? The patients
often know their bodies better than any one else can.
Post by David Johnston
Post by Caliban
Unfortunately, his being a lawyer, whose reputation these days is to argue
not for truth but to win a point or personal acclaim, subtracts from his
credibility in my eyes. It is so sad that one cannot assume lawyers have at
least as unbiased an opinion as researchers do. (Though I grant researchers
certainly may be biased.)
There are no lawyers who stand to personally profit from putting some
kind of restraint on "lawsuit culture". Therefore it is reasonable
to surmise that his intentions at least are sincere.
He is selling his book with this Op-Ed piece. Also, some people are out not
just for fortune but for fame and advertising.

I don't see it as black and white as you do.
David Johnston
2003-07-27 19:40:04 UTC
Permalink
Post by Caliban
Post by David Johnston
But that doesn't make the claim hyperbole.
Let's face it, there's a very limited causal connection between a
doctor actually having done anything wrong, and said doctor getting
sued.
We're not facing anything with more secong guessing.
What is wrong with second guessing?
Post by Caliban
Post by David Johnston
The relevant variable would be the injured party or next of
kin's tendency to sue when things go wrong, since more than 90%
of the time, the person laying the lawsuit is entirely incompetent
to evaluate whether or not the doctor did a good job and things
just turned out badly.
I'm sure the 90% is hyperbole,
Nope.

but for the sake of discussion, I am meeting
Post by Caliban
doctors everyday who have less knowledge than patients. Why? The patients
often know their bodies better than any one else can.
The patients only know what their symptoms feel like. They do not
generally know what the doctor is capable of doing to relieve said
symptoms or what the risks are for each alternative.
Caliban
2003-07-27 20:01:04 UTC
Permalink
"David Johnston" <***@telusplanet.net> wrote
snip
Post by David Johnston
The patients only know what their symptoms feel like. They do not
generally know what the doctor is capable of doing to relieve said
symptoms or what the risks are for each alternative.
Wow. I respectfully disagree that this is true or has to be true (given the
power of information sharing on the Internet of late), even in general. I am
underwhelmed about how ignorant doctors are of the statistical validity of
studies. Cases in point: Hormone replacement therapy, mammograms, prostate
treatment studies for years believed to be the last word are now being
demonstrated to have been flawed. Doctors push what is popularly (and I do
mean "mass popular") recommended, without giving consideration to the bias
of drug companies and others.
Mark Stahl
2003-07-28 13:07:01 UTC
Permalink
Post by Caliban
snip
Post by David Johnston
The patients only know what their symptoms feel like. They do not
generally know what the doctor is capable of doing to relieve said
symptoms or what the risks are for each alternative.
Wow. I respectfully disagree that this is true or has to be true (given the
power of information sharing on the Internet of late), even in general. I am
underwhelmed about how ignorant doctors are of the statistical validity of
studies. Cases in point: Hormone replacement therapy, mammograms, prostate
treatment studies for years believed to be the last word are now being
demonstrated to have been flawed.
umm, do you have anything specific in mind here? quite frankly, i don't
think you could be more wrong about this. there are many studies which show
initial promise and are believed to be provisionally true, but if they were
really considered to be the "last word", why would the long term official
studies be conducted in the first place? it seems like you're unclear on the
idea that we often work with incomplete information until definitive studies
(which take years, even decades) can be completed.
Post by Caliban
Doctors push what is popularly (and I do
mean "mass popular") recommended, without giving consideration to the bias
of drug companies and others.
nothing like making a sweeping generalization.... i can assure you this is
untrue of the doctors i train with. in fact, we just held a seminar on that
very topic.
Caliban
2003-07-28 13:35:41 UTC
Permalink
Post by Mark Stahl
Post by Caliban
snip
Post by David Johnston
The patients only know what their symptoms feel like. They do not
generally know what the doctor is capable of doing to relieve said
symptoms or what the risks are for each alternative.
Wow. I respectfully disagree that this is true or has to be true (given
the
Post by Caliban
power of information sharing on the Internet of late), even in general.
I
Post by Mark Stahl
am
Post by Caliban
underwhelmed about how ignorant doctors are of the statistical validity of
studies. Cases in point: Hormone replacement therapy, mammograms, prostate
treatment studies for years believed to be the last word are now being
demonstrated to have been flawed.
umm, do you have anything specific in mind here? quite frankly, i don't
think you could be more wrong about this. there are many studies which show
initial promise and are believed to be provisionally true, but if they were
really considered to be the "last word", why would the long term official
studies be conducted in the first place? it seems like you're unclear on the
idea that we often work with incomplete information until definitive studies
(which take years, even decades) can be completed.
I am convinced that, were many initial studies properly scrutinized
(especially absent drug company influence), their results would have been
seen as flawed, and they never would have been embraced.

The problem is many (the majority?) of MDs do not have the education to
acknowledge how incomplete some studies are. They become subject to group
think and not 'individual think.' The latter should be a hallmark of a good
physician. Instead, too many pretend that there is actual data to support a
group-think conclusion, instead of recognizing that they've been swept up in
a herd mentality.

I do agree I was being a bit harsh in my previous post (and people have
heard me complain about this here before).

Yet I also think that too many people still look at doctors as gods, who
know all. David's statement reminded me of this. I think it's dangerous.
David alleges patients do not know the risks. Doctors often don't know the
risks but will claim to! Now that so many ordinary people are competent at
using the Internet (and so many more could be instructed to do basic
research on the 'net), I think the public is much better equipped to
diagnose their own ailments and see at least, for example, whether it would
be worthwhile to find a second opinion.

I try to envision symptoms that could not be put into a computer program
such that all possible diseases would be spewed out and can't. Much of
medical education used to be rote memorization, combined with the honing of
interns' deductive reasoning skills, to facilitate diagnosis, after all. Now
it would seem that the only instances where such rote memorization is
critical is for E.R. doctors and surgeons.

I am drawing from a lot of reading of news reports on this subject,
buttressed by personal experience. E.g. several years ago I was having fits
of wheezing where I could not breathe for several moments. Only after seeing
a third doctor did the problem get correctly diagnosed. (Doctor #2 tried to
put me on prednisone, until a pharmacist buddy of mine said, 'Throw out this
stuff. Go see Dr. So-and-So, a specialist in asthma.') Dr. So and So (#3)
nailed the problem and had me feeling better in days. I was fully cured in a
few months using *routine*, mild asthma medications. I have other stories to
tell, but you get my message.

Have you always found your doctors to be knowledgeable and competent when
you had a specific ailment?
Post by Mark Stahl
Post by Caliban
Doctors push what is popularly (and I do
mean "mass popular") recommended, without giving consideration to the bias
of drug companies and others.
nothing like making a sweeping generalization.... i can assure you this is
untrue of the doctors i train with. in fact, we just held a seminar on that
very topic.
You'll have to explain why so many (like all of them) bought into hormone
replacement therapy and mammograms, among other procedures, then.
Mark Stahl
2003-07-30 00:51:12 UTC
Permalink
Post by Caliban
Post by Mark Stahl
Post by Caliban
snip
Post by David Johnston
The patients only know what their symptoms feel like. They do not
generally know what the doctor is capable of doing to relieve said
symptoms or what the risks are for each alternative.
Wow. I respectfully disagree that this is true or has to be true (given
the
Post by Caliban
power of information sharing on the Internet of late), even in general.
I
Post by Mark Stahl
am
Post by Caliban
underwhelmed about how ignorant doctors are of the statistical
validity
Post by Caliban
of
Post by Mark Stahl
Post by Caliban
studies. Cases in point: Hormone replacement therapy, mammograms,
prostate
Post by Mark Stahl
Post by Caliban
treatment studies for years believed to be the last word are now being
demonstrated to have been flawed.
umm, do you have anything specific in mind here? quite frankly, i don't
think you could be more wrong about this. there are many studies which
show
Post by Mark Stahl
initial promise and are believed to be provisionally true, but if they
were
Post by Mark Stahl
really considered to be the "last word", why would the long term official
studies be conducted in the first place? it seems like you're unclear on
the
Post by Mark Stahl
idea that we often work with incomplete information until definitive
studies
Post by Mark Stahl
(which take years, even decades) can be completed.
I am convinced that, were many initial studies properly scrutinized
(especially absent drug company influence), their results would have been
seen as flawed, and they never would have been embraced.
like which initial studies, specifically? the fact is that many initial
studies found encouraging results, while acknowledging that they were
incomplete. a physician has a responsibility to her patient to treat to the
best of her knowledge.

in terms of HRT, the finding of encouraging initial results makes perfect
sense, for many reasons. 1) HRT *does* relieve the proximal symptoms of
menopause (ie, hot flashes) 2) HRT really does improve osteoporosis
resulting in fewer bone fractures (something easy to observe) 3) HRT lowers
colon cancer risk 4) our current understanding of endocrinology strongly
suggested that HRT would improve cardiovascular health (not make it worse,
as was generally found) and possibly stave off alzheimer's (jury's still
out) and 5) the small effects on cardiovascular health were long term and
difficult to observe.

so sure, anecdotal information and short term, incomplete studies are a
problem- but in this case they agreed with standard models of health and
disease well enough that people were willing to embrace them for the good of
their patients who usually don't have a decade to find out the truth
everyone thought they knew. but that's why we do the studies anyway.

BTW, even with the HRT "scare", the problem is probably not what you seem to
think it is. the results may only be applicable to combination therapy. the
adverse effects, though statistically significant, were small indeed (though
important because cardiovascular disease is the major source of morbidity
and mortality in older women). the only thing that "should" have been seen
coming was the adverse effects on breast malignancy, which responsible
doctors discussed with their patients before the studies came out. so it's
hardly as if there was something obvious we or the drug companies were
hiding or something. i think you're convinced of something which just isn't
the case.
Post by Caliban
The problem is many (the majority?) of MDs do not have the education to
acknowledge how incomplete some studies are. They become subject to group
think and not 'individual think.' The latter should be a hallmark of a good
physician. Instead, too many pretend that there is actual data to support a
group-think conclusion, instead of recognizing that they've been swept up in
a herd mentality.
i have a hard time imagining what leads you to this conclusion. do you teach
medical school? been to medical school? anything to do with medical
education at all?

i will tell you that there is some truth to the idea that some physicians
are not as well versed in statistics as they could be. a standard medical
school curriculum does address critical reading to some extent though i
would say not enough. if you really want 'individual-think', see an MD/PhD
who has their PhD in a basic science discipline.

nevertheless, there is nothing wrong with the idea of "standards of care"
and the like that you criticize as "group-think". in fact, if doctors are
outside their fields of experience it's probably best that there exist some
consensus on certain matters so the wheel need not be reinvented on the fly.
Post by Caliban
I do agree I was being a bit harsh in my previous post (and people have
heard me complain about this here before).
Yet I also think that too many people still look at doctors as gods, who
know all. David's statement reminded me of this. I think it's dangerous.
sounds more like a problem with the "people" than the doctors, doesn't it?
Post by Caliban
David alleges patients do not know the risks.
often they don't.
Post by Caliban
Doctors often don't know the
risks but will claim to!
that has emphatically not been my experience or training, although there is
a certain something to be said for reassuring the patient.
Post by Caliban
Now that so many ordinary people are competent at
using the Internet (and so many more could be instructed to do basic
research on the 'net), I think the public is much better equipped to
diagnose their own ailments and see at least, for example, whether it would
be worthwhile to find a second opinion.
sure. many if not most physicians encourage this, especially the younger
ones. but of course the internet is a source for a hell of a lot of bad
information, too. i could tell horror stories from my and my colleagues'
clinical experiences about patients who try this technique. additionally,
there are a great many patients who *don't* have this access at all.

your point is somewhat valid for long term, progressive, lifetime diseases
that patients have time to become educated about. many cancer and AIDS
patients, for example, come to their docs with thoughts about their
treatment regimens, and i think that's a great thing. but it's a vast, vast
minority of patients who have even a remote idea of how the human body
works, much less how to fix it.

would you suggest we do away with auto mechanics because the schematics of
your automobile are online? i'm guessing most would rather have someone else
fix it regardless. medicine is somewhat similar.
Post by Caliban
I try to envision symptoms that could not be put into a computer program
such that all possible diseases would be spewed out and can't.
LOL... then the problem is most definitely with your ability to envision.
seriously, do you have any idea what the differential diagnosis for "pain in
my side" is? do you think a computer program would be very good at coming up
with the right questions to ask (without going through 100s of dead ends)?
would it come up with the thought that a patient's physical symptoms are
manifestations of mental problems like depression? how good is a computer at
performing physical exams? how about synthesizing a patient's medical
history, life situation, and personality to come up with treatments that are
likely to be both effective and adhered to properly?

a minute ago you were criticizing "groupthink" in medicine- now you want to
reduce it to a computer algorithm? what could be more "groupthink" than
that?

seriously, i'm not saying there aren't routine and boring medical problems
that computers or something couldn't handle in the near future. personally,
if i never see another obese asthma patient in ambulatory care i'll be
perfectly happy. but then i wouldn't want to forget the patient we
discovered was obese because she thought it would make her less attractive
to her sexually abusive father. does this make any sense?
Post by Caliban
Much of
medical education used to be rote memorization,
believe me, there's as much or more rote memorization than ever....
Post by Caliban
combined with the honing of
interns' deductive reasoning skills, to facilitate diagnosis, after all.
i think you're leaving out an awful lot there.
Post by Caliban
Now
it would seem that the only instances where such rote memorization is
critical is for E.R. doctors and surgeons.
no offense, but i think what it seems like to you and what it actually is
are pretty different. it's pretty damn important to have a solid grounding
in basic bioscience, pharmacology, microbiology, anatomy, physiology, and
more just to be conversant in what the *possibilities* for diagnosis and
treatment are. most patients simply don't have the time or inclination to
know these things... they understandably just want to feel better.
Post by Caliban
I am drawing from a lot of reading of news reports on this subject,
buttressed by personal experience.
ok... i'm drawing a lot from going to medical school, working on my PhD,
having several older relatives who are physicians, dating doctors, and
reading the actual literature.

the media tends to overblow their flavor of the month... like the HRT thing
for instance.
Post by Caliban
E.g. several years ago I was having fits
of wheezing where I could not breathe for several moments. Only after seeing
a third doctor did the problem get correctly diagnosed. (Doctor #2 tried to
put me on prednisone, until a pharmacist buddy of mine said, 'Throw out this
stuff. Go see Dr. So-and-So, a specialist in asthma.') Dr. So and So (#3)
nailed the problem and had me feeling better in days. I was fully cured in a
few months using *routine*, mild asthma medications. I have other stories to
tell, but you get my message.
well, honestly i don't. there wasn't much of a story there. what did the 1st
doctor say your problem was? the 2nd? also, the "*routine* mild asthma
medications" are often corticosteroids as well. what did you end up taking?
Post by Caliban
Have you always found your doctors to be knowledgeable and competent when
you had a specific ailment?
no one is perfect i suppose, but i have never had a problem. much of that i
am sure is that i generally have a pretty good idea of what i have, so i go
to the right doctor to begin with, but i'm not the best test case.

is your complaint that sometimes doctors think they know what they're doing
when they don't? i'll agree that humility isn't often big on the list of
traits, but it's been my experience that, yes, doctors generally are both
knowledgeable and competent or they make referrals to someone who is.
Post by Caliban
Post by Mark Stahl
Post by Caliban
Doctors push what is popularly (and I do
mean "mass popular") recommended, without giving consideration to the
bias
Post by Mark Stahl
Post by Caliban
of drug companies and others.
nothing like making a sweeping generalization.... i can assure you this is
untrue of the doctors i train with. in fact, we just held a seminar on
that
Post by Mark Stahl
very topic.
You'll have to explain why so many (like all of them) bought into hormone
replacement therapy and mammograms, among other procedures, then.
HRT was and is a good choice for some people, and the literature supported
that position. now we have more data, and the recommendations have changed.
even now it's a good choice for some patients, which is part of the problem
i am seeing with your argument- you're buying into a partial story fueled by
media sensationalism.


what problem are you referring to regarding mammograms? and "other
procedures"?


if you're looking for a crusade, though, you're on the right track with drug
companies. they involve themselves in many questionable practices. the
problem IMO is not so much with incompetent, unquestioning doctors who
swallow drug company propaganda- it's with ones (still fairly few, but not
insignificant) who have financial conflicts of interest. for information
about that, you should look into Jerome Kassirer's writings and talks (he
was here for a seminar on that very topic not long ago)

check this out:
http://abcnews.go.com/sections/wnt/DailyNews/NEJM_policychange020612.html


maybe that's even worse than incompetence, but there you have it.


the other drug company issue is their advertising convincing patients they
require some drug which they pressure doctors into prescribing against their
better judgement.
Caliban
2003-07-30 02:30:05 UTC
Permalink
snip
Post by Mark Stahl
Post by Caliban
I am convinced that, were many initial studies properly scrutinized
(especially absent drug company influence), their results would have been
seen as flawed, and they never would have been embraced.
like which initial studies, specifically?
Serazone, an anti-depressant, is a good example.

Mammogram studies is another.
Post by Mark Stahl
the fact is that many initial
studies found encouraging results, while acknowledging that they were
incomplete.
This statement is too vague to warrant a response.
Post by Mark Stahl
a physician has a responsibility to her patient to treat to the
best of her knowledge.
Yup.
Post by Mark Stahl
in terms of HRT, the finding of encouraging initial results makes perfect
sense, for many reasons. 1) HRT *does* relieve the proximal symptoms of
menopause (ie, hot flashes) 2) HRT really does improve osteoporosis
resulting in fewer bone fractures (something easy to observe) 3) HRT lowers
colon cancer risk 4) our current understanding of endocrinology strongly
suggested that HRT would improve cardiovascular health (not make it worse,
as was generally found) and possibly stave off alzheimer's (jury's still
out) and 5) the small effects on cardiovascular health were long term and
difficult to observe.
Are you an MD?

I think the jury is out again on 1. and 2.

I don't recall reading about 3., so no comment for now.

4. is too vague for comment.

You have disregarded above studies suggesting a correlation to breast
cancer, although you make some mention of this below.
Post by Mark Stahl
so sure, anecdotal information and short term, incomplete studies are a
problem- but in this case they agreed with standard models of health and
disease
I am unconvinced that any standard was met except group think.
Post by Mark Stahl
well enough that people were willing to embrace them for the good of
I agree to disagree that most MDs are knowledgeable enough to review the
nitty gritty of studies rather than accept the group think promoted at
seminars and in poorly critiqued journals.
Post by Mark Stahl
their patients who usually don't have a decade to find out the truth
everyone thought they knew. but that's why we do the studies anyway.
BTW, even with the HRT "scare",
I do not consider this a "scare." That you would label it thus is scary,
though.
Post by Mark Stahl
the problem is probably not what you seem to
think it is. the results may only be applicable to combination therapy. the
adverse effects, though statistically significant, were small indeed (though
important because cardiovascular disease is the major source of morbidity
and mortality in older women). the only thing that "should" have been seen
coming was the adverse effects on breast malignancy, which responsible
doctors discussed with their patients before the studies came out. so it's
hardly as if there was something obvious we or the drug companies were
hiding or something. i think you're convinced of something which just isn't
the case.
You're too blindly loyal above for me to give you credibility on this.

Last night I spoke with a relative who, while in her late 40s, saw an Ob/Gyn
for menopausal symptoms a few years ago. The Ob/Gyn's response: "Come back
when you're 50." My relative went to an RN/nurse practicioner, etc. who
helped enormously with calcium, anti-depressants, and discussion of HRT (I
think she was estrogen for awhile).

I have too much personal anecdotal evidence for me to trust at face value
what any MD says.
Post by Mark Stahl
Post by Caliban
The problem is many (the majority?) of MDs do not have the education to
acknowledge how incomplete some studies are. They become subject to group
think and not 'individual think.' The latter should be a hallmark of a
good
Post by Caliban
physician. Instead, too many pretend that there is actual data to
support
Post by Mark Stahl
a
Post by Caliban
group-think conclusion, instead of recognizing that they've been swept
up
Post by Mark Stahl
in
Post by Caliban
a herd mentality.
i have a hard time imagining what leads you to this conclusion. do you teach
medical school? been to medical school? anything to do with medical
education at all?
Have you had several courses in statistics? Performed statistical studies?
Been published at the journal level? How much time do you have to really
research all diseases and cures?

These credentials are what count here.

The mere fact that you would ask the questions above shows me that you're
about arrogance above and not substance. I hope you just slipped up, taking
my comments personally, and will take them objectively subsequently. It
really reveals a rather poor education, IMO. Or you're just young.

I know these comments are harsh. Killfile me if you want, or get a bit of
education. <shrug>
Post by Mark Stahl
i will tell you that there is some truth to the idea that some physicians
are not as well versed in statistics as they could be. a standard medical
school curriculum does address critical reading to some extent though i
would say not enough. if you really want 'individual-think', see an MD/PhD
who has their PhD in a basic science discipline.
nevertheless, there is nothing wrong with the idea of "standards of care"
and the like that you criticize as "group-think".
This is not the definition of "group think." It's a psychological term
meaning it's easier to go along with the majority, even when the majority
may be wrong, than go searching for the truth.
Post by Mark Stahl
in fact, if doctors are
outside their fields of experience it's probably best that there exist some
consensus on certain matters so the wheel need not be reinvented on the fly.
I don't think this is what we're really trying to discuss here. I agree
certain drugs and procedures have long been proven to be the best course. Of
course I don't expect any MD to question these, as long as no better
alternatives are evident.
Post by Mark Stahl
Post by Caliban
I do agree I was being a bit harsh in my previous post (and people have
heard me complain about this here before).
Yet I also think that too many people still look at doctors as gods, who
know all. David's statement reminded me of this. I think it's dangerous.
sounds more like a problem with the "people" than the doctors, doesn't it?
Not based on your comments above. :-)
Post by Mark Stahl
Post by Caliban
David alleges patients do not know the risks.
often they don't.
Post by Caliban
Doctors often don't know the
risks but will claim to!
that has emphatically not been my experience or training, although there is
a certain something to be said for reassuring the patient.
I can only guess at what this means.
Post by Mark Stahl
Post by Caliban
Now that so many ordinary people are competent at
using the Internet (and so many more could be instructed to do basic
research on the 'net), I think the public is much better equipped to
diagnose their own ailments and see at least, for example, whether it
would
Post by Caliban
be worthwhile to find a second opinion.
sure. many if not most physicians encourage this, especially the younger
ones. but of course the internet is a source for a hell of a lot of bad
information, too. i could tell horror stories from my and my colleagues'
clinical experiences about patients who try this technique.
I think many MDs would benefit from more time on the Internet. E.g. you re
the latest HRT studies.
Post by Mark Stahl
additionally,
there are a great many patients who *don't* have this access at all.
Yup. So high school education should include instruction on researching and
teaching one's self.
Post by Mark Stahl
your point is somewhat valid for long term, progressive, lifetime diseases
that patients have time to become educated about. many cancer and AIDS
patients, for example, come to their docs with thoughts about their
treatment regimens, and i think that's a great thing. but it's a vast, vast
minority of patients who have even a remote idea of how the human body
works, much less how to fix it.
Until I have a reasonable explanation of why *two* doctors could not cure my
minor but for some months terrifying asthma problem and in fact prescribed
me a dangerous drug that was inappropriate, then I cannot agree that MDs
automatically know more about every function of my body than I do.

These two knew nothing about my body.
Post by Mark Stahl
would you suggest we do away with auto mechanics because the schematics of
your automobile are online?
I said nothing about doing away with MDs. They do more good than bad. But
something has gone amiss... Or it's always been amiss, and the information
age has just made us all aware of it.
Post by Mark Stahl
i'm guessing most would rather have someone else
fix it regardless. medicine is somewhat similar.
Post by Caliban
I try to envision symptoms that could not be put into a computer program
such that all possible diseases would be spewed out and can't.
LOL... then the problem is most definitely with your ability to envision.
seriously, do you have any idea what the differential diagnosis for "pain in
my side" is?
Do you seriously think that's all that one would put into a computer program
designed to diagnose?

Also, I would suggest MDs use computers (they already do) as an aid to
diagnosis, and not the last word.

But the patient, too, should have access to computer programs that assist
with diagnosis.
Post by Mark Stahl
do you think a computer program would be very good at coming up
with the right questions to ask (without going through 100s of dead ends)?
I do. Computers have better memories.
Post by Mark Stahl
would it come up with the thought that a patient's physical symptoms are
manifestations of mental problems like depression? how good is a computer at
performing physical exams? how about synthesizing a patient's medical
history, life situation, and personality to come up with treatments that are
likely to be both effective and adhered to properly?
This sort of reveals, again, how lacking in education you are. It sounds
like you're claiming that hell you went through in medical school made you
infallible.

In many instances, a diagnosing computer would be better IMO.

Vision.
Post by Mark Stahl
a minute ago you were criticizing "groupthink" in medicine- now you want to
reduce it to a computer algorithm? what could be more "groupthink" than
that?
Like I said, you're not using the phrase correctly.
Post by Mark Stahl
seriously, i'm not saying there aren't routine and boring medical problems
that computers or something couldn't handle in the near future. personally,
if i never see another obese asthma patient in ambulatory care i'll be
perfectly happy. but then i wouldn't want to forget the patient we
discovered was obese because she thought it would make her less attractive
to her sexually abusive father. does this make any sense?
Yup. I am talking about the computer as an aid, not as the answer.
Post by Mark Stahl
Post by Caliban
Much of
medical education used to be rote memorization,
believe me, there's as much or more rote memorization than ever....
Post by Caliban
combined with the honing of
interns' deductive reasoning skills, to facilitate diagnosis, after all.
i think you're leaving out an awful lot there.
Post by Caliban
Now
it would seem that the only instances where such rote memorization is
critical is for E.R. doctors and surgeons.
no offense, but i think what it seems like to you and what it actually is
are pretty different. it's pretty damn important to have a solid grounding
in basic bioscience, pharmacology, microbiology, anatomy, physiology, and
more just to be conversant in what the *possibilities* for diagnosis and
treatment are. most patients simply don't have the time or inclination to
know these things... they understandably just want to feel better.
Sure. For the patients that don't want to think, go to an MD and get
prescribed the wrong drug...
Post by Mark Stahl
Post by Caliban
I am drawing from a lot of reading of news reports on this subject,
buttressed by personal experience.
ok... i'm drawing a lot from going to medical school, working on my PhD,
having several older relatives who are physicians, dating doctors, and
reading the actual literature.
the media tends to overblow their flavor of the month... like the HRT thing
for instance.
Oh Lord.
Post by Mark Stahl
Post by Caliban
E.g. several years ago I was having fits
of wheezing where I could not breathe for several moments. Only after
seeing
Post by Caliban
a third doctor did the problem get correctly diagnosed. (Doctor #2 tried
to
Post by Caliban
put me on prednisone, until a pharmacist buddy of mine said, 'Throw out
this
Post by Caliban
stuff. Go see Dr. So-and-So, a specialist in asthma.') Dr. So and So (#3)
nailed the problem and had me feeling better in days. I was fully cured
in
Post by Mark Stahl
a
Post by Caliban
few months using *routine*, mild asthma medications. I have other
stories
Post by Mark Stahl
to
Post by Caliban
tell, but you get my message.
well, honestly i don't. there wasn't much of a story there. what did the 1st
doctor say your problem was?
Strained throat, virus, or something.
Post by Mark Stahl
the 2nd?
Tracheitis.
Post by Mark Stahl
also, the "*routine* mild asthma
medications" are often corticosteroids as well. what did you end up taking?
Not prednisone. Can't remember. Something mild with an inhaler and some OTC
acid reflux tablets.
Post by Mark Stahl
Post by Caliban
Have you always found your doctors to be knowledgeable and competent when
you had a specific ailment?
no one is perfect i suppose, but i have never had a problem. much of that i
am sure is that i generally have a pretty good idea of what i have, so i go
to the right doctor to begin with,
Well, that seems to support my point: If someone else who doesn't have a
good idea does not go to the right specialist, and sees an MD who pretends
to know it all....
Post by Mark Stahl
but i'm not the best test case.
is your complaint that sometimes doctors think they know what they're doing
when they don't?
Yes.

Not all. Some. Maybe most.
Post by Mark Stahl
i'll agree that humility isn't often big on the list of
traits, but it's been my experience that, yes, doctors generally are both
knowledgeable and competent or they make referrals to someone who is.
Every year I become more underwhelmed with the medical profession.
Post by Mark Stahl
Post by Caliban
Post by Mark Stahl
Post by Caliban
Doctors push what is popularly (and I do
mean "mass popular") recommended, without giving consideration to the
bias
Post by Mark Stahl
Post by Caliban
of drug companies and others.
nothing like making a sweeping generalization.... i can assure you
this
Post by Mark Stahl
is
Post by Caliban
Post by Mark Stahl
untrue of the doctors i train with. in fact, we just held a seminar on
that
Post by Mark Stahl
very topic.
You'll have to explain why so many (like all of them) bought into hormone
replacement therapy and mammograms, among other procedures, then.
HRT was and is a good choice for some people, and the literature supported
that position. now we have more data, and the recommendations have changed.
even now it's a good choice for some patients, which is part of the problem
i am seeing with your argument- you're buying into a partial story fueled by
media sensationalism.
I do not reject HRT outright. All I'm saying is that there's plenty *now* to
indicate the original studies were not well-supported and that much more
caution should be used with it.
Post by Mark Stahl
what problem are you referring to regarding mammograms? and "other
procedures"?
Are you serious??

Mammograms are now found to do either no good or more harm, via invasive
procedures that do not increase life expectancy, than good.
Post by Mark Stahl
if you're looking for a crusade, though, you're on the right track with drug
companies. they involve themselves in many questionable practices.
Good for you! You've redeemed yourself partly in my eyes. :-)

Now I'm not saying the whole drug industry is evil. And I certainly agree
that in terminal cases, patients should have the option of being guineau
pigs with drugs with abysmal or even life-shortening side effects.
Post by Mark Stahl
the
problem IMO is not so much with incompetent, unquestioning doctors who
swallow drug company propaganda- it's with ones (still fairly few, but not
insignificant) who have financial conflicts of interest. for information
about that, you should look into Jerome Kassirer's writings and talks (he
was here for a seminar on that very topic not long ago)
I think there's a lot of problems with doctors who don't understand
statistics and don't read the literature carefully. Peer reviewers may be
the most guilty, as they are the first line of defense to prevent a
preliminary study from being seized upon by desperate people.
Post by Mark Stahl
http://abcnews.go.com/sections/wnt/DailyNews/NEJM_policychange020612.html
maybe that's even worse than incompetence, but there you have it.
the other drug company issue is their advertising convincing patients they
require some drug which they pressure doctors into prescribing against their
better judgement.
Yes.
Mark Stahl
2003-07-30 08:12:24 UTC
Permalink
Post by Caliban
snip
Post by Mark Stahl
Post by Caliban
I am convinced that, were many initial studies properly scrutinized
(especially absent drug company influence), their results would have
been
Post by Mark Stahl
Post by Caliban
seen as flawed, and they never would have been embraced.
like which initial studies, specifically?
Serazone, an anti-depressant, is a good example.
a good example of what?
Post by Caliban
Mammogram studies is another.
again, no specific studies or findings cited. why am i getting the distinct
feeling you're just talking out of your ass here?
Post by Caliban
Post by Mark Stahl
the fact is that many initial
studies found encouraging results, while acknowledging that they were
incomplete.
This statement is too vague to warrant a response.
LOL... that's rich, after the "studies" you cited above. moreover, my
statement isn't vague. it's a valid summary of the state of the literature.
if you dispute that, say how and why.
Post by Caliban
Post by Mark Stahl
a physician has a responsibility to her patient to treat to the
best of her knowledge.
Yup.
Post by Mark Stahl
in terms of HRT, the finding of encouraging initial results makes perfect
sense, for many reasons. 1) HRT *does* relieve the proximal symptoms of
menopause (ie, hot flashes) 2) HRT really does improve osteoporosis
resulting in fewer bone fractures (something easy to observe) 3) HRT
lowers
Post by Mark Stahl
colon cancer risk 4) our current understanding of endocrinology strongly
suggested that HRT would improve cardiovascular health (not make it worse,
as was generally found) and possibly stave off alzheimer's (jury's still
out) and 5) the small effects on cardiovascular health were long term and
difficult to observe.
Are you an MD?
BA, MS, MD, PhD
Post by Caliban
I think the jury is out again on 1. and 2.
nope. and nope.
Post by Caliban
I don't recall reading about 3., so no comment for now.
well i have read about it...
Post by Caliban
4. is too vague for comment.
no it's not vague. if you don't understand what i mean, ask for
clarification. it simply says that the initial findings were in line with
expectations, making them easy to accept. extraordinary claims and all that.
Post by Caliban
You have disregarded above studies suggesting a correlation to breast
cancer, although you make some mention of this below.
so in other words, i don't disregard them at all..... they're extremely
significant, but already well known.
Post by Caliban
Post by Mark Stahl
so sure, anecdotal information and short term, incomplete studies are a
problem- but in this case they agreed with standard models of health and
disease
I am unconvinced that any standard was met except group think.
what does that even mean? nothing as far as i can tell, unless by "group
think" you mean the collective experience and expectations based on
physiological knowledge and (limited) clinical data. is that what you mean?
Post by Caliban
Post by Mark Stahl
well enough that people were willing to embrace them for the good of
I agree to disagree that most MDs are knowledgeable enough to review the
nitty gritty of studies rather than accept the group think promoted at
seminars
so it's not valid for MDs to listen to more experienced doctors?
Post by Caliban
and in poorly critiqued journals.
such as? be specific as to which journals' standards of peer review you find
lacking and why.
Post by Caliban
Post by Mark Stahl
their patients who usually don't have a decade to find out the truth
everyone thought they knew. but that's why we do the studies anyway.
BTW, even with the HRT "scare",
I do not consider this a "scare."
that's because you're blindly accepting what the media or some website tells
you to think instead of reading the actual findings (something remarkably
similar to what you're accusing the medical profession of, ironically).
Post by Caliban
That you would label it thus is scary,
though.
in what sense?
Post by Caliban
Post by Mark Stahl
the problem is probably not what you seem to
think it is. the results may only be applicable to combination therapy.
the
Post by Mark Stahl
adverse effects, though statistically significant, were small indeed
(though
Post by Mark Stahl
important because cardiovascular disease is the major source of morbidity
and mortality in older women). the only thing that "should" have been seen
coming was the adverse effects on breast malignancy, which responsible
doctors discussed with their patients before the studies came out. so it's
hardly as if there was something obvious we or the drug companies were
hiding or something. i think you're convinced of something which just
isn't
Post by Mark Stahl
the case.
You're too blindly loyal above
where, exactly?
Post by Caliban
for me to give you credibility on this.
LOL, whatever.
Post by Caliban
Last night I spoke with a relative who, while in her late 40s, saw an Ob/Gyn
for menopausal symptoms a few years ago. The Ob/Gyn's response: "Come back
when you're 50." My relative went to an RN/nurse practicioner, etc. who
helped enormously with calcium, anti-depressants, and discussion of HRT (I
think she was estrogen for awhile).
sounds like it could be an MD who favored a responsible conservative
approach contrasted with an RN who caved to pressure to "do something". are
you aware of any solid evidence for calcium alleviating menopausal symptoms?
many such early perimenopausal symptoms ebb on their own, and treatment is
often unwarranted. but of course, you'd rather "do something" even if it
isn't in the patient's best long term interest because it helps you grind
your personal axe.
Post by Caliban
I have too much personal anecdotal evidence for me to trust at face value
what any MD says.
and you know what the value of anecdotal evidence is, don't you? isn't
anecdotal evidence what you were just lambasting the medical establishment
for relying on? you're a hypocrite at best here.
Post by Caliban
Post by Mark Stahl
Post by Caliban
The problem is many (the majority?) of MDs do not have the education to
acknowledge how incomplete some studies are. They become subject to
group
Post by Mark Stahl
Post by Caliban
think and not 'individual think.' The latter should be a hallmark of a
good
Post by Caliban
physician. Instead, too many pretend that there is actual data to
support
Post by Mark Stahl
a
Post by Caliban
group-think conclusion, instead of recognizing that they've been swept
up
Post by Mark Stahl
in
Post by Caliban
a herd mentality.
i have a hard time imagining what leads you to this conclusion. do you
teach
Post by Mark Stahl
medical school? been to medical school? anything to do with medical
education at all?
Have you had several courses in statistics?
yes, several.
Post by Caliban
Performed statistical studies?
to some degree. not as such, although i routinely test data for statistical
significance.
Post by Caliban
Been published at the journal level?
yes. feel free to search me on medline.
Post by Caliban
How much time do you have to really
research all diseases and cures?
more than i have to defend allopathic medicine on usenet to somebody with an
irrational dislike of the profession.
Post by Caliban
These credentials are what count here.
great!
Post by Caliban
The mere fact that you would ask the questions above shows me that you're
about arrogance above and not substance.
bullshit. they go directly to your knowledge and experience of what doctors
actually learn and know, as opposed to your (apparently baseless) notion of
same. what are your questions supposed to show me what *you're* about? and
what do the substantive facts i provided about your one red herring, HRT,
provide?
Post by Caliban
I hope you just slipped up, taking
my comments personally, and will take them objectively subsequently.
there's nothing to "take objectively", as you provided nothing but silly
generalizations and a just-so story. if you have something specific to offer
(as i have been asking you for all along), by all means provide it.
Post by Caliban
It
really reveals a rather poor education, IMO.
funny.
Post by Caliban
Or you're just young.
i like to think so.
Post by Caliban
I know these comments are harsh.
more like uninformed...
Post by Caliban
Killfile me if you want, or get a bit of
education. <shrug>
between the two of us, i'm not the one who needs education. but i'm trying
to help you.
Post by Caliban
Post by Mark Stahl
i will tell you that there is some truth to the idea that some physicians
are not as well versed in statistics as they could be. a standard medical
school curriculum does address critical reading to some extent though i
would say not enough. if you really want 'individual-think', see an MD/PhD
who has their PhD in a basic science discipline.
nevertheless, there is nothing wrong with the idea of "standards of care"
and the like that you criticize as "group-think".
This is not the definition of "group think." It's a psychological term
meaning it's easier to go along with the majority, even when the majority
may be wrong, than go searching for the truth.
i know exactly what it is, but you're using the term in an inappropriate
fashion. following expert advice is not groupthink.

what are established standards of care if not going along with the majority?
and please, do tell me exactly why subsequent sudies were ever carried out
and recommendations changed if we're all such mindless groupthinkers?
Post by Caliban
Post by Mark Stahl
in fact, if doctors are
outside their fields of experience it's probably best that there exist
some
Post by Mark Stahl
consensus on certain matters so the wheel need not be reinvented on the
fly.
I don't think this is what we're really trying to discuss here.
the thing is, i haven't the slightest idea *what* you're trying to discuss
here. what is your problem, exactly?
Post by Caliban
I agree
certain drugs and procedures have long been proven to be the best course. Of
course I don't expect any MD to question these, as long as no better
alternatives are evident.
i thought you had a problem with going along with the majority... which is
it? are we who believe HIV causes AIDS guilty of groupthink, and Duesberg
the hero for telling African leaders that AZT is really the cause? or is he
just an old man off his rocker? you can't have your cake and eat it too.
Post by Caliban
Post by Mark Stahl
Post by Caliban
I do agree I was being a bit harsh in my previous post (and people have
heard me complain about this here before).
Yet I also think that too many people still look at doctors as gods, who
know all. David's statement reminded me of this. I think it's dangerous.
sounds more like a problem with the "people" than the doctors, doesn't it?
Not based on your comments above. :-)
in what way? i also think that it's dangerous for people to think doctors
are gods, although some trust never hurts.
Post by Caliban
Post by Mark Stahl
Post by Caliban
David alleges patients do not know the risks.
often they don't.
Post by Caliban
Doctors often don't know the
risks but will claim to!
that has emphatically not been my experience or training, although there
is
Post by Mark Stahl
a certain something to be said for reassuring the patient.
I can only guess at what this means.
it has been my experience that some physicians, in an effort to reassure
their patients, sometimes appear to be more confident in their demeanors
than they actually are. this is not really something i'm a big fan of. but
these are often the same people who are then found late in the library,
digging out every last paper they can find to give that confidence a firmer
foundation.
Post by Caliban
Post by Mark Stahl
Post by Caliban
Now that so many ordinary people are competent at
using the Internet (and so many more could be instructed to do basic
research on the 'net), I think the public is much better equipped to
diagnose their own ailments and see at least, for example, whether it
would
Post by Caliban
be worthwhile to find a second opinion.
sure. many if not most physicians encourage this, especially the younger
ones. but of course the internet is a source for a hell of a lot of bad
information, too. i could tell horror stories from my and my colleagues'
clinical experiences about patients who try this technique.
I think many MDs would benefit from more time on the Internet.
if only to hear the latest misinformation....
Post by Caliban
E.g. you re
the latest HRT studies.
i can only guess what you mean by this.
Post by Caliban
Post by Mark Stahl
additionally,
there are a great many patients who *don't* have this access at all.
Yup. So high school education should include instruction on researching and
teaching one's self.
yeah, that'll be a big help for all the patients in the south bronx.
Post by Caliban
Post by Mark Stahl
your point is somewhat valid for long term, progressive, lifetime diseases
that patients have time to become educated about. many cancer and AIDS
patients, for example, come to their docs with thoughts about their
treatment regimens, and i think that's a great thing. but it's a vast,
vast
Post by Mark Stahl
minority of patients who have even a remote idea of how the human body
works, much less how to fix it.
Until I have a reasonable explanation of why *two* doctors could not cure my
minor but for some months terrifying asthma problem
so it was minor and terrifying? hmmm. that doesn't seem possible.
Post by Caliban
and in fact prescribed
me a dangerous drug that was inappropriate,
which one was that?
Post by Caliban
then I cannot agree that MDs
automatically know more about every function of my body than I do.
These two knew nothing about my body.
even if yours was a difficult or somehow unusual diagnosis or even if it was
just missed due to gross error on their parts, i would still be willing to
bet they knew more than nothing about the human body.
Post by Caliban
Post by Mark Stahl
would you suggest we do away with auto mechanics because the schematics of
your automobile are online?
I said nothing about doing away with MDs. They do more good than bad. But
something has gone amiss... Or it's always been amiss, and the information
age has just made us all aware of it.
can you identify that "something"? we're always looking to improve, but so
far i've only heard the vaguest generalizations that when examined don't
seem to be based in fact.
Post by Caliban
Post by Mark Stahl
i'm guessing most would rather have someone else
fix it regardless. medicine is somewhat similar.
Post by Caliban
I try to envision symptoms that could not be put into a computer program
such that all possible diseases would be spewed out and can't.
LOL... then the problem is most definitely with your ability to envision.
seriously, do you have any idea what the differential diagnosis for
"pain
Post by Caliban
in
Post by Mark Stahl
my side" is?
Do you seriously think that's all that one would put into a computer program
designed to diagnose?
i seriously know that's all you get from lots of patients.... if you're
lucky.
Post by Caliban
Also, I would suggest MDs use computers (they already do) as an aid to
diagnosis, and not the last word.
me too.
Post by Caliban
But the patient, too, should have access to computer programs that assist
with diagnosis.
ok, great. sounds like a good idea (really. informed patients are
universally better ones). but tell me what happens when patients come to the
wrong conclusions. tell me what happens when the software is provided by
pfizer. tell me what happens when the computer programs need test results,
physical exams, or anything else.
Post by Caliban
Post by Mark Stahl
do you think a computer program would be very good at coming up
with the right questions to ask (without going through 100s of dead ends)?
I do. Computers have better memories.
memory has little to nothing to do with interview skills. i think you give a
lot more credit to the state of artificial intelligence than is warranted.
Post by Caliban
Post by Mark Stahl
would it come up with the thought that a patient's physical symptoms are
manifestations of mental problems like depression? how good is a
computer
Post by Caliban
at
Post by Mark Stahl
performing physical exams? how about synthesizing a patient's medical
history, life situation, and personality to come up with treatments that
are
Post by Mark Stahl
likely to be both effective and adhered to properly?
This sort of reveals, again, how lacking in education you are.
no it doesn't. but your response reveals your unwarranted vitriol toward
anyone suspected of being a part of the medical profession.
Post by Caliban
It sounds
like you're claiming that hell you went through in medical school made you
infallible.
no, it doesn't sound like that at all- not to anyone who actually reads what
i wrote. it's simply a description of things i personally think human
doctors are much better at than computers... nothing more, nothing less. but
you're sounding more kooky all the time. care to see a doc--- er, i mean,
computer for that problem?
Post by Caliban
In many instances, a diagnosing computer would be better IMO.
in very few, IMO. but you might be heartened to know that there are some
such things out there, mostly designed to augment an interview by a medical
person (whether RN, MD, PA, etc.)
Post by Caliban
Vision.
Post by Mark Stahl
a minute ago you were criticizing "groupthink" in medicine- now you want
to
Post by Mark Stahl
reduce it to a computer algorithm? what could be more "groupthink" than
that?
Like I said, you're not using the phrase correctly.
i am using it as you did. what would you expect to find in those subroutines
other than medical consensus that you criticized as "groupthink"? you want
independent thought, searching for the truth behind those phantom poorly
reviewed journal articles from a computer program? be realistic.
Post by Caliban
Post by Mark Stahl
seriously, i'm not saying there aren't routine and boring medical problems
that computers or something couldn't handle in the near future.
personally,
Post by Mark Stahl
if i never see another obese asthma patient in ambulatory care i'll be
perfectly happy. but then i wouldn't want to forget the patient we
discovered was obese because she thought it would make her less attractive
to her sexually abusive father. does this make any sense?
Yup. I am talking about the computer as an aid, not as the answer.
i really don't know what you're talking about at this point.
Post by Caliban
Post by Mark Stahl
Post by Caliban
Much of
medical education used to be rote memorization,
believe me, there's as much or more rote memorization than ever....
Post by Caliban
combined with the honing of
interns' deductive reasoning skills, to facilitate diagnosis, after all.
i think you're leaving out an awful lot there.
Post by Caliban
Now
it would seem that the only instances where such rote memorization is
critical is for E.R. doctors and surgeons.
no offense, but i think what it seems like to you and what it actually is
are pretty different. it's pretty damn important to have a solid grounding
in basic bioscience, pharmacology, microbiology, anatomy, physiology, and
more just to be conversant in what the *possibilities* for diagnosis and
treatment are. most patients simply don't have the time or inclination to
know these things... they understandably just want to feel better.
Sure. For the patients that don't want to think, go to an MD and get
prescribed the wrong drug...
so patients should have to be expert in any and all injuries and ailments
they might incur? that would be nice, but most people aren't. and most
people don't get the wrong drug, either. so i'm really not sure of the point
you're going for here.
Post by Caliban
Post by Mark Stahl
Post by Caliban
I am drawing from a lot of reading of news reports on this subject,
buttressed by personal experience.
ok... i'm drawing a lot from going to medical school, working on my PhD,
having several older relatives who are physicians, dating doctors, and
reading the actual literature.
the media tends to overblow their flavor of the month... like the HRT
thing
Post by Mark Stahl
for instance.
Oh Lord.
meaning what? you clearly are unaware of or misinformed about the details of
the findings.
Post by Caliban
Post by Mark Stahl
Post by Caliban
E.g. several years ago I was having fits
of wheezing where I could not breathe for several moments. Only after
seeing
Post by Caliban
a third doctor did the problem get correctly diagnosed. (Doctor #2 tried
to
Post by Caliban
put me on prednisone, until a pharmacist buddy of mine said, 'Throw out
this
Post by Caliban
stuff. Go see Dr. So-and-So, a specialist in asthma.') Dr. So and So
(#3)
Post by Mark Stahl
Post by Caliban
nailed the problem and had me feeling better in days. I was fully cured
in
Post by Mark Stahl
a
Post by Caliban
few months using *routine*, mild asthma medications. I have other
stories
Post by Mark Stahl
to
Post by Caliban
tell, but you get my message.
well, honestly i don't. there wasn't much of a story there. what did the
1st
Post by Mark Stahl
doctor say your problem was?
Strained throat, virus, or something.
Post by Mark Stahl
the 2nd?
Tracheitis.
Post by Mark Stahl
also, the "*routine* mild asthma
medications" are often corticosteroids as well. what did you end up
taking?
Not prednisone. Can't remember. Something mild with an inhaler
almost certainly a steroid, and yet you're hyperbolic on the usenet about
how somebody almost killed you or something. yet you don't even know what it
was!
Post by Caliban
and some OTC
acid reflux tablets.
to treat tracheitis, perchance? i think you just have a weird chip on your
shoulder. besides, if you really had asthma, you wouldn't likely have been
"cured"; it's a chronic disease.
Post by Caliban
Post by Mark Stahl
Post by Caliban
Have you always found your doctors to be knowledgeable and competent
when
Post by Mark Stahl
Post by Caliban
you had a specific ailment?
no one is perfect i suppose, but i have never had a problem. much of
that
Post by Caliban
i
Post by Mark Stahl
am sure is that i generally have a pretty good idea of what i have, so i
go
Post by Mark Stahl
to the right doctor to begin with,
Well, that seems to support my point: If someone else who doesn't have a
good idea does not go to the right specialist, and sees an MD who pretends
to know it all....
i guess that's bad for them. fortunately that's not the experience of most
people. in fact, it wasn't even *your* experience-- sounds from here like
dr. #2 was right about your condition.
Post by Caliban
Post by Mark Stahl
but i'm not the best test case.
is your complaint that sometimes doctors think they know what they're
doing
Post by Mark Stahl
when they don't?
Yes.
Not all. Some. Maybe most.
ok, so some physicians have a god complex. this is true, and unfortunate.
it's not like you're revealing anything groundbreaking here. what do you
propose would improve the situation?
Post by Caliban
Post by Mark Stahl
i'll agree that humility isn't often big on the list of
traits, but it's been my experience that, yes, doctors generally are both
knowledgeable and competent or they make referrals to someone who is.
Every year I become more underwhelmed with the medical profession.
no kidding, really? me too, actually.
Post by Caliban
Post by Mark Stahl
Post by Caliban
Post by Mark Stahl
Post by Caliban
Doctors push what is popularly (and I do
mean "mass popular") recommended, without giving consideration to
the
Post by Mark Stahl
Post by Caliban
bias
Post by Mark Stahl
Post by Caliban
of drug companies and others.
nothing like making a sweeping generalization.... i can assure you
this
Post by Mark Stahl
is
Post by Caliban
Post by Mark Stahl
untrue of the doctors i train with. in fact, we just held a seminar on
that
Post by Mark Stahl
very topic.
You'll have to explain why so many (like all of them) bought into
hormone
Post by Mark Stahl
Post by Caliban
replacement therapy and mammograms, among other procedures, then.
HRT was and is a good choice for some people, and the literature supported
that position. now we have more data, and the recommendations have
changed.
Post by Mark Stahl
even now it's a good choice for some patients, which is part of the
problem
Post by Mark Stahl
i am seeing with your argument- you're buying into a partial story
fueled
Post by Caliban
by
Post by Mark Stahl
media sensationalism.
I do not reject HRT outright. All I'm saying is that there's plenty *now* to
indicate the original studies were not well-supported
like what, specifically? i do not think that is the case. the original
studies were fine as far as they went, and the recommendations that were
based on them were appropriate for the state of our knowledge at the time. i
cannot understand your problem with this. it's as if you're saying that now
that we know more, we automatically should have known it before we did the
studies. it's just not the way it works.
Post by Caliban
and that much more
caution should be used with it.
as we know now, and as the current recommendations reflect.
Post by Caliban
Post by Mark Stahl
what problem are you referring to regarding mammograms? and "other
procedures"?
Are you serious??
very.
Post by Caliban
Mammograms are now found to do either no good or more harm, via invasive
procedures that do not increase life expectancy, than good.
simply false. found by whom? where do you get this "information"? perhaps
you are providing exactly the example i am looking for in terms of patients
being misinformed by the internet and the like.

FYI, the American Cancer Society guidelines revised in 2003 still call for
routine mammography to begin at age 40. although different studies have
different findings, mortality has been shown to be decreased between 16-32%
(24% by meta-analysis). individual trials and meta-analyses of all trials
combined showed statistically significant mortality reductions for women
aged 40 to 69 associated with screening.

perhaps you refer to the widely trumpeted but also widely criticized report
from the Lancet by Olsen and Goetzsche which questioned study endpoints, but
even they found only a relative risk of 1 (not "more harm than good").

i really think you need to be better informed if you want to criticize
others for not being informed. and what "other procedures"?
Post by Caliban
Post by Mark Stahl
if you're looking for a crusade, though, you're on the right track with
drug
Post by Mark Stahl
companies. they involve themselves in many questionable practices.
Good for you! You've redeemed yourself partly in my eyes. :-)
at this point i am not so sure that's a good thing.
Post by Caliban
Now I'm not saying the whole drug industry is evil.
by no means.
Post by Caliban
And I certainly agree
that in terminal cases, patients should have the option of being guineau
pigs with drugs with abysmal or even life-shortening side effects.
i tend to agree, but it would be best to control these things in studies.
Post by Caliban
Post by Mark Stahl
the
problem IMO is not so much with incompetent, unquestioning doctors who
swallow drug company propaganda- it's with ones (still fairly few, but not
insignificant) who have financial conflicts of interest. for information
about that, you should look into Jerome Kassirer's writings and talks (he
was here for a seminar on that very topic not long ago)
I think there's a lot of problems with doctors who don't understand
statistics and don't read the literature carefully.
as i stated above, it's probably true that doctors (and even biological
scientists generally, myself included) could have a better understanding of
statistics, but i really don't know what "problems" this has really caused,
much less "lots" of unnamed problems. could you maybe name even one or two
such problems?
Post by Caliban
Peer reviewers may be
the most guilty, as they are the first line of defense to prevent a
preliminary study from being seized upon by desperate people.
no, the first line of defense is an honest investigator. not to continue to
demonize drug companies but i am aware of one particular study where
improved efficacy over standard treatment was shown for (i believe) 3
timepoints. all well and good, but apparently the company had results from
timepoints 4, 5, and 6 which showed a return to 'standard' efficacy or
actual reduction... and the rest of the data was never submitted. you could
argue that the reviewers should have demanded the expanded data set, but i
really don't place the blame there. whose peer review have you found
lacking?
http://abcnews.go.com/sections/wnt/DailyNews/NEJM_policychange020612.html
Post by Caliban
Post by Mark Stahl
maybe that's even worse than incompetence, but there you have it.
the other drug company issue is their advertising convincing patients they
require some drug which they pressure doctors into prescribing against
their
Post by Mark Stahl
better judgement.
Yes.
would you suggest restricting it (the advertising)? i know i would. not just
to patients, but to physicians as well.
David Johnston
2003-07-30 16:51:23 UTC
Permalink
Post by Caliban
snip
Post by David Johnston
The patients only know what their symptoms feel like. They do not
generally know what the doctor is capable of doing to relieve said
symptoms or what the risks are for each alternative.
Wow. I respectfully disagree that this is true or has to be true (given the
power of information sharing on the Internet of late),
When by "information" you include wild rumours, publicity blitzes by
people using it as a new form of advertising, and distorted and
incomplete versions of whatever you want to know.

even in general. I am
Post by Caliban
underwhelmed about how ignorant doctors are of the statistical validity of
studies. Cases in point: Hormone replacement therapy, mammograms, prostate
treatment studies for years believed to be the last word are now being
demonstrated to have been flawed.
Which hardly means that the average patient knows more about his
condition and what his doctor could do about it than does the doctor.
Caliban
2003-07-30 17:25:58 UTC
Permalink
snip stuff I agree to disagree on or responded to in Mark Stahl exchange

I am really just trying to impress upon people the value of the Internet as
a resource (even if it's just to supplement what their doctors says) for
their health needs.

Things are a mess in health care. A relative of mine has a spouse who has
been a civil servant professional for over 20 years. The relative has had
minor maladies, nothing serious, but now her husband's pension plan is
refusing to cover her health insurance. Too many claims, they say.

My message is to take more responsibility for your health. Saving for a
rainy day comes in many forms. One cannot count on doctors to give them the
very best medical care. Indeed, a doctor who overprescribes, taking
advantage of a generous corporate health insurer, say, may reduce one's
chances of getting health insurance in the future.

For many people, I think the way to go is to only have catastrophic health
insurance and pay as you go for everything else. I think large corporations
should have the same, actually, and just pay their employees a bit more to
compensate for the reduced price of corporate, catastrophic health insurance
premiums. This way, employees and doctors don't "milk" (not all; many?)
health insurers. They have to think twice before ordering that extra test,
because the patient pays directly for it. (Of course, the threat of lawsuits
is another factor doctors understandably must consider.)
Post by Caliban
even in general. I am
Post by Caliban
underwhelmed about how ignorant doctors are of the statistical validity of
studies. Cases in point: Hormone replacement therapy, mammograms, prostate
treatment studies for years believed to be the last word are now being
demonstrated to have been flawed.
Which hardly means that the average patient knows more about his
condition and what his doctor could do about it than does the doctor.
Sure. I agree doctors do more good than bad. But I think increasingly, since
one lives in one's own body, and a doctor, try as she or he may, cannot live
in another's body, many "ordinary" people can better ascertain their
condition than a doctor, or at least optimize their health care, using
resources like the Internet.
Caliban
2003-07-30 17:35:25 UTC
Permalink
Post by Caliban
Sure. I agree doctors do more good than bad. But I think increasingly, since
one lives in one's own body, and a doctor, try as she or he may, cannot live
in another's body, many "ordinary" people can better ascertain their
condition than a doctor, or at least optimize their health care, using
resources like the Internet.
I should add that since one has a greater self-interest in one's own health
than any doctor, that motivation may more than override the resulting and
(let's say) fine skills of any MD. That is, how much time does an MD have to
research a patient's situation? How well can she or he do it, not living in
one's own body and knowing every nuance of one's health?

The most effective doctors will encourage patients to study their health and
communicate what they have learned as it pertains to their bodies to them,
so that the most information about the situation is available and the best
decisions may be made.
J Alex
2003-07-30 17:53:57 UTC
Permalink
Post by Caliban
Post by Caliban
Sure. I agree doctors do more good than bad. But I think increasingly,
since
Post by Caliban
one lives in one's own body, and a doctor, try as she or he may, cannot
live
Post by Caliban
in another's body, many "ordinary" people can better ascertain their
condition than a doctor, or at least optimize their health care, using
resources like the Internet.
I should add that since one has a greater self-interest in one's own health
than any doctor, that motivation may more than override the resulting and
(let's say) fine skills of any MD. That is, how much time does an MD have to
research a patient's situation? How well can she or he do it, not living in
one's own body and knowing every nuance of one's health?
Not to mention (and I know this for a fact based on family experience) that,
when dealing with specific cases and drugs, reading a topical book or
spending an hour or two researching on the internet can make you more
informed than the doctor on the subject in question.

I'm thinking of some specific areas that doctors frequently don't concern
themselves with:
1) Vitamins/foods: What vitamins/foods can help/hinder certain illnesses,
and what symptoms are possibly related to food allergies. I'm thinking
specifically of a nephew treated for chronic ear infections that turned out
to be caused by a food allergy (the mom finally read up on it and diagnosed
it herself. She cut out the likely foods, and the problems disappeared).
2) What medications are ok or to be avoided for specific situations? What
I've seen is that doctors will give advice based on malpractice risk rather
than what is best for the patient.
David Johnston
2003-07-30 18:53:20 UTC
Permalink
Post by J Alex
2) What medications are ok or to be avoided for specific situations? What
I've seen is that doctors will give advice based on malpractice risk rather
than what is best for the patient.
But in a world where your chance of getting sued was actually
connected to giving bad advice and making bad decisions,
that the two things wouldn't be different.
J Alex
2003-07-30 19:00:02 UTC
Permalink
Post by David Johnston
Post by J Alex
2) What medications are ok or to be avoided for specific situations? What
I've seen is that doctors will give advice based on malpractice risk rather
than what is best for the patient.
But in a world where your chance of getting sued was actually
connected to giving bad advice and making bad decisions,
that the two things wouldn't be different.
That's right. And it is hard to fault the doctors for looking out for their
own interest. That's just human nature. But patients need to be aware what
the situation is, and that just because the doctor or the drug company says
it doesn't make it so.
Hunter Rose
2003-07-31 04:49:22 UTC
Permalink
Post by Caliban
Wow. I respectfully disagree that this is true or has to be true
(given the power of information sharing on the Internet of late),
even in general. I am underwhelmed about how ignorant doctors are of
the statistical validity of studies. Cases in point: Hormone
replacement therapy, mammograms, prostate treatment studies for
years believed to be the last word are now being demonstrated to
have been flawed. Doctors push what is popularly (and I do mean
"mass popular") recommended, without giving consideration to the
bias of drug companies and others.
In other words, they work with the most recent reliable
information available to them. This is not a bad thing.

HR

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