Thursday, December 4, 2014

Engagement, Overconfidence and Healthcare Decision Making

At the risk of repeating my stories, something that my children always accuse me of doing, in December 2013 I wrote a blog post which mentioned by own history, some thirty-seven years ago, of going to the Emergency Room when I was an intern in Chicago, with my self-diagnosed appendicitis which really turned out to be a kidney stone attack.  I was confident in my analysis, was able to back it up with my history, was able to convince the medical staff, and was totally wrong.  I was also an engaged patient, working with a medical and nursing personnel who knew me and treated me as a full partner in my care, and was still wrong. 

My personal story came to mind as I read two apparently unrelated articles.  The first is from ImproveDX, the newsletter of the Society to Improve Diagnosis in Medicine.  It is entitled, “Overconfidence, Humility,and Diagnostic Error” and it reports on a paper presented by John D. Banja PhD at the 7th annual Diagnostic Error in Medicine conference.  As reported in the newsletter, Dr. Banja’s view is that “the current medical culture promotes narcissistic behaviors: being self-oriented, self-enhancing, and defensive.”  The newsletter goes on to say that physicians have this narcissistic view because their sense of self-esteem is tied into their confidence and is, in our current environment, under “constant threat.”  Dr. Banja clarifies that he is not accusing physicians of being narcissists but rather of showing that type of behavior in response to our system and our culture.  The point is well taken.  Physicians especially, but all health professionals, tend to treat their own anxiety about diagnosis with a healthy dose of hubris even when uncertain.  They can have an overly confident view of their own judgment, and may have trouble admitting when their initial diagnosis is wrong.  This leads to diagnostic errors which the article points out can be clinically devastating. 

While the fact that doctors need a healthy dose of humility is hardly news, the other article forces one to keep a sense of perspective about that reality.  Writing in JAMA, in an article entitled, “Engaging to No Avail”, Irene Wielawski, a medical journalist writes about her own bout of appendicitis.  In her case, as an empowered patient, she delayed calling her doctor despite her severe pain, and when she finally called, it was only because she wanted to sleep and the pain would not let her sleep.  When she spoke to the medical professionals, they listened to her but did not obey her request for sleeping medication.  In the light of day, she realized that their ability to ignore her request saved her.  “But determined as I was to run this show, my insights and utterances really were quite worthless – except as evidence of the addling effect of bacteria overload.”  She goes on to say,

“But it was competence in my case, not arrogance that led everyone to ignore my wishes.  First up was the nurse practitioner on call at the medical group.  She listened to what I had to say, but her trained ear picked up far more important information, namely the thready voice, pauses, and repetitive phrasings of someone seriously ill. ” 

As the second article demonstrates, narcissistic behavior and maintaining a sense of self-esteem is not limited to doctors but also applies to patients!  The principles of shared decision-making and patient engagement should be endorsed wholeheartedly however respect for expertise that only comes with training, skills, and experience honed by caring for patients should be given equal weight.  To care for patients, one must listen to them and take their concerns into account.  However that can never take the place of a professional’s knowledge of health and illness. 

Doctors are human, and their judgment can include an unhealthy dose of self-importance however if I am in a crisis situation, give me a good, arrogant doctor any day over one who is humble and incompetent.  When I choose a doctor, I try my best to have someone who has both skill sets however if I am the victim of major trauma, or am in the midst of a major heart attack, I care much less about the personality defects of a skilled trauma surgeon or an interventional cardiologist. 

The fact is that all health professionals must learn to listen empathetically and to think and assess what they are hearing critically.  They must be attuned to hearing and assessing what is said and also attuned to how it is said.  The doctor or nurse who, in the mode of true “shared decision making” only follows the patient without the critical assessment skills needed to decide what needs to be done medically will make errors just as frequently as the doctor who arrogantly decides on a course and whose inability to admit an error, follows that course into disaster. 

Health professionals have to find the right balance between being attentive to patient’s desires, while also leading the patient where they need to be taken to achieve cure.   That is part of what makes medicine, nursing and other health professions more than jobs.  That professionalism must be encouraged and any catchphrase, such as “engagement” or “evidence based medicine” must never take the place of the education, skill and experience that good health professionals bring to their patients every day.