You Will See the Doctor’s Fallibility Now | Hacker News Reader

You Will See the Doctor’s Fallibility Now

well.blogs.nytimes.com

30 pointsdanso40 comments

I'm also a little disturbed by the x-ray technician. Are patients really so full of shit that often that it's normal to ignore what the patient says is obviously the wrong foot? I had a similar experience when my work required I have a very thorough medical examination including a Tuberculosis test. I was pumped full of massive amounts of the vaccine as a kid because I grew up in a third-world country, so the skin test would give a false positive. I told the doctor, they asked if I had ever had a positive result, and I said no because they always go straight to the chest x-ray. So they insisted I do a skin test first. My elbow swelled up like crazy, the nurse and the doctor freaked out and sent me to an infectious disease specialist. The freaking specialist still didn't want to see my vaccine records - she said I should have a chest x-ray and start strong antibiotics immediately. Chest x-ray came back clean. "Mysteriously", as the doctor said, I did not in fact have tuberculosis. It was like they were all deaf while I was explaining how many times I had been vaccinated, so OF COURSE it shouldn't have been a surprise that my blood was still loaded with anti-bodies.

I think you see similar situations in tech with users/support. If you routinely deal with users who have no idea what they're doing you start to discount what they're saying.

Granted someone who's good at troubleshooting should be able to judge the relative understanding of the user just like a good doctor should be able to judge the reliability of information coming from the patient.

> just like a good doctor should be able to judge the reliability of information coming from the patient.

Exactly! A good doctor must be able to read people well; their communication style, presuppositions, personality, and this will help the doctor determine if someone is exaggerating their symptoms, understating their pain, etc. etc.

Unfortunately, medical schools simply do not select for someone with this skillset, and this is not a new problem: "For decades, the medical profession has debated whether pre-med courses and admission tests produce doctors who know their alkyl halides but lack the sense of mission and interpersonal skills to become well-rounded, caring, inquisitive healers." Read more here: http://www.nytimes.com/2010/07/30/nyregion/30medschools.html

> that it's normal to ignore what the patient says is obviously the wrong foot

Some are, some aren't. I've had that experience with an x-ray technician and insisted they photograph the part I felt had the problem and they listened to me with barely an argument just "it's not listed in the orders" "do it anyway" "ok".

Maybe they are more OK with adding a test vs. changing a test?

I think this is pretty common. I had RSI that, after a bit of reading, was clearly not Carpal Tunnel Syndrome, but it didn't matter; as soon as the doctor I saw heard "wrists" she started talking about getting a carpal tunnel release even though the various field tests she did to "prove" to me I actually did have CTS didn't achieve the expected result.

I mean, I guess I get it because when I did tech support people would constantly tell me obviously wrong stuff and eventually I tuned them out. But what a frustrating experience.

Blame the leadership not the x-ray tech. Most likely leadership told the tech to do whatever the doctor says and did not advise on what action to take if the patient disputes the orders. Unlike software rarely are these policies and procedures QA tested.

Our radiographers always use common sense. If we order the wrong side, they will image the right side or chase up with us. If we order the wrong type of ct they will call us to discuss what we are looking at/reason for test and advise us in the correct test. Very important to put the full reason a doctor ants the test to assist in this process

That is so frustrating. And it's not just you talking out of your ass, you had your vaccine records there for them to see and they refused.

It's enough to make one wonder how accurate the show House MD really is. How many doctors believe their patients aren't only idiots, but lying idiots?

I'm sure more than none.

But there are also a lot of jobsworths who will do exactly what they're told, nothing more, and nothing less, irrespective of how much or how little sense it makes.

These people exist in all jobs, all fields. Some people simply do not have the capacity for lateral thought, and like being told what to do and doing exactly that.

It kind-of makes sense when you think about it. American's get pumped all day with media from pharmaceuticals telling them, "See your doctor if you experience any of these symptoms" and, well, lets face it; we're an anxious bunch these days so we run to the doc saying, "I have Bubonic plague because the TV and Dr. Oz said so!". After awhile the medical professionals probably just get tired of the bullshit and stick to their training. Its also probably quite a bit of them covering their asses.

That said, listening has become a lost art across many disciplines, sadly.

Ha, "laterally challenged" was a new and fantastic label, I'll try to apply that to myself whenever I get left and right wrong.

It's an interesting problem though, I have excellent sense of direction and I'm good at 3D visualization and map reading. I don't get the directions wrong, I get the words for the directions wrong.

I can happily point the left, know we should go to the left, and say "let's go right!"

So it's probably a very different problem from, say, people who lack sense of direction, my problem is more like extremely narrow aphasia. I don't know of anyone who confuses up and down in the same manner though, it's interesting that it's just left and right, and that it's not that uncommon!

Regarding up/down vs left/right. Perspective is an issue with left/right, but generally not for up/down. Everyone in the vast majority of circumstances share the same up/down perspective. When it comes to left/right, you often have to do some mental acrobatics to figure out what the frame of reference is, in order to figure out which way is left or right from that frame of reference. It's easy to just point and say "that way", but to know whether to say "left" or "right" you have to think, "ok, this is my left, but which way is he facing, is that his right? ok, but if I say right, will he think I'm saying his right or mine?"

That's why sailors invented port and starboard. Maybe we should apply this to doctors. "Ok, we're operating on the starboard knee today!"

To be fair, I assume they use left/right from the perspective of the patient, but I could see using a separate pair of terms being useful, the same way it's useful to say port/starboard instead of saying left/right and an understanding that the perspective is focused toward the bow (front) of the ship.

> To be fair, I assume they use left/right from the perspective of the patient.

That's correct. The trouble is in anatomy and hence in radiography, the standard position is having the patient facing you. Left and right are thus systematically inverted in medical images

> I don't know of anyone who confuses up and down in the same manner though

Maybe interview some astronauts.

I'm in the same boat. Unless I move the corresponding hand, I mix up left and right when I speak.

Also, unrelated: What's worse than autocorrect? Autocorrect in thé wrong language.

I had similar problem as a kid, just couldn't remember the words for left and right until someone finally told me "L for left hand".

Statistical reasoning is far more important for deciding tests and treatment than the ability to reliably distinguish between left and right. You can use a marker on the skin before surgery, but statistical reasoning may determine that surgery is not even the best option.

Unfortunately, if doctors were filtered based on their ability to do basic statistics, we would lose 90% of them.

Doctors are probably better, or at least no worse, than the general population on that account.

The problem is that "statistical reasoning" is so alien to normal de facto human reasoning that you need years of training before it sets in. Doctors are already taking on a completely different set of extensive training, and their elders did fine with only the most basic statistics knowledge, so clearly (sigh) there's no need to dig into the fancy pants version of the thing.

Epidemiologists probably know better, but how do you have them explain to the GPs that this is a useful tool to have???

This is a common problem in medicine. As some one who regularly prescribes xray to patients (in Orthopedic Surgery) we have very strict instructions to the radiology technicians to perform the imaging of the side that is mentioned in the orders. Due to a variety of reasons. But we sometimes do make mistakes.

But like the author describes doing the same mistake is the OR and performing a surgery is a disaster of several magnitudes. One of the common problem is that many times senior consultants have limited contact with the patients and their sole focus is doing surgeries. Usually residents and the younger docs are involved in the preoperative care of the patient.

On the topic of "Doctor Fallibility" there's a really good book that I recommend to pretty much everybody: How Doctors Think by Jerome Groopman. There's a lot of info in there on how and why doctors make mistakes and, more to the point, information on how you - as a patient - can avoid being the victim of a mistake (more specifically, a mis-diagnosis) by your doctor.

The ideas in there wouldn't necessarily help with this X-ray scenario, but I think it's wildly useful information for anybody who ever sees a doctor.

If you want something done right, you gotta take responsibility yourself. It's like that everywhere, be it as simple as archiving a single sheet of paper correctly. But especially when it's about your own body. Doctors have a tendency to advise the patient not to do research on their own and keeping the patient "dumb" (or calm, if you want to be more polite and less honest). This is very bad and worsens the problem.

Sure, but I mean, really. You don't have the doctor's training; you need his help. This should really be a collaborative process, although too often it is not.

I went with my Dad for neck surgery like 5 different people asked my dad if he was there for neck surgery. Now I understand the purpose.

Heard of clinics where they won't do a planned operation unless the patient (if in a state to do so), the surgeon and the anesthetist have all signed the body part during the preparation. Makes sure all parties involved are on one page and they actually have the right person on the table.

This person should not be a doctor. Not with this "profound left-right confusion". People with severe diabetes are not allowed to drive commercially. People with sea sickness don't usually captain boats.

---

Edit: Apparently I'm at my limit on my work laptop, but can read it on my phone.

Unlike other NYTimes articles, this link takes me directly to a paywall. I don't even get to see a blurb, abstract, teaser, or dateline. Going directly from Google also puts me at a paywall.

Is it because you've hit your free article limit for the month? What happens when you go incognito?

(I'm a subscriber so I'm logged in...however, going in incognito or with another browser works fine for me)

It appears the corporate-locked-down Chrome I'm using on the corporate laptop doesn't have Incognito as an option. I'll try my phone.

The husband of a co-worker could not get a commission in the Navy because he had red-green color blindness. I guess the Army didn't mind, but ships have red and green lights to indicate port and starboard.

> This person should not be a doctor.

Maybe. But since he has such strong self awareness of the problem his is able to self-implement protocols to correct and protect from the problem.

Just like people with controlled diabetes can drive.

A simple dot tattooed somewhere inconspicuous on the hand (make it look like a liver spot) would be enough to solve the problem.

> A simple dot tattooed somewhere inconspicuous on the hand (make it look like a liver spot) would be enough to solve the problem.

I have the same issue as the doctor and this wouldn't help me. I know which hand I write with. (My right). I always know which hand is my right but I still can't tell right or left for directions. It gets flipped during processing like dyslexia.

I'm a firm believer of marking the affected area before any procedure. It's cheap it's simple. HOWEVER only the patient is allowed to apply the mark.

I had knee surgery recently. Before I was given any medications, I met with my surgeon, we verified what he was going to do, and he marked and signed the area to be operated on with a sharpie marker.

It took less than a minute and gave me an awful lot of peace of mind that I wouldn't be a victim of a bad memory or procedural screw-up.

This article reminds me of the scariest joke:

What do you call the guy who graduated last in his class from medical school?

Doctor.

I've always felt that was ho-hum, as zingers go, since the standards can be so high that the lowest rank is still pretty good in absolute terms. It's like saying, "You know what I call a bronze medal? Last place." Er ... a bronze medal is still very impressive.

If you want a clever anti-doctor zinger, I'd use something like, "You know what it's called when a really well-read expert diagnoses you wrongly on a hunch, gets it wrong, leaves you suffering for years, and never has their work reviewed? Medicine."

A bronze medal is third place, not last place. Twenty-five countries competed in the luge in the 2010 Winter Olympics, and twenty-two of them went home without medals.

That's my point: bronze is last out of an unhelpfully narrow subset of the population, just like "last in your class of medical school" is last out of a well-qualified group of people to begin with.

And even if you were last at the Winter Olympics you mentioned, that's still better than the overwhelming majority of the world, and would say very little to establish that you're a bad athlete, as suggested by the medical school quip.

To rephrase it in terms of your example, it would be like if I said, "What do they call the 25th best skiier in the world? Last place [at the Olympics]."

Hold your hand up and make and L with the thumbs and forefingers of both hands, palms facing away from you:

1) "L" is your Left hand.

2) Is the patient facing towards you? "Left" is the opposite side on them.

Two rules that will revolutionize healthcare forever.

Oldest joke in med school:

Old surgeon to young one:

- Jim, amputate the left foot.

- Jim - the left!

- Jim - the foot!

lol

Reminds me of a story I once heard.

"And jokingly I told the surgeon that I will mark my arm with 'THIS ARM' before the surgery and she said 'Yes, please do this'"

Reply on news.ycombinator.com