White Coat Underground

Experts and accountability

My buddy Janet always makes me think, which is one of the things I like about her (that, and her cookies). Today, she wrote about a recent PLoS Biology article about the vaccine-autism debate (Orac has also covered it, of course). I especially like Janet’s take on expert status and accountability. Let’s examine these issues from a doctor’s perspective (and speaking of credentials, “Janet” is also Dr. Stemwedel, a professor of philosophy and ethics, and former physical chemist, so she’s not making this stuff up).

Who is an “expert”?

Dr. Stemwedel addresses this problem head-on, questioning how we tell experts from charlatans, and whether experts dilute autonomy (they do, to an extent) and what this means:

Don’t we want people to be critical consumers of information?

We do. The problem is how exactly people who are not experts are supposed to evaluate the expertise of others. If they knew enough about the subject matter on which the putative experts are holding forth, they could just evaluate the advice itself.

Yep. Not only are we unable to expertly evaluate information outside of our expertise, we can’t even evaluate the expertise of experts! (Say that five times fast.)


So how do I, as an expert in internal medicine, convince others of my status? This came up in a conversation with another friend recently who was trying to evaluate a physician who a relative was seeing. I was not able to give a good answer. It’s relatively easy to see if I’m licensed and board-certified, and it’s only a little more work to find out where I got my education. But what does that really say about my expertise? There are plenty of doctors who practice outside of the standard of care, and they haven’t been “expelled” from the group.

This is where social connections come into play. We are forced to rely on an inherently unreliable network of word-of-mouth. This leads to some interesting problems. If I trust, say, my friend’s opinion about the quality of a doctor, what does it mean when my friend then tells me that vaccines cause skin cancer? I trusted him enough to go to the doctor he recommended, so might I also not trust him about this? Both opinions required an assumed level of knowledge, and both are about related topics. The doctor disagrees with your friend. Who do you believe now?

Accountability

One of the big differences between the doctor and your friend is accountability. As a physician, I am ethically accountable to many parties, but not all are equal. Your friend does not share these responsibilities. Sure, there’s the possibility that I’m an unethical physician, but lack of good ethics is not likely to be the norm, so give me the benefit of the doubt.

My first responsibility is to my patients (and this gets tricky if two of my patients’ needs collide). If my patient declines vaccination based on the fear of skin cancer, I am bound to listen to these fears and acknowledge them. But I also have to find a way to explain to them why they should get vaccinated despite these fears. This may involve correcting false beliefs, or explaining risks vs. benefits, or even explaining to them why their sources of information are wrong—and all this has to be done without alienating the patient. It’s a big task (and not, incidentally, reimbursable).

As a physician, I also have a responsibility to public health. This not infrequently collides with my first responsibility. If, for example, I diagnose my patient with HIV, I have to strongly encourage them to behave responsibly, but I cannot go behind their backs and notify sexual partners. Sometimes we as a society decide in favor of the general good over individual autonomy. In some places, people with active TB are held and treated until they are no longer contagious. But this is the exception. Vaccination is an in-between. We strongly encourage it at a societal level (for example, requiring it for school enrollment), but we allow for exceptions. As a doctor, I must counsel my patient against vaccination if the evidence shows it would do more harm than good—but the belief in harm and good must be based on solid evidence, not supposition.

For example, the MMR vaccine is not given to people with severe immune problems (documented, real problems, not made up ones). If I have a patient with, say, leukemia whose immune system is in trouble, I must recommend against it, even though the public good would suggest they should get it. But my recommendations to my other patients have a broader affect than just protecting them as individuals. If my other patients are vaccinated, my leukemia patient is less likely to have to worry due to herd immunity. So I’ve managed to create a good for my patients, and a good for the public.

How do we trust?

Sometimes trust requires just that: trust. We are forced to trust our medical education and credentialing system. But individuals often have good reasons to be mistrustful, based on prior, perhaps unrelated, experiences. As a physician, I must earn the trust of each of my patients on every single visit, and all effective doctors must do the same. On the whole doctors are trusted in the U.S., at least as individuals. Doctors sometimes abuse this trust with fraud or abuse, but they also abuse it by using their status as experts to promulgate incorrect medical information, and this harms not just individual patients, but society as a whole. It makes it harder for each of us on the front line to maintain the trust of our patients and our community.

When people turn to improbably medical claims, they have not lost trust in doctors. They have made a choice to trust a particular doctor over all others, and that doctor has chosen to go against the needs of both the patient and society at large. Some might argue that the “unconventional” doctors at least listens, but listening is only part of our responsibilities. The other, harder task that alternative docs often abandon is that of giving bad news. There are ways to give bad news without completely destroying hope, and we must respect our patients enough to tell them the truth.

Respect. Truth. To these we experts are accountable. To these we must adhere, or lose our right to be called responsible experts.

Comments

  1. #1 D. C. Sessions
    May 28, 2009

    “Janet” is also Dr. Stemwedel, a professor of philosophy and ethics, and former physical chemist

    How does one become a “former physical chemist?”

    Is there a ceremony of renunciation, like maybe ripping up your Periodic Table or ritually stomping some lab glassware?

    Or is it maybe more like a “lapsed” or “nonpracticing” physical chemist? “I was brought up in a strict Physical Chemistry family, but haven’t actually been to lab in years.”

    And yes, whimsy aside she’s very much worth reading.

  2. #2 PalMD
    May 28, 2009

    Maybe we’ll go with “lapsed” physical chemist.

  3. #3 Whitecoat Tales
    May 28, 2009

    @D.C Sessions

    Actually, at the start of med school, they forced us engineers to give up our slide rules, our graphing calculators, and say renounce our belief in the supremity of mathematical models of the universe.

    They also beat us with paddles, made up jump on dorito’s that they told us were glass, forcefed us liqour after test days, and I’m told at the end of 4 years there will be an induction ceremony with funny robes and arcane language. After I leave, I’m told I’ll say “it was the best 4 years of my life!”, and have a hard time discussing normal, nonmedical subjects with nonexperts.

    …In retrospect, it’s alot like pledging a fraternity, but 10000 times more expensive, and eventually it pays better.

  4. #4 D. C. Sessions
    May 28, 2009

    In retrospect, it’s alot like pledging a fraternity, but 10000 times more expensive, and eventually it pays better.

    Or at least most of them — Skull and Bones might be an exception.

  5. #5 Kapitano
    May 29, 2009

    Some things fake experts tend to do:

    * Contradict themselves – if a person hasn’t thought through the issues enough to get them straight in their own head, they aren’t qualified to lecture you.

    * Slide between issues – If you ask a question about light waves, and the answer winds up all about string theory, the speaker doesn’t know what they’re talking about.

    * Evade the issue – if you get an answer (however correct) to a question other than the one you asked, you’re dealing with a politician or a fake.

    * Refusing to admit ignorance – an expert in organic chemistry will readily admit to being shaky on enzymology, though enzymology is part of molecular biology, which is an adjacent discipline of organic chemistry. Fakes like to be seen as experts on everything.

    * Waffle – if you ask a simple question and get a ten minute answer that can’t be summed up in a simple paraphrase – even if it’s “The question, once you unpack it, is so complex it can’t be answered simply” – then you’ve found a waffler.

    * Confuse factual issues with moral ones – If you ask a question about the viability of a foetus at three months, and get an answer about how doctors who practice abortion are evil, you’ve asked a fraud.

    * Bring religion into nontheological debate – If you ask about levitical laws on adultery and get an answer that mentions leviticus. If you ask about proposition 8 and the answer revolves around leviticus, you’re not listening to a legal expert.

    * Deny that people who disagree with them might have a point – Two archeologists arguing over the interpretation of a painted pot have to listen to each other’s arguments and try to refute them, while be willing to concede they might be wrong. A crank doesn’t grasp that other people’s objections are worth taking on board and considering.

  6. #6 JohnV
    May 29, 2009

    Pal, when I go to the red cross, one of the forms I sign is some sort of document telling me about the HIV testing that is done. If I remember correctly (I stopped reading the paperwork about a year ago…), if you test positive, they’ll inform you and the county health department. The health department will contact you and if you don’t tell your spouse/partner, the health department will. I have no idea how they verify that you’ve informed anyone, unless they just tell them. Guess I’ll read the form again next week.

    Do you know if that is state specific, or a side effect of donating blood, or would any doctor have to report it to the local health department?

    My apologies for making a comment so tangential to your post :p

  7. #7 suzanne
    May 29, 2009

    I’m glad you’ve addressed the issue of trust between physician and patient.

    “This is where social connections come into play. We are forced to rely on an inherently unreliable network of word-of-mouth.”

    I don’t know if I should mention this but did you know that a lot of people find their physician by asking a nurse? I hope I don’t get the nurses in trouble but I’ve been very lucky using the Nurse 4-1-1 system. Unreliable? Yes, but is has worked for me.

  8. #8 PalMD
    May 29, 2009

    A large number of my patients come from nurses at the hospital…

  9. #9 daedalus2u
    May 29, 2009

    JV, I am sure that that information is available from the local blood donor center or the American Red Cross, and is likely state specific.

    I did get a big scare once when I was trying to donate whole blood and was refused because a test on a batch of platelets was positive. This was at a drive on the weekend and I couldn’t get ahold of anyone to find out why until monday. Turns out it was “just” elevated liver enzymes (back when elevated liver enzymes was grounds for rejection, it isn’t now).

  10. #10 The Blind Watchmaker
    May 30, 2009

    “I don’t know if I should mention this but did you know that a lot of people find their physician by asking a nurse? I hope I don’t get the nurses in trouble but I’ve been very lucky using the Nurse 4-1-1 system. Unreliable? Yes, but is has worked for me.”

    A referral “network” of other health professionals would be much more reliable than the social network of a friend of a friend whose barber’s aunt knows someone who likes Dr. X.

  11. #11 Paul
    May 30, 2009

    * Refusing to admit ignorance – an expert in organic chemistry will readily admit to being shaky on enzymology, though enzymology is part of molecular biology, which is an adjacent discipline of organic chemistry. Fakes like to be seen as experts on everything.

    Kapitano, 5 – unfortunately many of the doctors that I’ve consulted over the last few years fall into this category. I’ll bet that it’s true for a lot of patients who have anything the least bit complicated.

    Which is part of what I think has caused this problem – doctors being all too sure what doesn’t cause the problem without being able to provide a persuasive explanation of what does cause it.

  12. #12 AutismNostrum
    May 30, 2009

    I’ve always asked nurses, too. I figure that if the doctor treats the nurses well, he/she probably treats patients well, too.

    If your doctor hasn’t been responsive about your concerns, you’re much more likely not to pay attention to their advice on things like vaccines.

    If, on the other hand, you have a doctor who listens to your concerns, acknowledges that you have a reason to feel that way, and THEN informs you, you’re a lot more likely to take their advice. And unfortunately in this world of billing, that’s a lot harder to come by. I’ve seen many, many doctors who were talking as fast as they could to speed through each appointment and get to the next billable service.

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