Posted by 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.
May 28, 2009
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