The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor's natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge. I supervise residents---they make the decisions, but it's my name and my ass on the line, so I keep a close eye on things. Some teaching physicians dictate every decision on patients, some do nothing at all. I try to keep toward the end of the spectrum that allows for resident autonomy. When I'm presented with a case, and asked what I would do, I cry foul:
"You are the doctor," I say. "Tell me what you're planning. I'll tell you if I disagree, and I'll let you know if I disagree enough to override your decision."
This technique must, like all others, be tailored to the individual learner, but I want them to worry---I want them to think, "if I don't do this right, no one else will, and a patient will be hurt," because that is what the rest of their careers will be---being awakened in the middle of the night out of a sound sleep, having to make a quick assessment, and being reasonably sure that you're right.
Except I've got their backs.
Of course, that confidence can lead to arrogance. It's an occupational hazard. If it's simply a personality quirk then it's annoying. If it includes a lack of humility, a lack of knowing what you don't know, then it is as dangerous as indecisiveness.
It takes years of training to develop the decision-making skills that go into being an effective attending physician.
This is one place where we part ways with the cranks and quacks.
Cranks and quacks lack humility in the face of disease. They have confidence without knowledge. As a real doctor, I know, with complete certainty, that I will have failures. I know that there are some diseases I can't beat. The variety, complexity, and horror of human diseases have taught me my place. I can't promise miracles, but I can give statistics.
Quacks and cranks do promise the improbable. They promise to stop you from aging. They promise to stop autism by fighting vaccination. They promise to twist your chi until your malaise relents. Most important, they don't know what they don't know, and that makes them dangerous.
The Jenny McCarthys of this world are intellectually lazy. They perceive a problem and develop a potential solution without regard to what may have been done before. They are arrogant and ignorant enough (a bad combination) to think that they have some special insight into a scientific problem that decades, maybe centuries, of dedicated professionals have missed.
Since they don't understand the science underlying their ideas, they have to invoke an array of deus ex machinae to remove them from their dead ends. Since they know mercury in vaccines cause autism (sic), and all the science disagrees, well then, there must be a vast conspiracy to hide the supporting evidence.
Scientologists know psychiatry is evil and murderous. Since the data don't seem to bear that out, once again, a conspiracy is invoked that can explain anything (and explanations of "everything" usually explain nothing).
HIV denialists are certain that HIV doesn't cause AIDS. It must be some combination of malnutrition, drugs, or other infections. This complicated and unproved explanation simply reaches in and plucks the denialists out of harms way as the truth bears down on them.
Lyme disease wackos (the discoverer of Lyme disease had to wear a Kevlar vest for a long time to protect himself from the peace-loving patients) often find themselves with symptoms, but no lab confirmation of their infection. What do they do? Simply change the rules---now, we can define an infection without any microbiological evidence. Deus ex machina. Smoke and mirrors and side-show miracles.
Real science is hard. Real medicine involves giving bad news---really bad news. You share the joys of your patients, but also their pain, suffering, and death. It's a package deal, unless you make wild promises, conflating false hope with true compassion.
Quacks and cranks aren't just wrong. They promote suffering. Not just through snake-oil cures and the like, but because the offer a false compassion, one arising from a lie. Real compassion often involves holding a hand and saying, "we've run out of tools to fight this. The disease will win. What is left is finding a way to live whatever time you have the best way possible." Real compassion is painful, but still rewarding.
Confidence without arrogance, humility without indecisiveness, knowing what you do and what you don't know: these traits, these skills are hard to acquire, hard to teach, hard to master. But the are at the core of medicine. They are the heart of medicine.
I wholeheartedly agree
You sound like a good teacher. Your style resounds with me because the good clinical instructors in law school would encourage me to make independent decisions with their licenses on the line. Then the followup is to give good criticism on the decisionmaking process.
"They have confidence without knowledge."
I have encountered many MDs with this problem in many fields.
The maxim of "confidence with humility" applies in any pursuit where consequential decisions must be made on the basis of less-than-complete empirical information and less-than-complete theoretical understanding. Groopman's book on medical decision-making makes this point very clearly and eloquently. It certainly applies to cutting-edge scientific research.
Allen Steere never claimed to have worn a Kevlar vest. Mark Klempner only said his kids asked him "What size bullet proof vest does he have to wear," which of course, was a lie.
I see that you are not a scientist.
Perhaps I can help you:
Not only are you not a scientist, you don't even have your data correct on the Lyme crimes.
HERE IS WHAT HAPPENED:
Kathleen M. Dickson
What Allen Steere did in Europe.
Kathleen M. Dickson
The Analytical Chemist who solved the cryme.
PAL, you must have an excellent knowledge of anatomy. You have really hit a nerve.
I strongly encourage following the links Kathleen left above. They are...interesting. The are emblematic of typical conspiracy theory techniques, such as "the lost photocopy". Classic stuff.
hi PAL! - great blog post - there certainly is a fine line between arrogance and indecision.
Re: Quackery- As a dermatologist (disinterested in anything cosmetic) i am constantly told by my patients something to the effect of "Well, my friend's mother suggested cream X, i tried my pharmacist who sold me some other stuff, then i saw 2 naturopaths, my chiropractor, an iridologist but finally in desperation i thought i'd see you.". I say "wow- if i had a skin problem the 1st person i'd see would be a skin specialist!".
Unfortunately, so much of dermatology is crazy people. People cut, burn, scratch, stab themselves- and then deny it. Delusions of parasitosis are extremely common. A new disease called "Morgellons" has even been invented.
Shlog, I have a different perspective on the set of symptoms called Morgellons. I think it is more of a hallucination, similar to the hallucinations that accompany cocaine and amphetamine abuse. I think they are both caused by the metabolic stress which results in low NO in the skin, which turns up the sensitivity of mast cells so that they degranulate with little or no provocation. A propagating wave of degranulation would be perceived as movement in the skin.
PalMD, I took your advice and followed Kathleen's links. Holy hell, she just made your case.
I had another thought I wanted to add regarding what constitutes a "delusional" symptom.
Phantom limb pain, the pain that someone with an amputated limb "experiences" in the limb which is no longer there, cannot be "real" because there is no limb. It is obvious there is no limb, even to the patient.
Why is "phantom limb pain" not called "delusional limb pain"? Why are people who experience delusional limb pain not called crazy the way that people who experience hallucinations of parasites in their skin are called crazy?
I appreciate that this is a rhetorical question. I am pretty sure that I know the answer but I would like to hear what other people have to say about it.
Beautiful teaching technique:
"You are the doctor," I say. "Tell me what you're planning.
--- forces the resident to a) generate a set of options and b) prioritize them into a plan
I'll tell you if I disagree,
--- gives them feedback to refine both steps above
and I'll let you know if I disagree enough to override your decision."
--- in a safe learning environment. Safe both for resident and patient.
Phantom limb pain is not called delusional limb pain because the person suffering from the pain does not belive that the pain is really there. The delusional parasitosis is a delusion because the sufferer believes that parasites are there when they are not.
FutureMD, if they don't believe the pain is really there, why are they seeking treatment for it?
Don't be a smart-aleck, Daedalus. You know what he meant: the patient doesn't believe the limb is the source of the pain.
I more or less agree: it's a delusion when the symptom is used (inaccurately) to provide evidence for a counterfactual statement. If a patient argues that his pain means he must have an arm there, and it's just invisible and intangible, that's delusional limb pain. Similarly, those who experience the sensation of itching under the skin and argue the sensation is sufficient evidence for the presence of a foreign substance despite biopsies showing no such irritants are delusional - and those who experience the sensation of itching under the skin and who are infected with filaria, for example, are
...are not delusional.
jen_m, The statement was quite clear, "the person suffering from the pain does not believe that the pain is really there". I understand that may have been sloppy speech and I am only trying to be a little bit smart-alecky.
It seems to me the underlying symptom is the sensation of itching and the creepy-crawly feelings in the skin just like the symptom of phantom limb pain is the sensation of pain. Showing a person that they don't have a limb doesn't make phantom limb pain go away. Showing someone they don't have parasites doesn't make those sensations go away either.
I suspect there are a lot of very compelling evolved pathways to impute sensations of movement in the skin to the presence of parasites. Our ancestors evolved in parasite rich environments. There are likely multiple and redundant pathways to detect parasites. The compulsion to act as if there are parasites present may not be solely under cognitive control. If so, it would be wrong to attribute some of these as being "in the mind". Reflexes are not "in the mind". Sensations of pain are not "in the mind" either.
When parasites are ruled out by biopsy, the cause of the symptoms remains unidentified. The most effective treatment is likely to be an SSRI. SSRIs can be quite effective for itch. Mast cells are triggered by serotonin. My presumption is that the SSRI changes the sensitivity of the mast cells to being triggered. The effectiveness of SSRIs may have nothing to do with any effects on the CNS.