What could be more important than a good old-fashioned flame war? I'll get to that in a moment, so please stick with me.
The recent imbroglio between some of our doctor bloggers and non-physician scientists got me thinking (so it couldn't be all bad).
As a quick summary, PhysioProf of the DrugMonkey blog used an incident of a doctor committing battery on a patient as a generalization regarding surgeons, all doctors, and medical education. Many of us who are actually doctors and physician educators took issue with that. PhysioProf apologized, but made it clear that s/he still feels that there is a valid point here, that doctors are bred to be arrogant, etc.
Let's move on from the fray, and dig through the battlefield relics that may help illustrate larger issues.
In the "old days", doctors were very much independent operators, and depended on the "wisdom of the greats", meaning that medical knowledge flowed from the experiences of the best of us, passed to succeeding generations. Evidence-based medicine (EMB) has moderated this significantly, bringing the harsh but beneficial light of science into medical practice. EBM has done much to erode the paternalism inherent in the old system, and as such has done much for medical ethics, albeit peripherally. When my father was training in the 40's, no one would think of questioning the attending physician---today, we count on it. My residents and students frequently challenge my decisions, bringing evidence to bear. Sometimes they are right, sometimes they are wrong, but the dialog encourages all of us to learn and become better doctors.
It may surprise some of you to learn that medical students receive some education in medical ethics, both formally and informally. Formally, medical students may have courses or lectures devoted to the topic; informally, they learn "applied" medical ethics as they take care of patients. Every case has potential ethical dilemmas, most of which are easily solved, but some seem insurmountable, and most hospitals have ethics committees to help with the difficult cases. In the same way that my residents question my medical decisions, they question the ethical ones. Since most medical-ethical conundrums do not have "correct" answers, it is useful to have at least a passing knowledge of medical ethics to bring to the table.
Medical ethics discussions generally invoke a few central principles: beneficence, non-maleficence, autonomy (to which I would add "paternalism"), and somewhat more recently, justice, dignity, and truthfulness (not to say that those are recently-added values, simply that they were not always an explicit part of the formal discussion). In particularly difficult cases, it helps to jot these down and write in some of the particulars of the case. Exploring ethical issues of cases, evaluating our own effectiveness, discussing patients' perceptions of doctors---these are things we do every day.
All this is by way of illustrating that, to put it crudely, we aren't a bunch of friggin' idiots. When people speak of "doctors" as arrogant, unfeeling, etc., I'm sure there must be valid personal experience behind such assertions, but in the real world, doctors receive explicit instruction in these matters and are encouraged to be reflective.
Time to integrate: arrogance, an accusation frequently leveled at doctors, is a personality problem, but also a potential ethical problem. Too much arrogance can lead a doctor into problems with patient autonomy, and with judging what constitutes "beneficence", among other things.
There isn't a good way to measure "arrogance levels" in physicians. Many hospitals conduct surveys and polls to gauge patient satisfaction, including satisfaction with physicians, but this is only so useful. I'm sure there are people who study such things, but information on patients' perceptions of physicians is not widely available.
So what of arrogance? Arrogance, as most of us are aware, can be a rather unpleasant personality trait. When does confidence become arrogance? I don't know. What I do know is that it is impossible to practice medicine effectively without a certain level of confidence. An issue at the heart of the paternalism question is the issue of professionalism. Doctors are professionals who have knowledge not available to everyone---notice I did not say "not known by everyone" but "not available to everyone". Anyone can buy medical texts, but not everyone can attain the knowledge and experience of a doctor, so we as patients are forced to trust our physicians. This gives doctors an awesome responsibility. We must constantly strive to not disappoint or abuse that trust. We must give the best advice available, and we must give the context to understand that advice.
By way of illustration, here is a conversation I've had with a patient (actually, with lots of patients):
Me: How are your blood sugars?
Patient: I check them sometimes.
Me: We've talked about this before---it's very important to check them three times a day like we've discussed.
Patient: I feel OK.
Me: Look, are you interested in ending up on dialysis? Would you like to have strokes and end up in a nursing home?
Horrified Patient: Wha....?
Me: Because you are doing everything right if those are your goals.
Patient: No one ever told me that...
Me: (knowing that isn't true, but not wishing to lose an ally) Well, now I'm telling you. We have to work harder to do this. Tell me what makes it hard to do these things and we'll figure out how to do better.
This conversation, depending on how you heard the voices as you read, can give the impression that I am both arrogant and paternalistic, and perhaps a bit of an ass. But I know my patients, and I know how to communicate with them, and how to judge when I'm losing them in a conversation. Practicing medicine isn't a matter of saying, "here are your options, now choose." It is also about persuasion and coercion. That's "necessary paternalism". Do I ever get it wrong and become either too paternalistic, or perhaps not paternalistic enough? Yep. But I am explicitly thinking about these things, as are many doctors (how many I haven't a clue).
So we doctors, as a group, may seem arrogant. That is a hazard in any profession. Changes in medicine over the last 2-3 decades have done much to level the ground between patients and doctors, but there will always be an asymmetry to the relationship. What we as physicians must do is recognize that asymmetry and make sure that when we exploit it, we do so properly, with the interests of the patient foremost.
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I have to second your observation about the changing nature of medical training. I'm a clinical psychologist in the field of behavioral medicine. When I'm brought in to consult on behavioral management of cases or to assess patients (I'm at a large training hospital), a part of my job is also to assess and give feedback to the residents and interns on the interactions I witness with the patient. Many of the attending physicians also report psychologists providing some aspects of their didactic training, and they strongly stress the importance to residents of the view that the "doctor is the drug" - a physician's style of interaction and recommendation, as you so well illustrate above, is often the most powerful intervention that a patient receives in any visit. If an MD is a prick, they're ineffective - we all know the older docs that still take a paternalistic approach, but the shift within the field, from this peripheral professional's view, is well underway.
May I add that when one is least confident it is all the more essential to project, if not confidence, at least equanimity? (Yes, I'm an emergency medic.) "Never let them see you sweat" is part of the training for a reason -- because they need us to be in control when they can't be.
Will some interpret this as arrogance? Given human variability, it's a safe bet.
Will some internalize the act? Same answer.
The training of doctors is probably excellent, but at the least here in the Netherlands some departments have a serious culture problem. It's still very much a white upper-class old boys network and if you haven't been a member of the right fraternity during your study, if you don't wear Lacoste and Polo Ralph Lauren and if you've got the wrong accent, they will not let you in.
I'd like to relate a personal experience that possibly involves a doctor "not [being] paternalistic enough" in case there are those who doubt such a thin. My mother was a long-time medical educator (but not in oncology). About five years after she retired, she was diagnosed with uterine cancer. Upon submitting herself to treatment at the only major hospital in her state (where she had retired, not where she taught), her oncologist turned out to be one of her former (and well liked) students. He determined on a hysterectomy with a course of radiation, but no course of chemotherapy. My mother asked him why he did not also recommend chemo, but not being an oncologist, she deferred to his judgment. Long story short, she did not have chemo, and a year later the cancer was found to have spread, and about two years later it eventually killed her (after two rounds of chemo).It is my belief that her original oncologist was not aggressive enough because he cared for the patient as a friend and mentor, and that colored his decision whether to subject her to the (painful, difficult, humiliating, etc) regime of chemo when it might not be strictly necessary. I believe that this otherwise competent doctor might have made the hard (but, I believe, medically correct) decision to do a round of chemo had his judgment not been clouded by personal affection for the patient.
I'm not a doctor (a lawyer, in fact; and no, I have no desire or intent to initiate any type of legal claim related to this), so I would be interested in hearing from the doctors whether they agree with my conclusion that too much deference or emotionally attachment can sometimes be as harmful as too little.
That's why we don't treat family. In certain communities, however, it's impossible not to treat friends or distant family members and we have to be very, very aware of this issue.
This vignette on not treating family or acquaintances is very interesting. What is interesting for me is the physiology behind it; and how specifically treating people that one has emotional attachment to clouds judgment. I will blog about it when I get the chance. Yes, it does involve nitric oxide. Many of the neural pathways involved in social behaviors have effects mediated through NO. I think that social interactions invoke the social brain, the theory of mind at the expense of the analytical brain, the theory of reality.
The lesson gets driven home hard the first time you have to "package up" a colleague.
I must say, though, that it's quite an experience having your patient directing the team securing hir to a backboard. Talk about being "on head!"
Outside the context of medicine, I am extremely leery of any accusation of arrogance. More often than not, it seems to me that the line between arrogance and confidence is drawn based on someone's unjustified, uninformed opinion that the allegedly arrogant person should not be confident about something they demonstrate confidence about.
More specifically, I don't know a single religious freethinker or skeptic about pseudoscience and the paranormal who hasn't been accused of arrogance simply and solely because they confidently reject some belief cherished by their accuser: No matter what extremes of courtesy or diplomacy are demonstrated by the skeptic, no matter that their opinion on the matter at hand may have been explicitly solicited rather than volunteered, by daring to display any confidence whatsoever in their skeptical opinion - that there are no gods, that homeopathy is medically ineffective, that ghost experiences are various forms of psychological delusion or hallucination, or whatever - they are judged "arrogant." And closer examination or inquiry will usually reveal that it isn't even the level of confidence in that opinion that constitutes arrogance in their accuser's eyes, but that merely having a negative opinion about the accuser's prized belief is enough.
The most annoying thing about such accusations of arrogance is the hypocrisy. Usually, the people who arrive at skeptical positions about popular beliefs have actually put some thought and consideration into it, and quite often they have carefully and extensively evaluated evidence and arguments, possibly for many years. In contrast, anyone who believes, for example, that homeopathy is any sort of real medicine either hasn't evaluated the evidence and arguments or is utterly incompetent at evaluating evidence and arguments. Thus, such a person's confidence in their opinion is entirely unjustified, yet they are so confident that they are right they accuse those who've reached a different, better-justified conclusion of being arrogant (i.e. having unjustified over-confidence).
I've grown to suspect that the accusation of arrogance is just a defense mechanism: A person who really, really wants to believe in bullshit often seems to realize that it's bullshit at some (possibly deeply buried) level, and the implicit awareness that their position cannot be defended drives them to go on the offensive instead. Accusations of "narrow-mindedness" and "arrogance" and the like are useful diversions. Perhaps "hypocrisy" is too strong a word, and what's really being exemplified in such cases is the common phenomenon of projection, ascribing one's own attitudes or flaws to others: After all, what could be more narrow or arrogant than rejecting evidence simply because one doesn't like where it leads?
To come back around to the matter at hand: Sure, the medical profession's history of paternalism (and worse than paternalism, especially in the historical treatment of women) may have a lot to do with the perception of doctors as arrogant. But some of it may just be due to the more common phenomenon of the ignorant accusing the knowledgeable of "arrogance" for reasons that have nothing to do with medical culture, past or present.
@G Felis:
Completely agree. Arrogance is one of those words, like terrorism, where the definition varies spectacularly according to the person using it.
hmmm...if i didn't hate the word "meme"...
Thanks for responding to my (somewhat off topic) post. We lawyers aren't supposed to "treat family" (or business partners!) either. With us, though, we have an easier method of drawing the ethical line: if we have any type of financial interest in any aspect of the job (other than getting paid for our services), we aren't supposed to do it. (The lawyers among us may recognize I am over simplifying, but it is still an easier rule than deciding whether you "like someone too much" to try and save their life).
Closer to the topic at hand: I think that another reason professionals (particularly scientists and doctors) can draw accusations of arrogance is when they reflexively defend one another from what they perceive as an unwelcome attack from outside. This is never more evident than when doctors get involved in malpractice suits as experts. Even though there are many doctors who will testify for plaintiffs, they (fairly or unfairly) get labeled by their colleagues as "hired guns" or worse, while most non-professional witnesses will go out of their way to give their medical colleague the "benefit of the doubt." The problem with the original vignette involving the tattoo is that it is too extreme. What would make a more controversial (and therefore interesting) story is one where medical "judgment" at least arguably comes into play. (Maybe a modern version of the 60 year old hysterectomy anecdote). Having grown up among scientists and doctors and having "defected" to the other side, I believe there is a certain level of arrogance in science and medicine, wherein practitioners get to the point of declaring the "truth" too complicated for non specialists to understand.
The most striking example of this is the debate over who should decide what is, and is not, "science" in the court room. (For the initiated, I am talking about the Daubert standard). Scientists overwhelmingly believe that only they (i.e., the scientific community) should be able to declare what is, and is not "good science."* While the standard does strongly take into account the extent to which a proffered opinion is "mainstream", the ultimate decision maker is the judge (a lawyer). 99% of the scientists (including doctors) that I've argued this point with believe that judges are not qualified to determine what is and is not "evidence" in this context. I believe that this view reflects a form of arrogance on the part of the scientific/medical professions. And they think my response reflects arrogance on the part of the legal profession.
* I have framed the question the way most scientists and doctors perceive it. The real question is "who should decide what a jury gets to hear and consider." That question will have fundamentally different answers depending on one's view of the purpose, role, and functioning of the judicial system.
Meh, all doctors are gay and want to look at your butt, not that there is anything wrong with that.
Please correct me if I'm wrong, but my understanding of Daubert is that it is in large part an due-process matter. It is intended to separate "expert opinion" from "just my opinion."
Being widely accepted in the relevant scientific community is a sufficient, but not a necessary, condition. It would also suffice if the witness arrived at his conclusions by a well-defined method which could in principle be repeated -- and thus challenged -- by another or sufficient skill in the art [1]. The last is crucial because "I say so and there's no way for you to challenge my word" is not "fair" to the opposing party. In order to be rebuttable, the methods used must be both adequately described and themselves sufficiently well-established that their reliability can be assessed by opposing witnesses -- so, for instance, you can't admit an opinion based on a well-described process which is dependent on some secret sauce.
The test is essentially procedural. Judges might not understand science, but I dare say that they have process down cold.
All of which is leading up to my impression of Daubert as the law essentially enforcing good scientific practice on expert witnesses. I suppose that none of us like being subjected to external discipline, especially in our own fields -- but we're also supposed to be adults and able to deal.
[1] My example for this is the expert testimony of Prof. Randall Davis in Computer Associates v. Altai which was a new method but one well-defined and grounded in accepted practice.
That is correct, but can also be viewed as begging the question since "due process" is a heavily freighted issue that can accused (at times) of subjectivism.
Being "accepted" (which is often measured strictly by whether you publish in peer reviewed journals) is sometimes sufficient, sometimes it is only a factor that is weighed. Plus, who gets to decide whether or not you have been "accepted"? The opposing lawyer will bring in the American Journal of Homeopathy and claim it reflects "acceptance"; or another will paint you the horrors of "peer review" to demonstrate why it isn't truly relevant that Dr. Doe can't get his papers published. The scientists/doctors I talk to believe that experts should only be allowed if they come with an official stamp of approval from an organization like the AAAS or one of the professional associations (AMA, APA, ACS, etc).
Accepting that validity is defined by repeatability is (a) not always helpful or applicable (e.g., in a medical malpractice case where the question is whether a doctor's (in)actions were negligent); or (b) sometimes beyond the sophistication of judges (particularly elected state court judges). Anyone who has seen how grant/tenure/publication review work will recognize that validating someone's work as "good science" is not always carried out as a strictly objective exercise amongst dispassionate professionals.Your perception may be slightly skewed towards the positive by over emphasizing patent litigation, where the Daubert issues are much different (the "one of skill in the art" test is different from the Daubert test, and is applied towards a different goal). Daubert is more akin to the question of "what is the relevant art." In a patent case, the relevant field is mainly defined by the specific invention. In a medical malpractice case, there is nothing (legally) that would prevent me from trying to convince a judge that a shaman or priest has a valid and important expert opinion to offer.I haven't done any empirical study, but I suspect that the fields where the "closest calls" arise are psychology/psychiatry, since the pace of advancement in those fields, the amount that reasonable practitioners will admit remains a mystery, and the close relationship with the role of the judicial system (i.e., deciding whether someone acted within a given set of normative bounds) leads to a perfect storm of charge and counter-charge. The penalty phase of a death penalty trial will shake any notion that two equally reasonable and respected scientific/medical professionals cannot have diametrically opposed opinions based on exactly the same evidence.
I fully agree with PalMD's point, and in fact I think it extends beyond the field of medicine. How often are experts in other fields accused of arrogance, when they display only a justified confidence? I have experienced this myself, even from other professionals with a slightly different area of expertise than myself.
Humans seem to have a deeply seated aversion to being corrected or otherwise treated as if they are not the complete equal of those around them. Particularly when they feel that they should be, for example when there is no significant age or status differential.
In fact, I'd suggest that learning to deal with this aversion is a major part of professional success and people skills in general. More in some fields than others, of course.
Some fields are more vulnerable than others. I rarely get any back pressure in my field (device-level electrical engineering) since to most people, even other EEs, the questions themselves are outside of their experience. They don't imagine themselves "able to do my job if I took the time."
Mechanical engineers aren't so lucky. Everyone imagines themselves an ME if they put any effort into it; after all, they have familiarity with nuts, bolts, etc. They can see the drawings and relate them to final product. How hard can it be?
Law and medicine suffer similarly. The average reasonably-well-educated person has taken civics and biology, and they are very intimate with their own bodies (or think they are). Law? It's just words, right? If anything, most people see the jargon as an artificial barrier to make something simple look hard enough to keep rates up.
It's all about perceived barrier to entry. Rightly or wrongly math and physics are perceived as genuinely hard, while more familiar things are not. "Arrogance" is perceived as the ratio of asserted authority to differential qualification, and the denominator is always the most important.
Well said PalMD, but I have to disagree in part. First, I agree with all that you said about training, patient interaction, and wanting to help people. I would be surprised if anyone would actually disagree with the idea that many, if not most, doctors feel this way. BUT (there's always a but) there is the otherside that is ignored here. Many of us teach "premeds," and we have dealt with the attitude "I need the grade and your course is basically shit except for the grade." Then we have seen these premeds go on to med school where they express little than a desire to know what the boards test. I understand this mentality since if the boards aren't passed, its game over. However, maybe the MDs might try some of that empathy they are endowed with and see it from the other side as well. Maybe student attitudes get readjusted, but I am skeptical.
Second, a significant part of medical school is wrapped up ritualistic anachronisms, we have a special ceremony celebrating getting into medical school with the bestowal of lab coats. We tell our students (admittedly not just in medical school, but our undergraduates, graduates, and other professionals) how wonderful they are for being where they are. Of course none of this rubs off on the students, many of whom already enter the process with a sense of privilege. This sense of privilege is endemic to the system and I expect its difficult for those in the system to see it. For example, when I obtained a training grant during graduate school (PhD), I had to sign a form saying I would remain in science at least as long as I had been on the grant OR I had to pay it back (in other words it was a taxable loan). However, if you are gifted and fortunate enough to get into an MD/PhD program, your first two years of med school is paid for (you know, because you are so awesome), if you then decide to quit the PhD portion, you complete med school with 2 years free and clear. Of course there's no way one of these bright students would get the feeling of entitlement from these kind of things.
I have worked with several gifted students who went to medical school that I expect will be the exact kind of doctor you refer to. I have also worked with students who went to medical school that I expect will be the exact kind of doctor PhysioProf referred to. I think both of you are wrong in your hyperbole, the system is rigged to encourage arrogance and god-like mentalities, but the field attracts some of the most concerned and caring individuals in society. At the end of the day it probably balances out, but I think both PalMD and PP do a disservice if they ignore each other (I am currently siding more with PP on this after they posted an apology on the hyperbole although not the content of their original post).
*leave 2 cents on the table*
I think these "anachronistic" ceremonies serve a good purpose, but that is probably a future post.
Assessing another person's level of arrogance is subjective depending on the person making the judgment. I have met people who would call Mother Theresa arrogant and insensitive. It's really impossible to please everyone.
I think you are right when you say, "What . . . physicians must do is recognize that asymmetry and make sure that when we exploit it, we do so properly, with the interests of the patient foremost." (I am not a physician, so don't take that "we" to include me.)
As for patients, if you're seriously not comfortable with one doctor you can go to the trouble of finding one you like. If, on the other hand, it's a matter of hating it when people tell you that you need to change something, well, I wouldn't want to be you. :oP
Esther, you might be better served by picking another illustrative counter-example: Mother Theresa was more than just arrogant and insensitive, she was outright callous. She constantly rejected palliative care for her patients out of her own perverse convictions about the spiritual benefits of pain and suffering - an imposition on others which strikes me as the pinnacle of arrogance. Her saintly reputation is just another appalling sham, as has been exposed repeatedly, most famously by Christopher Hitchens in The Missionary Position: Mother Teresa in Theory and Practice.
You're arrogant if:
You don't refer pts for noninvasive tx when effective
You are an educator and don't teach what's most needed, test what you teach, and care if it's remembered
You admit geniuses without heart and expect them to change
You read the evidence based results and still do it the old way...
You don't question how so much research was funded and published yet NO GOOD EVIDENCE BASED TRIALS!!!!
You know most of what we need is not known since so much trivia is thrown in...zebras taught, tested, retested
You have objectives or mission statements and anytime someone shows ways you are far from meeting them you call them a trouble maker. For ex: mission is to be efficient and effective and yet docs have 5 H&Ps on 1 pt, illegible, don't have true interdisciplinary work with nurses...
You're arrogant if:
You are an educator and don't teach what's most needed, test what you teach, and care if it's remembered
You admit geniuses without heart and expect them to change
You read the evidence based results and still do it the old way...
You don't question how so much research was funded and published yet almost no good EBM studies
You don't find and refer to best noninvasive treatment, ie don't even know that trigeminal neuralgia is often easily treated preventing years of excrutiating pain
You know most of what we need is not known since so much trivia is thrown in...zebras taught, tested, retested
You have objectives or mission statements and anytime someone shows ways you are far from meeting them you call them a trouble maker. For ex: mission is to be efficient and effective and yet docs have 5 H&Ps on 1 pt, illegible, not one problem list with nurses...
Anyone who doesn't know as much as someone else (and doesn't like to face that fact) will label that person as arrogant for failing to hide that gap in competence. This has been true in every level of education I've observed from elementary school up, where the smart kids are hated by everyone else if they don't have the good sense to hide what they know.
Some random thoughts:
1) My sense is that the arrogance of physicians (and surgeons in particular) is most evident outside of strictly medical affairs. They are more likely (in my admittedly limited experience working in hospitals) to act as though the world should shape itself to their desires.
For example they are far more likely to complain loudly about minor mechanical failures. ("this lightbulb has been out for more than two hours! Why hasn't anyone fixed it yet?)
2) Physioprof and others working in medical schools probably see the arrogance of their students at its greatest height. The students are relatively young, and potentially suffer from both the arrogance that comes from knowing less they think they do and feigned arrogance used as a defense against feelings of inadequacy. I suspect that the arrogance subsides during the years following medical school as they age.