When Doctors Are Wrong, and Patients Are Right

eilev on 8. December 2017

Medical Mistakes

Doctors are not infallible.

They often make diagnostic errors. Though the incidence of such errors can be hard to measure, autopsy studies provide one metric that is hard to dispute: “major diagnostic discrepancies” were identified in 10–20% of cases (Graber 2013). Other types of studies find similar results (see Graber 2013).

In some cases, doctors are systematically mistaken about important medical facts. In one study, gynecologists were asked about the likelihood that a woman who has tested positive on a mammogram actually has breast cancer. They were presented with four alternative answers, one of which was correct, and they were given the statistical facts needed to calculate their way to the correct answer, so the task should have been easy.

Only 21% chose the correct answer, which means that the doctors did slightly worse than we would expect them to do if they chose the answer at random (Gigerenzer et al. 2008).

Should We Be Worried?

These facts are troubling. When doctors are wrong, the consequences may be severe. It is tempting, therefore, to react with a scathing criticism of doctors and medical education.

In part, this is warranted. The human tendency to crash and burn when faced with problems that require Bayesian reasoning, which is what foiled the gynecologists in the study above, can be corrected with proper teaching (Gigerenzer et al. 2008). Diagnostic errors that result from cognitive biases could be removed using formalized procedures such as checklists (Ely et al. 2011).

However, as long as doctors remain human, errors will occur. Moreover, since medicine is a field characterized by risk and uncertainty, focusing on individual blame for mistakes runs the risk of focusing on outcomes rather than the procedure leading to those outcomes.

Malpractice

Malpractice suits, which are the legal manifestation of such a focus on individual blame, are more likely to be filed when outcomes are bad, such as when someone dies because of a delayed diagnosis of cancer. The likelihood of the filing (in the case of diagnostic errors) increases with the severity of the outcome (Tehrani 2013). But a bad outcome does not automatically entail any error of medical judgment.

Any positive diagnosis involves a risk of overdiagnosing a healthy patient. Any negative diagnosis involves a risk of underdiagnosing a patient with a serious ailment. As both overdiagnosis and underdiagnosis can lead to serious harm, the trick is to balance the risks according to their costs and benefits, but there is no way to completely avoid the risk.

The Costs of Blame

One serious cost of blaming doctors for mistakes is the phenomenon known as defensive medicine. The harms resulting from underdiagnosis and undertreatment are usually much more spectacular and easy to understand than the harms resulting from overdiagnosis and overtreatment. This means that doctors can minimize the risk of being sued for malpractice by erring on the side of the latter. According to one estimate, defensive medicine costs the US between $650 billion and $850 billion annually (jacksonhealthcare.com).

Another significant cost of the focus on blame is the harm that befalls doctors. Being a physician is stressful. Depression and burnout are common, and the suicide rate among doctors is frighteningly high—41% higher than average for men and 127% higher than average for women (Schernhammer 2004). A likely contributor to this is the blame and guilt associated with making mistakes, or even with making completely justified decisions that, because they involve risk, happen to result in bad outcomes.

Less obviously, focusing too much on the responsibility of the physician obscures the fact that the institution of modern medicine tends to marginalize and overlook a significant healthcare resource: the patient.

The Doctor as Authority

Modern healthcare is still very much an authoritarian institution, where patients come in and are told what to do by the Olympians in white coats. Even title of “patient”, which you automatically gain once you enter the system, denotes passivity, someone “to which something is done” (oed.com). Doctors have access to a special set of skills and knowledge, which is demarcated by high social status and pay and often romanticized in popular culture. To a patient, the doctor is an unapproachable expert, one to which you listen, sometimes literally, on pain of death.

It is no wonder, then, that most of us are afflicted by what Wegwarth and Gigerenzer call the trust-your-doctor heuristic, which is the decision-making rule most of us follow in matters regarding our medical needs: consult your doctor and simply follow her commands (2013).

Because the gap in relevant knowledge between physician and patient is assumed to be astronomical, the responsibility for arriving at the right conclusions is placed squarely on the shoulders of the physician. Though the 20^th century has given us the doctrine of informed consent, an institution intended to protect patient autonomy; the underlying picture is still that of a commanding doctor and consenting patient. By being bound by this framework, we risk losing out on the resources patients could bring to bear on solving their own medical problems.

Bridging The Gap With Google

As Andreas Eriksen discussed in his excellent post a couple of months ago, the advent of the internet and Google has increased the information easily available to the average person by several orders of magnitude. This means that the knowledge-gap between doctor and patient is less absolute.

No doubt it’s true that a doctor with Google is better suited to diagnose and propose treatments than most patients with Google. However, it is also true that most patients spend a lot more time thinking about their medical condition, their symptoms and how it affects their life than their doctors do. A doctor can’t spend hours researching on Google every consultation, and they cannot routinely monitor their patients as they go about their daily lives.

Every patient should be considered an expert on her circumstances of life. More and more, the medical knowledge they can muster through the use of Google and other resources should be taken seriously. When combined, these two insights make a good argument that a healthcare model based on the idea that responsibility and authority in medical matters should belong solely to the physician is obsolete.

Taking The Patient Seriously

The involvement of patients in medical decisions should not be regarded merely as matters concerning the protection of their autonomy but as an important part of improving the medical decisions themselves. Through the last couple of centuries, medicine has seen a gradual shift towards a focus on the patient in several ways, through informed consent and, more recently, the ideal of shared decision-making. This is a trend that should continue.

Doctors are sometimes wrong. Patients are sometimes right. On an authoritarian model, the instances where these situations overlap will result in doctors overriding their patients’ correct judgments with their own mistaken ones. In an ideal situation, a patient’s correct judgment should correct the doctor’s mistake. Taking the patient’s resources to make medical decisions seriously should be a step towards achieving this ideal.

Litterature

Ely, John W., Graber, Mark L. & Croskerry, Pat. 2011. “Checklists to Reduce Diagnostic Errors”. Academic Medicine. 86 (3).

Gigerenzer, Gerd, Gaissmaier, Wolfgang, Kurz-Milcke, Elke, Schwartz, Lisa M. & Woloshin, Steven. 2008. “Helping Doctors and Patients Make Sense of Health Statistics”. Psychological Science in the Public Interest. 8 (2). 53–96.

Graber, Mark L. 2013. “The incidence of diagnostic error in medicine”. BMJ Quality & Safety. Online First.

Schernhammer, Eva S. & Colditz, Graham A. 2004. “Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis)”. The American Journal of Psychiatry. 161. 2295–2302.

Tehrani, Ali S. Saber, Lee, Hee Won, Mathews, Simon C. Shore, Andrew, Makary, Martin A., Pronovost, Peter J. & Newman-Toker, David E. 2013 “25-year summary of US malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank.” BMJ Quality & Safety. 22. 672–680.

Wegwarth, Odette & Gigerenzer, Gerd. 2013. “Trust Your Doctor: A Simple Heuristic in Need of a Proper Social Environment”. In Simple Heuristics in the Social World. Hertwig, Ralph, Hoffrage, Ulrich & The ABC Research Group. Oxford University Press.

Authors comment: This post was written after binging a season of “Doctors vs. Google” (originally: “Hva feiler det deg”) the Norwegian TV series that pits a team of people without medical education, but with access to google, against a team of doctors without google. The task: to correctly guess the diagnosis of people based on a brief anamnesis and some rounds of questioning. Andreas mentions the show in his post, which is where I found out about it, and it is worth watching, as it’s both entertaining and a fair showcase of the potential (and the limits) of what patients can achieve with the help of google. Though the doctors often come out on top, this is probably in part because in the weightiest task point-wise, a time constraint means that there is almost no time to use google.

Ainar Miyata-Sturm is a PhD student at the Centre for the Study of Professions (SPS), and part of the project Autonomy and Manipulation: Enhancing Consent in the Health Care Context. He is also the editor of Professional Ethics.

Photo: Sonja Balci

Professional ethics in the age of AI: Upgrading to v3.0

eilev on 6. September 2017

Andreas Eriksen, a philosopher who works on professional ethics and role morality.

Doctors versus Google

Can a team of laypeople armed with Google beat doctors at diagnostics? That is the premise of a Norwegian TV show that has won international acclaim. Doctors are seemingly happy to participate and defend the honor of their practice. But the very fact that this is a realistic challenge is symptomatic of a more general and fundamental shift in the traditional power base of the professions. Developments in the field of artificial intelligence and the proliferation of online services are making accessibility of knowledge less dependent on traditional modes of professional practice. I believe this calls for a new perspective in professional ethics that takes these shifts seriously. As I will explain, “professional ethics version 3.0” may be an appropriate term for this upgrade.

“Increasingly capable machines”

The developments that necessitate this new perspective in normative theorizing are vividly portrayed in Richard and Daniel Susskind’s book The Future of the Professions (2015). They argue that technology is dismantling the monopolies of the traditional professions—for the better. In what they call our current “technology-based Internet society,” new ways of sharing expertize are refashioning public expectations. The book presents telling numbers on how artificial intelligence and online services are outcompeting traditional practices of providing academic courses, medical information, tax preparation, legal advice and more. Tasks that have been performed by professionals are taken over by “increasingly capable machines” that allegedly deliver services cheaper, faster, and better.

Normative theorists need to consider what these findings and predictions imply with regard to standards of professional role morality. Given that we are facing complex and fundamental change due to the possibilities of artificial intelligence, theories of professional ethics need to address how this alters the ground for legitimate public expectations and the conditions of trust. In particular, how does technological change in practice affect the merits of professional decisions and actions?

Professional ethics before AI

The call for a “third version” of professional ethics may sound hyperbolical, but let me explain how it relates to two previous stages. Version one concerned individual professionals. The early professional ethics codes were highly aware of how the behavior and values of the single role holder reflected on the public standing of the profession as a whole. Although this aspect has never disappeared, we can speak of a second stage (version two) when organizations and their procedural regulations gained more attention. This has been called “the institutional turn” in professional ethics (cf. Thompson, 1999). While organizations have always shaped professional practice, the appreciation of their significance for professional responsibility was gradual. The question now is how the swift arrival of artificial intelligence and new modes of sharing expertize changes our moral relation to professionals.

Philosophers should work in tandem with sociologists here. In this regard, consider how a call for a transition from version one to version two was foreshadowed in sociological writing. Thirty years ago, Andrew Abbott noted in his cornerstone contribution to professional sociology—The System of Professions (1988)—that the public approval of professional jurisdictions rested on outdated archetypes of work. The professions want to appear as virtuous, but the public image of the virtuous professional did not really track institutional reality. Abbott drew attention to how the public continued to think of the professionals in the image of a romanticized past: “Today, for example, when the vast majority of professionals are in organizational practice, and indeed when only about 50 percent of even doctors and lawyers are in independent practice, the public continues to think of professional life in terms of solo, independent practice” (p. 61).

When machines become professionals

How is the third version special compared to the previous two? One important distinction is how the third version is gradually dispelling the social logic of ordinary morality, which arguably remained perceptibly intact even in the organizational setting. That is, the organizational aspect of professional practice does not by itself imply a radical break with the kind of interaction we are familiar with from the ordinary or non-institutional morality. There are still face-to-face interactions that enable immediate emotional responses.

Care, loyalty, and respect are key virtues of role holders in hospitals or classrooms. They are also concepts that most clearly apply to the relations between agents who encounter each other directly. To care about patients or pupils, for example, seems to involve being concerned about the condition of concrete individuals, as opposed to more abstract categories. Similarly, loyalty to clients often requires attentiveness to how needs and interests are expressed (how they matter to this client), not just mechanical subsumption under institutional rules. Moreover, respect for autonomous decisions requires that conditions are present for making a professional judgment about relevant agent capacities of the decision-maker (e.g., understanding, free deliberation).

A natural question, then, for those who have worked with ethical theories for traditional practice will be how the old concepts translate to the new scene. What happens to the values of professional practice that were grounded in genuine human engagement and direct emotional participation? Susskind and Susskind are not worried about this; they believe machines will become better than humans to engage with understanding and empathic emotions (2015, p. 280). But whatever the technological realism of this stance, there is reason to stop and consider the conceptual difficulties it faces. We appreciate sincere expressions of empathy precisely because they communicate genuine like-mindedness. Many of our emotional reactions are tied to ideas about human dignity, fellowship, and mutual respect. We might have to find a new moral base for our interaction with machines. My suggestion here is that the third version of professional ethics needs to explain how the traditional moral concepts change meaning and significance when professional work is being gradually decomposed into more specialized tasks where new technology takes over old tasks.

New standards for professional practice?

A professional ethics for the new age is not just about the substance of norms and emotions, but also about how the standards for this normative order are derived or constructed. That is, even the basic sources of legitimate professional standards may be changing. Professional associations have traditionally developed their codes through appeals to the “internal” or “intrinsic” values of their practice. Some may hold that radical change in this regard is called for by the opportunities of technology. Technology may not merely be a vehicle of diffusing information; it may entail a form of “democratization” of the legislative process for professional norms. For example, one could argue that what is needed, for the most part, are efficient systems for registering user contentment. Now that people are being serviced in greater numbers at greater distances, the argument goes, the important thing is getting tools for aggregating satisfaction and adjusting the systems accordingly.

I believe, to the contrary, the standards of professional ethics cannot be reduced to aggregating satisfaction. It is a mark of professional integrity to resist pandering, to aim to rectify self-serving beliefs, and to making decisions responsive to genuine professional values. While some choice-friendly aspects of the new systems can overcome pernicious forms of paternalism that were made possible by traditional practice, there is still a need to allow professional judgment to be a counterweight to mere user satisfaction.

What machines can’t do

One reason for emphasizing the need for professional judgment is the lack of collaborative ability in machines. There is no mutual agreement on the appropriate end to pursue; the machine cannot adequately make normative assessments of the cognitive processes of others and it cannot place goals within a larger space of meaning (a lifeworld). The machine basically aids us in achieving our ends as they are, with at most a weak ability to interpret our situation or make counter-suggestions. In short, machines do not understand us and do not engage with us to determine our goals. This is a point argued at length in Steven Sloman and Philip Fernbach’s The Knowledge Illusion (2017). These cognitive scientists are skeptical about the potential for automated services to replace professional judgment. One of their findings is that using services like WebMD has the effect of raising people’s confidence in their own level of knowledge, without raising the actual level of knowledge accordingly. People tend to have rather a blurred sense of the distinction between what they know and what knowledge is available.

What does this mean for professional ethics?

None of the above is an argument against letting technology change professional practice. It is rather a point about how a theory of professional ethics can highlight considerations to which the new system needs to respond. The professional practice of the “technology-based Internet society” should be reformed in light of the genuine virtues of professional ethics, not vice versa. While it is important to understand the gains in efficiency derived from compartmentalization, standardization, and automatization, it is also necessary to operate with an adequate conception of what kind of efficiency we should strive for. This does not just require the participation of practitioners of good judgment in the development of the systems. It also requires that theorists of professional ethics help articulate public frameworks for identifying the new ethical challenges that arise.

References

Abbott, A. (1988). The System of Professions. Chicago: The University of Chicago Press.

Sloman, S., & Fernbach, P. (2017). The Knowledge Illusion. London: Macmillan.

Susskind, R., & Susskind, D. (2015). The Future of the Professions. Oxford: Oxford University Press.

Thompson, D. (1999). The institutional turn in professional ethics. Ethics and Behavior 9(2), 109-118.

Andreas Eriksen is a Postdoctoral Fellow at ARENA Centre for European Studies.

Photo: Private