Wednesday, December 31, 2014

A Tricky Question

This article first appeared in the December 2014 issue of the RACGP Publication Good Practice. I have linked to PubMed for the articles, and included links to full text in the references at the end.

One of the most difficult questions in healthcare may be, “Are you a good doctor?”

I am sure, dear reader, that you are a good doctor. You know everything, and you know the things you need to learn. You can see through the twinkle in a drug rep’s eye faster than you can say Vioxx. You are all much better than average, and, even as you know enough statistics to be able to dismiss this as an impossibility, you also know that it is certainly not you who is below average. 

Now that we are patting each other on the back in mutual admiration, here are some people to spoil the party. Let me introduce you to Dr Dunning and Dr Kruger, who won an Ig Nobel prize in 2000 for their work, in experiments showing those who were the least competent in various tasks were also the most likely to rate themselves highly competent.

They also found the same people are the most self-confident. There’s something about not being very good at something that makes you blind to the areas that you don’t know, or even realise that they exist. It’s a good job nothing like that could happen in medicine.

Except, however, research evidence can sometimes be as disquieting as a mirror in a brightly lit room. In JAMA in 2006, Davis and colleagues did a systematic review comparing self-assessment with external observation. The evidence revealed that we are not very good at assessing our own competence. Meanwhile, two years later In Medical Teacher, another systematic review also shows us that we are not that good at assessing our own learning needs.   

In both situations it is the least skilled of us who are the worst at self-assessing, and who are the most confident. 

And then there’s research that consistently shows we think we’re immune to drug repmarketing, no matter how often it’s shown that we’re not. This evidence is entirely consistent with other sociological and psychological research, which confirms that doctors are part of the human race, no matter how much we want to think our training makes us otherwise.

Apply Dunning and Kruger’s research to our profession, and you can see the danger in asking “Are you a good doctor?” It may be the very areas in which we feel highly confident are just those areas we are worst at. It may be that those of us who think they are expert at seeing through drug rep spin are those most susceptible. 

What if those of us who say they are good doctors are the ones we need to be most wary of?

Of course, you could dispute the evidence. All that stuff about education and drug reps doesn’t apply to you, or to Australia. But that is just what you would say, wouldn’t you, if you were subject to the Dunning-Kruger effect! 

In order to show how competent we are, we might have to admit some uncertainty over our competence. In fact, in real life, I have discovered that the doctors I really admire all feel that they will be tapped on the shoulder and outed as a fraud at any moment.

For any eager regulators out there wanting to put conditions on the registration of anyone admitting they think they are a good doctor, the solution is even simpler. As a profession, with specific knowledge and expertise, self-regulation often means peer review. We need - and should welcome - others around us to help us see our blind spots. Perhaps “Are you a good doctor?” is not such a dangerous question if the answer is “You’re asking the wrong person.”

Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. Journal of personality and social psychology. 1999 Dec;77(6):1121-1134.  

Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA : the journal of the American Medical Association. 2006 Sep;296(9):1094-1102

Colthart I, Bagnall G, Evans A, Allbutt H, Haig A, Illing J, et al. The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Medical teacher. 2008 Jan;30(2):124-145.

Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003 Jul;290(2):252-255

The Hunger Games

This article first appeared in the July 2014 issue of the RACGP Publication Good Practice. It was written for a GP audience, who I hope would have fond memories of all the food terminology. Perhaps it was just me. The published version was edited slightly, but this is the original.

Being a doctor makes me hungry. Surely, many of us spend a morning clinic thinking about lunch, and an afternoon clinic wondering about dinner. I’m pretty sure it has been the same throughout history. I imagine Hippocrates eating herring, Galen tucking into grapes and Vesalius enjoying veal. However, I think they had stronger stomachs than me. I trained at one of those traditional medical schools that did dissection, and the combination smell of meat and formalin meant I was never hungry. 

This didn’t seem to be true for previous generations of pathologists, though. All those historical types were clearly distracted by their stomachs, as any quick leaf through a medical textbook will tell you. I imagine that as their assiduous students examined yet more examples of pathological body fluids, they’d ask their teachers for adequate descriptions.
“What does this stool look like?”

“Redcurrant jelly.”

“And this one?”

“Rice water. Better wash your hands. It’s supper time.”

There would be no fluid too disgusting to describe in tasty terms, every internal organ was ripe for culinary description.

“Your next patient looks a little unwell. Yeuch, he’s just vomited in the waiting room.”

“So he has. And, my goodness, it looks like coffee grounds. Remarkable.”

“Oh. I thought it looked like soil.”

“Watch and learn, dear pupil.”

The analogies continued. As they probed deeper, medicine became like a banquet. The main course was cauliflower ear, with subtle flavouring found in livers that looked like nutmeg. The cheese course was supplied by chest granulomas described as caseating. No-one could resist the chocolate cysts on the ovaries. After the food had settled, the skin was eagerly examined for port wine stains and café-au-lait spots.
It appears we might now be running out of foods to use. Arguments break out, amid confusing errors as to precisely which diseased organ looks like a strawberry. 

“Wasn’t it that strawberry naevus?”

“No, I thought it was a strawberry cervix.”

“Actually, I was talking about the strawberry tongue. I’m not sure how you missed it!”

I’m not sure I believe they really could see these things. Perhaps all they were cooking were the books.

And back to reality. If the thought of all that pathology puts me off my next meal, this is reinforced by my next patients who bring with them the strangest of menus. The first person tells me he has a frog in his throat. The next person has butterflies in her stomach. She’s worried, she tells me. Something is eating away at her. Up next is someone who knows something is wrong from her gut instinct. It’s quite a relief to find my next patient is so hungry she could eat a horse, but she is pleased as the treatment seems to be bearing fruit. My final patient has a few lumps in various places, which I carefully examine and document their sizes – a grain of rice, a pea, and, most surprisingly, a grapefruit. 

I reach the end of my surgery, running particularly late. After this procession of unpalatable symptoms, all I have the appetite for now is my apple, which is successful at keeping the doctor away from his lunch.

As my afternoon patients start arriving and peeling off their coats in the waiting room, I anticipate the feast to come. I reassure myself that, running late, slow food is healthier for all of us. Feeling better, my appetite for the work is not diminished. I look forward to the afternoon with relish.