22 Things Amiss in Medicine Today
A column from Sep 6, 2011 by Dr. George Lundberg and Dr. Clifton Meador about a set of 22 false assumptions, practice failures, and everyday clinical errors that they believe are common in modern medical practice:
- Lack of appreciation of the phenomenon of physician persuasion and its hidden power. The placebo effect is scientific, potent, and worthy of use.
- Lack of understanding of the power of prevalence or pretest probability in the diagnostic process, leading to frequent false positives and “overdiagnosis” of nonexistent diseases.
- Lack of understanding that many disease processes are gradual and progressive — not "on or off" signals; analog and not digital. This leads to great confusion about when to diagnose and treat. For example, at what percent stenosis is an artery "diseased" and in need of treatment?
- Incorrect assignment of reductions in death rates and increasing life expectancy to curative medicine rather than to preventive efforts.
- Medicine has a tendency to remove many physicians from relying on direct experience and personal observations and replace this with a reliance on indirect information. This leads to an over-reliance on lab and imaging findings by both patients and doctors.
- Lack of long-term clinical outcome data, stratified by gender and age, leading to an inability to obtain a truly informed consent.
- The mind-body dichotomy, present since René Descartes in the 1600s, holds erroneously that the mind and body are completely separated. This false separation leads us to believe that the lack of evidence for disease in the body of a symptomatic patient confers a diagnosis of mental disease: Thus the non-helpful statement to the patient, "Don’t worry, it’s all in your head."
- Lack of appreciation for what is scientifically established versus what is still in the thought stage of development.
- A failure of medicine to recognize what it can effectively treat and what it cannot, and admitting that some diseases have no effective treatment.
- Failure to recognize that the fields of human biology and clinical medicine overlap but do not coexist. Schools of medicine are becoming more schools of human biology and less schools of clinical medicine.
- Absence of a test that will distinguish well from sick. The lack of a test leads to the erroneous assumption of sickness as the rule of thumb for almost all patients.
- Lack of a blood or urine test that can measure mental status. Dementia can be missed in up to 20% of admissions to hospitals.
- Lack of full understanding of the intense secondary gain of illness.
- Fallacy of the first lesion found being assigned importance, whether or not it is the cause of the symptoms.
- Fallacy of any lesion found being sufficient to explain symptoms.
- Failure to stop a drug or treatment when it is not helping.
- Failure to identify what abnormality or test result is to be followed to determine success or not, when someone is being treated.
- Failure to look for little signs of improvement and stick with the treatment rather than change it too soon.
- Failure to know a patient well enough to know what their wishes are in terminal or hopeless situations.
- Failure to recognize and advise the family when a condition or situation is futile and should move to palliation and comfort care.
- Failure to keep the number of drugs to a minimum.
- An exaggerated and unfounded fear of malpractice suits with abdication of professional responsibility just to avoid any chance of being sued.
And, number 22, perhaps the most important to today’s society:
Many of the false assumptions listed here can be found in Clifton Meador’s book "A Little Book of Doctors’ Rules" published in 1992 by Hanley & Belfus, out of print, but still available at Amazon.
