Particularities of Individuals

I continue to read experiments from the various branches of psychology. And they continue to mystify me. Who do they apply to? What is one to make of these generalizations derived from incomprehensible statistical analyses? When examined closely, the differences between conditions or individuals are due to multiple factors and relatively small, albeit statistically significant. What kind of game is this statistical analysis anyway?

When I find myself pondering these questions, I often turn to the work or Robert Coles. Coles is one of those rare individuals who combine a deep appreciation and knowledge of literature with his work as a physician, social researcher, and child psychiatrist. A recipient of one of the first MacArthur genius awards, he is the author of over eighty books and is Professor of Psychiatry and Medical Humanities at the Harvard Medical School.

For years Coles has taught a legendary course on the relationships between literature and the practice of medicine. He attributes his life-long interest in this topic to the work of the poet and doctor William Carlos Williams who became a close friend while he was a medical resident. In an interview Coles said, “I became so impressed with the dual life he lived as a physician and as a writer/social observer of sorts that I thought maybe I’d give it a try myself.”

In Times of Surrender Coles writes about his friendship with Williams and how it led him to realize the inherent affinity between medicine and literature—their common interest in the concreteness of particular human experience. Williams had written

“The abstract, categorical mind can be wonderful…But we‘ve got to keep a close check on all that....The doctor treating a patient out there on the front line falls back on himself…and he has to come to terms with not only a disease but a particular person: this patient, not patienthood, not lungs, in general, or kidneys or hearts in general, but one guy, one gal, one kid who has some trouble and is handling it in a way that may be different than anyone else’s way!”

And in his own work, Coles has emphasized he uniqueness of each individual; that variation is ever-present in the work he does. He put it this way, “I’m constantly impressed with mystery, and maybe even feel that there are certain things that cannot be understood or clarified through generalizations, that resolve themselves into matter of individuality, and again, are part of the mystery of the world that one celebrates as a writer, rather than tries to solve and undo as a social scientist.”

This is why he and other physicians have turned to literature and to writing about the lives of particular individuals, whether in a work of fiction as in Chekhov, Walker Percy and recently Rivka Galachen or non-fiction, as exemplified in the recent articles and books of Jerome Groopman and Autul Gawande, both of whom I have written about in this blog.

Doctors often write well because they never loose sight of specific patients and the way they express their illness. In his essays, Groopman has reminded us how our current medical beliefs are subject to qualification and often refutation. This is often the case with comparative research studies (clinical trials), whose findings may be relevant to some patients but not to others. These studies usually fail to pinpoint those to whom it applies and those to whom it doesn’t.

In reading literature we get to know a person as an individual, not an example of a personality dimension or character type. Quite often we get to know them better than the so-called real people we know or read about in research reports. In Reading Chekhov, Janet Malcolm wrote, “We never see people in life as clearly as we see the people in novels, stories, and plays; there is a veil between ourselves and even our closest intimates, blurring us to each other.”

And we don’t have to worry if their lives follow a common pattern or theoretical prediction. Their life is its own truth--unique and non-replicable.

Who Knows Best?

Jerome Groopman’s essay, “Health Care: Who Knows “Best”?” in the February 11th New York Review of Books isn’t going to help pass the moribund legislation before Congress. Groopman argues that there are serious problems in relying on studies of comparative effectiveness to improve the quality of care--one of the central components of both the House and Senate bills.

Obama often says, Let’s study and figure out what works and what doesn’t. And let’s encourage doctors and patients to get what works. Let’s discourage what doesn’t.

According to Groopman, it’s not quite that simple. The findings of comparative effectiveness research are always open to further testing and ultimate refutation or qualification. What is true today is often false tomorrow.

Groopman cites several examples: “Best practices” research once demonstrated that blood sugar levels should be tightly controlled in critically patients in intensive care. Later research showed that this practice was not only shown to be wrong but resulted in a high likelihood of death when compared with measures allowing a more flexible treatment and higher blood sugar.”

He points to another failure in treating hip and knee replacement by orthopedic surgeons. In this case, conforming to or deviating from the “best practice” procedures based on comparative research had no effect on the rate of complications from the operation or the outcome of the treated individuals.

Groopman claims physicians are growing increasingly dubious of efforts to standardize clinical practice based on comparative effectiveness studies.

“…clinical trials yield averages that often do not reflect the real world of individual patients, particularly those with multiple medical conditions. Nor do current findings on best practices take into account changes in an illness as it evolves over time. Tight control of blood sugar made help some diabetics, but not others.”

As our knowledge of the disease process grows, the care and treatment of patients has become overwhelming complex. So it is not surprising that the clinical application of the best practices model is fraught with difficulties. As Groopman points out, the findings fail to distinguish between those patients where it works and those where it doesn’t.

To add to this complexity, Groopman develops further the role of cognitive biases in medical decision making and the pitfalls of human reasoning in situations where an easily made error can end a person’s life. He takes special note of the following potential sources of error

• Overconfidence Bias—over estimating the importance of his own work and analytical skills

• Confirmation Bias—the tendency to ignore and discount contradictory evidence

• Focusing Illusion—basing a decision on a single patient change that is mistakenly employed in predicting the effects on the overall condition.

Groopman’s essay calls into question one of the basic tenants of Obama’s health care proposal. He concludes: “The care of patients is complex and choices about treatments involve difficult tradeoffs. That the uncertainties can be erased by mandates from experts is a misconceived panacea, a focusing illusion.”

This does not imply comparative effectiveness research should be disregard. To the contrary, it means there is much more that has to be taken into account in medical decision making-- the history and state of the individual patient, the boundary conditions of the research findings, the experience of the physician in dealing with the patient’s problem and the numerous value judgments that both the physician and the patient will want to consider.

Medical Reasoning

Lately I’ve been hearing one tale after another about the problems people are having with their medical care—can’t get an appointment, duplicate billing, failure to return calls, in some cases, calls that require immediate attention and finally perhaps the most frequent, incorrect or delayed diagnosis. Who has not heard such tales?

In the November 2009 New York Review of Books, Jerome Groopman, author of How Doctors Think, gives a thought-provoking account of why patients sometimes receive such poor care. He begins by describing a clinical conference he conducted for interns and residents at the Massachusetts General Hospital.

The conference focused on how doctors arrive at a diagnosis of their patient’s ills. “Some 10 to 15 percent of all patients either suffer from a delay in making the correct diagnosis or die before the correct diagnosis is made.”

At once I was struck by Groopman’s methodological approach to this problem. Unlike the usual one of discussing medical successes, Groopman begins by discussing failures. He writes, “The most instructive moments are when you are proven wrong, and realize that you believed you know more than you did, wrongly dismissing a key bit of information that contradicted your presumed diagnosis…”

Science or any empirical discipline (or individual for that matter) doesn’t move forward by pointing to its successes. If that were the case, it would scarcely ever change. Rather we learn far more from the mistakes that have made, from those cases that disprove our conjectures.

Groopman points out that the most common sources of diagnostic errors are the cognitive biases that physician’s make in trying to understand a patient’s condition. (These errors are not confined to physicians. Rather they are errors that anyone is prone to make in making a decision under conditions of uncertainty). He identifies three of the most common biases:

…anchoring where a person overvalues the first data he encounters …; availability where recent or dramatic cases quickly come to mind and color judgment about the situation at hand; and attribution where stereotypes can prejudice thinking so conclusions arise not from data but from such preconceptions.

The second notable methodological point in Groopman’s account is his emphasis on the limits of empirical generalizations in any particular case. He points out that subjects in clinical trial investigations (upon which these generalizations are based) are often highly selective as those who have multiple conditions or are taking other medications or do not fit into a narrow age range (usually too old or too young) are excluded from the study

Groopman comments, “Yet these excluded patients are the very people who heavily populate doctor’s clinics and seek their care.”

The other major sources of physician error stems from the heavy patient load they are now asked to carry. One physician “said she spends less and less time conversing with her patients. Instead she felt glued to a computer screen, checking off boxes on an electronic medical record…”

Another pointed out that “…work rounds were frequently conducted in a closed conference room with a computer rather than at the patient’s bedside.” And finally in describing the case of a seriously ill cancer patient, Groopman reports that “… no one attending to her had sat down in a chair at her [hospital] bedside and conversed at eye level, asking questions and probing her thoughts and feelings about what was being done to combat her cancer and how much more treatment she was willing to undergo.”

This may be hard to believe for anyone familiar with the days when doctors routinely came to your home if you were will or told you to come right over to his or her office if you felt poorly, or indeed, called you at the end of the day to see if you were feeling any better.

In the end Groopman makes clear that the solution to these problems will come about “…only by dogged thinking that requires the kind of time and inquiry that is absent in much of modern medical care." Dream on Dr. Groopman

Decision Making Errors

I was reminded of Jerome Groopman’s recent book, How Doctors Think, in blogging about medically trained writers yesterday. Groopman writes about the biases and errors that intrude on the decision making process of physicians. They occur far more often than is normally believed, sometimes with devastating consequences.

When I read the book, I was impressed by Groopman’s knowledge of recent cognitive research on heuristics and biases. His account is up-to date in all respects.

Some of the errors that physicians make can and do often occur to anyone. Groopman’s goal is to insure that when physicians shift from theoretical studies to practical applications, they are more mindful of the biases and uncertainty inherent in diagnosing patient illnesses.

He believes that overconfidence is one of the most common errors that physicians make, largely as result of their past diagnostic experiences. He writes: “You have to be prepared in your mind for the atypical and not so quickly reassure yourself, and your patient, that everything is okay.”

And later: “I learned from this to always hold back, to make sure that even when I think I have the answer, to generate a short list of alternatives. That simple strategy is one of the safeguards against cognitive errors.”

Taking issue with Malcolm Gladwell’s claims his wildly popular Blink: The Power of Thinking Without Thinking, Groopman cautions about making snap diagnostic judgments based on intuition.

He writes: “Much has been made of the power of intuition, and certainly initial impressions formed in a flash can be correct. But…intuition has its perils. Cogent medical judgments meld first impressions—gestalt—with deliberate analysis.”

In addition to Overconfidence some of the common inferential errors that Groopman discusses include the following:

Representative Error: Your decision is too strongly influenced by a prototype “so you fail to consider possibilities that contradict the prototype and thus attribute the symptoms to the wrong cause.”

Confirmation Bias: Your decision is based on attending to supporting evidence exclusively, ignoring or “minimizing data that contradict it.

Commission Error: “This is the tendency toward action rather than inaction.”

Availability Bias: Reaching a decision on the basis of a recent, vivid or easily recalled situation that is unrepresentative of case under consideration.

Groopman suggests that “most misguided care results from a cascade of cognitive errors.” He urges physicians to avoid premature closure, indeed, to be ever mindful of alternative accounts and keep inquiring “What else could it be?”

Everyone could benefit from such advice. It bears repeating: “Be ever mindful of alternative accounts and keep inquiring.”