Thursday, July 25, 2013

Why Lisa Can't Run

Lisa Rosenbaum is a cardiologist who used to be an “avid runner.”

Naturally, when she injured a hamstring she sought the best medical care. As a physician she was well placed to find the best doctor.

But that’s not what happened. Writing in The New Yorker Rosenbaum compares her experiences with two different physicians, a man she calls Dr. D. and a woman who she designates as “my person.”

The two physicians took radically different approaches to Rosenbaum’s hamstring.

Here she tells her story:

I used to be an avid runner, but have had a slew of running injuries—the most enduring of which is a chronic hamstring problem that has made sitting uncomfortable, and running impossible. But for a long time, my approach to any given injury was simple: run through it.

In my quest for quick fixes, I have seen more orthopedists than I can count. But there was one doctor, Dr. D., who tried to teach me the error of my ways. He told me that the problem was not with my body but with my behavior. He said I didn’t need MRIs or steroid injections but rather to stop running and give myself time to heal. And I, in turn, found much that was wrong with him: he started late, didn’t return phone calls, had bad breath, typed with one finger, and, above all, didn’t seem to listen to me. I decided he was the worst doctor in the world and went searching for a new one.

Many months and doctors later, last year, I found “my person.” Most important, she told me I would run again. That she was so nice, so pretty, and so put together (and she injected my aching gluteal region with steroid every time I asked) only reinforced my sense that I was in the most expert of hands. I loved her as much as I wanted to be her.

If you had mailed me a satisfaction survey, you can imagine which doctor would have gotten a bonus. But in the end, it’s Dr. D who was right. I still can’t run, but had I heeded his advice, I’d likely be back to doing marathons.

If we were talking about an everyday patient with limited medical knowledge, her choice would be easily understood. Uninformed patients are more likely to allow themselves to be influenced by the packaging and the appearance. They do not know enough about the science so they respond to what they do understand.

Yet, how can a patient who knows science have so easily allowed herself to be seduced?

The cognitive scientists call this a “halo effect” and associate it with cognitive bias. But, isn’t this really just a modern variant on the idea that love is blind?

Many patients, no matter how well informed, choose the thrill of having the best dressed and best looking physician with the best decorated office.

It’s not just about love. It’s also about status. Rosenbaum’s preferred physicians seemed to have a much higher status. Thus, she could talk about consulting with her “person” with her friends and enjoy the benefits that accrue to someone who associates with a more important physician.

Apparently, these thrills compensate for the failure to get better.

To be fair, how many of us would also have dismissed Dr. D. out of hand? His poor manners, his bad breath, his failure to return phone messages… wouldn’t that have set off your mental alarms.

Shouldn’t someone tell Dr. D. that mouthwash will not compromise the way he practices medicine.

Rosenbaum is questioning patient satisfaction surveys. Apparently, physicians who tell their patients what they want to hear, who are better looking and more willing to give injections receive higher ratings than do those who tell the truth and offer the most effective treatment.

One must note that Dr. D. was not going to get rich advising his patient to change her behavior. Rosenbaum’s other doctor was undoubtedly doing much better financially by dressing up, offering a swanky locale and injecting steroids.

One might note, as Rosenbaum does, that oncologists, for example, find a therapeutic benefit in allowing their patients to believe that a treatment might be more effective than it really is.

But, Rosenbaum’s hamstring problem does not fit in that category. Besides, a new study suggested that patients who liked their physicians more spend more on medical treatment.  This produced higher mortality rates.

In her words:

But do higher scores on a satisfaction survey translate into better health? So far, the answer seems to be no. A recent study examined patient satisfaction among more than fifty thousand patients over a seven-year period, and two findings were notable. The first was that the most satisfied patients incurred the highest costs. The second was that the most satisfied patients had the highest rates of mortality. While with studies like this one it is always critical to remember that correlation does not equal causation, the data should give us pause. Good medicine, it seems, does not always feel good.

I think she is right not to jump to conclusions, but the next time you consult with a physician who has a perfectly appointed office and whose appearance oozes glamor, be skeptical. And the next time you consult with an unkempt, disorganized physician who offers advice that does not seem to benefit him at all, pay closer attention.


Webutante said...

I too suffered an IT band problem last spring while climbing mountains and jumping on and off 4-wheelers. Thought it would heal quickly but it didn't...and was constantly exacerbated by climbing steps at home and more mountains in Wyoming....

So when I got out west, I did sports medicine, deep massage, acupuncture (and cupping whatever in God's name that is) chiropractic along with icing to the point I gave myself frostbite on my right thigh, Tylenol, ALEVE which has made me terribly drowsy all day and DMSO which makes me smell like garlic and doesn't help that much either.

The one who got it right for me was the chiropractor who sat me down and told me to take it easy this summer and not climb I could hike in the fall and get back to normal.

So I finally took his advice and am doing ice, rest, flat walking
and warm Epsom salt wash cloths---for as long as it takes....this is not what I wanted to do either, but have no other choice....

What a great piece on being snookered by superficialities in doctors.

Bobbye said...

Stuart, you are correct in stateing that people give higher satisfaction marks for physicians or facilities that do more instead of less, whether or not doing more helps or hurts. People want to be told that someone( the physician) can fix what is wrong. The idea that medicine is science is only marginally valid. Physicians get doctorate degrees in 'The Medical Arts' not in Medical Science. Physicians have 'practices'. Chemists, physisists, and engineers do not have 'practices'. Hey Mr. Einstein, where's your physics practice located? Huh?

JPL17 said...

And the next time you consult with a[] ... physician who offers advice that does not seem to benefit him at all, pay closer attention.

Amen to that! Years ago I was experiencing severe tooth pain. I was sure it would require root canal, so I made an appointment with the endodontist nearest my office. He examined me for about a minute, asked a few questions, and then announced he could do nothing for me because I didn't need root canal. He recommended a simple procedure that my regular dentist could do instead.

Dumfounded that I'd discovered an endodontist who couldn't find any reason to perform a root canal, I followed his advice. Of course, it worked.

Bottom line, I've recommended this endodontist to friends numerous times, just on the basis of this one visit.