Medicine is a social practice. Doctors and patients do things ‘as one does them’ and there are about two and a half libraries to offer evidence of that. But there is an aspect of such practices that, I think, hasn’t been discussed enough. It’s the practice of medical/diagnostic errors. I was reminded of this when I went to see a doctor in Poland. This is my second post about the visit (the previous one was about how much it cost).
This is something I’ve been thinking about for some time. I think there is a significant difference in how medicine is practiced in the United Kingdom and in Poland (I would suspect these practices are not limited to these two places). And so, I want to stress that I am writing only about my experiences. I would like to do research on it but so far, I haven’t.
And so, the two ways on practicing medicine are about how medics deal with type I and type II errors. These errors are called false positives and false negatives, respectively. The former is often called a false alarm. It happens when a doctor’s diagnoses/indicates a condition/disease when none, in fact, exists. There are many anecdotes about doctors diagnosing a terminal disease, their patients selling all their possessions in order to have fun in the last months of their lives, only to discover they are in fact healthy. The false negative is the opposite. It’s when a doctor declares all clear when, in fact, you are ill. I haven’t heard any funny anecdotes about such a scenario, probably because the scenario can be quite grim.
And so, when I go to see a doctor in my native Poland, the doctor is at pains to make sure that s/he does not miss an illness. Polish doctors seem to be quite scared of false negatives. I would suggest that it might be about the assumption that if I come to see the doctor, there must be something wrong with me and the doctor’s role is to discover it. This is why you often leave the doctor’s surgery with tests to be done just in case. In fact, on a few occasions I actually left a doctor’s surgery with medication ‘just in case’ I would feel worse or the possible (suspected) condition would develop. It’s better safe than sorry for Polish doctors – it seems that it’s better to err on the side of illness and make sure that you do not fall prey to a false negative.
Interestingly, British medicine is the opposite. Doctors here seem to be scared of a false positive more than of anything else. British medics’ favourite course of action seems to be ‘paracetamol and plenty to drink’ and waiting. Well, watchful waiting. This is the way to go, as one of the most celebrated texts in British medicine is called ‘The art of doing nothing’, written by Iona Heath. It’s an apologia for all those brave doctors who decided to do nothing. Nada. Zilch. As Polish doctors are visited only by ill people, British doctors seem to think that their patients are oversensitive wooses who just can’t wait a couple of days or weeks during which they would discover that they are in fact fine and they will not waste the doctor’s precious time.
I must admit that sometimes, I actually wonder about the nature of death in British medicine. If I die, at least there will be certainty I was actually ill. My death would offer the moment the doctor would know for sure they were right. Die and prove me right! And all of you who balk at the thought, let me tell you then when I saw my GP after my myocardial infarction about a year and so ago, he seemed to be genuinely pleased. The smile and his happy ‘It’s finally happened’ suggested that I offered him relief. He was, after all, right. He seemed to have been waiting for my heart attack to congratulate himself on a job well done. And now, he could genuinely do something. Before the hospitalisation, well, let’s wait some more, let’s make sure. And what if I die? Oh well, at least we would know for sure….I’m going too far? Well, I must admit it doesn’t feel too far.
And so, when you do your battery of tests in Poland, in the UK you pop the paracetamol in, as the doctor ponders how to be even more frugal with the bloods. I would not, of course, underestimate the role of the financial context of the blood tests – after all in the NHS, it’s the taxpayer who picks up the bill.
I’d suggest that it is this attitude to the type I error that results in British doctors debating till they are blue in the face the notion of ‘too much medicine’, with the BMJ offering an institutional anchor to the initiative. Indeed, when you google ‘too much medicine’, half the internet will be in the results. It gets better. Even when you type ‘too little medicine’, the results of ‘too much medicine’ appear! No, no one seems to be bothered about whether I could have too little medicine.
And me? Well, quite a number of my blogs where about watchful waiting and how much I hated it. I continue to wonder why it’s about ‘too much medicine’ and not about ‘as much medicine as is needed’. I also keep preferring the option of doing more. At least on me it has a therapeutic effect of the doctor doing something. I do hate Iona Heath’s notion of the doctor’s courage to wait. I keep thinking that this is courage at my expense, and as doctors congratulate each other and themselves on their bravery, I do wish they spared a thought for me. I wrote more about this in the post on the art of doing something.
Yes, I understand the argument that more tests might mean more worries. But does it? As I was asked to do strange sounding tests a couple of weeks ago, I had absolutely no idea what they meant or what exactly they were for. Moreover, the doctor explained why she was ordering them. Was I worried? No, not really. I felt that at long last someone took me seriously and was wanting to do a thorough job. I somehow doubt that I am the only one. Moreover, I would love to hear a discussion on such arguments when you bang on on end about too much medicine.
But I want to finish with a different reflection. Again, judging by how I thought about medicine, I think we, patients, tend to perceive clinical judgements in terms of objectivity and impartiality. The doctor will order whatever tests are necessary, and such a decision is based on sound medical knowledge and, probably, the doctor’s experience. It hasn’t, and cannot have, anything to do with a sort fashion or group obsession. But can it? As I (hopefully) understand practicing of medicine more and more, I wonder whether doctors I see understand it. How much do they reflect on the sources of their decisions? What are those sources? To what extent are they medical? To what extent are they social with a huge unpicking to be done what exactly that would mean?
Some time ago, a Polish doctor asked me whether I preferred Polish or British doctors. I said that British doctors are hands down better in setting up and maintaining relationships with their patients. Yes, of course, it’s not paradise and running on a flowery meadow in slow motion on a sunny afternoon, but on the whole, the British reflection on how to communicate, on empathy, on therapeutic alliance is a very important one. I do wish such a robust debate on the doctor-patient relationship were happening in Polish medicine.
But on balance, I prefer the way Polish doctors practice of treating patients. I really hate watchful waiting and I did way too much of it. I really would prefer my GP to tell me that he was doing something. Waiting meant more suffering on my own, as the doctors were pulling silly faces aiming to tell me how they cared. And if doing something had meant mistakes, wrong decisions, well, so be it, at least I would have known that medicine was on my side. All too often did I think that I was on my own.
And finally, even my worst consultation ever (I described it here) didn’t end with watchful waiting. It ended with that nightmarish doctor sending me to hospital for tests. I dearly hated that doctor, but, it’s worth mentioning, that her gut feeling proved to be right. 3 months later I ended up in hospital because I ignored her.