I’ve been mulling over this topic for awhile, but it’s been more of a passive, background consideration as opposed to an active inquiry – until now. Recently, I read this comment on my guest post for KevinMD, Dear Alternative Medicine – Stop Testing!
Doctors like yourself who take pride in bashing alternative medicine practitioners, do you even ask yourselves why people keep going to these folks. These are not poor [un]educated folks who you could argue do not know any better. Many of these people are rich, educated and probably smarter than you.
I’m going to let the lumping of poor and uneducated go for the time being, as quibbling with that would waylay me from the point of this piece. I will, however, focus on the fact that rich, well-educated people who are smarter than I make incredibly stupid decisions about their healthcare.
Understanding that the first thing people think of when they hear about intelligent people making dumb medical decisions is Steve Jobs initially refusing surgery for his pancreatic mass – a cancer that ultimately led to his demise – I don’t want to use that as my index case. This unfortunate series of events has been covered ad nauseam over the years, with the most comprehensive and thoughtful treatment I’ve seen on the website, Science Based Medicine. I recommend reading the articles in order: here, then here, and finally here.
Before diving into the specific reasons why brilliant folks can’t be trusted with their own bodies, we need to explore a few critical, general concepts that influence our decision-making processes:
Intelligence breeds hubris.
Think about the people you work with, or your family members, or perhaps the know-it-all at the golf club in your retirement community. I’m guessing it took you all of three seconds to come up with the name of a smart person you know who’s been drinking his own Kool Aid. Doctors are actually a great example of this concept. Most of us are pretty darn smart, which leads us to assume that we should naturally excel in any endeavor. What we fail to realize is that, the reason why we’re so successful practicing medicine is because we have dedicated tens of thousands of hours to the study of medicine. Our accumulated medical knowledge does not translate into expertise assessing – for example – investment opportunities, which explains why high-income physicians are among the most frequent targets of unscrupulous financial industry shysters.
Investment crooks take advantage of the fact that physicians don’t like to look stupid, and we are usually not humble enough to admit when we don’t understand something. When presented with a complicated “business opportunity,” a physician with an aversion to not being the smartest person in the room may smile and nod as the finance guy explains the deal, without fully knowing to what he’s agreeing. The truly amazing aspect of this interaction is that, by the time the deal is signed, the doctor has convinced himself of the greatness of this opportunity, which of course reinforces his belief that his innate brilliance led him to this point.
Sound like a good way to arrive at a sensible decision? Didn’t think so. You may be a high-powered professional, a retired Master of the Universe, or simply a whip-smart person with impeccable logic, but if you aren’t humble enough to realize that your doctor may know more about your body than you do, you probably can’t be trusted to consistently make good healthcare decisions.
Intelligent people have a harder time maintaining awareness of their inbuilt, cognitive biases.
In their book, The Stupidity Paradox, Mats Alvesson and André Spicer explain how we tend to make split-second decisions; then, we search for facts to back up our decisions. Along the way, we ignore facts that don’t back up our arguments. Instead of carefully weighing evidence, we make our decisions based on past beliefs or chance associations.
In medicine, I see patients do this every day, multiple times per day: “I had mussels a few nights ago, which I rarely eat, and then yesterday I broke out in a rash and my right knee started to hurt. Must have had a reaction to those mussels!” Yes, I see really smart people use this incredibly non-intellectually rigorous process to arrive at conclusions about how their bodies operate.
Questioning our beliefs makes us uncomfortable, so when the facts don’t support our beliefs, we prefer to change the facts. I need look no further than my own organization for an illustrative case. A few years ago, we went through a painful round of cost-cutting measures, which were billed as necessary for the continued viability of the group. One of the measures included an ill-conceived reorganization of a process that is critical to the operational success of any large healthcare group – I’d love to be more specific, but any further details would make my identity obvious to anyone from my group who stumbles across this blog.
Suffice it to say that the decision was made impulsively, facts supporting the decision were touted in talking points, and facts contradicting the decision were studiously ignored despite the objections of many strident voices. 2-3 years and millions of dollars in lost revenue later, our administrators have finally owned up to the mistake and are taking steps to right the ship. Even after the admission, though, they still maintain that the initial decision was the right one – it just wasn’t well-executed. Sorry guys, but no. My practice is still suffering from the fallout, and the current attempts to fix it feel like elaborate but ineffectual workarounds. This provides a segue into my next point:
If you’re not humble enough to admit and fully own a mistake, you are doomed to repeat it.
When we blame others or otherwise make excuses for our mistakes, then we clearly haven’t learned from the mistake. Many high-functioning people will readily admit that they have learned more from their mistakes than their successes, which should make perfect sense to all the smart folks out there. Whenever something transpires to mar an otherwise admirable record, we hone in on that and try to fix it. More importantly, we ask how it can be prevented from occurring again.
Unfortunately, in order to get to this point, we have to be capable of resisting the entirely natural impulse to be defensive. It’s ok to have a defensive reaction; we all do. But the highest performers out there can breathe with that emotion for a few seconds, and then begin the harder work of asking themselves the tough questions: How did this happen? What went wrong? How can I do better?
Now that we’ve explored the general concepts that govern our flawed decision-making process, let’s dive into the specific reasons why we make stupid choices when it comes to our health:
1. We employ magical thinking. Why would otherwise intelligent people – who probably don’t aim the Cruciatus Curse at a particularly unpleasant coworker and expect it to actually work – believe that homeopathic tinctures with one part per billion of active ingredient will cure their ailments? I think it has something to do with the fact that the body is an extraordinarily complex organism and is incompletely understood. If it is incompletely understood by doctors who have spent years studying it, then it’s not surprising that laypeople could be taken in by treatments that promise an easy, safe, low-risk fix for problems. They could work, right? I mean, when we get right down to it, who really knows what’s going on inside this mysterious mass of carbon? Maybe the anti-inflammatory and anti-neoplastic properties of turmeric could slow down the growth of the metastatic tumors raging in your liver. Yes, anything is possible in medicine, but not everything is likely.
2. The desire to believe is powerful. This is the corollary to employing magical thinking. Have you ever read the reviews for a supplement – any supplement – on Amazon.com? Every potion seems to have a 5-star rating. Seriously, the rare comment that “it didn’t work” is drowned out by a cacophony of positive gushing. The true beauty of this is that, whatever the supplement claims to do, it works. The same pill can cure reflux, decrease joint pain, banish headaches, increase libido, and cause weight loss – it’s good news about the stronger sex drive, because that increased libido will come in handy when your new, thinner body starts getting noticed more by other horny supplement takers. Listen, the idea that swallowing a few pills can dramatically change our lives is incredibly appealing, and it tends to cause even the most level-headed people to get carried away. It can be very difficult to be objective about the probability of something actually working when there are scores or even hundreds of bots – er, I mean people – claiming it changed their lives.
3. We are wired to seek out the simplest explanation, but if the simple fix is hard, then we’re wired to seek out the easiest fix. We have an axiom in medicine that the simplest explanation is usually the correct one. Therefore, it must stand to reason that your fitful sleep, insulin resistance, and poor exercise tolerance could all be fixed by finding the single mineral in which you are deficient. Just take some magnesium – that’ll address everything. Simple. Done? No. Taking magnesium is easy and can sometimes be useful. But the simple explanation here is that your diet, sleep hygiene, stress management, and workout program all need major tune-ups. If that sounds way harder than just popping some magnesium pills, it’s because it is.
4. We want to be “natural.” After all these years, I’m still flabbergasted by patients who are eager to take supplements for diseases they don’t have, while refusing to take medications or have surgery for diseases they do have. You want to be natural? Eat well, exercise well, sleep well, meditate, manage stress, and nurture your relationships. The universe provides all these opportunities free of charge, and none needs to be detoxified by your liver. Of course, if you have a real disease with a well-recognized pharmacologic option that is known to be effective, then for the love of all that is holy – take your medicine, and stop experimenting with unregulated chemicals that only work for Amazon.com customers.
5. We suffer from “I was never like this before” syndrome. About 8 or 9 years ago, I noticed that I had a few pairs of pants that felt snugger in the waist than previously. I was pissed…that my pants were clearly shrinking. My spouse must have put them in the dryer instead of hanging them to dry, right?! Putting aside that I do most of the laundry in our house, I was completely blind to the possibility that I could be gaining weight. After all, I’d never had any trouble staying thin. I could eat pretty much whatever I wanted without giving it a second thought. I was an athlete; I couldn’t be gaining weight. Never mind that I hadn’t actually been an athlete for decades by this time.
Even though I had a habit of periodically stepping on the scale at work just to see the number, and I had slowly crept up to about 8 pounds above baseline (doesn’t sound like much to many of you, but I’m not that big so it’s a significant percentage of my total body weight), I still didn’t put two and two together at the time. My capacity for self-delusion seemed limitless; I must have been gaining muscle mass from my lifting at the gym, right? Mind you, I’d been doing the same stale routines for about 15 years, with little to no cardio. I had developed some subtle love handles, which I convinced myself were just some “extra skin.”
Really, HD?! But you’re supposed to be an Endocrinologist! How could you be so stupid?
Pulling out my retrospectoscope, I can now see how ridiculous this all looks. At the time, however, I was clearly suffering from “I was never like this before” syndrome. In fact, I probably spent several years in this state of denial. It actually took a health scare to shock me into realizing that I was no longer a soccer and track & field star; I could not eat whatever I wanted without consequences; and I clearly did not know anything about how to achieve a high level of fitness outside of playing competitive sports as a teenager.
This whole experience helped me appreciate the fact that health is not a static entity. If you attain good health, you cannot slack off and expect to keep it. It takes constant nurturing, attention, and reassessment. Sure, I have a better 6-pack now than I did 20 years ago, but if I keep hitting the chocolate chip cookies like I have been the last few weeks (darn the holiday season!), I’ll be left with a 2-pack – if I’m lucky.
6. Nonspecific constellations of symptoms defy diagnosis. As a general rule, doctors are not great at finding a single, unifying explanation for your grab-bag of random symptoms. That’s usually because there isn’t an easy fix for this situation. I’ve written about this extensively in other posts, and I touched on it above in #3. Unfortunately, because people have been conditioned to expect that there is a quantifiable answer for every problem, they become increasingly desperate, and desperate people will reach for any lifeline that is thrown. That tends to leave them vulnerable to the loudest, most histrionic, or most charming voices on the internet. Sadly, the owners of these voices – who claim to have the answers – rarely do. This sends even the smartest people chasing down rabbit holes…over and over and over.
7. There is too much manufactured controversy on the internet. I’ve also covered this topic in other posts. One of alternative medicine’s cleverest strategies is to convince you that reasonable experts in the field disagree about the merits of a “conventional” treatment for any given condition. This opens the door for them to promote their alternative treatment, appropriating credibility by casting doubt on whether standard therapy should really be the standard. First off, whatever controversy they claim exists either doesn’t or, it has been severely distorted to serve the purpose of their argument. Second, it confuses the heck out of smart people, who come to me complaining that they’ve read so much contradictory, yet plausible-sounding information that now they have no idea what to believe.
8. People distrust Big Pharma. Look, I agree that there is a lot wrong with BP. Inexorable price gouging isn’t helping their case, either, as it encourages conspiracy theorists to shout that you don’t need any of what BP is selling. BP’s lousy reputation causes significant collateral damage to the doctor-patient relationship, as skeptical patients assume that doctors have been bought off, brainwashed, or otherwise duped by BP-sponsored studies showing that these drugs actually do good things. When people refuse the standard of care for their disease because they don’t trust BP, they are generally trading the low risk of a serious side effect from the medication for a higher risk of a disease-related complication. I recently saw a patient who left her hyperthyroidism untreated for years because she didn’t like the treatment options; she re-presented to my office with atrial fibrillation and heart failure, two conditions that will not necessarily resolve now that her hand has been forced to treat the thyroid problem.
I know many people in the pharmaceutical industry: PhD researchers, MD liaisons, nurse educators, and sales representatives. Sure, sometimes I want to shower after a particularly slimy interaction with a sales rep, but most of the people I know – sales reps included – are passionate about what they do and do it because they want to help people. Hmmm…that’s exactly the same reason why I went into medicine and why I started this blog. How curious.
We should not impugn the motives of the entire pharmaceutical industry and condemn their products as instruments of the devil, just because the financial arm of the industry has contributed to the havoc in our medical system. We need to be more thoughtful than that, evaluating each treatment based on its merits and risks.
9. People believe that being proactive is always best. “Don’t just stand there, do something!” That’s the message I regularly receive from my patients. But in medicine, sometimes the best course of action is to watch and wait. I treat a lot of people with thyroid cancer. As such, I have patients with all stages of the disease. Many of my patients have low-level elevations of their blood tumor marker and/or evidence of very tiny, indeterminate-appearing lymph nodes on their neck ultrasound. Could these factors represent recurrent thyroid cancer? Yes, absolutely. Should I send the surgeon back in right away to “clean it out,” or should I blast the patient with more radioactive iodine? Not necessarily. In many of these cases, a treatment initiated prematurely will treat our sense of needing to do something, but it will not lead to a cure or lasting remission from the thyroid cancer. That can be difficult for many patients to accept, as our society has conditioned people to believe that they must “beat cancer,” putting it in their rearview mirror forever. Some cancers don’t always work that way, and thyroid can be one of them. Sometimes, it makes more sense to monitor with blood work and imaging, initiating treatment when the cancerous nodes in the neck are actually large enough for a surgeon to see when she goes back into the neck for the second or third time. That waiting process can last for years and require me to repeatedly reassure my patients that we are not acting in a supremely irresponsible fashion by doing “nothing.”
10. Over-testing leads to bad decisions. If there is any topic I’ve beat to death in other posts, it’s this one. My patients invariably want “the whole panel.” It doesn’t matter if we’re talking about thyroid, testosterone, estrogen, or just “hormones.” There’s got to be a panel, and that’s what they think they want. Most of the things I can test for have little to no clinical relevance, so I don’t order these mythical panels. But naturopaths and other practitioners with a minimal understanding of Endocrinology do, and they initiate all kinds of “treatments” based on the meaningless results. While some of the treatments are harmless, others can be quite dangerous.
Although I often focus on lab testing, it should also be noted that the overuse of imaging can lead to disastrous outcomes. If you have a CT scan of any body part nowadays, it is almost guaranteed that the report will mention an “incidentaloma” somewhere. These little (usually benign) bumps in lungs, liver, kidneys, and other organs can lead to invasive biopsies or even surgery, exposing people to all the potential complications of invasive procedures. It is not uncommon for someone to have a CT scan of the chest because she’s extraordinarily worried about having a certain condition and the doctor is trying to reassure her. The CT may show that the original concern was unfounded, but it detects a worrisome nodule in the lung, which leads to a biopsy, which leads to a pneumothorax, which leads to an acute decompensation, which leads to an ICU stay, which leads to ventilator-associated pneumonia, which leads to heavy-duty antibiotics, which lead to a C. diff infection…I’ll stop there, as I think you get my point.
The open secret here is that it’s not just smart people who are at risk for making bad decisions about their healthcare. I see my fair share of less intelligent people who also make poor choices. However, I do think that some of my less-sophisticated, less-intelligent patients are more likely to put their complete trust in me, asking “what do you think I should do, doc?” Then, they typically adhere to what I think is the best course of action.
But what practical, take-home message can I convey to all you smartypants people? How can you make better decisions? You must become aware of your ingrained biases, which will move you along the spectrum from intelligent toward wise. How to do that is the basis of entire texts on philosophy and human behavior, so I’m afraid we’ll have to explore it further in a future post. Or not – that kind of stuff is way above my pay grade.
What do you think about why people make stupid decisions about their health? Are you aware of your biases, and do you try to account for that when you make decisions? If you’re a doctor, have you noticed that intelligence does not equate with being smart about healthcare? What do you think people can do to make better choices when it comes to their medical care? Comment below!
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