[HD: This is Part II of a two-part post. If you haven’t yet read Part I, please do so now, or this won’t make as much sense as it should.]
In Part I, I posed the question of what I should do after evaluating a patient and realizing that it’s not likely she has a condition within my area of expertise. I then proceeded to work through the first four options listed below:
A. Explain the various hormonal diagnoses I’ve considered during our visit and discuss why I don’t believe she has any of them.
B. Refer her to any other physicians I think might have something to offer, assuming I suspect a diagnosis that is not within my field (e.g. Sleep Medicine to discuss possible obstructive sleep apnea).
C. Run a few additional tests to “rule out” rare hormonal conditions that she probably doesn’t have, but are within the realm of feasibility.
D. Run additional testing that is outside my area of expertise, in the interest of getting closer to a diagnosis.
E. Tell her I’m fairly certain I know what’s going on with her, and reassure her that she’s going to get better.
When Good Doctors Go Bad
Finally, let’s talk about Choice E (tell the patient I know exactly what’s going on, despite a complete lack of evidence to back up my assertion). You know how a satellite orbits the Earth along a predictable path, held along this path by the Earth’s gravitational pull? Well, imagine that the gravitational pull malfunctions for a second – the satellite would shoot off its orbital path on a tangent into the darkness of space. This is choice E.
Years ago, when I was doing my fellowship in Endocrinology, I had friends who were fellows in Rheumatology. One of their attending physicians, a respected member of our academic institution, began making increasingly less plausible diagnoses. It seemed as if he simply decided what he wanted the patient to have; then, he would run tests and assign his preconceived diagnosis regardless of the results. Eventually, he left the department to strike out on his own in private practice. I heard he even wrote a book.
Take another example of a respected Endocrinologist at a well-regarded academic institution in the southern United States. A friend of mine was an Endocrinology fellow under this mentor and assured me that this doctor was intelligent and appeared to demonstrate excellent clinical judgment. This Endocrinologist ultimately wrote a book about the thyroid and struck out on his own in private practice, attracting patients from around the world. By happenstance, I evaluated a “hypothyroid” patient who had received her original diagnosis from this doctor. After reviewing her case, I was fairly certain that she did not have – nor had she ever had – hypothyroidism. Of course, this would explain why she had never felt any better after years of treatment. I obtained her original workup, which included something called a TRH stimulation test – something we don’t typically do in the U.S. for the workup of hypothyroidism. Regardless, the TRH test results were normal!
Currently, I sometimes see patients who have also seen an Allergist (let’s call her Dr. Jones) in my group practice. This Allergist is well-trained, very smart, and often practices great medicine. However, she has cultivated a tendency to “think outside the box,” which unfortunately has led to frequent detachment from a normal orbit. Her patients can spend months or even years monkeying around with various “treatments” that ultimately fail to improve their health. Sometimes, they experience significant harm – I coined the term JIO (Jones-Induced Osteoporosis, a play on Glucocorticoid-Induced Osteoporosis), as some of her patients have inappropriately taken bone-destroying steroids for way longer than necessary.
So, what motivates these doctors to go rogue? Do they realize how far outside the mainstream they’ve strayed? Do they believe in what they’re doing? How do we reconcile the fact that they can vacillate between practicing sound medicine and quackery; does this make them good doctors, bad doctors, or is it more complicated than that?
Why They Go Rogue
In each of the above cases, these doctors were/are late career (the last 1/3 of a typical career-length); I think this distinction is important. When we first finish our training, most physicians are great at practicing evidence-based medicine, something that is drilled into us at academic institutions. As we gain experience in the real world, we see more cases that don’t fit into any neat pigeon holes; this is what helps our clinical judgment mature. After all, when there is no clear, right answer, we have to use our best judgment. Of course, our judgment should cull from a sound evidence base. The problem is, when a physician has been practicing for decades, the lines between evidence and personal experience become blurred. It takes discipline and effort to continually review the medical literature and challenge our assumptions and current practice style. If I’ve been doing something for 20+ years and I think it works, then it works. Right?
As an aside, if we extrapolate the above reasoning, you can see why naturopaths are rogue from Day One. They have little evidence-based training, as most of their field is based on theory, dogma, and personal experience of their teachers. This is why most naturopaths start out bad and just get worse.
In addition to the blurring of lines between evidence and experience, late career physicians have also accumulated more “zebra” (medical students are taught when you hear hoofbeats, think horses – not zebras) diagnoses under their belts. This has the potential to convince them that rare presentations of common diseases are more common than conventional wisdom would suggest. The Rheumatologist I described above might have fallen prey to this, diagnosing gout and other common ailments with a lack of supporting evidence.
The zebra diagnoses they’ve seen can also convince them that rare conditions aren’t as rare as one would think, leading them to hunt for problems that are unlikely to be present, at best. When doctors have been practicing medicine for a long time, their gut instincts become well-honed and well-trusted. If they have a strong feeling that a patient has something unusual, they might become invested in that diagnosis, even if test results suggest otherwise. After all, testing isn’t perfect; if it comes back negative, they could dismiss it as a false negative and make the diagnosis anyway. This might help explain why the Endocrinologist I described above diagnosed a patient with hypothyroidism, despite normal thyroid function studies, negative thyroid antibodies, no evidence for a pituitary problem, and a negative TRH stimulation test!
Another reason why doctors go rogue is because we want to help people, as I’ve already explained. But it’s more complicated than that. All three of the rogue physicians I described have created a cult of personality that feeds their egos, and that gets scary real fast. Take the Allergist for example, because I know her best. She is the classic BWOC (Big Woman on Campus). To our colleagues and patients who don’t know any better she speaks in pseudo-scientific language – dense with Immunology references – which goes way above our heads and, therefore, sounds like she must know what she’s doing. I’ve checked with other Allergists I trust, though, and guess what? She’s operating in a data-free zone.
But where do my colleagues send a patient who has something that defies diagnosis? Dr. Jones, the Allergist. Allow me to set the scene for that first visit: the patient has been bouncing around various specialties for months or years, with no answers. The patient then lands in Dr. Jones’ office and she says, with supreme confidence, “I know what you have, and I’m going to make you better.” For good measure, she even draws diagrams of T-cells and other technical immunological stuff that the patient has no hope of comprehending, thus solidifying her godlike status in the patient’s mind. I have seen patients work with her for years, as she always has another rabbit hole she can drag them down when her first fifteen treatments haven’t worked.
The most frustrating part? They keep following her like lemmings. I believe that this also helps explain why my patients who have nearly been killed by their naturopaths return to the same quacks. The naturopaths talk a great game, proving that it’s better to look good than to be good. All you need is confidence; forget knowledge.
Rogue Doctors Have No Idea They’re Rogue
I’m sure there are plenty of quacks out there who deliberately mislead and defraud patients. I’m not talking about them. Rather, I’m referring to otherwise good doctors who sometimes do weird stuff. These doctors do not consider themselves fringe practitioners. They may admit that they think outside the box, but they wear that as a badge of honor. They probably even view their colleagues who disagree with them as too rigid.
I bet you the Endocrinologist who attracts patients from all over the world believes his own hype. If he wrote a book offering thyroid solutions, and that book has been widely read, and people who’ve read it flock to him from all corners of the globe, then he must be the messiah. That mindset helps explain the sense of obligation he must feel to these patients who see him. How could he possibly tell someone who bought his book and traveled halfway around the world to see him, “I’m sorry, but it’s not your thyroid.” I’m not saying he intentionally lies to people, but the pressure to have profound insight and give these people hope probably leads him to imply plausibility of a diagnosis where plausibility doesn’t exist.
Does Rogue Doctor = Bad Doctor?
It’s a simple question with a complicated answer. As I’ve explained above, these doctors can practice good, evidence-based medicine. The problem is, if you’re a primary care provider with limited knowledge of the rogue physician’s specialty, you can’t be confident that your patients are going to get good care. If you’re a patient seeing the rogue doctor, you’re essentially screwed, as there is no way a layperson is going to know if they’re embarking on a foolish treatment course.
But, there are plenty of times when thinking outside the box can be helpful. Although I’ve beat up on the Allergist, I admit that there are many patients who idolize her because she really was the only doctor who ever figured out what was going on with them and made them better.
So which is it – good doctor or bad doctor? I would argue that the best way to answer this question is to reframe it: “Would I send my wife/husband/parent/child to this doctor?” If we frame the question that way, the answer is almost always going to be no. Complicated made simple, right?
What do you think? Have you seen a doctor you eventually suspected of quackery? Are you a doctor who works with other physicians who do dubious things? Comment below!
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