The Changing Nature Of Authority: Doctors

Medical doctors have long been considered paragons of authority and expertise in our society. Their authority derives from long, rigorous academic training and is refined through continual clinical practice. We should listen to doctors because they are the best chance we have to get a reliable diagnosis based on the best science available. Or are they?

In What’s Wrong With Doctors, Richard Horton reviews How Doctors Think, a book by Jerome Groopman. The review points out that on average 15 percent of doctors diagnoses are inaccurate (still pretty good compared to the error rate that used to be attributed to reference librarians–was it 55%? what ever happened to that by the way?).

Doctors go wrong in many ways: they misapply evidence-based medicine; their training doesn’t teach them how to learn from mistakes (actually they can’t even admit when they make a mistake); they are susceptible to bribes and misinformation from big pharma; they are prone to a host of cognitive errors that they are unaware of–attribution error, availability error, search satisfying error, confirmation bias, diagnostic momentum, commission bias; they work in a system that rewards hurrying as many patients through as possible; and finally the classic–they don’t listen to patients.

Horton points out that the authority of doctors is no longer sacred and that a better educated public with access to more information is more and more willing to question the gospel. Groopman suggests that doctors should ally themselves with patients in a partnership to guard against error.

But are patients up to the responsibility? A doctor friend of mine told me how the mother of one of his patients told him that she stopped her son’s medication months ago. Why? he asked. Because of something she read on the Internet, she said. He was surprised. What did you read? Was it a study? How was the study done? Are you sure your son’s situation is sufficiently similar to what you read? Do you know the risks associated with discontinuing the medication?

Reading as much as you can about an illness that affects you or a family member–good. Going against your doctor’s advice without consulting your doctor first–not so good.

Learning about an illness is one of the most concrete ways that information literacy skills can be put to use in what we often call “lifelong learning.” We get sick; we’re get scared; we want more information. Has anyone ever taught us how to go about finding information in this situation? Not really, though the more education in general one has the better off one is. Finding and making sense out of medical information has a lot of pitfalls–from filtering out noise on Internet bulletin boards to finding reliable information that’s free and available to understanding how much about medicine is really unknown and uncertain, especially how it applies to your specific situation. It takes a great deal of knowledge even to know what kind of questions to ask your doctor. And who’s got the time to do all this research?

It’s good that we realize that doctors are fallible. Yet this doesn’t imply that by doing a search on PubMed we know more than our doctors. The changing nature of authority requires new skills for both experts and non-experts. Experts (including professors and librarians) have to get used to not having a complete monopoly on information and should have an understanding of where they can and do go wrong. Non-experts need to know where to find reliable or alternative sources of information and how to put this information into context. And both need to figure out how to talk to each other so the right questions get asked and answered at the right time, so that the chances for error are reduced as much as possible, and the chances for finding the truth are increased as much as possible.