I was a philosophy minor in college because one aspect of philosophy appealed to me — logic. People unintentionally make logical fallacies nearly every day. That’s when you make decisions or argue a point with someone based upon an illogical assumption or relationship. For instance, in health and mental health research, many, many researchers and health reporters confuse cause and effect and often report a finding as though we know X causes Y, even when the research showed no such causative relationship.
So I was very happy to read an article in The Boston Globe today entitled, The mistakes doctors make by Dr. Jerome Groopman. Unfortunately, the online version of the article doesn’t have the informative graphic that accompanies the paper version. Dr. Groopman nicely illustrated a single case where fallacies in doctors’ reasoning led to a woman being misdiagnosed over and over again.
Why and how could this occur? Aren’t doctors taught to think logically and critically?
Well, it occurs for numerous reasons, but Dr. Groopman noted,
Physicians are rarely taught about pitfalls in cognition. During their training, they work as apprentices to senior doctors. They learn largely by doing. In today’s medical system, where there is intense pressure to see as many patients as possible, the quick judgment is often rewarded. Unfortunately, working in haste is a setup for errors in thinking.
Doctors (and therapists) don’t receive any formal education in logical fallacies. And call it laziness or human nature, but once a person has a diagnosis given by another professional (especially one given by a professional in the same specialty or degree as oneself), that tends to be the starting point for the next professional, not a blank slate.
It is for this reason that many people have diagnoses added to their record, but few removed. New professionals don’t rule out the possibility of the old diagnosis, they just add another one to capture what they believe is going on with the individual.
Only when a person finds a professional who is willing to look very critically at the client’s or patient’s record and question all previous assumptions (ala “House M.D.”) does a person break free from a pattern of misdiagnosis.
The article is worth a read and the emphasis on critical thinking is worth a second look for medical and graduate schools.
(4 votes, average: 4.5 out of 5)
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2 Responses to “Doctors and Fallacies in Logic”
Cindy Mullis. Ph.D. at 6:56 pm on
June 17th, 2007
The cynical and pessimistic part of me agrees wholeheartedly with what you’ve written here. I am frequently discouraged by the number of clinicians who think that they don’t have time to review client records. I have always believed that this use of time is a false economy - sort of like buying cheap shoes or cheap tools: in the end you will spend way more time fooling around than if you had just started out right in the first place. Or to put it another way, even people who admit that hindsight is 20/20 fail to take advantage of the rich source of hindsight sitting there in the client’s file. Between that and the lack of parsimony in the diagnostic summaries you alluded to above . . . well, sometimes it’s enough to make me weep.
On the other hand, I can’t wait to get my hands on Dr. Groopman’s book because I suspect that psychologists (or at least psychologists who have been trained in certain ways) may be able to feel a certain vindication of their nororiously slow, inefficient, and unreliable diagnostic methods. I ran across a sample chapter that I read with great interest and I have also looked at a few reviews. Over the past couple years I’ve developed a few ideas about why physicians get themselves into such tangles when they make errors and or confused, but haven’t really known how to write or talk about them since I don’t really work in a setting where I get to hang around with primary care docs. I’ve tried to test drive some of my ideas on clients or friends who are trying to get better care from physicians, though, and tried to read whatever I could about the cultural aspects of being a physician, and I really think I’m onto something here.
The way I see it, usually what physicians do works pretty well. But when things don’t go well, the skills and techniques that psychlogists
use every day aren’t really in the physician’s standard repertoire. Some of the things we can do with impunity that they can’t include:
1. Collaring a colleague in the hall and saying, “Here’s a strange thing: what do you think of this?” or “What would you do if you were me?” or some such thing. Physician’s don’t really seem to know how to consult. They ‘refer’ and the specialist takes care of the problem. They send a report back to the other doctor, but this doesn’t mean the 1st doctor knows how to do it himself next time it happens!
2. Say to a patient, “Hmmm. That’s a good one. I have some ideas (or no idea!), but I need some time to think it over. Let’s take this up again next week. First of all, physicians don’t see their patient weekly. Second of all, they don’t get paid to think: they get paid to know the answer. (Yikes! I couldn’t work like that!!!)
3. Say, “Well, I’ve never done this before, but I’m willing to learn. Do you want to be a guinea pig, or should I refer to someone with more experience?” There are some good reasons why we can say this without making a patient run for cover while physicians can’t. But then again, most things a Primary care physician does won’t kill you if he/she screws up, so why not just tell the truth? The patient can hear the risks and benefits (and running off to a specialist that you know nothing about, who may also be a total jerk is a not inconsiderable risk in any medical procedure) This might cause patients to panic — but then they’d get used to it. No client has ever panicked when I said it; some stayed and some chose another clinician. But it was always fine with both of us and didn’t involve any hard feelings on either side.
I have problems with their reliance on algorithms too because I think that in tough cases algorithms can constrain thinking too much. Also, what happens if you start with the wrong algorithm? And when you hit the final “no” in one of those flow charts, it’s hard to know where to go next. The conclusion that the patient does not have the disease under investigation and the conclusion that the person is well are entirely different, but those algorithms make it very easy to lose that distinction. Psychologists don’t have this problem because we can always fall back on personality disorders (I swear — I’m kidding about that!!!! This would be the default diagnosis for any lazy psychological diagnostician. I could have another totally separate rant on this.), but physicians are stuck with patients who keep coming back insisting that they are not getting better (i.e. - your efforts are not helping me!). I suspect that this is the moment when doctors are most vulnerable to the impulse to either start writing prescriptions willy nilly or simply get angry and start to blame the patient for his or her hypochondriasis. Obviously, no good can come of the doctor patient relationship once this pattern has set in. Do they teach medical students how to avoid this dynamic? I don’t know, but I’ve never heard that they do.
This is a long reply, but as I said, I’ve been thinking about this issue for some time. I think it would be both presumptious and useless to say that physicians (or, as I’m fond of saying, “REAL Doctors”) should be more like psychologists, I do think that between managed care and their own cultural values, medicine has a small but serious systemic problem that psychologists just might be able to help them out with.
Any thoughts on this?
Cindy M.
P.S. I don’t look at your site regularly, so forgive me if I’m stating the obvious: Ken Pope has a nice essay on logical pitfalls in interpreting psychological data on his web site. You probably know it, but just in case . . . I mention it mainly because the dearth of medical sites telling you how to avoid logical errors has been mentioned and I wanted to provide just one example of a relative wealth of resources for psychological reasoning.
PJ SCOTT at 3:55 am on
June 20th, 2007
I just clicked over to your site via JEROMEGROOPMAN.COM and I must say you make a great first impression.
As I read the passage [in your article DOCTORS AND FALLACIES IN LOGIC] about doctors’ reluctance to overrule previous diagnoses, it occurred to me that this tendency [to accept and expand rather than reject and replace]seems to afflict {or affect] professionals in many different fields. In law they call it STARE DECISIS.
Regards,
PJ Scott
Denver
Be a Part of the Conversation! Comment on this Entry
The cynical and pessimistic part of me agrees wholeheartedly with what you’ve written here. I am frequently discouraged by the number of clinicians who think that they don’t have time to review client records. I have always believed that this use of time is a false economy - sort of like buying cheap shoes or cheap tools: in the end you will spend way more time fooling around than if you had just started out right in the first place. Or to put it another way, even people who admit that hindsight is 20/20 fail to take advantage of the rich source of hindsight sitting there in the client’s file. Between that and the lack of parsimony in the diagnostic summaries you alluded to above . . . well, sometimes it’s enough to make me weep.
On the other hand, I can’t wait to get my hands on Dr. Groopman’s book because I suspect that psychologists (or at least psychologists who have been trained in certain ways) may be able to feel a certain vindication of their nororiously slow, inefficient, and unreliable diagnostic methods. I ran across a sample chapter that I read with great interest and I have also looked at a few reviews. Over the past couple years I’ve developed a few ideas about why physicians get themselves into such tangles when they make errors and or confused, but haven’t really known how to write or talk about them since I don’t really work in a setting where I get to hang around with primary care docs. I’ve tried to test drive some of my ideas on clients or friends who are trying to get better care from physicians, though, and tried to read whatever I could about the cultural aspects of being a physician, and I really think I’m onto something here.
The way I see it, usually what physicians do works pretty well. But when things don’t go well, the skills and techniques that psychlogists
use every day aren’t really in the physician’s standard repertoire. Some of the things we can do with impunity that they can’t include:
1. Collaring a colleague in the hall and saying, “Here’s a strange thing: what do you think of this?” or “What would you do if you were me?” or some such thing. Physician’s don’t really seem to know how to consult. They ‘refer’ and the specialist takes care of the problem. They send a report back to the other doctor, but this doesn’t mean the 1st doctor knows how to do it himself next time it happens!
2. Say to a patient, “Hmmm. That’s a good one. I have some ideas (or no idea!), but I need some time to think it over. Let’s take this up again next week. First of all, physicians don’t see their patient weekly. Second of all, they don’t get paid to think: they get paid to know the answer. (Yikes! I couldn’t work like that!!!)
3. Say, “Well, I’ve never done this before, but I’m willing to learn. Do you want to be a guinea pig, or should I refer to someone with more experience?” There are some good reasons why we can say this without making a patient run for cover while physicians can’t. But then again, most things a Primary care physician does won’t kill you if he/she screws up, so why not just tell the truth? The patient can hear the risks and benefits (and running off to a specialist that you know nothing about, who may also be a total jerk is a not inconsiderable risk in any medical procedure) This might cause patients to panic — but then they’d get used to it. No client has ever panicked when I said it; some stayed and some chose another clinician. But it was always fine with both of us and didn’t involve any hard feelings on either side.
I have problems with their reliance on algorithms too because I think that in tough cases algorithms can constrain thinking too much. Also, what happens if you start with the wrong algorithm? And when you hit the final “no” in one of those flow charts, it’s hard to know where to go next. The conclusion that the patient does not have the disease under investigation and the conclusion that the person is well are entirely different, but those algorithms make it very easy to lose that distinction. Psychologists don’t have this problem because we can always fall back on personality disorders (I swear — I’m kidding about that!!!! This would be the default diagnosis for any lazy psychological diagnostician. I could have another totally separate rant on this.), but physicians are stuck with patients who keep coming back insisting that they are not getting better (i.e. - your efforts are not helping me!). I suspect that this is the moment when doctors are most vulnerable to the impulse to either start writing prescriptions willy nilly or simply get angry and start to blame the patient for his or her hypochondriasis. Obviously, no good can come of the doctor patient relationship once this pattern has set in. Do they teach medical students how to avoid this dynamic? I don’t know, but I’ve never heard that they do.
This is a long reply, but as I said, I’ve been thinking about this issue for some time. I think it would be both presumptious and useless to say that physicians (or, as I’m fond of saying, “REAL Doctors”) should be more like psychologists, I do think that between managed care and their own cultural values, medicine has a small but serious systemic problem that psychologists just might be able to help them out with.
Any thoughts on this?
Cindy M.
P.S. I don’t look at your site regularly, so forgive me if I’m stating the obvious: Ken Pope has a nice essay on logical pitfalls in interpreting psychological data on his web site. You probably know it, but just in case . . . I mention it mainly because the dearth of medical sites telling you how to avoid logical errors has been mentioned and I wanted to provide just one example of a relative wealth of resources for psychological reasoning.
I just clicked over to your site via JEROMEGROOPMAN.COM and I must say you make a great first impression.
As I read the passage [in your article DOCTORS AND FALLACIES IN LOGIC] about doctors’ reluctance to overrule previous diagnoses, it occurred to me that this tendency [to accept and expand rather than reject and replace]seems to afflict {or affect] professionals in many different fields. In law they call it STARE DECISIS.
Regards,
PJ Scott
Denver
