One of the most helpful insights I have found is from Taleb’s “The Black Swan”, namely the fact that what you know is not as important as what you don’t know. This is kind of shock for people with a lot of education (like physicians) but it is nonetheless true.
If a patient comes in with lower abdominal pain, the differential diagnosis is huge. Appednicitis, diverticulitis, kidney stone, genitourinary infection, musculoskeletal injury or strain, an undiagnosed malignancy, neurologic disorder such as shingles, or a ruptured aortic aneuryusm are just some of the things to consider. It’s possible to rule out a bunch of those, if you have the time. If it happens to be a rupturing AAA, then you most likely don’t have the time to work the process out and the patient is likely to die. Even at the beginning, the unknowns include how much time you have to get to the right answer.
Therefore “not being able to know it all” is a given, and not only that but a lot of what we know is probably wrong, too. The thinking when I was in medical school was that estrogen replacement for postmenopausal women was pretty much all good. It was supposed to be good for the heart and bones, and may help stave off dementia. In the last 10 years, all of that has been proven wrong. It’s worse for the heart, the phosphonates are better drugs for the bones with fewer side effects, there is no effect on dementia and it probably worsens breast cancer risk in some patients. Anyone who says “the science is settled” is overgeneralizing or wrong, particularly in medicine. The example of peptic ulcer disease being primarily caused by bacteria is yet another world-shaking discovery that proved nearly everything wrong that other authoritative people built their careers around.
If this weren’t bad enough, there is a couple of trainloads worth of new data coming toward medicine in the form of genomics. It will probably end up being a two to three-year fellowship after a full three-year internal medicine residency. We’re learning so much more everyday that keeping up is getting to be not just difficult but impossible.
Most docs don’t feel the need to protect the incompetent though what happens most often is that they are shunned. Nobody wants to get involved in their cases because they don’t want to end up named in a suit. It becomes difficult for them to practice, and so they leave some location and head elsewhere. Often the proximate cause of their departure is threatening of their hospital privileges, and since that is a reportable event to the National Practitioner Data Bank (and often to state medical boards) most docs in that situation would rather resign than have the black mark against them, and most hospitals would rather they leave instead of pursuing something likely to land them in court. I get worried when a physician has a career comprised of 2-3 year stints in multiple states.
We are told by medical malpractice insurers that bad outcomes don’t generate suits, angry people do. Particularly if a physician doesn’t communicate well, or angers patients or their families. The hole in the whole bad doctor problem is that if a physician is personable and incompetent, it can be very difficult for accusations of their incompetence to be seen by the public as anything other than professional jealousy. Their patients love them, they talk to their patients, they listen to their patients, and the patients will raise a stink, particularly in small towns. A physician who demonstrates that they care in a convincing fashion and yet lacks clinical skills commensurate with their perceived competence is very hard to dislodge.
