Day: July 22, 2018

pervocracy:

slatestarscratchpad:

jooyous:

pervocracy:

I know I say this a lot, but: 

If there’s one thing I’d like the public to know about medicine in the US, it’s that it is not standardized.  For the same condition, one doctor will recommend surgery, another will send you to physical therapy, a third one will put you on painkillers, a fourth one will give you steroids, and a fifth one will say “there’s no effective treatment but it will get better on its own.”

Each one of these doctors will say “this is the evidence-based standard of care, I have studies backing me up, and everyone who’s up-to-date with the research does it this way.”  (The studies will be real, too.  There’s just other studies showing other things.)

This isn’t true for every condition, nobody’s going to prescribe PT for strep throat*, but for something like chronic pain or mental health issues it’s especially important to keep in mind.

*I… think.  I’ve worked with some weird doctors.

@slatestarscratchpad can you comment on this?

Agreed, though with some caveats.

(like: all doctors are weird doctors)

There are a few things that are really obvious and almost universally agreed, like the strep throat example.

But other things are total judgment calls. Should a depressed patient
be treated with antidepressants, therapy, or both? Well, it depends.
How bad is their depression? What kind of exogenous stressors
contributed to it? Are those exogenous stressors solveable? Is the
patient “psychologically minded”, ie smart and self-critical enough that
she can understand complicated therapy concepts like “self-esteem”?
Does she have poor coping strategies and self-defeating beliefs? Does she have an hour per week to devote to therapy? Has she had very
positive or very negative experiences with medication or therapy before
in the past? Is she taking ten medications already that would interact
with antidepressants? Does she have some other condition that the
antidepressants would coincidentally solve (eg if she is underweight, we
can give her Remeron which is an antidepressant that causes weight
gain). Does her insurance cover one but not the other?

There is no
guideline that can possibly consider all of these factors, so it comes
down to the doctor consulting their Vague Intuitions. That means even
with a single perfectly-consistent doctor, they’ll prescribe different
things for superficially-similar patients. And if by chance doctors have
different Vague Intuitions, they’ll prescribe different things for the
same patient without either of them necessarily doing anything terribly
wrong.

Other times the correct treatment is “the one you’re most familiar with”. With very rare exceptions, I only prescribe four benzodiazepines – Ativan, Xanax, Klonopin, and Valium. I know there are like two hundred others, but they really have no advantage over my four, and I’m not that familiar with them – I might get the dose wrong, or forget about a side effect. I know some other doctors who trained in weird places and are really familiar with Serax or something, and they should use Serax rather than switch to something they don’t understand. Likewise, as a psychiatrist I (claim to) understand all sorts of weird antidepressants, and I might give you a weird antidepressant perfectly tailored to your situation, but I don’t want a random primary care doctor prescribing clomipramine because he heard it’s good sometimes. I don’t even want a psychiatrist who specializes in schizophrenia and hasn’t really worked with clomipramine doing that. In return, I don’t use clozapine, even though I know it’s great, because I don’t have enough schizophrenia experience to use it properly (I also don’t have the support from labs and nurses it would take to monitor it well). If there’s a patient who really needs it, I’ll refer them to a clozapine specialist. But if they can’t go to the clozapine specialist for some reason, I’ll probably use one of the few antipsychotics I’m super-comfortable with. If I were a Dr House level genius, I would know all of these drugs and use them all confidently, but almost nobody is that great. In some fields, I’m not even good enough to fully know what I don’t know. There are two thousand different schools of therapy. I know about three of them well enough to feel comfortable practicing them, and another ten well enough to feel comfortable knowing when to refer someone for them, but if one of my patients could benefit from Gestalt Therapy or something else I have barely even heard of, they’re just screwed.

(keep in mind that when a doctor says they’re “comfortable” with a certain treatment, they don’t just mean “I heard about this one time in medical school and mostly remember it”, they mean “if I screw this up, you will die, but don’t worry, I’m confident I know it well enough not to screw up.” This can be a high bar, and not always a level of confidence everyone can maintain about everything)

Still other times, doctors have different values and experiences. I usually trust my patients, and I believe informed people who understand the risks and benefits should have the choice about what to do with their own bodies. I also coincidentally have met a lot of people whose lives have been devastated from having the medications that helped them taken away by gatekeepers on grounds of “we’ve got to fight addiction!” So I am more likely to prescribe (and especially continue) potentially addictive substances than some other doctors I know are. I have had generally good luck with these, so I continue to prescribe them. I think a doctor who works in an area devastated by drug addiction, and who was more temperamentally conservative and less temperamentally libertarian, would be more careful with these, as would a doctor who got unlucky and their first benzo patient became a junkie and overdosed and died. Some doctors value patient satisfaction/comfort more or less compared to getting results. Some doctors are more worried about the risk of side effects that haven’t been discovered yet and so more conservative about supposedly-provably-safe medications. Some doctors value patient autonomy more or less compared to giving the most effective treatment. Some doctors value being absolutely sure something works more or less compared to being willing to try promising experimental treatments. Guidelines aren’t always going to help here.

(a particularly common place I see this come up is in pain management. If there’s a condition that will go away on its own after two weeks, but be really painful until then, how aggressively do you treat it? What if the aggressive treatment has risks or side effects? You can find a doctor with basically any conceivable philosophy on this question.)

And finally, is this really that surprising? Or is every profession like this? Will two financial advisors always recommend the same investments? Will two computer programmers always write programs with the same structure? Will two lawyers always try the same argument? I think it’s pretty common in skilled professions for there to be multiple different ways of handling something, none of which are wrong. Medical students often get asked to make lists of the top five things to do in a certain situation, and often everyone makes a different top choice but has approximately the same five choices on their list. I think this is normal and not necessarily incompatible with people being basically reasonable.

I don’t want to claim there aren’t a lot of doctors who are incompetent, or who disagree with the guidelines just because they’re contrarian. I often disagree with the guidelines just because I’m contrarian (did you know the sleep guidelines say melatonin doesn’t work?), and I am very likely incompetent in some ways I don’t currently understand. But it’s not 100% that.

I’m reblogging this because it’s important context and I don’t want my original post to sound like “care isn’t standardized because doctors are all just stubborn jerks.”  Two doctors who are both caring and knowledgeable can still have very different recommendations, and that’s important for patients to be aware of.