Monday, February 04, 2013

The three kinds of doctors

The Doctor, by Sir Luke Fildes (1891)
There are three kinds of doctors.

The doctors who know that they know are the doctor’s doctors – the world authorities , who do the research and to whom other doctors will refer their complex patients when they are perplexed. However, these are few and far between – often because there is a lot in medicine which we do not really know or understand !

The wise doctors are the mature physicians who know that they do not know. They understand the limits of modern medicine and do not hesitate to share these with their patients. They do not pretend to know more than what is known – and are quite comfortable acknowledging their ignorance with their patients , so that patients can make well-informed decisions after understanding the extent to which medicine can help them , and to which it can't .

The really dangerous doctors are the so-called experts , who don't know that they don't know. Typically, they  think that they know the truth , but actually don't - or , even worse, they think that they know , but in reality what they know is actually wrong. These are the ones who will overtest and overtreat , but in trying to help patients, they end up doing a lot of home. Unfortunately , because these doctors are often influential, they end up causing a lot of inadvertent harm , because they don't know any better - and because other patients and other doctors don't know any better either. Some of the myths and fallacies which they espouse continue getting propagated because these are often the so called leaders in medicine - the people who publish papers and present at conferences , repeatedly propounding their incorrect point of view. Most other doctors do not have a very good way of being able to differentiate between what's true and what’s not – and are quite happy to accept the viewpoints of these experts as being gospel truth. Many of these flawed opinions ( and there’s an embarrassingly large list !) become accepted dogma in mainstream medicine , until a true expert comes up with a scientific study which challenges the previous assumptions and proves that they were wrong.

However, it requires a lot of maturity to be able to accept the fact that sometimes we don't know stuff ! In an ideal world, translational research would allow us to convert benchside hypotheses into tried and tested clinical advances, but it’s extremely hard to do this in real life . I think clinicians need to be very clear about what they're doing , and to explain this and share this openly with their patient . If they are trying out stuff which has not been shown to work ( but which they believe is useful), they should frankly tell their patients that they are now entering the realm of the unknown – and provide reasons as to why they think the course of action which they are proposing is likely to be helpful.

We have multiple areas of ignorance in IVF – and rather than exploit our patient’s vulnerabilities by pushing untested and unproven ( and expensive !) interventions, a little bit more openness, honesty and transparency with our patients would help patients as well as doctors. If patients knew that they were being subjected to unproven or uncertain treatments, many are mature enough to accept this uncertainty; and expert patients could use their own experiences in order to further the field of medical knowledge , provided doctors are willing to be open with them !

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