Current Editorial Winter 2013, Published March 12, 2013
By Robert A. Kagan, MD, FACRO
Note: The views expressed in the following editorial are not necessarily those of the American College of Radiation Oncology.
“Ego-based medicine” should be one’s personalized distillation of good medical practices, based upon clear evidence. Unfortunately, it usually isn’t. Over the years, the meaning of “ego” in physicians has morphed to connote some unflattering characteristics like aggressiveness, a macho attitude, an inability to listen, alarming stubbornness, and/or an attitude of superiority towards co-workers. Klitzman in his book “When Doctors become Patients” writes that sick doctors are frequently very unhappy and angry when they are treated as patients.
Doctors in charge of cases can become preoccupied with showing off to attract attention. To put it another way, the ego characteristics of careful thought tempered with compassion that patients expect can be displaced by efforts to be “right” and to act dictatorially, strengthening the doctors’ ego at the expense of an ill and helpless patient.
Physicians sometimes behave as if they expect to be perfect and always in control. Just like anyone else, however, they perform poorly at tasks that they find distasteful or unpleasant. Such tasks include end-of-life counseling and alerting a patient or his/her caregivers that an error has occurred. Both challenge the ‘I can do no wrong” assumption of a physician’s ego. Poorly effective, expensive end-of-life treatments with high morbidity may sometimes substitute for more informed options involving compassionate care.
Ego-based medicine leaves no wiggle room for mistakes or more compassionate judgments. Unfortunately, neither a discussion of compassionate options nor one of medical errors is a part of our clinical training. To be named in a malpractice suit implies guilt for doing the wrong thing. Best Practices do not allow for the probability that mistakes or unrealized assumptions can be made, nor for alterations of treatment that may be mandated by the changing condition of the patient. Denying full responsibility for medical events by shifting some of the blame, pleading poor patient compliance, or referring a disputed case to a committee are ways that some physicians deal with mistakes that cast doubt on the high value with which they invest their own judgment.
The clinical rule-makers, regulators and framers of practice algorithms are at the cutting edge of ego-based medicine. They make the rules so complex in a fruitless effort to imagine every possible clinical presentation, then mandate management in a way that diminishes or negates the core values of our trade: thoughtful judgment and discretion.
While their effort might help to eliminate some of the worst judgments, it might also preclude the very best judgments by experienced and thoughtful practitioners. Practitioners are told that all the rules are based on hard evidence– hence “evidence-based medicine.” This is only partly true, since methods, conclusions and patient populations are seldom identical in two or more published research reports. “Consensus-based medicine” might be a more precise term, because interpretative committees often have the final say in putting together the results of distributed studies. The seemingly strict recipes for individual patient management often differ between the US and Europe and between authoritative clinical organizations within countries. They may provide “egocentonic” grist for the physicians who follow them without qualification or further consideration.
Peer-reviewed publications are inherently biased. The fact that positive results get published a lot more frequently than negative ones sometimes makes us discount contradictory research data in order to stay loyal to our own assumptions. It is easy to become dazzled by discussions of the efficacy of the latest medical-surgery interventions and the resulting “evidence-based” outcomes. What one can be certain of is that the newer diagnostic and treatment techniques are often more expensive. In spite of industrial marketing claims of excellence and the resulting marked changes in health care practices, the incremental benefits are frequently miniscule. A great many of these advances have been statistically significant but not clinically significant! Even anti-smoking efforts have yielded limited effects in the past 50 years. Nothing seems to induce investigators to publish studies that yield negative or inconclusive results, and nothing has been done to reward them appropriately for doing so. Researchers may choose not to do so from fear of personal embarrassment, loss of monetary sponsors, or damage to academic careers. Investigators may simply be unwilling to fight upstream against a river of prejudice against what they would otherwise like to make known in the scientific literature.
Clinical decisions are based on clinical expertise, patient preference and research evidence. Evidence-based medicine challenged the domination of observational studies by demanding that we give randomized clinical trials the higher priority. Such trials, however, are very expensive and take a long time to finish. Clinical effective research based on electronic records review is at present cheaper and gives information data which are as good but more useful in clinical practice.
Ego-based medicine depends on attitude. The frenetic search for the best research method has helped to emphasize numerical values, relegating social skills to the lowest value of training. To a large degree, doctors go into denial when criticized for their rude behavior. The ability to make patients feel comfortable by ameliorating fears and anxieties, showing compassion, being empathetic (in other words, by having a good bedside manner) has diminished significantly. Physicians’ knowledge that they do not know everything makes them a bit insecure. The ego they adopt and selectively develop in response to that insecurity interferes with the doctor-patient relationship. It has been suggested that only by being a patient in the hospital can one learn how insensitive doctors can get!