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Hypocritical oaths — medicine’s dirty secrets | Charlotte Blease | TEDxFulbrightDublin

December 15, 2019


Translator: Denise RQ
Reviewer: Lorcan Walsh True fact about George Clooney. Story begins with a guy
named Gerald Barnes. Now, Barnes lived to work. Every day he received
patients into his office like he was receiving visitors
into his home. After 20 years, this consummate
bedside manner was well rewarded. Barnes was appointed
Head Physician and Medical Director at Executive Health Group, Los Angeles. No ordinary medical practice. Barnes was personally tasked
with overseeing the health checkups of members of the FBI,
California Highway Patrol, senior officials in the Federal
Reserve Bank, amongst others. Just one problem. Gerald Barnes never went
to Medical School. What was his training? His now ex-wife recalls that Gerald’s favorite TV show
was a hospital drama: E.R. (Laughter) George Clooney taught Gerald Barnes
how to act like a doctor. But what does it mean
to act like a doctor? Barnes had scant medical knowledge. For around two decades, he was relying on his own gut instincts
about how well he was pulling off the act. But here’s the next surprise,
so did accredited doctors. Doctors lack professional insight. That statement may strike you
as strange, even insulting. Surely doctors are the foremost experts
on what it is they do. Wrong. I’m a cognitive scientist, and I’m going
to show you why medicine needs outsiders. Current medicine
is being played like a game and the fortune of good health
is like Russian roulette. Genetics, access to healthcare,
even relative social inequalities can load a bullet in this
spinning chamber of the gun. But I’m not going to talk about the politics of healthcare systems
or demographic issues; I’m going to tell you about the bullets
that you didn’t know existed because after you’ve made
your appointment, and you’re sitting
in the consultation room, how you perceive your doctor, and how your doctor perceives you in turn, can influence your health outcome. I’m going to talk about
medicine’s psychological problems. Here are the hard facts. Money talks. Patients of a higher socioeconomic status receive an average of 20% more time
with their doctor, more positive talk, and better explanations
for their health problems. Skin color matters. In the United States, around 13% of the population
identifies as African-American, but just under 4%
of medical doctors are black. And that’s one factor that may be leading
to health inequalities. Take just one example: cardiac patients. Black patients presenting with the same
clinical need as white patients are three times less likely
to be referred for cardiac surgery. And even in the same hospital,
with the same health insurance package, black patients receive
less catheterisation, less angioplasty, less bypass surgery. Ageism is rife. Prolonging life isn’t
medicine’s only goal; but too often doctors are relying on
patient’s chronological age, rather than their biological age, a fact that’s been recognised by the National Cancer
Institute in the States. Age may be a barrier to treatment.
Here’s one example. Around 50% of breast cancer patients
are over the age of 65, yet only 8% of that demographic
was recently invited onto drug trials. And if you’re one of a third
of the population of the developed world who’s clinically obese, studies show
that around 50% of doctors will readily label you lazy,
awkward, or non-compliant. Attitudes that aren’t lost on patients. But they may also be leading to
health differentials. Again, one example. If you’re clinically obese, you’ve got a 50% increased chance
of developing colorectal cancer. But studies show that even given the same number
of prior medical appointments as so called ‘normal weight patients’, you’ve got a 25% decreased chance
of being screened for colorectal cancer. Those are just some
of medicine’s psychological problems, but they are leading to diagnostic
inaccuracy, inferior consultations, and we know empathy is the cornerstone
of treatment compliance, a fact that’s been recognised
by the World Health Organization. If you perceive that your doctor
is listening to you, studies show you’re more likely
to listen to your doctor in turn. But here’s the next surprise. The medical community has known about medicine’s psychological problems,
it’s biases, for over 30 years. So why do these problems persist? Why are people still dying
and being harmed because of medicine’s
psychological problems? Why do Hippocratic oaths
sometimes become hypocritical oaths? Well, there are many reasons, but I’m going to talk about three of them. And the first reason is best explained
by me posing some questions to you. So. Stand up if you’re racist. Stand up if you condescend
toward the elderly. Not many people are standing up. You know, I guess, you’re probably
sitting there thinking, “well, that’s pretty insulting,” you might even be thinking: “Well, you know, you may
be like that, but I’m not.” But I guess if we’re asked
these kinds of questions, we don’t tend to stand up
en masse and declare, in a kind of Spartacus like gesture:
“I am discriminating.” And that in a nutshell helps to explain why medicine’s psychological
problems persist. Because for individual doctors,
as for the rest of us, these kinds of disparages and biases
are somebody else’s problem. But we know from social psychology
and cognitive psychology that our implicit biases
can leak into our behaviour even while we remain resolutely unaware. One example. When polled around 80% of Americans
will declare that they are not racist, but implicit association tests reveal that around 60-75% of people
display implicit racial biases. We also know from social psychology that we tend to have
a rather rose tinted view of ourselves. We tend to regard ourselves as above average, better looking, kinder,
more popular than the average person. And this is being dubbed
the ‘Lake Woebegone’ effect. Taken from Garrison
Keiller’s fictional town where everybody, including
the children, is above average. And I want to say that medicine
resides in Lake Woebegone, and doctors have a lakeside view. Here’s an example. Best selling New York Times
medical writer and Chair of Medicine
at Harvard Medical School says: “I can recall every misdiagnosis I made
during my 30 year career.” Looks like a pretty candid admission. Except studies show that between 10 and 20%
of consultations result in misdiagnoses. Maybe Groopman has got
a superhuman memory, more likely he’s deluding himself. And incidentally, this is leading
to deaths, through misdiagnosis, in America, of around 160,000
people every year. Some people regard that
as a conservative estimate, but that is the equivalent of between four to five 9/11s every single month. Just on American soil. So, introspection, it’s a bit like the characters
in reality TV shows; it’s superficial, shallow, but compelling. So it’s got to come with a warning sign. The second reason
medicine’s psychological problems persist is medicine is missing
the cognitive revolution, and that includes evolutionary psychology. Doctors are Stone Age people,
just like the rest of us. We have Palaeolithic instincts. So what looks like modern misbehavior has its roots in the old psychology
bequeathed to us by evolution. Here’s an example. We crave highly calorific foods. Foods that were scarce
in our hunter gatherer days, today leads to health problems
with an over abundance of such foods. But similarly, we can look to evolution to help explain our psychological
tendencies and capacities. Why it is we tend to give prolonged,
preferential attention, to people who have more of the good stuff; whether it is good looks,
access to fine things, skills. Why we find it hard, on the other hand,
to give sustained attention to the have-nots,
the disadvantaged, the elderly. But in the words of the evolutionary
psychologist Jerome Barkow: “Biology is only destiny if we ignore it.” In other words, we’ve got to come to terms
with, medicine’s got to come to terms with our profoundly un-PC home truths
about our psychological behaviour. Now, the third reason medicine’s
psychological problems persist is modern medicine misconceives itself. It’s well documented
that medical students tend to perceive their curriculum
as cleaved into two kinds of courses. So, on the one hand,
there’s the need to know biomedical facts about pharmacology,
physiology, anatomy, and so on. And then, on the other hand,
there’s the softer, nice to know facts, behavioral sciences, medical ethics,
sociology, psychology and so on. And I want to argue
that this dangerous division is smuggled in to the age old phrase
‘The art of medicine.’ Here’s an illustration of what I mean. Around 50 medics were polled recently
at the University of Alberta in Canada, and they were asked: “What does
the art of medicine mean to you?” Now the replies were vague and varied, but there was an underlying theme
running throughout them all. Here’s a potpourri of their replies. “Medicine has the scientific part,
but the art is the communication aspect, the tasteful, emotional side.” “The art of medicine is about developing
your own style of communication.” Or, as one senior faculty member said: “The art of medicine is the difference between being an average doctor
and a really good doctor”. I want to say that this sentiment
‘The Art of Medicine’ brings to mind Marshall
McLuhan’s observation: “Art is anything you can get away with”. So, we’ve got to lose this slogan
‘The Art of Medicine.’ Why? Because it carries
conceptual baggage. Cognitive linguists tells us the concepts that we use
can influence our thinking. When we think about art, we think about
individuality, freedom of expression, – certainly something that can’t be
taught, or is not informed by science. But the practice of medicine
is informed by science, and ultimately it needs
to be evidence led. The practice of medicine needs
an injection of the human sciences, in fact more than that, it needs to be on an intravenous drip
of the human sciences indefinitely. Given medicine’s psychological problems and given some of the reasons
that these persist, well what can we hope to do
about any of this? There are no easy answers,
but here’s a few ideas. First of all, in the long term,
the digitisation of medicine, including the development
of diagnostic software, may help to create
a level playing field for all patients. But what about the central
doctor-patient relationship? Well, we can look to an unlikely source
– I would argue – for some tips, and that’s the US military. The social psychologist Jack Dovidio
was interested in discrimination in the military and he suggested
that the following statement be read to appointment committees. “We know that there are
good female candidates. We know that there are
good black candidates. We don’t expect to see
underrepresentation of minorities when you’re making your appointments, and if we do, we are going to hold you
personally responsible. Now that statement was sufficient
to eliminate discrimination. Why? Dovidio says that officers
were forced to become reflective about all of our implicit biases. Perhaps medicine
could deploy similar tactics. But what about all of us? What could all of us do to ensure that we get the right kind
of medical attention? Well, we can begin by putting
a premium on empathy, and we can do that
by going into the consultation and talking to our doctor
in a way we want to be spoken to. And if that isn’t reciprocated,
we can flag this up with the doctor. If that doesn’t work, we can be
our own best health advocate by finding a doctor who does give us
the right kind of attention. Medicine needs to get mindful. But, the psychological revolution
in medicine needs us all. Thank you. (Applause)

11 Comments

  • Reply Michal Szpak June 25, 2014 at 4:38 pm

    They way google-caption service is being tricked by Charlottes' accent is hilarious!

  • Reply tfyfyftyfytfty tytyfyfyfty August 15, 2014 at 7:05 pm

    This is what happen when you put someone who don't know nothing about medicine to talk about the problems of medicine

  • Reply DR BONO August 16, 2014 at 2:46 am

    Nice delivery (wearing black and red outfit), but the content is not worth much! She promotes the idea that DOCTORS must be blind robotic automatons, and criticize them from using their intelligence and experience when they are real doctors.  She is surprised that "people from low socioeconomic levels gets less attention". Well it takes a pert academic psychologist to be surprised at that! Other people understand it is because most people (above average people) find them BORING, unless discussing TV broadcasts of football is your all-engulfing interest. The human brain is a wonderful thing, and science of psychology have struggled for 111 years to get …. nowhere! Maybe because it is still a opinionated fake science? I think it is both… and not even descriptiv.

  • Reply Tom Lawson August 16, 2014 at 4:27 pm

    This is a first rate, knowledgeable talk which demonstrates a thoroughly researched subject. It is well-worth listening to.

  • Reply Allan Stokes August 18, 2014 at 9:07 pm

    I wanted to be blown away by this talk, but I wasn't.  First, she throws out the concept of "level playing field" without showing any awareness of the Berkeley gender bias case (aka Simpson's paradox).  Equal opportunity does not always translate into equal outcomes: the applicants themselves might self-select.  Second, if you take a doctor who spends twenty minutes with one patient and ten minutes with another, then insist he or she spends fifteen minutes with each, you might well end up with poorer medical care, if the doctor was already astute "on the margin" of his or her own skill as economists tend to phrase it.  The doctor might have exhausted his/her capacity to help one of the two patients after ten minutes; perhaps the doctor is wise about time investment, but needs additional training to recognize more opportunities to contribute medical gain.  Third, the much cited Lake Wobegon effect is completely meaningless in any setting where there are highly divergent personal standards.  In her capacity as a trained cognitive scientist, I wanted to see the speaker take on all the dragons and not turn this into a cognitive-bias shell game–we won't achieve a global improvement in outcome by replacing superficial cognitive problems with more subtle cognitive problems. Equality by fiat does tend to "level the playing field", though not necessarily in a good way. 

  • Reply ki Itabashi August 23, 2014 at 5:54 pm

    Wonderful work, I did learn something.

  • Reply ChronoSerum August 30, 2014 at 5:39 am

    Great. Um… what is your opinions on space aliens? Yea… I     have    things      happppening. 

  • Reply Gerard Rodgers March 31, 2015 at 10:04 pm

    disappointing but very good communication skills

  • Reply Minda Carpenter July 2, 2015 at 1:53 pm

    The CC is terrible on this video.

  • Reply Stuart Blakley October 10, 2015 at 6:49 pm

    A brilliant accomplished performance. Well done Dr Blease

  • Reply Stuart Blakley May 2, 2016 at 7:38 pm

    Dr B you're the reason why TED was invented. Quite seriously, this really is food for thought.

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