False assumptions and clinical errors in modern medical practice

Here are 22 false assumptions, practice failures, and everyday clinical errors that we believe are common in modern medical practice:

1. Lack of appreciation of the phenomenon of physician persuasion and its hidden power. The placebo effect is scientific, potent, and worthy of use.

2. Lack of understanding of the power of prevalence or pretest probability in the diagnostic process, leading to frequent false positives and “overdiagnosis” of nonexistent diseases.

3. Lack of understanding that many disease processes are gradual and progressive — not “on or off” signals; analog and not digital. This leads to great confusion about when to diagnose and treat. For example, at what percent stenosis is an artery “diseased” and in need of treatment?

4. Incorrect assignment of reductions in death rates and increasing life expectancy to curative medicine rather than to preventive efforts.

5. Medicine has a tendency to remove many physicians from relying on direct experience and personal observations and replace this with a reliance on indirect information. This leads to an over-reliance on lab and imaging findings by both patients and doctors.

6. Lack of long-term clinical outcome data, stratified by gender and age, leading to an inability to obtain a truly informed consent.

7. The mind-body dichotomy, present since René Descartes in the 1600s, holds erroneously that the mind and body are completely separated. This false separation leads us to believe that the lack of evidence for disease in the body of a symptomatic patient confers a diagnosis of mental disease: Thus the non-helpful statement to the patient, “Don’t worry, it’s all in your head.”

8. Lack of appreciation for what is scientifically established versus what is still in the thought stage of development.

9. A failure of medicine to recognize what it can effectively treat and what it cannot, and admitting that some diseases have no effective treatment.

10. Failure to recognize that the fields of human biology and clinical medicine overlap but do not coexist. Schools of medicine are becoming more schools of human biology and less schools of clinical medicine.

11. Absence of a test that will distinguish well from sick. The lack of a test leads to the erroneous assumption of sickness as the rule of thumb for almost all patients.

12. Lack of a blood or urine test that can measure mental status. Dementia can be missed in up to 20% of admissions to hospitals.

13. Lack of full understanding of the intense secondary gain of illness.

14. Fallacy of the first lesion found being assigned importance, whether or not it is the cause of the symptoms.

15. Fallacy of any lesion found being sufficient to explain symptoms.

16. Failure to stop a drug or treatment when it is not helping.

17. Failure to identify what abnormality or test result is to be followed to determine success or not, when someone is being treated.

18. Failure to look for little signs of improvement and stick with the treatment rather than change it too soon.

19. Failure to know a patient well enough to know what their wishes are in terminal or hopeless situations.

20. Failure to recognize and advise the family when a condition or situation is futile and should move to palliation and comfort care.

21. Failure to keep the number of drugs to a minimum.

And, number 22, perhaps the most important to today’s society:

22. An exaggerated and unfounded fear of malpractice suits with abdication of professional responsibility just to avoid any chance of being sued.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association and Clifton Meador is an endocrinologist on the faculties of Vanderbilt and Meharry Medical Schools.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

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  • Anonymous

    Number eight is important, especially for regular folks who read about medicine in the papers ( example: autism and vaccines) but also for docs (drug-eluting stents).  Much disorder arises in medical minds due to a poor understanding of the limitations of statistical studies.  Combine this with a lack of time and you get docs “learning” from drug reps and the health section of the NY Times.
    Number 13 is also important, and under-discussed.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Having been through two med mal suits which were unfounded and with little or no merit , I know how emotionally crippling and exhausting, financially expensive , and how long they last ( 5-7 years) before resolution and finality occurs. I am not sure if Dr Lundberg, working in academia has experienced similar things. His suggestion on #22 will change when the system changes giving clinicians the support they need to not practice defensively.

  • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

    These are interesting thoughts. I think they all point to the lack of connection between patient and physician as the root cause. When doctors really know their patients and patients truly trust their doctor, then much of these assumptions and medical errors will go away. The problem is that we are practicing at a time when we are “forced” to see so many patients that we do not take the time or have the time to establish deep connections with our patients. As such, we rely on prescription medicines, labs, radiology to maintain our relationships. We practice defensive medicine because we are seeing so many patients and since we do not have the rapport with our patients, we are afraid that we will get sued. That is very real. 
    One way out is to transition to a direct-pay method of healthcare. Sure, less patients to take care of, but more time per patient. More time to develop patient connections. Less need to write prescriptions, order labs when we know our patients. Less lawsuits because our patients trust us. What we need is deep patient connections, not nec. more patient connections.

  • Anonymous

    I think this article by George Lunberg et al about false assumptions in medicine is excellent.  These assumptions are especially deadly and deliberate when it comes to the mental death profession since all their bogus life destroying stigmas are invented by them, totally subjective since they lack any scientific evidence in their creation or application, political, based on prejudices of the time, are about social control and totalitarianism rather than medicine.  These stigmas are created with BIG PHARMA and the government with special emphasis on the FDA, the national institutes of medicine and politicians needing huge donations for campaigns.  Sadly, their greed and evil knows no limits since they now prey on toddlers and babies no less along with others in the most vulnerable groups like abused women and children, people who are mobbed and bullied at work and elsewhere to use their social distress, normal reactions of stress and their ill gotten power and greed to invade our every institution and life process so they can inflict their fraud stigmas to force their toxic poison “drugs” on one and all.  The vaccine industry and the rest of medicine using psychiatry as their god has more than followed suit (See SNAKES IN SUITS: WHEN PSYCHOPATHS GO TO WORK, POLITICAL PONEROLOGY) and indeed these psychopaths in the power elite have been working very hard to destroy as many normal people who see through them as quickly and efficiently as possible as in NAZI Germany (See Dr. Jay Lifton’s THE NAZI DOCTORS).

    As far as lawsuits, it is usually arrogant, narcissistic  doctors who refuse to listen to patients, lie and act in a high handed manner who get sued.  Studies have found that when doctors apologized and/or expressed empathy for the patients feelings, patients were far less likely to sue.

    Anyway, given my own long term experience with our broken health care system, I believe this article is right on and not the least bit ivory tower.  Many lives are destroyed by expoitative, greedy, power driven, dishonest practices in medicine while at the same time they try to rob patients of all their rights including the right to sue for the most egregious damages.  It is very hard to sue win any lawsuits against such power, wealthy, well ensured people or entities for the “average Joe” since most lack the knowledge, power, status or resources to do so.   The pretense that lawsuits are such a threat is a desire by medicine/government to get away with the most outrageous practices with impunity while makeing patients increasingly powerless.

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