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Cognitive Dissonance in the Medical Field
Marty Makary, M.D. has written a fascinating and frightening book about the Blind Spots that people in the medical field are subject to—the kinds we saw especially play out during Covid 19. But the reason for the lies and deceptions run much deeper than experts running amok and exerting excessive power. Dr. Makary has done the research—that’s right—real scientific research—to explain the crippling effect that cognitive dissonance has on medical and research professionals. I plan to review the book fully when I finish it, but I couldn’t resist explaining the impact of cognitive dissonance. What is cognitive dissonance?
Cognitive dissonance is a discomfort caused by inconsistency which most of us are then motivated to try to reduce. In particular, it can be a feeling of hypocrisy or a realization of having made a mistake, and it’s unpleasant. Or it’s supposed to be unpleasant.
In another post I will summarize his findings about misinformation that has been distributed about peanut allergies, hormone replacement therapy, antibiotics, and cholesterol. I consider myself to be pretty well-informed, but I was stunned to learn how the facts were misrepresented.
Dr. Makary explains the reasons why the field of medicine is so reluctant to at least consider new information. He gives some examples that were baffling to me.
One of the first was surgery for an appendix, which he has done hundreds of times. He had a patient come in one day with what was clearly appendicitis. The problem was that the patient was going to his sister’s wedding the next day! Clearly, surgery would not allow him to do that. And Dr. Makary remembered he had an alternative treatment:
Then one day, a new study challenged our go-to treatment of this ancient disease. The study found that a short course of antibiotics alone can cure appendicitis, avoiding the need for surgery. The study seemed to be well-conducted with dramatic results.
Makary was torn about the decision, even after consulting his patient, who was thrilled at this other option. The doctor gave him the antibiotics which worked within hours. The young man never needed surgery. The antibiotics had worked.
But many physicians are extremely reluctant to even consider new ideas. Makary told a colleague about the study, and he refused to believe it; he insisted that a randomized controlled study be conducted. When one was completed successfully, the surgeon colleague insisted he needed two to believe it. And after the second, he insisted on a third. Later, Makary asked him about his reluctance since he knew his colleague as an honest man of integrity. Here’s what the colleague said:
‘Marty, I just think people are better off with their appendixes out,’ he replied. Amazing. All the research in the world wouldn’t matter. For him, it wasn’t a scientific view, it was a belief system. My colleague (now retired) did not want to change his mind.
According to Makary, after a decade, only half of surgeons have incorporated the use of antibiotics into their treatment plans; the rest are still conducting surgery.
I related to this story as a former cancer patient, but I had a different kind of issue: how much information should a doctor have before changing the protocols? When I was receiving chemotherapy, my oncologist told me that he would like me to go through six treatments, every three weeks. He was honest about the fact that the decision to finish all six treatments would depend on how my body responded to chemo. He didn’t explain what the repercussions might be. I admit, I didn’t ask him.
After four treatments, I said to the nurse providing the treatment that I would see her again in three weeks. Oh no, she said, that was the last treatment. After dealing with my confusion, I visited my oncologist and asked what was going on. He finally explained that the protocol used to be four treatments but a new study had shown that six treatments got better results than four. I asked, how much better? He couldn’t tell me. I think now I should have stayed with the original protocol, but I agreed to negotiate: if I could tolerate the fifth treatment, I would continue. I found out later (by accident) that after four treatments, I was already getting early signs of peripheral neuropathy (numbness in my toes). No one asked me if I had any signs, including my oncologist, and the signs were so slight that I wasn’t even sure that I was experiencing symptoms. Did my doctor know the number of people who experienced peripheral neuropathy after these treatments? Should I have been told that neuropathy might occur? Should I have expected to be fully informed?
After the fifth chemo treatment, my toes and the front of my feet went numb.
Now, I know that medicine is as much art as science. But I want to believe that my doctors are fully informed, and that they will fully inform me about the consequences of my treatments.
If we can’t trust them, who can we trust?
Published in Science and Technology
Wow. Your story about your oncologist makes me appreciate mine all the much more. I have an excellent care team at the University of Rochester, Wilmot Cancer Center. I just had my quarterly appointment and mule-kick shot in the patoot yesterday.
They have never been in a hurry to finish an appointment, and have always explained all options in detail. I think it helps that I have access to the reports that they get from all the tests and imaging, with adequate time to google all the medicalese, so I understand what they are seeing, and can ask good questions. When you’re fighting a war you want to have all the good intel you can get.
I’m glad you’re a former cancer patient. I’m not there, but the little SOB is definitely on the run; my PSAs have been zeroed out for almost three years now. I’ll probably be playing whack-a-mole with it for the rest of my days, but I’m confident that I have the best care that could be had. Last year I got a CT scan that was developed specifically for prostate cancer, and there were only two facilities in the country that offered it; one was UR. Worth driving an hour into Rochester for appointments.
Oh, forgot to mention. I have had neuropathy since I injured my back 20 years ago. Gabapentin has helped me a lot. That and having a cat curl up on my feet at night.
That’s interesting. I was never offered a treatment. Although I hate the idea of taking one more pill! Thanks, Doug, and I’m so glad you’re doing so well!
Funny you should mention it. I have never minded taking pills or getting shots; in fact, I sort out my daily pill regimen and find it comforting. I think it goes back to my childhood asthma, which was pretty terrible. That was before inhalers, so I had to take a little pink pill if I was having an asthma attack, and I think I imprinted on the relief those pills offered.
I’m glad you’re doing well, too. You had a much rougher ride than I have had. I’ve been very fortunate that the prostate cancer has been controlled with hormone therapy. It saps my energy and can lead me into depression, but that beats the heck out of what some of my friends have gone through with chemo. Besides, I can self-medicate with coffee. In my world, coffee is like chocolate in Harry Potter world.
Hurray for coffee!
I just noticed a sign in my local CVS stating non-mRNA COVID shots are available now. Is this just marketing to the vax-reluctant? Nearby was a Shingrix ad saying that if you are over 50 the probability that you carry the shingles virus is 99%. Scare tactics?
This came after taking Mrs B to her doctor. There were displays in the waiting room for several types of medications – IIRC diabetes, high cholesterol, and migraine. Is this really a good thing?
More and more I wonder about the meds my doctor prescribes for me. They are much more expensive and have worse possible side effects. It seemed to me I was doing ok on the old ones.
My confidence in the medical profession has cratered since covid. Every hospital and doctor’s office around seemed to have a strict masking policy then. Surely the docs must have known better, but are they really the ones calling the shots?
It’s hard to get good information if we aren’t confident about our doctors’ advice. I didn’t mention that I was having bad body pain and mentioned it to my GP, but not to the oncologist; my GP suggested it was arthritis. When I grumbled to my oncologist months later for a regular exam, he knew immediately that it was a new drug he had put me on. If I hadn’t asked, I might still be in pain. And yes, I’m still seeing the oncologist every six months for blood tests and check-in because I like him personally, but I will make sure from now on to ask questions!
The author of the referenced article from Psychology today might have some cognitave dissonance problems of his own:
I mainly borrowed the definition of cognitive dissonance, since I wasn’t interested in the political implications. I’ll be more careful next time!
BTW, we are all subject to cognitive dissonance–unwilling, at times, to look at new information that contradicts what we believe. If anyone thinks they are free of this, let me know.
I just finished that excellent book. Marty is a marvel.
No, we weren’t. State DPH’s were giving clear instructions to medical facilities.
And sorry to say, the head of NC DHHS was awarded the CDC directorship for her compliance. The day Trump fires her I will have a toast in his honor.
There are exceptions.
I’ve thought about writing a post about the series of medical experiences I had a little more than a decade ago; everything turned out well, but along the way I saw firsthand how much of modern medicine is a guessing game. Medicine is a science, but I don’t think most clinicians are scientists; they rely on gut feelings and their own experiences — which are, by definition, anecdotal — as much as on data.
The funny thing is, as patients, we seem to like it that way. We want that human touch; we want competent and experienced doctors who know the data, but trust their gut when tough calls need to be made. Most of the time I think this approach works just fine, but it is worth being reminded that even good doctors, like all humans, are capable of flawed reasoning and poor decision-making.
pUbLIc hEaLtH hAs eaRNeD tHe tRUst oF maNkInD
Makary is excellent. I have heard him interviewed on a number of podcasts.
I have long been skeptical about medical professionals. My first inclinations in this direction was due to some questionable diagnoses my veterinarian made about one of my dogs, and that was before the advent of vet insurance and the consequent insane rise in their pricing.
However, one experience stands out in my memory. Back in the 1980s I was married and my mother-in-law who had high blood pressure suddenly experienced a very frightening increase in both her systolic and dyastolic pressures. That she didn’t have a stroke was a pure miracle.
I knew that she had a new doctor due to the retirement of her old doc. My wife told me that the new doc had put her on a different med to control the BP. I also knew from a friend I worked with at Merrill who had been a leading salesman for Johnson and Johnson that doctors rarely if ever read the contraindications pamphlet enclosed with medicines. They, instead relied on the drug company salesman to fill them in. I asked my wife to give me the names of the two drugs, the one she was currently on and the one she has been on previously.
I went down to the pharmacy and got the pamphlets or both drugs and read them. The previous med she had been on clearly stated that once on that drug you were on it for life. The new on was not capable of replacing it effectively. I called my wife back, told her to put her mother back on the old drug, and within a few hours her BP returned to normal readings.
My wife had spoken to the new doc several times over those critical days. He has never thought to check the meds. He hadn’t asked for her to be brought to his office or to a hospital emergency room. She may well have died or been severely injured by a stroke had I not taken the few minutes necessary to act.
That entire episode left me with a real skepticism not only about doctors but of drug companies as well. I have been fortunate over the last 15 years to have excellent care. My curent care provider is a Physician’s Assistant (PA). I trust him a lot more than the physician who supervises him. I had two surgeries prior to retiring 13 years ago, a sinus surgery and a repair of a hiatus hernia. Both surgeons were exceptionally good. I consider myself very lucky to both have dependable care and exceptionally good health for my age. I never got Covid, and haven’t had a cold or other infection for a very long time. I do take my health seriously enough to monitor my blood pressure daily and to maintain a program of regular exercise and proper diet. I don’t depend on the medical profession to keep me healthy. I do it myself.
Yes.
And you should expect the physicians to be informed. Let’s acknowledge it’s like many other professions in that time must be managed to stay current, and much more again to explore possible alternative treatment studies. It is a credit to physicians who find the time to do this.
I have the utmost respect for some doctors, and not much respect for the professional organizations that ostensibly represent them, educate them, and set the agenda for the culture around the medical profession. It would be nice to have confidence in them.
I’ll go with whatever you say, Joel. ;-)
This is a very thoughtful comment, BXO. In one sense, I think my oncologist was trusting his gut for my chemo treatments; I just wish he’d mentioned the potential for neuropathy.
Absolutely. We are responsible for our health, Eugene!
I’ll depend on them for a sitrep and intel, but they won’t be my only source. I’m the one that decides strategy, they can advise me on tactics.
I’ve mentioned before a masterful book called The Emperor of All Maladies, which everyone in the oncology business is required to read. Fortunately it is available in an extremely well performed audiobook. When I got my first diagnosis I listened to it three times. As things progressed, my oncology team understood that I knew what they were talking about, most of the time, and if I didn’t, I would find out. They deal with a lot of people, and I think they were pleased that they didn’t have to work through the denial and grieving stages with me. Boots on the ground, objective set, move out. It made their job easier.
Outstanding, Doug! That’s called taking responsibility!
That really is impressive.
Not really. I’ve had a lot of time to think about it and plan for it. Every member of my father’s side of the family died of cancer, including Dad and my older brother Larry. Oddly, there doesn’t seem to be a genetic predisposition; I had that test done so I could warn my son, but it turned up nothing. Still, I encourage every man over 50 to get annual PSA screening and regular colonoscopies. An occasional CT scan to check your pancreas would be good too; I’ve lost two friends in the last two years due to pancreatic cancer that no one noticed until it was too late. Cancer sucks like that.