Preface

It is hard to stand this book, as a human being.  When To Err Is Human was written in 1999, one could read through it and perceive an underlying humanistic intent – to improve the care of humans, by humans.  That purpose was cynically distorted by power-grabbers for their own purpose, which involved the wreckage and restructuring of medicine.  I believe, thought, that it was born in innocence.

Improving Diagnosis in Healthcare has no such humanism, or even pretense of humanism.  It reeks of contempt and superiority, the arrogance of the Master People in pointing out the worthlessness of their inferiors.

I am always crestfallen when Ayn Rand wins.  I long thought that Ayn Rand and her book, Atlas Shrugged, was overblown and exaggerated.  I find that I am ever beating a retreat left and right, conceding points to her that I once thought were hyperbolic, but now appear concretely in our society.

She offered a character in that book, Dr. Floyd Ferris of the State Science Institute, who is the author of Why Do You Think You Think? — a book that declares that “Thought is a primitive superstition” and that “Nothing exists but contradictions.”  I thought that the construction of a character offering such a vulgar and cynical book was impossible – an absurdity, a detriment to Rand’s  founding her beliefs in modern reality.

And then came Improving Diagnosis in Healthcare.  It conclusively asserts (with scant proof) that medical diagnosis is merely a ritual of ignorant charlatans, biologically deficient in the rational skills necessary to examine another human being and detect illness.  We should give up straightaway.  We are not built for it.

Discussion

Thanks to the new inquiry on Diagnosis, published by the IOM and such, the term Diagnosis has entered Newspeak as an infinitely flexible tool for defining medicine.
Improving Diagnosis in Health Care, published by the NAP, the National Academies Press. ISBN 978-0-309-37769-0 gives you free access to the eBook.
The National Academies Press (NAP) was created by the National Academy of Sciences to publish the reports of the National Academies of Sciences, Engineering and Medicine, operating under a charter granted by the Congress of the United States.  It has published this work, with the ominous authorship of the Committee – the Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine.

I am quite interested in the process of diagnosis in medicine.  As an Internist, the process is one of my most intriguing elements of study and ongoing refinement.

Diagnosis, to me, is a process that can be identified in isolation but really arises in the care of a person throughout the episodes of the dialectic.  Patients will offer a unique, experiential narrative in which everything has meaning, although not always consistent relevance to one or another disease process in medicine.  The narration of the patient-as-storyteller is encouraged and expanded during brief intervals of inquiry and interrogation about the narrative  By my experience, certain aspects tend to cluster together as though they are products of some process.

Processes should be named – taxonomically – only to the degree that they are understood.  A cluster of cough, fever and dyspnea should not necessarily be refined beyond a symptom/sign cluster, unless the physician believes that an underlying pathological process drives the manifestation of symptoms.

I believe that I am an excellent diagnostician.  In reviewing this work, I find much of the assertions in the work to be ignorant, noxious rubbish.

The theory of human mentation is whittled down to fit what has been written by Kahneman in 2011. [Kahneman, D. 2011. Thinking fast and slow. New York: Farrar, Strauss and Giroux.] Perhaps others have investigated human mentation. The topic does not merit an exploratory paragraph or two to cite any others who may have explored the topic (e.g. Kant, Critique of Pure Reason etc.)
Kahneman offered on the dust-jacket blurb, “(Thinking) System 1 is fast, intuitive, and emotional; (Thinking) System 2 is slower, more deliberative, and more logical. The impact of overconfidence on corporate strategies, the difficulties of predicting what will make us happy in the future, the profound effect of cognitive biases on everything from playing the stock market to planning our next vacation―each of these can be understood only by knowing how the two systems shape our judgments and decisions.”

System 2 uses hypothetico-deductivism, a highfalutin’ word if there ever was one.

This systemic but skin-thin analysis is reminiscent of the baleful psychobabble gestures asserting a separation of the Martian and Venusian characteristics of the genders and how they think.  Blarney and bigotry mix in the attempt to figure out what’s really underneath men’s or women’s brainpan, a familiar and bigoted quest that still lurks around our societal campfire.  This rubbish spins off as the foundation for pop-psychology Meyers-Briggs “methods of thinking” which are just offered as factoids – there are analytical and intuitive thinkers, and that’s that.  It is separate from championing the medieval postulates of race-mind only by fear of being roundly condemned for one’s assertions, not by any private sense of intellectual disagreement.

Fast system 1 (nonanalytical, intuitive) automatic processes require very little working memory capacity. They are often triggered by  stimuli or result from overlearned associations or implicitly learned activities. (The term “system 1” is an oversimplification because it is unlikely there is a single cognitive or neural system responsible for all system 1 cognitive processes.) Examples of system 1 processes include the ability to recognize human faces (Kanwisher and Yovel, 2006), the diagnosis of Lyme disease from a bull’s-eye rash, or decisions based on heuristics (mental shortcuts), intuition, or repeated experiences.

The concept is muddied into incomprehensibility by that sentence, were it comprehensible without it.

Heuristics—mental shortcuts or cognitive strategies that are automatically and unconsciously employed—are particularly important for decision making (Gigerenzer and Goldstein, 1996). Heuristics can facilitate decision making but can also lead to errors, especially when patients present with atypical symptoms. (refs) When a heuristic fails, it is referred to as a cognitive bias. Cognitive biases, or predispositions to think in a way that leads to failures in judgment, can also be caused by affect and motivation (Kahneman,
2011). Prolonged learning in a regular and predictable environment
increases the success of heuristics, whereas uncertain and unpredictable environments are a chief cause of heuristic failure (Kahneman, 2011; Kahneman and Klein, 2009).

What Archie Bunker would have called men’s thinking and women’s thinking in 1970, now tars the process of human mentation across all genders.  What was once considered giving a sop to “women’s intuition” now slurs human cognition in general.
The New Aryans suggest that computers, being inherently ‘better’ in rational linear thinking, are better equipped than humans are at thinking, in the same way that equations composed of linear differentials are superior to those with higher-order differentials, because they can usually be solved.
[Any engineer should burst out laughing at this truism.]

The idiocy of these arguments, dismissing heuristic methods of thought as inferior, is itself horribly defective as an example of human reasoning.  Were this book the best example of human reasoning, we should indeed hang our heads in shame.

It is likely that clinician age has an impact on clinical reasoning abilities (Croskerry and Musson, 2009; Eva, 2002; Singer et al., 2003; Small, 2001). As clinicians age, they tend to have more trouble considering alternatives and switching tasks during the diagnostic process (ibid).

This rubbish continues unabated, leading one strongly towards the conclusion that human beings are far too irrational and arbitrary to attempt diagnosis – the human mind is just not equipped for the complexity.

What are we to do then?

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